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The medical risks and potential benefits of neonatal circumcision have been studied. The British Medical Association, states that “there is significant disagreement about whether circumcision is overall a beneficial, neutral or harmful procedure. At present, the medical literature on the health, including sexual health, implications of circumcision is contradictory, and often subject to claims of bias in research.” Studies making cost-benefit analyses comparing circumcision complications with the potential gain in expected longevity, and the medical costs of circumcision compared with the expected reduction in lifetime health costs have varied. Some found a small net benefit, some found a small net decrement, and others found that the benefits and risks of circumcision balanced each other out and suggest the circumcision decision "most reasonably be made on nonmedical factors."
Risks of circumcision
Circumcision is a surgical procedure. While the risk of complications in a competently performed medical circumcision is very low, complications resulting from poorly carried out circumcisions, post-operative bleeding, and infection can be catastrophic. According to the AMA, blood loss and infection are the most common complications, although bleeding is mostly minor and hemostasis can be achieved by pressure application. Kaplan identified other circumcision complications, including urinary fistulas, chordee, cysts, lymphedema, ulceration of the glans, necrosis of all or part of the penis, hypospadias, epispadias, impotence and removal of too much tissue, sometimes causing secondary phimosis. He stated “Virtually all of these complications are preventable with only a modicum of care. Unfortunately, most such complications occur at the hands of inexperienced operators who are neither urologists nor surgeons.” Infant circumcision may result in skin bridges, when the cut skin does not heal neatly but attaches to the glans penis instead. This does not commonly require surgical correction; rather, a brief, simple office procedure may be performed.
The American Medical Association quotes a complication rate of 0.2%–0.6%,[9] based on the studies of Gee and Harkavy. These same studies are quoted by the American Academy of Pediatrics. The American Academy of Family Physicians quotes a range of anywhere between 0.1% and 35%. The Canadian Paediatric Society cite these results in addition to other figures ranging anywhere between 0.06% to 55%, and remark that Williams & Kapila suggested that 2-10% is a realistic estimate.
Meatal stenosis may be a common longer-term complication from circumcision. Recent publications give a frequency of occurrence between 0.9% and 9% to 10%.
Fatal complications have been reported. The American Academy of Family Physicians states that death is rare, and cites an estimated death rate with circumcisions of infants of 1 in 500,000.[76] Gairdner's 1949 study reported that during the 1940s an average of 16 children per year, out of an estimated 90,000, died following circumcision in the UK. He found that most deaths had occurred suddenly under anaesthesia and could not be explained further, but hemorrhage and infection had also proven fatal. Deaths attributed to phimosis and circumcision were grouped together, but Gairdner argued that such deaths were probably due to the circumcision operation. The RACP states that the penis is lost in 1 in 1,000,000 circumcisions.
A 2004 Cochrane review, which compared the dorsal penile nerve block and EMLA (topical anaesthesia) found both anaesthetics appear safe, but neither of them completely eliminated pain. Razmus et al reported that newborns circumcised with the dorsal block and the ring block in combination with the concentrated oral sucrose had the lowest pain scores. Ng et al found that EMLA cream, in addition to local anaesthetic, effectively reduces the sharp pain induced by needle puncture. Adult circumcisions are often performed without clamps, and require 4 to 6 weeks of abstinence from masturbation or intercourse after the operation to allow the wound to heal.[98] Lander et al., studying neonatal circumcision without anesthesia, found that patients "exhibited homogeneous responses that consisted of sustained elevation of heart rate and high pitched cry throughout the circumcision and following. Two newborns ... became ill following circumcision (choking and apnea)."
HIV
Initial population based studies suggested that circumcision might protect against HIV infection. However, in these studies, factors such as religion may skew the results. In March 2005, the Cochrane review of the medical evidence found the current quality of evidence at that point "insufficient" to consider implementing circumcision "as a public-health intervention" but the positive results of observational studies suggested that circumcision was "worth evaluating in randomised controlled trials."
The most recent data indicate that circumcision is correlated with a 50-60% reduction in risk of HIV transmission (from female to male) during heterosexual intercourse.[100] The results of the first randomised controlled trial was published in November 2005. It found a 60% reduction in the rate of new HIV infection (from 2.1 per 100 to 0.85 per 100 in the intervention group. The authors said, "Male circumcision provides a degree of protection against acquiring HIV infection, equivalent to what a vaccine of high efficacy would have achieved. Male circumcision may provide an important way of reducing the spread of HIV infection in sub-Saharan Africa." Two further randomised trials conducted in Uganda and Kenya were stopped early on December 13, 2006 on grounds that circumcision was so effective that it would be unethical to continue the experiment and not offer circumcision in the uncircumcised men who were acting as controls. The results showed that circumcised males in Uganda were, depending upon the analysis, 51%-60% less likely to be infected. In Kenya, circumcised males were 53%-60% less likely to be infected. A paper published in the journal PLoS Medicine in July, 2006, calculated that if all men in sub-Saharan Africa were circumcised over the next 10 years, two million new infections could potentially be avoided.
The World Health Organization (WHO) said: "Although these results demonstrate that male circumcision reduces the risk of men becoming infected with HIV, the UN agencies emphasize that it does not provide complete protection against HIV infection. Circumcised men can still become infected with the virus and, if HIV-positive, can infect their sexual partners. Male circumcision should never replace other known effective prevention methods and should always be considered as part of a comprehensive prevention package, which includes correct and consistent use of male or female condoms, reduction in the number of sexual partners, delaying the onset of sexual relations, and HIV testing and counselling.".[102] Others have also expressed concern that some may mistakenly believe they will be fully protected against HIV through circumcision and see circumcision as a safe alternative to other forms of protection, such as condoms.[103][104] An interim analysis from the Rakai Health Sciences Program in Uganda suggested that newly circumcised HIV positive men may be more likely to spread HIV to their female partners if they have sexual intercourse before the wound is fully healed. “Because the total number of men who resumed sex before certified wound healing is so small, the finding of increased transmission after surgery may have occurred by chance alone. However, we need to err on the side of caution to protect women in the context of any future male circumcision programme," said Dr Maria Wawer, the study's principal investigator.
There is also a danger of HIV being spread from unhygienic circumcision procedures. Brewer et al. studied HIV infection rates in Kenya, Lethotho and Tanzania and found that "[circumcised] male and female virgins were substantially more likely to be HIV infected than uncircumcised virgins. Among adolescents, regardless of sexual experience, circumcision was just as strongly associated with prevalent HIV infection. However, uncircumcised adults were more likely to be HIV positive than circumcised adults." The authors concluded, "HIV transmission may occur through circumcision-related blood exposures in eastern and southern Africa."
On March 28, 2007, the World Health Organisation and UNAIDS issued joint recommendations concerning male circumcision and HIV/AIDS. These recommendations are:
* Male circumcision should now be recognized as an efficacious intervention for HIV prevention.
* Promoting male circumcision should be recognized as an additional, important strategy for the prevention of heterosexually acquired HIV infection in men.
Langerhans cells and HIV transmission
Langerhans cells are part of the human immune system. Three studies identified high concentrations of Langerhans and other "HIV target" cells in the foreskin and Szabo and Short suggested that the Langerhans cells in the foreskin may provide an entry point for viral infection. McCoombe, Cameron, and Short also found that the keratin is thinnest on the foreskin and frenulum. Fleiss, Hodges and Van Howe had previously stated a belief that the prepuce has an immunological function. While their specific hypothesis was criticised on technical grounds. a study published in 2007 by de Witte and others said that Langerlin, excreted by Langerhans cells, is a natural barrier to HIV-1 transmission by Langerhans cells.
HPV
Several studies have shown that uncircumcised men are at greater risk of human papilloma virus (HPV) infection. While most genital HPV strains are considered harmless, some can cause genital warts or cancer although there is a vaccine against most cancer causing strains of HPV. One study found no statistically significant difference between men with foreskins for HPV infection than those who are circumcised, but did note a significantly higher incidence of HPV lesions and urethritis in uncircumcised men.
Hygiene
The American Academy of Pediatrics observes "Circumcision has been suggested as an effective method of maintaining penile hygiene since the time of the Egyptian dynasties, but there is little evidence to affirm the association between circumcision status and optimal penile hygiene." It states that the "relationship among hygiene, phimosis, and penile cancer is uncertain" and further remarks that "genital hygiene needs to be emphasized as a preventive health topic throughout a patient's lifetime."
The Royal Australasian College of Physicians emphasizes that a non-circumcised infant's penis requires no special care and should be left alone, stating that attempts to forcibly retract the foreskin, e.g. to clean it, are painful, often injure the foreskin, and can lead to scarring, infections and pathologic phimosis. It is recommended that, while there is no special age where the foreskin should be retractable, once the foreskin becomes retractable, the child should gently wash it with soap and water. It has been suggested, however, that excessive washing of the foreskin and the glans will make infections such as balanitis more likely.
Circumcision reduces the amount of smegma produced by the male. Smegma is a combination of exfoliated epithelial cells, transudated skin oils, and moisture that can accumulate under the foreskin of males and within the female vulva area. It has a characteristic strong odor and taste, and is common to all mammals—male and female. While smegma is generally not believed to be harmful to health, the strong odour may be considered to be a nuisance or give the impression of a lack of hygiene. In rare cases, accumulating smegma may help cause balanitis.
It has been suggested that circumcision arose in peoples living in arid and sandy regions as a public health measure intended to prevent recurring irritation and infection caused by sand accumulating under the foreskin.[123] Darby, after checking the official war histories of Britain, Australia and New Zealand and other records, and finding no mention of ‘balanitis’ or ‘foreskin’ or ‘circumcision’, dismissed this idea as a “medical urban myth," concluding that "sand under the foreskin,’ balanitis, and circumcision were not significant problems during either of the World Wars."
Infectious and chronic conditions
Studies have found that boys with foreskins tend to have higher rates of various infections and inflammations of the penis than those who are circumcised. The reasons are unclear, but several hypotheses have been suggested:
* The foreskin may harbor bacteria and become infected if it is not cleaned properly.
* The foreskin may become inflamed if it is cleaned too often with soap.
* The forcible retraction of the foreskin in boys can lead to infections.
The usual treatment for balanoposthitis is to use topical antibiotics (metronidazole cream) and antifungals (clotrimazole cream) or low-potency steroid creams. There are less invasive treatments than circumcision for posthitis.
Balanitis
Main article: Balanitis
Balanitis, an inflammation of the glans penis, has a variety of causes. Some of these, such as anaerobic infection, occur more frequently in uncircumcised men, while others, such as fungal infection, have no statistically significant differences in frequency of occurrence between circumcised and uncircumcised men. There are less invasive treatments than circumcision that have been shown to be effective in treating most mild cases of balanitis. Birley, et al, found that in 90% of their cases of chronic or recurring balanitis "use of emollient creams and restriction of soap washing alone controlled symptoms satisfactorily". They also state that circumcision "might be of benefit in a patient whose balanitis relapses despite these measures, and remains the principal treatment for specific conditions such as lichen sclerosus and plasma cell balanitis." The, less invasive procedures are not as successful in treating balanitis xerotica obliterans, or BXO, which is much less common but harder to treat.
Lichen sclerosus et atrophicus (LSA) produces a whitish-yellowish patch on the skin, and is not believed to be always harmful or painful, and may sometimes disappear without intervention. Some consider balanitis xerotica obliterans to be a form of LSA that happens to be on the foreskin, where it may cause pathological phimosis. Circumcision is believed to reliably reduce the threat of BXO.
Penile cancer
Main article: Penile cancer
Penile cancer is cancer of the penis, i.e. on the glans or the foreskin. Most cases have been found to occur in men over the age of 70.[138] In 1979, Boczko and Freed remarked that since Wolbarst's 1932 review, "there have been only eight documented cases of penile carcinoma in an individual circumcised in infancy." They described the ninth reported case, concluding that "performing it in infancy continues to be the most effective prophylactic measure against penile carcinoma."[139] The AMA remarked that in six case series published from 1932 and 1986, "all penile cancers occurred in uncircumcised individuals." Maden et al reported in 1993 that the risk of penile cancer was 3.2 times greater in men who were never circumcised and 3 times greater among those who were circumcised after the neonatal period; this study was referenced in an editorial by Holly and Palefsky. They compliment the study for noting other risk factors for penile cancer, as well as for providing corroborating evidence as to the association between a lack of neonatal circumcision and the development of penile cancer. However, their criticisms include the study's combining data from invasive and in situ cancers. They concluded that as the new study reported circumcision at birth in 20% of the men with penile cancer, the recommendation of circumcision for medical indications remains somewhat controversial and the risks and benefits must be weighed. The American Academy of Pediatrics made similar criticism, also noting the possibly inaccurate use of self-report to determine circumcision status. Schoen et al studied the association between neonatal circumcision and invasive penile cancer in 2000, and found that the relative risk for uncircumcised men was 22 times that of circumcised men.
In 2005, the American Cancer Society said that while studies suggest that circumcision may reduce the risk of more invasive forms of penile cancer, it is important to concentrate on the main risk factors: poor hygiene, having unprotected sex with multiple partners, and cigarette smoking. They further state that the current consensus of most experts is that circumcision should not be recommended as a prevention strategy for penile cancer.
The American Academy of Pediatrics states that studies suggest that neonatal circumcision confers some protection from penile cancer, but circumcision at a later age does not seem to confer the same level of protection. Further, penile cancer is a rare disease and the risk of penile cancer developing in an uncircumcised man, although increased compared with a circumcised man, remains low. Similarly, the American Medical Association states that although neonatal circumcision seems to lower the risk of contracting penile cancer, because it is rare and occurs later in life, the use of circumcision as a preventive practice is not justified.
Kochen and McCurdy performed a life table analysis on penile cancer rates. They assumed that these cancers occur exclusively in uncircumcised males and that age-specific rates calculated from older groups were applicable to the 1971 birth cohort. Their overall analysis finds an estimated occurrence rate in uncircumcised males of 1 in 600, or 0.167%, with a median age of occurrence of 67 years old. However, they close their predictions section with the following “Since the uncircumcised male is uniquely susceptible, virtually all of these cancers are preventable by neo-natal circumcision. The number of lifetime incident cancers that could be prevented annually by circumcision can be estimated with birth statistics available for 1971. In that year, there were 1,822,910 recorded live male births. If none had been neonatally circumcised, our analysis predicts that one in 600, or more than 3,000 would have penile cancer in their lifetimes."
Phimosis and paraphimosis
It is normal for an infant's foreskin to be attached to the glans. Pathological phimosis is a condition when the foreskin remains so tight that retraction over the glans is painful or impossible. Dawson and Whitfield, say "True phimosis is rare but may cause appreciable problems in either childhood or adolescence." Rickwood suggested that the term 'phimosis' should be restricted to cases in which the prepuce loses suppleness and becomes scarred. The AAP state that the true frequency of problems such as phimosis is unknown. Fergusson et al found phimosis in 16% of non-circumcised boys, while Herzog and Alvarez found it in 2.6%. Rickwood and Walker raised concern that phimosis is frequently misdiagnosed by physicians confusing it with the developmentally non-retractable foreskin. Several researchers have described less invasive treatments for phimosis than circumcision, and recommend that they be tried first.
Several studies have identified phimosis as a risk factor for penile cancer. The British Medical Journal published one letter that stated it would be irresponsible to expose a patient to risk for longer than necessary.
Paraphimosis is an acute condition when a tight foreskin is stuck behind the glans and cannot be returned to its original position, curbing the blood flow to the glans. In children, it is sometimes caused by a caregiver trying to forcibly retract the infant foreskin.
Urinary tract infections
Twelve studies have indicated that neonatal circumcision reduces the occurrence rate of Urinary tract infections in male infants by a factor of about 10. The March 1999 AAP statement notes that premature infants are usually not circumcised because of their fragile health status. Studies have found that 1 in 10 premature infants will have a urinary tract infection during the first month of life. Some of the UTI studies have been criticised for not taking these and other factors into account. A Swedish study found that the cumulative incidence of UTIs in boys under 2 years of age was 2.2%. The AMA cites evidence that the incidence of UTI’s is “small (0.4%–1%)” in uncircumcised infants, and “depending on the model employed, approximately 100 to 200 circumcisions would need to be performed to prevent 1 UTI…One model of decision analysis concluded that the incidence of UTI would have to be substantially higher in uncircumcised males to justify circumcision as a preventive measure against this condition."
The Canadian Paediatric Society poses the question of whether increased UTI and balanitis rates in non-circumcised male infants may be caused by forced premature retraction. According to the Lerman and Liao, aside from its effects on UTI infection rates, "Most of the other medical benefits of circumcision probably can be realized without circumcision as long as access to clean water and proper penile hygiene are achieved."
Policies of various national medical associations
United States
The American Academy of Family Physicians recommends that physicians discuss the potential harms and benefits of circumcision with all parents or legal guardians considering circumcision for newborn boys.
The American Academy of Pediatrics recommends that parental decisions on elective circumcision should be made with as much accurate and unbiased information as possible, taking physiological, cultural, ethnic, and religious factors into account.
The American Medical Association supports the general principles of the 1999 Circumcision Policy Statement of the American Academy of Pediatrics.
Canada
The Fetus and Newborn Committee of the Canadian Paediatric Society posted Circumcision: Information for Parents in November of 2004, and Neonatal circumcision revisited statements in 1996, undergoing revision as of 2004 in which, due to the evenly balanced reasons pro and con, they do not recommend routine circumcision.
United Kingdom
As of June of 2006, the British Medical Association's position was that male circumcision for medical purposes should only be used where less invasive procedures are either unavailable or not as effective. The BMA specifically refrained from issuing a policy regarding "non-therapeutic circumcision," stating that as a general rule, it "believes that parents should be entitled to make choices about how best to promote their children’s interests, and it is for society to decide what limits should be imposed on parental choices."
Australasia (Australia, New Zealand and nearby islands)
The Royal Australasian College of Physicians takes the position that there is no medical indication for routine neonatal circumcision, and if the procedure is to be performed for non-medical reasons, it should be performed by competent operator, using appropriate anaesthesia and in a safe child-friendly environment.
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