Medical analysis of circumcision 221587 226162000 2008-07-17T02:43:24Z Tremello22 2253537 /* Possible protections gained by circumcision */ Changed non-neutral title Numerous medical studies have examined the effects of [[circumcision|male circumcision]] with mixed opinions regarding the benefits and risks of the procedure. ==Positions of major health organizations== ===United States=== The [[American Academy of Pediatrics]] (1999) found both potential benefits and risks in infant circumcision, however, there was insufficient data to recommend routine neonatal circumcision. In the case of circumcision, when the procedure is not essential to the child’s current well-being, parents should determine what is in the best interest of the child. To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss the decision to circumcise or not. They said it was legitimate to take medical, cultural, ethnic, traditional, and religious factors into account. If a decision to circumcise is made, the AAP recommended using analgesia to reduce pain, and also said that circumcision should only be performed on stable and healthy newborns.<ref name = "AAP19992">{{cite journal | last = Task Force on Circumcision | coauthors = | year = 1999 | month = [[March 1]], | title = Circumcision Policy Statement | journal = Pediatrics | volume = 103 | issue = 3 | pages = 686&ndash;693 | doi = 10.1542/peds.103.3.686 | id = {{ISSN|0031-4005}} PMID 10049981 | url = http://pediatrics.aappublications.org/cgi/reprint/pediatrics;103/3/686.pdf | format = PDF | accessdate = 2006-07-01 | pmid = 10049981 }} <small>“Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In the case of circumcision, in which there are potential benefits and risks, yet the procedure is not essential to the child’s current well-being, parents should determine what is in the best interest of the child. To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision. It is legitimate for parents to take into account cultural, religious, and ethnic traditions, in addition to the medical factors, when making this decision. Analgesia is safe and effective in reducing the procedural pain associated with circumcision; therefore, if a decision for circumcision is made, procedural analgesia should be provided. If circumcision is performed in the newborn period, it should only be done on infants who are stable and healthy.”</small> </ref> The [[American Medical Association]] (1999) noted that medical associations in the US, Australia, and Canada did not recommend routine circumcision of newborns. It supported the general principles of the 1999 Circumcision Policy Statement of the American Academy of Pediatrics<ref name = "CSA:I-99" /> The [[American Academy of Family Physicians]] (January 2007) acknowledges the controversy surrounding circumcision and recommends that physicians discuss the potential harms and benefits of circumcision with all parents or legal guardians considering circumcision for newborn boys.<ref name = "AAFP2">{{cite web | url = http://www.aafp.org/online/en/home/clinical/clinicalrecs/circumcision.html | title = Circumcision: Position Paper on Neonatal Circumcision | accessdate = 2007-01-30 | year = 2007 | publisher = [[American Academy of Family Physicians]] | quote = <small>Considerable controversy surrounds neonatal circumcision. Putative indications for neonatal circumcision have included preventing UTIs and their sequelae, preventing the contraction of STDs including HIV, and preventing penile cancer as well as other reasons for adult circumcision. Circumcision is not without risks. Bleeding, infection, and failure to remove enough foreskin occur in less than 1% of circumcisions. Evidence-based complications from circumcision include pain, bruising, and meatitis. More serious complications have also occurred. Although numerous studies have been conducted to evaluate these postulates, only a few used the quality of methodology necessary to consider the results as high level evidence.<br /> <br /> The evidence indicates that neonatal circumcision prevents UTIs in the first year of life with an absolute risk reduction of about 1% and prevents the development of penile cancer with an absolute risk reduction of less than 0.2%. The evidence suggests that circumcision reduces the rate of acquiring an STD, but careful sexual practices and hygiene may be as effective. Circumcision appears to decrease the transmission of HIV in underdeveloped areas where the virus is highly prevalent. No study has systematically evaluated the utility of routine neonatal circumcision for preventing all medically-indicated circumcisions in later life. Evidence regarding the association between cervical cancer and a woman’s partner being circumcised or uncircumcised, and evidence regarding the effect of circumcision on sexual functioning is inconclusive. If the decision is made to circumcise, anesthesia should be used.<br /> <br /> The [[American Academy of Family Physicians]] recommends physicians discuss the potential harms and benefits of circumcision with all parents or legal guardians considering this procedure for their newborn son.</small> }} </ref> The [[American Urological Association]] (May 2007) states there are benefits and risks to circumcision. It feels that parents should consider medical benefits and risks, and ethnic, cultural factors when making this decision. <ref name="AUApolicy"> {{cite web |url=http://www.auanet.org/about/policy/services.cfm#circumcision |title=Circumcision |accessdate=2007-08-26 |author=American Urological Association |format= |work=About AUA - Policy Statments |quote= <small>The American Urological Association, Inc.® (AUA) believes that neonatal circumcision has potential medical benefits and advantages as well as disadvantages and risks. Neonatal circumcision is generally a safe procedure when performed by an experienced operator. There are immediate risks to circumcision such as bleeding, infection and penile injury, as well as complications recognized later that may include buried penis, meatal stenosis, skin bridges, chordee and poor cosmetic appearance. Some of these complications may require surgical correction. Nevertheless, when performed on healthy newborn infants as an elective procedure, the incidence of serious complications is extremely low. The minor complications are reported to be three percent. Properly performed neonatal circumcision prevents phimosis, paraphimosis and balanoposthitis, and is associated with a decreased incidence of cancer of the penis among U.S. males. In addition, there is a connection between the foreskin and urinary tract infections in the neonate. For the first three to six months of life, the incidence of urinary tract infections is at least ten times higher in uncircumcised than circumcised boys. Evidence associating neonatal circumcision with reduced incidence of sexually transmitted diseases is conflicting. Circumcision may be required in a small number of uncircumcized boys when phimosis, paraphimosis or recurrent balanoposthitis occur and may be requested for ethnic and cultural reasons after the newborn period. Circumcision in these children usually requires general anesthesia. When circumcision is being discussed with parents and informed consent obtained, medical benefits and risks, and ethnic, cultural, religious and individual preferences should be considered. The risks and disadvantages of circumcision are encountered early whereas the advantages and benefits are prospective. Three studies from African nations published in 2005 and 2007 provide convincing evidence that circumcision reduces by 50-60% the risk of transmitting the human immunodeficiency virus (HIV) to HIV negative men through sexual contact with HIV positive females. While the results of studies in African nations may not necessarily be extrapolated to men in the United States at risk for HIV infection, the American Urological Association recommends that circumcision should be presented as an option for health benefits. Circumcision should not be offered as the only strategy for HIV risk reduction. Other methods of HIV risk reduction, including safe sexual practices, should be emphasized.<small/>}} </ref> ===Canada=== The Fetus and Newborn Committee of the [[Canadian Paediatric Society]] does not recommend routine circumcision for newborn boys. It posted "Circumcision: Information for Parents" in November 2004,<ref name = "CPSIFP2">{{cite web | url = http://www.caringforkids.cps.ca/babies/Circumcision.htm | title = Circumcision: Information for parents | accessdate = 2006-10-24 | year = 2004 | month = November | work = Caring for kids | publisher = [[Canadian Paediatric Society]] | quote = <small>Circumcision is a “non-therapeutic” procedure, which means it is not medically necessary. Parents who decide to circumcise their newborns often do so for religious, social or cultural reasons. To help make the decision about circumcision, parents should have information about risks and benefits. It is helpful to speak with your baby’s doctor. After reviewing the scientific evidence for and against circumcision, the CPS does not recommend routine circumcision for newborn boys. Many paediatricians no longer perform circumcisions.</small> }} </ref> and "Neonatal circumcision revisited" in 1996. The 1996 position statement says that "circumcision of newborns should not be routinely performed," (a statement with which the Royal Australasian College of Physicians concurs,) and the 2004 advice to parents says it "does not recommend circumcision for newborn boys. Many paediatricians no longer perform circumcisions."<ref name = "CMAJ2"> {{cite journal | last = Fetus and Newborn Committee | year = 1996 | month = March | title = Neonatal circumcision revisited | journal = Canadian Medical Association Journal | volume = 154 | issue = 6 | pages = 769&ndash;780 | doi = | id = | url = http://www.cps.ca/english/statements/FN/fn96-01.htm | format = | accessdate = 2006-07-02 }} <small>“We undertook this literature review to consider whether the CPS should change its position on routine neonatal circumcision from that stated in 1982. The review led us to conclude the following. There is evidence that circumcision results in an approximately 12-fold reduction in the incidence of UTI during infancy. The overall incidence of UTI in male infants appears to be 1% to 2%. The incidence rate of the complications of circumcision reported in published articles varies, but it is generally in the order of 0.2% to 2%. Most complications are minor, but occasionally serious complications occur. There is a need for good epidemiological data on the incidence of the surgical complications of circumcision, of the later complications of circumcision and of problems associated with lack of circumcision. Evaluation of alternative methods of preventing UTI in infancy is required. More information on the effect of simple hygienic interventions is needed. Information is required on the incidence of circumcision that is truly needed in later childhood. There is evidence that circumcision results in a reduction in the incidence of penile cancer and of HIV transmission. However, there is inadequate information to recommend circumcision as a public health measure to prevent these diseases. When circumcision is performed, appropriate attention needs to be paid to pain relief. The overall evidence of the benefits and harms of circumcision is so evenly balanced that it does not support recommending circumcision as a routine procedure for newborns. There is therefore no indication that the position taken by the CPS in 1982 should be changed. When parents are making a decision about circumcision, they should be advised of the present state of medical knowledge about its benefits and harms. Their decision may ultimately be based on personal, religious or cultural factors.</small> </ref> ===United Kingdom=== The British Medical Association's position (June 2006) 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.”<ref name = "BMAGuide2"> {{cite web | url = http://www.bma.org.uk/ap.nsf/Content/malecircumcision2006?OpenDocument&Highlight=2,circumcision | title = The law and ethics of male circumcision - guidance for doctors | accessdate = 2006-07-01 | author = Medical Ethics Committee | year = 2006 | month = June | publisher = [[British Medical Association]] | quote = <small>'''Circumcision for medical purposes'''<br /> Unnecessarily invasive procedures should not be used where alternative, less invasive techniques, are equally efficient and available. It is important that doctors keep up to date and ensure that any decisions to undertake an invasive procedure are based on the best available evidence. Therefore, to circumcise for therapeutic reasons where medical research has shown other techniques to be at least as effective and less invasive would be unethical and inappropriate. Male circumcision in cases where there is a clear clinical need is not normally controversial. Nevertheless, normal anatomical and physiological characteristics of the infant foreskin have in the past been misinterpreted as being abnormal. The British Association of Paediatric Surgeons advises that there is rarely a clinical indication for circumcision. Doctors should be aware of this and reassure parents accordingly.<br /> <br /> '''Non-therapeutic circumcision'''<br /> Male circumcision that is performed for any reason other than physical clinical need is termed non-therapeutic (or sometimes “ritual”) circumcision. Some people ask for non-therapeutic circumcision for religious reasons, some to incorporate a child into a community, and some want their sons to be like their fathers. Circumcision is a defining feature of some faiths.<br /> <br /> There is a spectrum of views within the BMA’s membership about whether non-therapeutic male circumcision is a beneficial, neutral or harmful procedure or whether it is superfluous, and whether it should ever be done on a child who is not capable of deciding for himself. The medical harms or benefits have not been unequivocally proven except to the extent that there are clear risks of harm if the procedure is done inexpertly. The Association has no policy on these issues. Indeed, it would be difficult to formulate a policy in the absence of unambiguously clear and consistent medical data on the implications of the intervention. As a general rule, however, the BMA 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.</small> }} </ref> ===Australasia=== The [[Royal Australasian College of Physicians]] states '''there is no medical indication for routine neonatal circumcision''' (emphasis as in the original). It states, "If the operation is to be performed, the medical attendant should ensure this is done by a competent operator, using appropriate anaesthesia and in a safe child-friendly environment" <ref name = "RACPSumm">{{cite web | url = http://www.racp.edu.au/download.cfm?DownloadFile=A453CFA1-2A57-5487-DF36DF59A1BAF527 | title = Policy Statement On Circumcision | accessdate = 2007-02-28 | year = 2004 | month = September | format = PDF | publisher = [[Royal Australasian College of Physicians]] | pages = | language = | archiveurl = | archivedate = | quote = <small>The Paediatrics and Child Health Division, The Royal Australasian College of Physicians (RACP) has prepared this statement on routine circumcision of infants and boys to assist parents who are considering having this procedure undertaken on their male children and for doctors who are asked to advise on or undertake it. After extensive review of the literature the RACP reaffirms that '''there is no medical indication for routine neonatal circumcision.''' Circumcision of males has been undertaken for religious and cultural reasons for many thousands of years. It remains an important ritual in some religious and cultural groups.…In recent years there has been evidence of possible health benefits from routine male circumcision. The most important conditions where some benefit may result from circumcision are urinary tract infections, HIV and later cancer of the penis.…The complication rate of neonatal circumcision is reported to be around 1% to 5% and includes local infection, bleeding and damage to the penis. Serious complications such as bleeding, septicaemia and meningitis may occasionally cause death. The possibility that routine circumcision may contravene human rights has been raised because circumcision is performed on a minor and is without proven medical benefit. Whether these legal concerns are valid will be known only if the matter is determined in a court of law. If the operation is to be performed, the medical attendant should ensure this is done by a competent operator, using appropriate anaesthesia and in a safe child-friendly environment. In all cases where parents request a circumcision for their child the medical attendant is obliged to provide accurate information on the risks and benefits of the procedure. Up-to-date, unbiased written material summarising the evidence should be widely available to parents. Review of the literature in relation to risks and benefits shows there is no evidence of benefit outweighing harm for circumcision as a routine procedure in the neonate.</small> }} </ref> ==Circumcision procedures== Circumcision removes the [[foreskin]] from the [[penis]]. For infant circumcision, clamps, such as the [[Gomco clamp]], [[Plastibell]], and Mogen are often used.<ref>{{cite journal | last = Holman | first = John R. | coauthors = Evelyn L. Lewis, Robert L. Ringler | year = 1995 | month = August | title = Neonatal circumcision techniques - includes patient information sheet | journal = American Family Physician | volume = 52 | issue = 2 | pages = 511&ndash;520 | id = {{ISSN|0002-838X}} PMID 7625325 | url = http://www.findarticles.com/p/articles/mi_m3225/is_n2_v52/ai_17281985 | accessdate = 2006-06-29 }} </ref> Clamps cut the blood supply to the foreskin, stop any [[hemostasis|bleeding]] and protect the glans. Before using a clamp, the foreskin and the glans are separated with a blunt probe and/or curved hemostat. * With the Plastibell, the foreskin and the clamp come away in three to seven days. * With a Gomco clamp, a section of skin is first crushed with a [[hemostat]] then slit with scissors. The foreskin is drawn over the bell shaped portion of the clamp and inserted through a hole in the base of the clamp. The clamp is then tightened, "crushing the foreskin between the bell and the base plate." The crushing limits bleeding (provides hemostasis). While the flared bottom of the bell fits tightly against the hole of the base plate, the foreskin is then cut away with a scalpel from above the base plate. The bell prevents the glans being reached by the scalpel.<ref>{{cite journal | last = Peleg | first = David | coauthors = Ann Steiner | year = 1998 | month = [[September 15]], | title = The Gomco Circumcision: Common Problems and Solutions | journal = American Family Physician | volume = 58 | issue = 4 | pages = 891&ndash;898 | id = {{ISSN|0002-838X}} PMID 9767725 | url = http://www.aafp.org/afp/980915ap/peleg.html | accessdate = 2006-06-29 }} </ref> * With a Mogen clamp, the foreskin is grabbed dorsally with a straight hemostat, and lifted up. The Mogen clamp is then slid between the glans and hemostat, following the angle of the corona to "avoid removing excess skin ventrally and to obtain a superior cosmetic result," than with Gomco or Plastibell circumcisions. The clamp is locked shut, and a scalpel is used to cut the foreskin from the flat (upper) side of the clamp.<ref name="Pfenninger">{{cite book | last = Pfenninger | first = John L. | coauthors = Grant C. Fowler | title = Procedures for primary care | origyear = 1994 | origmonth = | url = | format = | accessdate = | accessyear = | accessmonth = | edition = 2nd | date = [[July 21]], [[2003]] | year = | month = | publisher = Mosby | location = | language = | id = ISBN 978-0-323-00506-7 {{LCCN|2003|0|56227}} | doi = | pages = | chapter = | chapterurl = | quote = }} </ref><ref name="Reynolds">{{cite journal | last = Reynolds | first = RD | year = 1996 | month = July | title = Use of the Mogen clamp for neonatal circumcision | journal = American Family Physician | volume = 54 | issue = 1 | pages = 177&ndash;182 | doi = | pmid = 8677833 | url = | format = Abstract | accessdate = 2006-07-18 }} </ref> The [[Frenulum of prepuce of penis|frenulum]] is cut if frenular chordee is evident.<ref>{{cite journal |author=Griffin A, Kroovand R |title=Frenular chordee: implications and treatment |journal=Urology |volume=35 |issue=2 |pages=133–4 |year=1990 |pmid=2305537 |doi=10.1016/0090-4295(90)80060-Z}}</ref><ref name = "Shechet">{{cite journal | last = Shechet | first = Jacob | coauthors = Barton Tanenbaum | year = 2000 | title = Circumcision---The Debates Goes On | journal = [[Pediatrics (journal)|Pediatrics]] | volume = 105 | issue = 3 | pages = 682–683 | pmid = 10733391 | doi = 10.1542/peds.105.3.681 | url = http://pediatrics.aappublications.org/cgi/reprint/105/3/681.pdf | format = PDF | accessdate = 2007-04-06 }} </ref> == Possible Complications of Circumcision== '''The complications listed here have been reported in medical journals.''' Williams & Kapila state: "the literature abounds with reports of morbidity and even death as a result of circumcision."<ref name="WillKap">{{cite journal | last = Williams | first = N | coauthors = L. Kapila | year = 1993 | month = October | title = Complications of circumcision [http://www.cirp.org/library/complications/williams-kapila/ (full text)] | journal = British Journal of Surgery | volume = 80 | issue = 10 | pages = 1231&ndash;1236 | doi = 10.1002/bjs.1800801005 | pmid = 8242285 | url = http://www.bjs.co.uk/bjsCda/cda/microJournalArticleDetail.do;jsessionid=96BD3288E9BFA69C74CC1737D0AA6B90?DOI=10.1002%2Fbjs.1800801005&issueDOI=10.1002%2Fbjs.v80%3A10&vid=2 | format = Abstract | accessdate = 2006-07-11 }} </ref> Complications may be immediate or delayed, and complications from bleeding, infection and poorly carried out circumcisions can be catastrophic.<ref>{{cite journal | last = Ahmed A, | first = A | coauthors = Mbibi NH, Dawam D, Kalayi GD | year = 1999 | month = March | title = Complications of traditional male circumcision | journal = Annals of Tropical Paediatrics | volume = 19 | issue = 1 | pages = 113&ndash;117 | doi =10.1080/02724939992743 | pmid = 10605531 {{ISSN|0272-4936}} | url = | format = | accessdate = 2006-07-01 }} </ref> The immediate complications may be classified as surgical mishap, [[hemorrhage]], [[infection]] and [[anesthesia|anesthetic risk]]. The [[American Medical Association]] quotes a complication rate of 0.2%–0.6%,<ref name = "CSA:I-99" /> based on the studies of Gee<ref>{{cite journal | last = Gee | first = W.F. | coauthors = J.S. Ansell | year = 1976 | month = December | title = Neonatal circumcision: a ten-year overview: with comparison of the Gomco clamp and the Plastibell device | journal = Pediatrics | volume = 58 | issue = 6 | pages = 824&ndash;827 | doi = | pmid = 995507 | url = http://pediatrics.aappublications.org/cgi/content/abstract/58/6/824 | format = Abstract | accessdate = 2006-07-11 }} </ref> and Harkavy.<ref>{{cite journal | last = Harkavy | first = K.L. | year = 1987 | month = April | title = The circumcision debate | journal = Pediatrics | volume = 79 | issue = 4 | pages = 649&ndash;650 | doi = | pmid = 3822689 | url = | format = Pubmed Entry | accessdate = 2006-07-11 }} </ref> These same studies are quoted by the [[American Academy of Pediatrics]].<ref name = "AAP1999">{{cite journal | last = American Academy of Pediatrics Task Force on Circumcision | coauthors = | year = 1999 | month = [[March 1]], | title = Circumcision Policy Statement | journal = Pediatrics | volume = 103 | issue = 3 | pages = 686&ndash;693 | doi = 10.1542/peds.103.3.686 | id = {{ISSN|0031-4005}} PMID 10049981 | url = http://pediatrics.aappublications.org/cgi/reprint/pediatrics;103/3/686.pdf | format = PDF | accessdate = 2006-07-01 | pmid = 10049981 }} </ref> The [[American Academy of Family Physicians]] quotes a range of anywhere between 0.1% and 35%.<ref name = "AAFP">{{cite web | url = http://www.aafp.org/online/en/home/clinical/clinicalrecs/circumcision.html | title = Circumcision: Position Paper on Neonatal Circumcision | accessdate = 2007-01-30 | year = 2007 | publisher = [[American Academy of Family Physicians]] }} </ref> The [[Canadian Paediatric Society]] cite these results in addition to other figures ranging anywhere between 0.06% to 55%, and remark that Williams & Kapila<ref name="WillKap">{{cite journal | last = Williams | first = N | coauthors = L. Kapila | year = 1993 | month = October | title = Complications of circumcision [http://www.cirp.org/library/complications/williams-kapila/ (full text)] | journal = British Journal of Surgery | volume = 80 | issue = 10 | pages = 1231&ndash;1236 | doi = 10.1002/bjs.1800801005 | pmid = 8242285 | url = http://www.bjs.co.uk/bjsCda/cda/microJournalArticleDetail.do;jsessionid=96BD3288E9BFA69C74CC1737D0AA6B90?DOI=10.1002%2Fbjs.1800801005&issueDOI=10.1002%2Fbjs.v80%3A10&vid=2 | format = Abstract | accessdate = 2006-07-11 }} </ref> suggested that 2-10% is a realistic estimate. <ref name = "CMAJ">{{cite journal | last = Fetus and Newborn Committee | year = 1996 | month = March | title = Neonatal circumcision revisited | journal = Canadian Medical Association Journal | volume = 154 | issue = 6 | pages = 769&ndash;780 | doi = | id = | url = http://www.cps.ca/english/statements/FN/fn96-01.htm | format = | accessdate = 2006-07-02 }}</ref> The RACP states that the penis is lost in 1 in 1,000,000 circumcisions.<ref name = "RACPComp">{{cite web | url = http://www.racp.edu.au/hpu/paed/circumcision/complications.htm | title = Complications Of Circumcision | accessdate = 2006-07-11 | year = 2004 | month = October | work = Paediatric Policy - Circumcision | publisher = The Royal Australasian College of Physicians }} </ref> Deaths have been reported.<ref name="kaplan"/><ref>{{cite web | url = http://www.pulsus.com/Paeds/12_04/Pdf/zwol_ed.pdf | title = Coroner's Corner Circumcision: A minor procedure? | author = Paediatric Death Review Committee: Office of the Chief Coroner of Ontario | accessdate = 2007-06-17 | year = 2007 | month = April | work = Paediatric Child Health Vol 12 No 4, April 2007 pages 311-312 | publisher = Pulsus Group Inc. }} </ref> The American Academy of Family Physicians states that death is rare. It estimates a death rate from circumcision of 1 infant in 500,000.<ref name = "AAFP" /> Gairdner's 1949 study reported that an average of 16 children per year out of about 90,000 died following circumcision in the [[United Kingdom|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, and Gairdner argued that such deaths were probably due to the circumcision operation.<ref name = "Gairdner">{{cite journal | last = Gairdner | first = Douglas | year = 1949 | month = December | title = The Fate of the Foreskin | journal = British Medical Journal | volume = 2 | issue = 4642 | pages = 1433&ndash;1437 | doi = | pmid = 15408299 | url = http://www.cirp.org/library/general/gairdner/ | format = | accessdate = 2006-07-01 }} </ref> 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. <ref name="aafpadult">{{cite journal | last = Holman | first = John R. | coauthors = Keith A. Stuessi | year = 1999 | month = [[March 15]], | title = Adult Circumcision | journal = American Family Physician | volume = 59 | issue = 6 | pages = 1514&ndash;1518 | doi = | id = {{ISSN|0002-838X}} PMID 10193593 | url = http://www.aafp.org/afp/990315ap/1514.html | accessdate = 2006-06-30 }} </ref> ===Immediate Complications=== According to the AMA, [[Bleeding|blood loss]] and [[infection]] are the most common complications. Bleeding is mostly minor; applying pressure will stop it. <ref name = "CSA:I-99">{{cite web | year = 1999 | month = December | url = http://www.ama-assn.org/ama/pub/category/13585.html | title = Report 10 of the Council on Scientific Affairs (I-99):Neonatal Circumcision | format = | work = 1999 AMA Interim Meeting: Summaries and Recommendations of Council on Scientific Affairs Reports | pages = 17 | publisher = [[American Medical Association]] | accessdate = 2006-06-13 }} </ref> These complications are less likely with a skilled and experienced circumciser. Kaplan identified other complications, including urinary [[fistulas]], [[chordee]], [[cyst]]s, [[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" and "most such complications occur at the hands of inexperienced operators who are neither urologists nor surgeons.”<ref name="kaplan">{{cite journal | last = Kaplan | first = George W., M.D. | coauthors = | year = 1983 | month = August | title = Complications of Circumcision | journal = Urologic Clinics Of North America | volume = 10 | issue = 3 | pages = 543&ndash;549 | id = | url = http://www.cirp.org/library/complications/kaplan/ | format = HTML | accessdate = 2006-09-29 }} </ref> * Infection : Infections are usually minor and local, but sometimes they have led to [[urinary tract infection]]<ref>{{cite journal |last=Goldman |first=Michael |authorlink= |coauthors=J. Barr, T. Bistritzer and M. Aladjem |year=1996 |month=Nov |title=Urinary tract infection following ritual Jewish circumcision |journal=Israel Journal of Medical Sciences |volume=32 |issue=11 |pages=1098–1102 |id= |url=http://www.cirp.org/library/disease/UTI/goldman/ |accessdate= |quote= }}</ref>, life-threatening [[systemic infections]] <ref name=Ngan>{{cite journal |last=Ngan |first=John H., M.D. |authorlink= |coauthors=J Waldhausen M.D., Richard Santucci M.D. |year=1996 |month=Apr |title="I think this child has an infected penis after neonatal circumcision..." |journal=Online Pediatric Urology |volume= |issue= |pages= |id= |url=http://www.infocirc.org/fourn.htm |accessdate= |quote= }}</ref>, [[meningitis]]<ref> {{cite journal |last=Scurlock |first=Jacqueline |authorlink= |coauthors=P.J. Pemberton |year=1977 |month= |title=Neonatal meningitis and circumcision |journal=Medical journal of Australia |volume=1 |issue=10 |pages=332–4 |pmid= 323660 |url=http://www.cirp.org/library/complications/scurlock1/ |accessdate= |quote= }}</ref> or death <ref> {{cite journal |last=Cleary |first=TG |authorlink= |coauthors=S. Kohl |year=1979 |month= |title=Overwhelming infection with group B beta-hemolytic streptococcus associated with circumcision. |journal=Pediatrics |volume=64 |issue=3 |pages=301–3 |pmid= 481971 |url=http://www.cirp.org/library/complications/cleary/ |accessdate= |quote= }}</ref>. :'''Staphylococcal infections''' are a growing problem in hospitals for any operation, <ref> {{cite journal |last=Bamberger |first=David M |coauthors=S.E.Boyd |year=2005|month=Dec|title=Management of Staphylococcus aureus Infections |journal=[http://www.aafp.org/afp American Family Physician]|volume=72 |number=12 |pages=2474–81 |pmid= 16370403 |url=http://www.aafp.org/afp/20051215/2474.html}} </ref> <ref>{{cite web |url=http://www.rsinewsrxreportingfrom.com/content.asp?myid=39&tid=353 |title=Community-Acquired MRSA Continues to Rise Among Newborn |work= News Coverage from American Academy of Pediatrics |date = [[October 12]], [[2005]] }} </ref> and MSSA (methicillin susceptible) <ref>{{cite journal|last=Hoffman |first=KK |coauthors=DJ Weber, R Bost, WA Rutala |year=2000 |month=Feb |title=Neonatal staphylococcus aureus pustulous rash outbreak linked by molecular typing to colonized healthcare workers |journal=Infection control and Hospital Epidemiology |volume=21 |issue=2 |id= |url=http://www.cirp.org/library/complications/hoffman1/ |pages=136}}</ref> strains of ''s.aureus'' have affected neonatal nurseries. Some research has found a statistically significant relationship between golden staph (Staphylococcus aureus) infections and whether an infant has been circumcised<ref> {{cite journal|last=Nguyen|first=Dao M.|coauthors=E. Bancroft, L Mascola R. Guevara and L. Yasuda | title=Risk Factors for Neonatal Methicillin-Resistant Staphylococcus aureus Infection in a Well-Infant Nursery|url=http://www.journals.uchicago.edu/ucp/WebIntegrationServlet?call=ContentWeblet&url=http://www.journals.uchicago.edu/ICHE/journal/issues/v28n4/2006109/2006109.web.pdf?erFrom=2272035787602246278Guest&current_page=content |journal=| Infection Control and Hospital Epidemiology|volume=28 |year=2007|pages=406–411 | doi=10.1086/513122 | format={{dead link|date=June 2008}} &ndash; <sup>[http://scholar.google.co.uk/scholar?hl=en&lr=&q=author%3ANguyen+intitle%3ARisk+Factors+for+Neonatal+Methicillin-Resistant+Staphylococcus+aureus+Infection+in+a+Well-Infant+Nursery&as_publication=%7C+Infection+Control+and+Hospital+Epidemiology&as_ylo=2007&as_yhi=2007&btnG=Search Scholar search]</sup>}} </ref><ref> (''Pediatr Res'' 1989; 25: 193A). </ref> Boys have been found to be far more susceptible to golden staph infections than girls and methicillin susceptible strains (MSSA) have infected circumcision wounds. Enzenauer stated: "Circumcision, which is performed on approximately 90 per cent of male infants born in our hospital, may be a factor. Circumcision, by its very nature. requires more staff-patient "hands-on" contact, both during the procedure and during preoperative and postoperative care." <ref> {{cite journal |last=Enzenauer |first=RW|coauthors=CR Dotson T Leonard Jr, J Brown 3rd, PG Pettett, ME Holton|title=Increased incidence of neonatal staphylococcal pyoderma in males|journal=Military Medicine|year=1984 |volume=149 |month=Jul |issue=7 |url=http://www.cirp.org/library/complications/enzenauer2/ |pmid= 6431327 |pages=408–10}} </ref> ::Images of an infant with a life threatening ''s.aureus'' infection may be found here<ref name="Ngan"/> ====Herpes==== :'''Herpes'''. A minority of Jewish circumcisers practise ''Metzizah b'peh'', (oral suction). It has been linked with 8 cases of herpes infection in Israeli infants, one of whom suffered brain damage <ref> {{cite journal |last=Gesundheit |first=B |coauthors= G Grisaru-Soen ''et al.'' |title=Neonatal genital herpes simplex virus type 1 infection after Jewish ritual circumcision: modern medicine and religious tradition. |journal=Pediatrics |year=2004 |month=Aug |issue=114(2) |pages=e259–63 |url=http://pediatrics.aappublications.org/cgi/content/full/114/2/e259 |doi=10.1542/peds.114.2.e259 |volume=114 |pmid=15286266 }} </ref> <ref name=Warner>{{cite web |title=Traditional Jewish practice may put babies at risk for genital herpes infection |url=http://my.webmd.com/content/article/91/101352.htm |last=Warner |first=Jennifer |publisher=Genital Herpes Health Center |work=Genital Herpes Guide |year=2004 |month=Aug}} </ref>. In New York, three cases of herpes were linked with oral [[metzizah]]. One baby died and one suffered brain damage <ref> {{cite web |title=City Urges Halt To Ritual Practice |last=Cohen |first=Debra N |url=http://www.thejewishweek.com/news/newscontent.php3?artid=11807 |work=Jewish Week |year=2005 |month=Dec}} </ref>. In response to this, New York public health officials warned the Jewish community about the dangers of ''metzizah b'peh'' <ref name="NYCbefore"> {{cite web |url=http://www.nyc.gov/html/doh/html/std/std-bris.shtml |title=Before the bris: How to protect your infant against herpes infection caused by metzitzah b’peh |accessdate=2007-09-03 |author=The New York City Department of Health and Mental Hygiene}}</ref> :The Israeli researchers said: ::"We support ritual circumcision but without oral metzitzah, which might endanger the newborns and is not part of the religious procedure," write researcher Benjamin Gesundheit, MD, of Ben Gurion University in Israel, and colleagues <ref name=Warner/> :The New York City Department of Health and Mental Hygiene said: ::'''Because there is no proven way to reduce the risk of herpes infection posed by metzitzah b'peh, the Health Department recommends that infants being circumcised not undergo metzitzah b'peh.''' <ref name="NYCbefore"/> (emphasis in the original) :However, in In May of 2006, the Department of Health for [[New York State]], issued a protocol for the performance of metzitzah b'peh.<ref>{{cite web | url = http://www.health.state.ny.us/diseases/communicable/herpes/newborns/circumcision_protocol.htm | title = Circumcision Protocol Regarding the Prevention of Neonatal Herpes Transmission | accessdate = 2006-11-23 | year = 2006 | month = November (revised) | publisher = Department of Health, New York State }} </ref> Dr. Antonia C. Novello, Commissioner of Health for New York State, together with a board of rabbis and doctors, worked to allow the practice of metzizah b'peh to continue while still meeting the Department of Health's responsibility to protect the public health.<ref>{{cite web | url = http://www.health.state.ny.us/diseases/communicable/herpes/newborns/2006-05-08_letter_to_rabbis.htm | title = Dear Rabbi Letter | accessdate = 2006-11-23 | last = Novello | first = Antonia C. | date = [[May 8]], [[2006]] | publisher = Department of Health, New York State | quote = The meetings have been extremely helpful to me in understanding the importance of metzizah b'peh to the continuity of Jewish ritual practice, how the procedure is performed, and how we might allow the practice of metzizah b'peh to continue while still meeting the Department of Health's responsibility to protect the public health. I want to reiterate that the welfare of the children of your community is our common goal and that it is not our intent to prohibit metzizah b'peh after circumcision, rather our intent is to suggest measures that would reduce the risk of harm, if there is any, for future circumcisions where metzizah b'peh is the customary procedure and the possibility of an infected mohel may not be ruled out. I know that successful solutions can and will be based on our mutual trust and cooperation. }} </ref> :Dr. Novello said: ::“I want to reiterate that the welfare of the children of your community is our common goal and that it is not our intent to prohibit metzizah b'peh after circumcision, rather our intent is to suggest measures that would reduce the risk of harm, if there is any, for future circumcisions where metzizah b'peh is the customary procedure and the possibility of an infected mohel may not be ruled out. I know that successful solutions can and will be based on our mutual trust and cooperation.” * Hemorrhage : Bleeding after circumcision is usually minor and easily controlled, but on rare occasions it has led to shock from blood loss ([[hypovolemic shock]]) or death ([[exsanguination]])<ref>{{cite journal |last=Hiss |first=J. |authorlink= |coauthors=A. Horowitz, T. Kahana |year=2000 |month= |title=Fatal haemorrhage following male ritual circumcision |journal=J Clin Forensic Med |volume=7 |issue= |pages=32–34 |id= |url=http://www.cirp.org/library/death/hiss1/ |accessdate= 2008-03-12 |quote=|doi=10.1054/jcfm.1999.0340 }}</ref>. Coagulation disorders affect from 2 to 4 per cent of the population and the condition is underdiagnosed/<ref>{{cite journal |last= |first= |authorlink= |coauthors= |year=2005 |month=Summer |title=Coagulation disorders often not detected |journal=Pediatric update ([www.mattel.ucla.edu Mattel Children's hospital at UCLA]) |volume=12 |issue=2 |pages= |id= |url=http://www2.healthcare.ucla.edu/pedsupdate/Peds-Update-Summer05.pdf |accessdate= 2008-03-12 |quote= }}</ref> Severe bleeding following circumcision may be a sign of hemophilia [http://www.emedicine.com/med/topic3528.htm]. * Surgical mishap : Mistakes can happen with any surgery. Surgical mistakes from circumcision include documented cases of penile denudation[http://www.cirp.org/library/complications/sotolongo1/], cutting off part or all of the [[glans penis]][http://www.cirp.org/library/complications/sherman1/], [[fistula|urethral fistula]][http://www.cirp.org/library/complications/baskin/], several types of injury associated with certain types of circumcision clamps used [http://www.fda.gov/cdrh/safety/circumcision.html] and penile [[necrosis]] which results in loss of the entire penis. * Anesthetic risk : Anesthetic risk includes [[methaemglobinaemia]][http://www.cirp.org/library/complications/arda1/][http://www.cirp.org/library/complications/couper1/]. ===Delayed Complications=== *[[Meatal stenosis]][http://www.emedicine.com/PED/topic2356.htm] may be a common longer-term complication from circumcision. Recent publications give a frequency of occurrence between 0.9%<ref>{{cite journal | last = Yegane | first = Rooh-Allah | coauthors = Abdol-Reza Kheirollahi, Nour-Allah Salehi, Mohammad Bashashati, Jamal-Aldin Khoshdel, and Mina Ahmadi | year = 2006 | month = May | title = Late complications of circumcision in Iran | journal = Pediatric Surgery International | volume = 22 | issue = 5 | pages = 442&ndash;445 | doi = 10.1007/s00383-006-1672-1 | pmid = 16649052 | url = http://www.springerlink.com/(qzpwjv55lf23wj454qsmor45)/app/home/contribution.asp?referrer=parent&backto=issue,9,19;journal,4,147;linkingpublicationresults,1:101176,1 | format = Abstract | accessdate = 2006-07-02 }} </ref> and 9% to 10%.<ref>{{cite web | url = http://www.emedicine.com/PED/topic2356.htm | title = http://www.emedicine.com/PED/topic2356.htm | accessdate = 2006-07-02 | last = Angel | first = Carlos A. | date = [[June 12]], [[2006]] | work = eMedicine | publisher = WebMD }} </ref> * [[Urinary retention]] [http://bmj.bmjjournals.com/cgi/content/extract/309/6955/660]; * [[Venous stasis]], the slowing down of venous blood flow [http://www.cmaj.ca/cgi/content/full/169/3/216] [http://www.pulsus.com/Paeds/12_04/Pdf/zwol_ed.pdf] * Concealed penis [http://www.cirp.org/library/complications/trier1/][http://www.ncbi.nlm.nih.gov/pubmed/11223758]; * Adhesions [http://www.cirp.org/library/complications/gracely1/]; * Skin bridges [http://www.cirp.org/library/complications/naimer2/], when the cut skin attaches to the [[glans penis]]. Skin bridges do not commonly require surgical correction; rather, a brief, simple office procedure may be performed.<ref>{{cite journal | last = Naimer | first = Sody A. | coauthors = Roni Peleg, Yevgeni Meidvidovski, Alex Zvulunov, Arnon Dov Cohen, and Daniel Vardy | year = 2002 | month = November | title = Office Management of Penile Skin Bridges with Electrocautery | journal = Journal of the American Board of Family Practice | volume = 15 | issue = 6 | pages = 485&ndash;488 | pmid = 10605531 | url = http://www.jabfm.org/cgi/reprint/15/6/485 | format = PDF | accessdate = 2006-07-01 }} </ref> * Painful erections. [http://www.cirp.org/news/perth1/] * [[Meatitis]] The opening to the urethra ([[urinary meatus|meatus]]) may also be affected, leading to inflammation [http://www.cirp.org/library/complications/brennemann1/], [[ulcer|meatal ulceration]][http://www.cirp.org/library/complications/freud1/], and narrowing of the urethra ([[stenosis|meatal stenosis]][http://www.cirp.org/library/complications/kunz1/][http://www.cirp.org/library/complications/persad/]. Some also argue that anger over being circumcised as a child is also a complication of circumcision.[http://www.cirp.org/news/penthouse11-01-01/] === Pain, stress, trauma, and interference with breastfeeding initiation === The [[American Academy of Pediatrics]]' policy states: :Some common painful minor procedures, such as circumcision, do not always receive the warranted attention to comfort issues. Available research indicates that newborn circumcisions are a significant source of [[pain]] during the procedure and are associated with irritability and feeding disturbances during the days afterward. Opportunities for alleviating pain exist before, during, and after the procedure, and many interventions are effective.[http://aappolicy.aappublications.org/cgi/content/full/pediatrics%3b108/3/793] :<small>-- ''The Assessment and Management of [[Acute pain|Acute Pain]] in Infants, Children and Adolescents'', 2001.</small> Many studies have examined adverse effects of the procedure; some employing various forms of [[analgesic|pain relief]]. A few of these findings are summarised in the following table. <table border=0 cellspacing=2 cellpadding=2> <tr><th>Study<sup>1</sup></th><th>Effects noted</th> <!-- Unstated --> <td colspan=2 bgcolor=#e0e0e0>'''Unstated'''</td></tr> <tr><td>Marshall (1982) [http://www.cirp.org/library/birth/marshall2/]</td><td>Brief and transitory effects on mother-infant interactions observed during hospital feeding sessions.</td><td></td></tr> <!-- No pain relief --> <td colspan=2 bgcolor=#e0e0e0>'''No pain relief'''</td></tr> <tr><td>Howard (1994) [http://www.cirp.org/library/pain/howard/]</td><td>Significant increases in [[heart rate]], [[respiratory rate]], and crying. Deteriorated feeding behaviour.</td><td></td></tr> <tr><td>Taddio (1997) [http://www.cirp.org/library/pain/taddio2/]</td><td>Stronger pain response during vaccination 4 to 6 months later.</td><td></td></tr> <tr><td>Lander (1997) [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9417009&query_hl=1] [http://www.cirp.org/library/pain/lander/] </td><td>Sustained elevation of heart rate and high-pitched cry. Choking and apnea in 2 of 11 infants circumcised without pain relief.</td><td></td></tr> <!-- Acetaminophen (Tylenol/Paracetamol) --> <td colspan=3 bgcolor=#e0e0e0>'''Acetaminophen (Tylenol/Paracetamol)'''</td></tr> <tr><td>Howard (1994) [http://www.cirp.org/library/pain/howard/]</td><td>Significant increases in heart rate, respiratory rate, and crying. Deteriorated feeding behaviour. Improved comfort after postoperative period.</td><td></td></tr> <tr><td>Taddio (1997) [http://www.cirp.org/library/pain/taddio2/]</td><td>Stronger pain response during vaccination 4 to 6 months later, though attenuated as compared to [[placebo]].</td><td></td></tr> <!-- EMLA --> <td colspan=2 bgcolor=#e0e0e0>'''EMLA (topical anaesthetic)'''</td></tr> <tr><td>Lander (1997) [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9417009&query_hl=1]</td><td>Significantly less crying and lower heart rates compared with those circumcised without anaesthetic (see above).</td><td></td></tr> <!-- DPNB --> <td colspan=2 bgcolor=#e0e0e0>'''Dorsal penile nerve block (DPNB)'''</td></tr> <tr><td>Kirya (1978) [http://www.cirp.org/library/pain/kirya1/] </td><td>Circumcision pain eliminated except when the injection needle was misplaced.</td><td></td></tr> <tr><td>Lander (1997) [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9417009&query_hl=1]</td><td>Significantly less crying and lower heart rates than circumcision without anaesthetic. Not effective during foreskin separation and incision.</td><td></td></tr> <!-- Ring block --> <td colspan=2 bgcolor=#e0e0e0>'''Ring block'''</td></tr> <tr><td>Lander (1997) [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9417009&query_hl=1]</td><td>Significantly less crying and lower heart rates than circumcision without anaesthetic. Equally effective through all stages of the circumcision</td><td></td></tr> </table> ''<sup>1</sup> Studies investigating several forms of pain relief have one entry for each form.'' Howard ''et al'' report that neonatal circumcision without [[anaesthesia]] and using [[acetaminophen]] (Tylenol) results in deteriorated breast-feeding immediately after circumcision.[http://www.cirp.org/library/pain/howard/] They commented: :Numerous studies have shown that circumcision causes severe pain. This is shown by measures of crying, heart rate, respiratory rate, transcutaneous PO<sub>2</sub>, and cortisol levels ...[]... Neonatal circumcision are often performed on the day of discharge with many neonates leaving the hospital 3 to 6 hours postoperatively. Thus the observed deterioration in ability to [[breast feeding|breast-feed]] may potentially contribute to breast-feeding failure. Furthermore some neonates in this study required formula supplementation because of maternal frustration with attempts at breast-feeding, or because the neonate was judged unable to breast-feed postoperatively. This finding is disconcerting because early formula supplementation is associated with decreased breast-feeding duration. Howard ''et al.'' concluded that: :Acetaminophen was not found to ameliorate either the intra-operative or the immediate postoperative pain of circumcision, although it seems that it may provide some benefit after the postoperative period.[http://www.cirp.org/library/pain/howard/] Many other studies have investigated the pain caused by circumcision, and the effectiveness of different forms of analgesia and anaesthesia. Taddio ''et al'' reported behavioural changes (heightened pain responses) during vaccinations in children circumcised with EMLA cream and with no anaethesia at the 99.9+% statistical confidence level (p<0.001) four to six months after their circumcision, suggesting a persistent effect on pain response. [http://www.cirp.org/library/pain/taddio2/] The researchers commented: : "Study of the vaccination pain response of infants who had received more effective circumcision pain management (i.e., dorsal penile nerve block and adequate postoperative pain management) would be interesting." Kirya and Werthmann investigated the effect of [[dorsal penile nerve]] block (DPNB), describing it as "painless".[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=660375&query_hl=1] However, Lander ''et al'' found that DPNB is less effective than ring block.[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9417009&query_hl=1] Marshall ''et al'' report that the stress of [[neonatal circumcision]] may alter feeding behaviour and some male infants may be unable to breastfeed after circumcision.[http://www.cirp.org/library/birth/marshall2/] They commented: :Despite differences between control and experimental infants shortly after surgery, by 24 h post-operatively no significant differences were observed between the groups. The behavioral effects of circumcision in the present study were immediate but brief. This should be comforting information to those who provide care for newborns and for their parents.[http://www.cirp.org/library/birth/marshall2/] Marshall ''et al'' did not report whether anaesthesia was used. Fergusson ''et al.'' found no evidence in their study of an association between neonatal circumcision and breastfeeding. They concluded that "the findings do not support the view that neonatal circumcision disrupts breastfeeding."<ref>{{cite journal |title=Neonatal circumcision: Effects on breastfeeding and outcomes associated with breastfeeding |journal=Journal of Paediatrics and Child Health |author=Fergusson DM |coauthor=Boden, JM; Horwood, J |volume=[OnlineEarly] |doi= 10.1111/j.1440-1754.2007.01202.x |year=2007 |pages=070907133943009}}</ref> ===Emotional consequences=== Moses ''et al.'' (1998) state that "scientific evidence is lacking" for psychological and emotional harm, and cite a longitudinal study finding no difference in developmental and behavioural indices.<ref>{{cite journal |author=Moses, S |coauthors=Bailey, RC; Ronald AR |title=Male circumcision: assessment of health benefits and risks |journal=Sex Transm Infect |year=1998 |volume=74 |pages=368–73}}</ref> Goldman (1999) discussed the possible trauma of circumcision on children and parents, anxieties over the circumcised state, a tendency to repeat the trauma, and suggested a need on the part of circumcised doctors to find medical justifications for the procedure.<ref>{{cite journal | last = Goldman | first = R. | year = 1999 | month = January | title = The psychological impact of circumcision | journal = BJU International | volume = 83 | issue = S1 | pages = 93&ndash;102 | doi = 10.1046/j.1464-410x.1999.0830s1093.x | id = | url = http://www.blackwell-synergy.com/doi/pdf/10.1046/j.1464-410x.1999.0830s1093.x | format = PDF | accessdate = 2006-07-02 }} </ref> Some organizations have formed support groups for men who are resentful about being circumcised.<ref name = "Milos">{{cite journal | last = Milos | first = Marilyn Fayre | coauthors = Donna Macris | year = 1992 | month = March-April | title = Circumcision: A medical or a human rights issue? | journal = Journal of Nurse-Midwifery | volume = 37 | issue = 2 S1 | pages = S87–S96 | pmid = 1573462 | doi = 10.1016/0091-2182(92)90012-R | url = http://www.cirp.org/library/ethics/milos-macris/ | accessdate = 2007-04-06 }} </ref> ==Further Medical Analysis== === Prostate cancer === [[Prostate cancer]] rates vary greatly. They are lowest in South and East Asia, higher in Europe - though the rates vary widely between countries - and highest in the United States [http://www.jncicancerspectrum.oxfordjournals.org/cgi/statContent/cspectfstat%3b99]. In the USA, prostate cancer is the second most common male cancer, with a lifetime risk of 1 in 6 and rising.[http://www.hsc.stonybrook.edu/som/urology/urology_cp_prostatecancer.cfm]. According to the American Cancer Society, [[prostate cancer]] is least common in Asian men, more common in European men and most common in Black men [http://www.cancer.org/docroot/CRI/content/CRI_2_2_2X_What_causes_prostate_cancer_36.asp?sitearea=] [http://www.hsc.stonybrook.edu/som/urology/urology_cp_prostatecancer.cfm]. However, these high rates may reflect increased detection rates [http://jama.ama-assn.org/cgi/content/abstract/273/7/548]. Neither the American Cancer Society nor the professional medical organizations' policy statements on circumcision cited here mention a relationship between circumcision and prostate cancer. Early [[ecological study|ecological studies]] suggested that circumcision may have a protective effect against [[prostate cancer]]. Ravich and Ravich [N Y State J Med. 1951 Jun 15;51(12):1519-20.] reported that in patients operated on for prostatic obstruction, 1.8% of obstructions in Jews were cancerous, compared with 19% in non-Jews. [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14853120] Ecological studies are considered unreliable but later [[case-control study|case-control studies]] obtained results as follows: Ross ''et al.'' [J of the National Cancer Institute. 1987 May;78(5):869-74] reported on two case-control studies in Southern California. Both studies included 142 cases and both found that circumcised men were at reduced risk (relative risk of 0.5 in whites and 0.6 in blacks).[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=3471995] Mandel & Schuman [J Gerontology. 1987 May;42(3):259-64].reported on a case-control study with 250 cases. Compared with controls drawn from their neighborhood, circumcised men were less likely to develop prostate cancer (odds ratio 0.82). [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=3553301] Ewings & Bowie [Br J Cancer. 1996 Aug;74(4):661-6] performed a case-control study of 159 cases of prostate cancer, and found that circumcised men were at a reduced risk (odds ratio 0.62) [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8761387]. They noted: ''"...some statistically significant associations were found, although these can only be viewed as hypothesis generating in this context."'' ===Human Papilloma Virus (HPV)=== Several studies have shown that uncircumcised men are at greater risk of [[human papilloma virus]] (HPV) infection, including a study of healthy Mexican military men <ref>{{cite journal | last = Lajous | first = Martín | coauthors = Nancy Mueller, Aurelio Cruz-Valdéz, Luis Victor Aguilar, Silvia Franceschi, Mauricio Hernández-Ávila, and Eduardo Lazcano-Ponce | year = July | month = 2005 | title = Determinants of Prevalence, Acquisition, and Persistence of Human Papillomavirus in Healthy Mexican Military Men | journal = Cancer Epidemiology Biomarkers and Prevention | volume = 14 | issue = 7 | pages = 1710&ndash;1716 | doi = 10.1158/1055-9965.EPI-04-0926 | pmid = 16030106 | url = http://cebp.aacrjournals.org/cgi/reprint/14/7/1710.pdf | format = PDF | accessdate = 2006-07-09 }} </ref> and Castellsagué ''et al'' (2002), who found that male circumcision correlated with a reduced risk of penile human papillomavirus (HPV) infection in the man and of [[cervical cancer]] in his female partner if the man had had more than six sexual partners. <ref name="Castellsague2002">{{cite journal | last = Castellsagué | first = Xavier | coauthors = et al. | year = 2002 | month = [[April 11]], | title = Male circumcision, penile human papillomavirus infection, and cervical cancer | journal = The New England Journal of Medicine | volume = 346 | issue = 15 | pages = 1105&ndash;1112 | doi = 10.1056/NEJMoa011688 | pmid = 11948269 | url = http://content.nejm.org/cgi/reprint/346/15/1105.pdf | format = PDF &mdash; free registration required | accessdate = 2006-07-09 }} </ref> That study was criticized on methodological grounds.[http://www.cirp.org/library/disease/cancer/letters10-31-02/] [http://www.cirp.org/library/disease/cancer/vanhowe2006b/] but Baldwin ''et al'' (2004) [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15388997] also found less HPV infection in circumcised men in their sample. Some genital [[HPV]] strains some can cause genital warts, cervical or penile [[cancer]] [http://www.sciencedaily.com/releases/2004/11/041123162300.htm]. One study found no statistically significant difference in HPV infection between circumcised and uncircumcised men, but did note a significantly higher incidence of urethritis in the uncircumcised.<ref>{{cite journal | last = Aynaud | first = O. | coauthors = D. Piron, G. Bijaoui, and JM Casanova | year = July | month = 1999 | title = Developmental factors of urethral human papillomavirus lesions: correlation with circumcision | journal = BJU International | volume = 84 | issue = 1 | pages = 57&ndash;60 | doi = 10.1046/j.1464-410x.1999.00104.x | pmid = 10444125 | url = http://www.blackwell-synergy.com/doi/pdf/10.1046/j.1464-410x.1999.00104.x | format = PDF | accessdate = 2006-07-09 }} </ref> === HPV and cervical cancer === Is [[smegma]] [[carcinogen]]ic? Pratt-Thomas ''et al.'' in 1956, found that horse smegma had a carcinogenic effect on laboratory mice {{Fact|date=March 2007}} and Heins ''et al,'' 1958 found that human smegma also had a carcinogenic effect on mice. [http://www.circs.org/library/heins/index.html] However, Reddy and Baruah (1963) were unable to reproduce this effect, and they concluded that the carcinogenic effect <!-- on mice, on women or both?--> must be weak. Wynder (1964) was uncertain about the connection between male circumcision, smegma and cervical cancer [http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1816029]. In 2006 Van Howe and Hodges described and discussed human smegma, asserting that the claims of harm in it were a myth that "has evolved over time and with retelling."[http://www.cirp.org/library/disease/cancer/vanhowe2006/] Some medical researchers have found evidence of a link between a higher incidence of [[cervical cancer]] in female partners of uncircumcised men and a higher incidence of penile human papillomavirus (HPV) in uncircumcised men. [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15388997] [http://sti.bmjjournals.com/cgi/content/full/78/3/215] <ref name="Castellsague2002"/> Stern and Neely (1962) observed no protective effect of male circumcision in female partners. [http://www.cirp.org/library/disease/cancer/stern1/], Punyaratabandhu ''et al.'' (1982) reported a protective effect in Thai women [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=7119622], Kjaer ''et al.'' (1991) reported an apparently protective effect in Dutch women, that failed to achieve statistical significance.[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=2019457] and Agarwal ''et al.'' (1993) observed a significantly protective effect among Indian women.[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8348498]. The role of male circumcision in female infection with HPV remains controversial. As Castellsagué (2002) said, "...it would not make sense to promote circumcision as a way to control cervical cancer in the United States, where [[Pap smear]]s usually detect it at a treatable stage." An HPV vaccine that is effective against the two strains of HPV that are responsible for 70% of the cases of cervical cancer is now being distributed [http://www.health.gov.au/internet/wcms/publishing.nsf/Content/gardasil_hpv.htm]. In 2000, cervical cancer deaths in [[Great Britain]] were 3.9 per 100,000 patient-years, 3.3 in the USA, 2.8 in Canada, and 2.4 in Australia. [http://www.wrongdiagnosis.com/c/cervical_cancer/deaths.htm] In Great Britain, cancer deaths in women under 35 had tripled between 1967 and 1987. Gilham ''et al'' found that national cervical screening prevented many deaths from cervical cancer by reversing that trend. In their estimation, one in 65 of all British women born since 1950 would have died from cancer of the cervix without the screenings [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15262102]. === Penile cancer === {{main|Penile cancer}} [[Penile cancer]] is a rare form of [[cancer]]. Annually, there is one case in 100 000 men in [[developed nation|developed countries]]. [http://jncicancerspectrum.oxfordjournals.org/cgi/statContent/cspectfstat%3b101] [http://www.cancer.org/docroot/CRI/content/CRI_2_4_1X_What_are_the_key_statistics_for_penile_cancer_35.asp?sitearea=] The overall five-year survival rate for all stages of penile cancer is about 50 per cent. One 1980 study estimated that the lifetime risk of an uncircumcised man developing invasive penile cancer (IPC) is one in 600 [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=7377156&dopt=Abstract]. This was more than 3 times higher than for males neonatally circumcised. [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11144896&dopt=Abstract] [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8380060&dopt=Abstract] [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8260177&dopt=Abstract] Most cases of penile cancer occur in men over the age of 70. Childhood circumcision has been associated with a reduced incidence of penile cancer in numerous studies. [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11196386&dopt=Abstract] [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11144896&dopt=Abstract] [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=7377156&dopt=Abstract] [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11405332&dopt=Abstract] [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10643514&dopt=Abstract] [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10699138&dopt=Abstract] <ref>{{cite web | url = http://www.cancerhelp.org.uk/help/default.asp?page=6833 | title = Cancer of the penis (penile cancer) | accessdate = 2006-09-26 | date = [[January 14]], [[2004]] | work = Questions and Answers: Penis cancer questions | publisher = [[Cancer Research UK]] | quote = Penile cancer is more common in older men. Most cases are in men over 70. It is rare in men under 40. }} </ref> Boczko and Freed (1979) stated 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."<ref>{{cite journal |last=Boczko |first=S |coauthors=Freed, S |title=Penile carcinoma in circumcised males |journal=N Y State J Med |year=1979 |volume=79 |issue=12 |pages=1903–4}} [http://www.cirp.org/library/disease/cancer/boczko/]</ref> The AMA remarked that in six case series published from 1932 and 1986, "all penile cancers occurred in uncircumcised individuals."<ref name = "CSA:I-99" /> Maden ''et al'' (1993) reported 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.<ref>{{cite journal |title=History of circumcision, medical conditions, and sexual activity and risk of penile cancer |first=C |last=Maden |coauthors=''et al'' |journal=J Natl Cancer Inst |year=1993 |month=Jan |volume=85 |issue=1 |pages=19–24 |pmid=8380060 |doi=10.1093/jnci/85.1.19}}</ref> An editorial by Holly and Palefsky complimented the study for noting other risk factors for penile cancer, and also for providing corroborating evidence as to the association between a lack of neonatal circumcision and the development of penile cancer. However, they criticised include the study for combining data from invasive and ''in situ'' cancers. They concluded that as Maden reported that 20% of the men with penile cancer were circumcised at birth, the recommendation of circumcision for medical indications remained somewhat controversial and the risks and benefits must be weighed.<ref>{{cite journal |doi= 10.1093/jnci/85.1.2 |last=Holly |first=EA |coauthors=Palefsky, JM |title=Factors related to risk of penile cancer: new evidence from a study in the Pacific Northwest |journal=J Natl Cancer Inst |year=1993 |month=Jan |volume=85 |issue=1 |pages=2–4}}</ref> The American Academy of Pediatrics made similar criticism, also noting the possibly inaccurate use of self-report to determine circumcision status.<ref name = "AAP1999" /> 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.<ref>{{cite journal |url=http://pediatrics.aappublications.org/cgi/content/full/105/3/e36 |title=The highly protective effect of newborn circumcision against invasive penile cancer |first=EJ |last=Schoen |coauthors=Oehrli, M; Colby, C; Machin, G | journal=Pediatrics |year=2000 |month=Mar |volume=105 |issue=3 |pages=e36 |doi=10.1542/peds.105.3.e36 |pmid=10699138}}</ref> The [[American Cancer Society]] states that “In the United States, men who are circumcised in childhood have a lower rate of penile cancer. It’s not known whether this is due to the absence of the foreskin or other lifestyle factors. Recent studies have found that circumcised men are less likely to be infected with HPV, even after this risk is adjusted for differences in sexual behavior. Circumcision has been associated with a lower incidence of [[Human Papilloma Virus]] infection in males in several studies. HPV infection is a known risk factor in the development of penile cancer.[http://content.nejm.org/cgi/pmidlookup?view=short&pmid=11948269] [http://content.nejm.org/cgi/content/extract/347/18/1452] [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15388997] [http://sti.bmjjournals.com/cgi/content/full/78/3/215] Other studies suggest that circumcision may reduce the risk of more invasive forms of penile cancer.”, “In weighing the risks and benefits of circumcision, doctors consider the fact that penile cancer is one of the least common forms of cancer in the United States” and “Ultimately, decisions about circumcision are highly personal and depend more on social and religious factors than on medical evidence”. They state that it is important to concentrate on the main risk factors: poor hygiene, having unprotected sex with multiple partners, and cigarette smoking.<ref name="CancerRisk">{{cite web | url = http://www.cancer.org/docroot/CRI/content/CRI_2_4_2X_What_are_the_risk_factors_for_penile_cancer_35.asp?sitearea= | title = What Are the Risk Factors for Penile Cancer? | accessdate = 2006-10-01 | date = [[May 31]], [[2006]] | work = Cancer Reference Information | publisher = [[American Cancer Society]] }} </ref> They also state that the current consensus of most experts is that circumcision should not be recommended as a prevention strategy for penile cancer.<ref>{{cite web | url = http://www.cancer.org/docroot/CRI/content/CRI_2_4_2X_Can_penile_cancer_be_prevented_35.asp | title = Can Penile Cancer Be Prevented? | accessdate = 2006-10-01 | date = [[May 31]], [[2006]] | work = Cancer Reference Information | publisher = [[American Cancer Society]] }} </ref> The [[American Academy of Pediatrics]] (1999) stated 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.<ref name = "AAP1999" /> 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.<ref name = "CSA:I-99" /> Kochen and McCurdy performed a [[life table]] analysis on penile cancer rates. They assumed that penile cancer occurred only in uncircumcised males and that the rates from older groups applied to the 1971 birth cohort.<ref name="Kochen">{{cite journal | last = Kochen | first = Mosze | coauthors = Stephen McCurdy | year = 1980 | month = May | title = Circumcision and the risk of cancer of the penis. A life-table analysis | journal = American Journal of Diseases of Children | volume = 134 | issue = 5 | pages = 484–486 | doi = 10.1001/archpedi.134.5.484 | pmid = 7377156 | url = http://www.circs.org/library/kochen/index.html | accessdate = 2006-09-26 | doi_brokendate = 2008-06-28 }} </ref> They estimated a rate of 1 in 600, or 0.167% in uncircumcised males, with a median age of occurrence of 67 years. They stated, “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.”<ref name = "Kochen" /> The Medical College of Georgia is now studying the impact of the new vaccine against "HPV types 16 and 18, the two most common causes of cervical and penile cancer" [http://www.sciencedaily.com/releases/2004/11/041123162300.htm] ====Positions of medical organisations==== The [[American Medical Association]] and the [[Royal Australasian College of Physicians]] both stated that the use of infant circumcision to prevent [[penile cancer]] alone in adulthood is not justified. [http://www.ama-assn.org/ama/pub/category/13585.html] [http://www.racp.edu.au/hpu/paed/circumcision/print.htm] The [[American Cancer Society]] stated:: :In the past, circumcision has been suggested as a way to prevent penile cancer. This suggestion was based on studies that reported much lower penile cancer rates among circumcised men than among uncircumcised men. However, most researchers now believe those studies were flawed because they failed to consider other factors that are now known to affect penile cancer risk [http://www.cancer.org/docroot/CRI/content/CRI_2_4_2X_Can_penile_cancer_be_prevented_35.asp]. : <small>(last revised [[10 March]] [[2006]])</small> Elsewhere, the ACS stated: :Whether circumcision actually reduces risk is uncertain. :One line of reasoning is based on comparisons of risk across countries. Some studies fail to take into account other known risk factors such as the number of sexual partners, smoking, or personal hygiene which would be considered [[confounding factor | confounding factors]]. Furthermore, the risk of penile cancer is lower in Denmark, where only 2% of men are circumcised than in the USA. [http://www.cancer.org/docroot/CRI/content/CRI_2_4_2X_What_are_the_risk_factors_for_penile_cancer_35.asp?rnav=cri]. And: :Recent studies have found that circumcised men are less likely to be infected with HPV, even after this risk is adjusted for differences in sexual behavior. Other studies suggest that circumcision may reduce the risk of more invasive forms of penile cancer. However, it is important that the issue of circumcision not distract the public's attention from avoiding known penile cancer risk factors – poor hygiene, having unprotected sex with multiple partners (increasing the likelihood of human papillomavirus infection), and cigarette smoking. [http://www.cancer.org/docroot/CRI/content/CRI_2_4_2X_What_are_the_risk_factors_for_penile_cancer_35.asp?rnav=cri] : <small>(last revised [[10 March]] [[2006]])</small> ===Phimosis=== [[Phimosis]] is the inability to retract the prepuce over the glans penis after separation from the glans has occurred. The foreskin is joined to the glans, and is naturally unretractable when a baby is born. But there are differences of opinion about how long this should continue, and how the foreskin should be treated if it remains too tight for too long. Gairdner[http://www.cirp.org/library/general/gairdner/] published data regarding the age of first foreskin retraction in 1949 that is now thought by some to be incorrect. However, these data are still presented in medical textbooks and taught in medical schools.[http://www.mja.com.au/public/issues/178_11_020603/matters_arising_020603-1.html] Many doctors, therefore, are misinformed about the natural development of the foreskin, and this contributes to the mis-diagnosis of the normal non-retractile foreskin of childhood as pathological disease. Rickwood and Walker (1989) raised concern that phimosis is frequently misdiagnosed by physicians confusing it with the developmentally non-retractable foreskin.<ref name = "Rickwood2">{{cite journal | last = Rickwood | first = AM. | coauthors = Jenny Walker | year = 1989 | month = September | title = Is phimosis overdiagnosed in boys and are too many circumcisions performed in consequence? | journal = Annals of the Royal College of Surgeons of England | volume = 71 | issue = 5 | pages = 275–277 | pmid = 2802472 | url = http://www.cirp.org/library/treatment/phimosis/rickwood2/ | accessdate = 2006-10-10 }} </ref>, and Rickwood ''et al.'' write in their 2000 paper "Towards evidence based circumcision of English boys" in the ''British Medical Journal'' [http://bmj.com/cgi/content/full/321/7264/792]: :''Too many English boys, especially those under 5 years of age, are still being circumcised because of misdiagnosis of phimosis. What is phimosis? At birth, the foreskin is almost invariably non-retractable, but this state is transient and resolves in nearly all boys as they mature through puberty. Such normality, with an unscarred and pliant preputial orifice, is clearly distinguishable from pathological phimosis, a condition unambiguously characterised by secondary cicatrisation of the orifice, usually due to [[balanitis xerotica obliterans]]. This problem, the only absolute indication for circumcision, affects some 0.6% of boys, peaks in incidence at 11 years of age, and is rarely encountered before the age of 5. (...) Strictly, only some 0.6% of boys with pathological phimosis need to be circumcised, although more relaxed criteria would allow for a similar proportion affected by recurrent balanoposthitis.'' A 1968 Danish study of 9,545 boys, which distinguished between phimosis and preputial adhesion, found that both conditions steadily declined with age. Phimosis was 8% among 6-7 year olds but only 1% among 16-17 year olds. Similarly, preputial adhesion was 63% among 6-7 year olds but only 3% among 16-17 year olds. The author, Jakob Øster, concluded: :''Phimosis is seen to be uncommon in schoolboys, and the indications for operation even rarer if the normal development of the prepuce is patiently awaited. When this policy is pursued, in the majority of cases of phimosis, it is seen to be a physiological condition which gradually disappears as the tissues develop. [http://www.cirp.org/library/general/oster/]'' It has been observed that Øster's study may not be representative of wider populations. [http://www.mja.com.au/public/issues/178_11_020603/matters_arising_020603-3.html] The true incidence of phimosis is controversial. Osmond found that 14% of British soldiers had phimosis, and Schoeberlein noted that 9.2% of uncircumcised German men had phimosis[http://www.mja.com.au/public/issues/178_11_020603/matters_arising_020603-3.html]. Reporting on a New Zealand study, Fergusson ''et al'' found that 3.7% of boys had phimosis,<ref name = "Ferg">{{cite journal | last = Fergusson | first = DM | coauthors = JM Lawton and FT Shannon | year = 1988 | month = April | title = Neonatal circumcision and penile problems: an 8-year longitudinal study | journal = Pediatrics | volume = 81 | issue = 4 | pages = 537&ndash;541 | doi = | pmid = 3353186 | url = http://www.circs.org/library/fergusson/index.html | format = | accessdate = 2007-07-18 }}</ref> while Herzog and Alvarez found it in 2.6%. [http://www.circs.org/library/herzog/index.html] Dawson and Whitfield, say "True phimosis is rare but may cause appreciable problems in either childhood or adolescence."[http://www.bmj.com/cgi/content/full/312/7041/1291] The AAP state that the true frequency of problems such as phimosis is unknown.<ref name = "AAP1999" /> Several researchers have described less invasive treatments for phimosis than circumcision, and recommend that they be tried first. <ref name="dewan">{{cite journal | last = Dewan | first = P.A. | coauthors = Tieu H.C., and Chieng B.S. | year = 1996 | month = August | title = Phimosis: Is circumcision necessary? | journal = Journal of Paediatrics and Child Health | volume = 32 | issue = 4 | pages = 285&ndash;289 | pmid = 8844530 | doi = 10.1111/j.1440-1754.1996.tb02554.x}}</ref><ref name="beauge">{{cite journal | last = Beaugé | first = Michel | year = 1997 | month = September/October | title = The causes of adolescent phimosis | journal = British Journal of Sexual Medicine | volume = 26 | url = http://www.cirp.org/library/treatment/phimosis/beauge2/ | accessdate = 2006-06-14}}</ref> Several studies have identified phimosis as a risk factor for penile cancer. A letter to the British Medical Journal stated it would be irresponsible to expose a patient to risk for longer than necessary.<ref>Robin J Willcourt, "Re: Circumcision is a last resort - to be avoided, whenever possible" - letters to the editor, ''British Medical Journal'' [http://bmj.bmjjournals.com/cgi/eletters/321/7264/792#110919 http://bmj.bmjjournals.com/cgi/eletters/321/7264/792#110919]</ref> Phimosis is also a complication of circumcision, that can occur when too little foreskin is removed.[http://www.cirp.org/library/complications/blalock1/] Images of phimosis.[http://147.46.43.65/~circum/hwimage/phimosis2.jpg][http://www.midori-clinic.or.jp/phimosis/palaphi.jpg][http://www.vghtpe.gov.tw/~peds/lecture/phimosis/42.jpg] === Circumcision and Urinary tract infection (UTI) === [[Urinary tract infection|Infections of the urinary tract]] (kidneys, ureters, bladder and urethra) can lead to kidney damage if undetected, but can generally be treated effectively with antibiotics. Twelve studies have indicated that neonatal circumcision reduces the rate of [[Urinary tract infections]] in male infants by a factor of about 10.<ref name="singhgrewal2005">{{cite journal | last = Singh-Grewal | first = D. | coauthors = J. Macdessi, and J. Craig | date = [[August 1]], [[2005]] | title = Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomised trials and observational studies | journal = Archives of Disease in Childhood | volume = 90 | issue = 8 | pages = 853–858 | doi = 10.1136/adc.2004.049353 | pmid = 15890696 | url = http://adc.bmjjournals.com/cgi/reprint/90/8/853.pdf | format = PDF | accessdate = 2006-09-21 }} </ref> According to the American Medical Association, "There is little doubt that the uncircumcised infant is at higher risk for urinary tract infection (UTI)." Some of these studies have been extensively criticized for their methodology. The [[American Academy of Pediatrics]] noted in its 1999 circumcision policy statement: : Few of the studies that have evaluated the association between UTI in male infants and circumcision status have looked at potential confounders (such as prematurity, breastfeeding, and method of urine collection) in a rigorous way. For example, because premature infants appear to be at increased risk for UTI, the inclusion of hospitalized premature infants in a study population may act as a confounder by suggesting an increased risk of UTI in uncircumcised infants. Premature infants usually are not circumcised because of their fragile health status. In another example, breastfeeding was shown to have a threefold protective effect on the incidence of UTI in a sample of uncircumcised infants. However, breastfeeding status has not been evaluated systematically in studies assessing UTI and circumcision status. <ref name="AAP1999"/> (Studies have found that 1 in 10 premature infants will have a urinary tract infection during the first month of life. [http://www.drspock.com/article/0,1510,5362,00.html]) A 1998 Canadian population based cohort study by To et al. [http://www.cirp.org/library/disease/UTI/to2/] reported a relative risk of 3.7. The overall incidence of UTIs in infants was low, 1.88 and 7.02 per 1000 respectively. More recently, randomized controlled trials[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11793114] and other studies have confirmed the protective effect of circumcision[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11772190] [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11156067] [http://pediatrics.aappublications.org/cgi/content/full/105/4/789]. UTIs are usually detected through urine tests. Depending on the method of urine collection, there is a varying risk of false positives through contamination. The bacteria detected may in fact come from the foreskin itself, not the urinary tract. In spite of this, an increased risk of UTI in uncircumcised males is generally considered plausible, a higher likelihood of bacterial colonization being the proposed mechanism. However, studies of UTI and circumcision do not classify groups of circumcised males according to their mothers' handling of the foreskin, making it impossible to infer any link with specific hygienic practices. You should never retract the foreskin of an infant. The foreskin retracts of it's own accord.[http://www.cirp.org/library/normal/aap/]. The [[Canadian Paediatric Society]] questions whether increased [[Urinary tract infection|UTI]] and [[balanitis]] rates in uncircumcised male infants may be caused by [[forcible retraction of the foreskin|forced premature retraction]].<ref name = "CMAJ" /> Hodges and Fleiss claim that "it has been proven that retraction and washing of the infant foreskin can cause urinary tract infections by irritating the mucous membranes and destroying the naturally occurring beneficial flora which protects against pathogens." More recent research has shown that in fact fewer pathogens are present in circumcised males.[http://pediatrics.aappublications.org/cgi/eletters/81/4/537#1382] Lerman and Liao state that apart 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."<ref name="lerman2001">Lerman SE, Liao JC. Neonatal circumcision. ''Pediatr Clin North Am.'' 2001 December;48(6):1539-57. PMID 11732129</ref> UTIs in boys are most common during the first years of life[http://pediatrics.aappublications.org/cgi/content/full/104/2/222]. A Swedish study found that the cumulative incidence of UTIs in boys under 2 years of age was 2.2%.<ref name="jakobsson1999">Jakobsson 1999, ''et al''. Minimum incidence and diagnostic rate of first urinary tract infection. ''Pediatrics.'' 1999 August;104 (2 Pt 1):222–6. ([http://pediatrics.aappublications.org/cgi/content/full/104/2/222 full text])</ref> 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.”<ref name = "CSA:I-99" /> Based upon their data, To et al. estimate that 195 circumcisions would be needed to prevent one hospital admission for UTI in the first year of life. === Circumcision and HIV/AIDS === {{update}} In 1989 the Cameron study <ref> {{cite journal |last=Cameron |first=DW |authorlink= |coauthors=Simonsen JN, D'Costa LJ, Ronald AR, Maitha GM, Gakinya MN, Cheang M, Ndinya-Achola JO, Piot P, Brunham RC, et al. |year=1989 |month=Aug |title=Female to male transmission of human immunodeficiency virus type 1: risk factors for seroconversion in men. |journal=Lancet |volume=19 |issue=2(8660) |pages=403–7 |pmid= 2569597 |url= |accessdate= |quote= |doi=10.1016/S0140-6736(89)90589-8 }} </ref> was published and reported an 8.2 times higher risk of [[HIV]] infection among uncircumcised men. Since then some 38 studies have covered the issue of the protective effect accruing through male circumcision against female-to-male HIV transmission through vaginal sex. A recent study in Rakai, Uganda also observed a 30% reduction in male-to-female HIV transmission[http://www.eurekalert.org/pub_releases/2006-02/jhmi-rsm020306.php], suggesting some protective effect for the female partner as well. There is no evidence yet, however, of a protective effect against transmission from the active partner to the passive partner in homosexual oral or anal intercourse. Changedia and Gilada (2002) reported that "Though circumcision offers protection in acquisition of HIV infection, our findings reveal that it does not reduce transmission of HIV in conjugal settings."[http://www.aegis.com/conferences/iac/2002/ThPeC7420.html] Hunter ''et al.'' (1994), however, report that "Women whose husband or usual sex partner was uncircumcised had a threefold increase in risk of HIV, and this risk was present in almost all strata of potential confounding factors."[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=8011242&query_hl=8&itool=pubmed_docsum] Fonck ''et al.'' (2000) reported that "Partners of circumcised men had less-prevalent HIV infection."[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=10949433&query_hl=16&itool=pubmed_docsum] The USAID document [http://www.psi.org/resources/pubs/male-circ.pdf Male Circumcision:Current Epidemiological and Field Evidence] summarized research as at September 2002. It states: :A systematic review and meta-analysis of 28 published studies by the London School of Hygiene and Tropical Medicine, published in the journal AIDS in 2000, found that circumcised men are less than half as likely to be infected by HIV as uncircumcised men. A subanalysis of 10 African studies found a 71 percent reduction among higher-risk men. A September 2002 update considered the results of these 28 studies plus an additional 10 studies and, after controlling for various potentially confounding religious, cultural, behavioral, and other factors, had similarly robust findings. Recent laboratory studies in Chicago found HIV uptake in the inner foreskin tissue to be up to nine times more efficient than in a control sample of cervical tissue.[http://www.psi.org/resources/pubs/male-circ.pdf] However, the Cochrane Library for Evidence-based Medicine's review of the data (2004) reported: :We found insufficient evidence to support an interventional effect of male circumcision on HIV acquisition in heterosexual men. The results from existing observational studies show a strong epidemiological association between male circumcision and prevention of HIV, especially among high-risk groups. However, observational studies are inherently limited by confounding which is unlikely to be fully adjusted for. In the light of forthcoming results from RCTs, the value of IPD analysis of the included studies is doubtful. The results of these trials will need to be carefully considered before circumcision is implemented as a public health intervention for prevention of sexually transmitted HIV.[http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003362/frame.html] Nevertheless, the positive results of observational studies suggested that circumcision was "worth evaluating in randomised controlled trials.”<ref name="Sig">{{cite journal | last = Siegfried | first = N | coauthors = M Muller, J Deeks, J Volmink, M Egger, N Low, S Walker, and P Williamson | year = 2005 | month = March | title = HIV and male circumcision—a systematic review with assessment of the quality of studies | journal = The Lancet Infectious Diseases | volume = 5 | issue = 3 | pages = 165&ndash;173 | doi = 10.1016/S1473-3099(05)01309-5 | pmid = 15766651 | url = http://download.thelancet.com/pdfs/journals/1473-3099/PIIS1473309905013095.pdf | format = PDF &mdash; free registration required | accessdate = 2007-07-09 }} </ref> (See the "Recent results" section below for results of these trials.) Both UNAIDS and the Centers for Disease Control of the United States Public Health Service recommend that male circumcision should now be recognized as an efficacious intervention for HIV prevention and they are promoting that male circumcision should be recognized as an additional, important strategy for the prevention of heterosexually acquired HIV infection in men. Connolly ''et al.'' (2004) studied the effects of circumcision in South Africa. They report that, among racial groups, "circumcised Blacks showed similar rates of HIV as uncircumcised Blacks, (OR: 0.8, p = 0.4) however other racial groups showed a strong protective effect, (OR: 0.3, p = 0.01)." They added "When the data are further stratified by age of circumcision, there is a slight protective effect between early circumcision and HIV among Blacks, OR: 0.7, p = 0.4." They conclude that "in general, circumcision offers slight protection."[http://www.aegis.com/conferences/iac/2004/MoPeC3491.html] Thomas ''et al.'' (2004) report that "male circumcision is not associated with HIV or STI prevention in a U.S. Navy population."[http://www.aegis.com/conferences/iac/2004/TuPeC4861.html] Other researchers have contested the findings which indicate that circumcision reduces HIV transmission. For example, Van Howe, an anti-circumcision campaigner, produced a [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10215123 meta-analysis] which presented circumcised men at a greater risk for HIV infection. He further speculated that circumcision may be responsible for the increased number of partners, and therefore, the increased risk. Van Howe's work was reviewed by [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10726934&dopt=Abstract O'Farrell and Egger] who found methodological flaws in his work. [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11089625&dopt=Abstract Weiss, Quigley and Hayes] carried out a new meta-analysis on circumcision and HIV and found as follows: :Male circumcision is associated with a significantly reduced risk of HIV infection among men in sub-Saharan Africa, particularly those at high risk of HIV. These results suggest that consideration should be given to the acceptability and feasibility of providing safe services for male circumcision as an additional HIV prevention strategy in areas of Africa where men are not traditionally circumcised. There are other studies of note. Kelly ''et al.'' reported in "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10199231 Age of male circumcision and risk of prevalent HIV infection in rural Uganda]" that circumcision before the age of 12 resulted in a reduction to 0.39 of the odds of being infected. The degree of protection varied with the age at which circumcision was performed. Those circumcised at between 13 and 20 years had an odds ratio of 0.46, and those circumcised after the age of 20 at an odds ratio of 0.78. They concluded: "Prepubertal circumcision is associated with reduced HIV risk, whereas circumcision after age 20 years is not significantly protective against HIV-1 infection." With regard to the effects of behaviour on infection risk [http://www.unaids.org/NetTools/Misc/DocInfo.aspx?LANG=en&href=http%3a%2f%2fgva-doc-owl%2fWEBcontent%2fDocuments%2fpub%2fPublications%2fIRC-pub03%2flusaka99_en%26%2346%3bhtml Buvé] in USAID funded multi-site study on behalf of UNAIDS found that "In conclusion, differences in the rate of HIV spread between the East African and West African cities studied cannot be explained away by differences in sexual behaviour alone. In fact, behavioural differences seem to be outweighed by differences in HIV transmission probability." Bailey reported [http://www.aegis.com/aidsline/2000/jul/a0071414.html]: :These results suggest that differences between circumcised and uncircumcised men in their sex practices and hygienic behaviors do not account for the higher risk of HIV infection found among uncircumcised men. Further consideration should be given to male circumcision as a prevention strategy in areas of high prevalence of HIV and other sexually transmitted diseases. Studies of the feasibility and acceptability of male circumcision in traditionally noncircumcising societies are warranted. Kiwanuka ''et al.'' (1996) studied the relationship between religion and HIV in Rural Uganda and [http://www.aegis.org/aidsline/1997/jan/m9714101.html concluded]: "Lower rates of HIV infection among [[Pentecostal]]s appear to be associated with less [[alcohol]] consumption, [[sexual abstinence]] and fewer sexual partners, whereas the low HIV prevalence in [[Muslim]]s appears to be associated with low reported alcohol consumption and male circumcision." Muslims, despite having the lowest rate of sexual abstinence and the highest rate of having two or more sexual partners, had the lowest level of HIV infection compared with the other religious groups in the study ([[Catholic]]s, [[Protestant]]s, and Pentecostals). The factor in common between the Muslims (14.5% seropositive) and the Pentecostals (14.6% seropositive) was the lower alcohol consumption rate in these two groups than amongst Protestants (19.2%) and Catholics (19.9%). Studies have also been carried out as to the acceptability of male circumcison within traditionally non-circumcising communities. [http://sti.bmjjournals.com/cgi/content/full/79/3/214 Kebaabetswe] found that: :Male circumcision appears to be highly acceptable in Botswana. The option for safe circumcision should be made available to parents in Botswana for their male children. Circumcision might also be an acceptable option for adults and adolescents, if its efficacy as an HIV prevention strategy among sexually active people is supported by clinical trials. [http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12478073&dopt=Abstract Lagarde] found that "More than 70% of the non-circumcised men (NCM) stated that they would want to be circumcised if MC were proved to protect against sexually transmitted diseases (STD)." Lagarde cautioned that "Our results strongly suggest that interventions including MC should carefully address the false sense of security that it may provide." Bailey in his study <ref>Adult male circumcision in Kenya: safety and patient satisfaction</ref> looked at the possible adverse effects of introducing male circumcision on a public health scale and the post operative satisfaction levels of 380 circumcsions on 18-24 year old consenting men. As to satisfaction; "At 30 days post-surgery, 99.3% of men reported being very satisfied and 0.7% somewhat satisfied with circumcision. None were dissatisfied." And with regard to adverse effects; "All were mild or moderate and resolved within hours or several days of detection." In a recently published study in this regard in [[The Lancet]], [http://pdf.thelancet.com/pdfdownload?uid=llan.363.9414.original_research.29166.1&amp;x=x.pdf '''Male circumcision and risk (2004) of HIV-1 and other sexually transmitted infections in India'''], Reynolds and Bollinger found that male circumcision was strongly protective against HIV-1 infection with circumcised men being almost seven times less at risk of HIV infection than uncircumcised men.[http://news.bbc.co.uk/1/hi/health/3570223.stm] They further state that: :"The specificity of this relation suggests a biological rather than behavioural explanation for the protective effect of male circumcision against HIV-1." [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15655778 Baeten] ''et al'' in a study published in The ''Journal of Infectious Diseases'' in 2005 found that uncircumcised men were at a greater than two-fold increased risk of acquiring HIV per sex act when compared with circumcised men. They conclude as follows: :"Moreover, our results strengthen the substantial body of evidence suggesting that variation in the prevalence of male circumcision may be a principal contributor to the spread of HIV-1 in Africa." Newell and Bärnighausen (2007) also stated there was "firm evidence that the risk of acquiring HIV is halved by male circumcision."<ref name = "Newell">{{cite journal | last = Newell | first = Marie-Lousie | coauthors = Till Bärnighausen | date = [[February 24]], [[2007]] | title = Male circumcision to cut HIV risk in the general population | journal = [[The Lancet]] | volume = 369 | issue = 9562 | pages = 617–619 | pmid = 17321292 | doi = 10.1016/S0140-6736(07)60288-8 | url = http://download.thelancet.com/pdfs/journals/0140-6736/PIIS0140673607602888.pdf |format = PDF | accessdate = 2007-04-01 }} </ref><ref name="baileyrct">{{cite journal | last = Bailey | first = Robert C | coauthors = Stephen Moses, Corette B Parker, Kawango Agot, Ian Maclean, John N Krieger, Carolyn F M Williams, Richard T Campbell, Jeckoniah O Ndinya-Achola | date = [[February 24]], [[2007]] | title = Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial | journal = [[The Lancet]] | volume = 369 | issue = 9562 | pages = 643–656 | pmid = 17321310 | doi = 10.1016/S0140-6736(07)60312-2 | url = http://download.thelancet.com/pdfs/journals/0140-6736/PIIS0140673607603122.pdf | format = PDF | accessdate = 2007-04-01 }} </ref><ref name="grayrct">{{cite journal | last = Gray | first = Ronald H | coauthors = Godfrey Kigozi, David Serwadda, Frederick Makumbi, Stephen Watya, Fred Nalugoda, Noah Kiwanuka, Lawrence H Moulton, Mohammad A Chaudhary, Michael Z Chen, Nelson K Sewankambo, Fred Wabwire-Mangen, Melanie C Bacon, Carolyn F M Williams, Pius Opendi, Steven J Reynolds, Oliver Laeyendecker, Thomas C Quinn, Maria J Wawer | date = [[February 24]], [[2007]] | title = Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial | journal = [[The Lancet]] | volume = 369 | issue = 9562 | pages = 657–666 | pmid = 17321311 | doi = 10.1016/S0140-6736(07)60313-4 | url = http://download.thelancet.com/pdfs/journals/0140-6736/PIIS0140673607603134.pdf | format = PDF | accessdate = 2007-04-01 }} </ref> However, Garenne (2006) doubted its value in reducing HIV.<ref name = "Garenne">{{cite journal | last = Garenne | first = Michel | year = 2006 | month = January | title = Male Circumcision and HIV Control in Africa | journal = [[PLoS Medicine]] | volume = 3 | issue = 1 | pages = e78 | pmid = 16435906 | doi = 10.1371/journal.pmed.0030078 | url = http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0030078 | accessdate = 2007-04-01 }} </ref> and Talbott (2007), in a controversial paper [http://www.plosone.org/annotation/listThread.action?inReplyTo=info%3Adoi%2F10.1371%2Fannotation%2F723&root=info%3Adoi%2F10.1371%2Fannotation%2F723] stated that cross country regression data pointed to prostitution as the key factor in the AIDS epidemic rather than circumcision.<ref name = "PROSTITUTION">{{cite journal | last = Talbott | first = John R. | year = 2007 | month = June | title = Size Matters: The Number of Prostitutes and the Global HIV/AIDS Pandemic | journal = [[PLoS ONE]] | volume = 2 | issue = 6 | pages = e543 | doi = 10.1371/journal.pone.0000543 | url = http://www.plosone.org/article/fetchArticle.action?articleURI=info:doi/10.1371/journal.pone.000054 | accessdate = 2007-07-09 }} </ref> A World Health Organization AIDS Prevention Team official Tim Farley disagreed with the findings of the paper, while Chris Surridge, PLoS One's managing editor, defended its publication.<ref>{{cite journal |title=Circumcision for HIV needs follow-up |author=Butler, D; Odling-Smee, L |journal=Nature |year=2007 |month=June |volume=447 |pages=1040–1041 |url=http://www.nature.com/nature/journal/v447/n7148/box/4471040a_BX1.html |doi=10.1038/4471040a}}</ref> In 1999 the American Medical Association had stated, "behavioral factors are far more important in preventing these infections than the presence or absence of a foreskin."<ref name = "CSA:I-99" /> Despite evidence of a significant protective effect of infant male circumcision, "male circumcision should not be actively promoted for HIV prevention unless and until the RCTs (Randomized controlled trials) confirm MC to be effective in reducing HIV infection".[http://www.psi.org/resources/pubs/male-circ.pdf] [http://www.jaids.org/pt/re/jaids/abstract.00126334-200712150-00017.htm Millett] ''et al'' in a study published in The ''Journal of Acquired Immune Deficiency Syndromes'' in 2007 found no association in three major US cities between circumcision and HIV infection among Latino and black men who have sex with men (MSM) . They conclude as follows: :"In these cross-sectional data, there was no evidence that being circumcised was protective against HIV infection among black MSM or Latino MSM." If proper hygienic procedures are not adhered to, the circumcision operation itself can spread HIV. Brewer ''et al.'' (2007)<ref>{{cite journal | last = Brewer | first= Devon | year = 2007| month= February | title = Male and Female Circumcision Associated with Prevalent HIV Infection in Virgins and Adolescents in Kenya, Lesotho, and Tanzania | journal = Annals of Epidemiology | volume = 17 | issue = 3| pages = pp.217–226 | url = http://www.annalsofepidemiology.org/article/PIIS1047279706002651/abstract | doi = 10.1016/j.annepidem.2006.10.010}}</ref> report, "[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." They concluded: "HIV transmission may occur through circumcision-related blood exposures in eastern and southern Africa." ==== Randomised Controlled Trials ==== [[Africa]] has a [[List of countries by HIV/AIDS adult prevalence rate| higher rate]] of HIV infection than anywhere in the world. Three [[randomized controlled trial|randomised control trials]] were commissioned to investigate whether circumcision could lower the rate of HIV contraction. All 3 were conducted in Africa. The first one to publish it's results was named ANRS-1265. It was funded by the French government’s research agency, Agence Nationale de Recherches sur la SIDA (ANRS) and carried out in [[Orange Farm, Gauteng]]. The purpose was to test the effect of adult male circumcision on HIV acquisition.<ref name = "NIAIDQA">{{cite web | url = http://www3.niaid.nih.gov/news/QA/AMC12_QA.htm | title = [[NIAID]]QUESTIONS AND ANSWERS Sponsored Adult Male Circumcision Trials in Kenya and Uganda | accessdate = 2008-07-11 | date = [[December 13]], [[2006]] | publisher = National Institute of Allergy and Infectious Diseases ([[NIAID]]0 }} </ref> The study was lead by Dr. Bertran Auvert of [[Versailles University]]. It enrolled 3,274 men, aged 18-24. The participants were split into 2 equal groups. One group was circumcised straight away; the other group, serving as a control, was to be circumcised 21 months later. 146 of the original participants were found to have HIV at the start of the trial - they were not excluded for fear of stigmatization. It was planned that all the men would visit the research clinic four times during this 21-month period, and that they would be tested for HIV each time. They were instructed not to have sex for six weeks after the operation, and asked at each clinic visit to provide detailed information about their sexual activity. The circumcision procedure used was the forceps-guided method [http://www.phru.co.za/pdf/circumcision/pitfalls.pdf], carried out by three local general practitioners in their surgical offices. After 17 months, 20 men had contracted HIV in the circumcised group and 49 in the controlled intact group. The trial was halted on ethical grounds.<ref name = "ANRS"/> The results of the trial were published in November 2005. 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.”<ref name = "ANRS">{{cite journal | last = Auvert | first = Bertran | coauthors = Dirk Taljaard, Emmanuel Lagarde, Joëlle Sobngwi-Tambekou, Rémi Sitta, Adrian Puren | year = 2005 | month = November | title = Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: The ANRS 1265 Trial | journal = PLoS Medicine | volume = 2 | issue = 11 | pages = 1112&ndash;1122 | doi = 10.1371/journal.pmed.0020298 | pmid = 16231970 | url = http://medicine.plosjournals.org/archive/1549-1676/2/11/pdf/10.1371_journal.pmed.0020298-S.pdf | format = PDF | accessdate = 2006-07-09 }} </ref> A recent analysis of the potential impact of circumcision on HIV in Africa, based upon the South African RCT, suggested that male circumcision could substantially reduce the burden of HIV in Africa, particularly in southern Africa where the existing prevalence of male circumcision is low and the existing prevalence of HIV is high. More specifically it predicted that if full coverage with MC was achieved in sub-Saharan Africa over the next ten years, MC could prevent approximately 2.0 (1.1 to 3.8) million new HIV infections over that ten year period and a further 3.7 million in the ten years after that. <ref name = "PLoS-7-06">{{cite journal | last = Williams | first = Brian G. | authorlink = | coauthors = James O. Lloyd-Smith, Eleanor Gouws, Catherine Hankins, Wayne M. Getz, John Hargrove, Isabelle de Zoysa, Christopher Dye, Bertran Auvert | year = 2006 | month = July | title = The Potential Impact of Male Circumcision on HIV in Sub-Saharan Africa | journal = [[PLoS Medicine]] | volume = 3 | issue = 7 | pages = e262 | doi = 10.1371/journal.pmed.0030262 | pmid = 16822094 | url = http://medicine.plosjournals.org/archive/1549-1676/3/7/pdf/10.1371_journal.pmed.0030262-p-L.pdf | format = PDF | accessdate = 2006-07-13 }} </ref> The above conclusions drawn from the Orange Farm study have been criticised by Michel Garenne (2006) of the [[Institut Pasteur]]. In his critique, published on the PLoS Journal of Medicine, he concludes that: "'male circumcision should be regarded as an important public health intervention for preventing the spread of HIV' appears overstated. Even though large-scale male circumcision could avert a number of HIV infections, theoretical calculations and empirical evidence show that it is unlikely to have a major public health impact, apart from the fact that achieving universal male circumcision is likely to be more difficult than universal vaccination coverage or universal contraceptive use." [http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0030078]. Mills and Siegfried (2006) point out that trials that are stopped early tend to over estimate treatment effects. They argue that a meta-analysis should be done before further feasibility studies are done.[http://www.thelancet.com/journals/lancet/article/PIIS0140673606695135/fulltext] The [[National Institute of Allergy and Infectious Diseases| NIAID]], part of the [[National Institutes of Health| NIH]], supported 2 more RCT trials. The primary objectives of these studies were to determine whether adult male circumcision 1) can be administered safely, and 2) reduce the risk of acquiring HIV infection through heterosexual contact.<ref name = "NIAIDQA"/> After an initial HIV screening and a medical exam, eligible men were randomly assigned either to receive circumcision immediately or to wait two years before circumcision. All participants were closely followed for two years to collect information about their health, sexual activity, and theirs and their partners’ attitudes about circumcision; to counsel participants in HIV prevention and safe sex practices; and to check the HIV status of the volunteer. Participants in the Kenyan study were scheduled for six visits over the two-year follow-up, compared with four visits for the Ugandan trial participants. In addition to the study visits, men enrolled in the Kenyan trial were encouraged to receive all of their outpatient health care at the study clinics, which enabled researchers to collect information on the safety of the procedure and the number of other sexually transmitted diseases the men had during follow-up. The Ugandan trial began August, 2003 in [[Rakai District| Rakai]], [[Uganda]], with 4,996 men aged between 15 and 49 years old.<ref>http://hivinsite.ucsf.edu/InSite?page=jl-11-03 Male Circumcision for HIV Prevention in Men in Rakai, Uganda: A Randomised Trial</ref> It was led by Drs. Ronald Gray and Maria Wawer of [[Johns Hopkins Bloomberg School of Public Health]] and Drs. David Serwadda and Nelson Sewankambo of [[Makerere University]] in [[Kampala]], Uganda. The circumcision procedure used in the Kenyan trial was the foreskin clamp method. The Kenyan trial procedure took about 25 minutes and used stitches to control bleeding and improve wound closure. Trained and certified physicians performed the circumcisions in well-equipped operating rooms. Post-operative follow-up visits were scheduled at 24-48 hours, 5-9 days, and 4-6 weeks. HIV testing, physical examination, and interviews were repeated at 4-6 weeks, 6-, 12-, and 24-month follow-up visits.<ref>{{cite web | url = http://hivinsite.ucsf.edu/InSite?page=jl-11-03 | title = Male Circumcision for HIV Prevention in Men in Rakai, Uganda: A Randomised Trial | accessdate = 2008-07-11 | date = [[March 26]], [[2007]] | publisher = UCSF Institute for Global Health Literature Digest }} </ref> After 24 months, 964 of the original 2387 men of the circumcised men had been retained of whom 22 had contracted HIV. 980 out of the original 2430 intact men had been retained of whom 45 had contracted HIV. The Kenyan trial, also known as the UNIM trial (Universities of Nairobi, Illinois and Manitoba trial), started in February 2002, in [[Kisumu]], [[Kenya]]. It was a collaborative effort between U.S., Canadian and Kenyan researchers, lead by Dr. Robert Bailey, of the [[University of Illinois]]. Also involved were Stephen Moses, [[University of Manitoba]], Jeckoniah Ndinya-Achola, [[University of Nairobi]], and Kwango Agot, [[UNIM]]. The trial was funded by the NIAID and the [[Canadian Institutes of Health Research]]. This trial enrolled 2,784 men between 18 and 24 years old. The participants were assessed by HIV testing, medical examinations, and behavioural interviews during follow-ups at 1, 3, 6, 12, 18, and 24 months. The circumcision procedure used in the Ugandan trial is known as the sleeve method and takes about 30 minutes. The Ugandan trial used cauterization of the blood vessels to control bleeding and stitches to close the wound. 22 men in the intervention group and 47 in the control group had tested positive for HIV when the study was stopped on ethical grounds. Both trials were stopped early on December 13, 2006 on ethical grounds after it found that those belonging to the intact control group had a greater number of men with HIV than the circumcised group. <ref name="grayrct">{{cite journal | last = Gray | first = Ronald H | coauthors = Godfrey Kigozi, David Serwadda, Frederick Makumbi, Stephen Watya, Fred Nalugoda, Noah Kiwanuka, Lawrence H Moulton, Mohammad A Chaudhary, Michael Z Chen, Nelson K Sewankambo, Fred Wabwire-Mangen, Melanie C Bacon, Carolyn F M Williams, Pius Opendi, Steven J Reynolds, Oliver Laeyendecker, Thomas C Quinn, Maria J Wawer | date = [[February 24]], [[2007]] | title = Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial | journal = [[The Lancet]] | volume = 369 | issue = 9562 | pages = 657–666 | pmid = 17321311 | doi = 10.1016/S0140-6736(07)60313-4 | url = http://hssp.ph/pubdocs/HIV-Lancet%20-%20MC%20Uganda%2002.24.07.pdf | format = PDF | accessdate = 2007-07-11 }} </ref><ref name="baileyrct">{{cite journal | last = Bailey | first = Robert C | coauthors = Stephen Moses, Corette B Parker, Kawango Agot, Ian Maclean, John N Krieger, Carolyn F M Williams, Richard T Campbell, Jeckoniah O Ndinya-Achola | date = [[February 24]], [[2007]] | title = Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial | journal = [[The Lancet]] | volume = 369 | issue = 9562 | pages = 643–656 | pmid = 17321310 | doi = 10.1016/S0140-6736(07)60312-2 | url = http://download.thelancet.com/pdfs/journals/0140-6736/PIIS0140673607603122.pdf | format = PDF | accessdate = 2007-04-01 }} </ref> On Wednesday, March 28, 2007, the [[World Health Organisation]] (WHO) and [[UNAIDS]] issued joint recommendations concerning male circumcision and HIV/AIDS. <ref name="WHOpr0307">{{cite web |title=WHO and UNAIDS announce recommendations from expert consultation on male circumcision for HIV prevention |publisher=World Health Organisation |month=March |year=2007 |url=http://www.who.int/hiv/mediacentre/news68/en/index.html}} </ref> 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. <ref name="WHO-C&R">{{cite paper | title = New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications | publisher = [[World Health Organization]] | date = [[March 28]], [[2007]] | url = http://www.who.int/hiv/mediacentre/MCrecommendations_en.pdf | format = PDF | id = | accessdate = 2007-08-13 }} </ref> Kim Dickson, coordinator of the working group that authored the report, commented:[http://www.newscientist.com/article.ns?id=dn11481&feedId=online-news_rss20] * Male circumcision "would have greatest impact" in countries where the HIV infection rate among heterosexual males is greater than 15 percent and fewer than 20 percent of males are circumcised. * WHO further recommends that the procedure must be done by a trained physician. * Protection is incomplete and men must continue to use condoms and have fewer partners. * Newly circumcised men should abstain from sex for at least six weeks. 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.”. <ref name="WHOsec">{{cite web | url = http://www.who.int/mediacentre/news/statements/2007/s04/en/index.html | title = WHO and UNAIDS Secretariat welcome corroborating findings of trials assessing impact of male circumcision on HIV risk | accessdate = 2007-02-23 | date = [[February 23]], [[2007]] | publisher = World Health Organization}}</ref> 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.<ref>{{cite web | url = http://www.who.int/mediacentre/news/statements/2006/s18/en/index.html | title = Male circumcision reduces the risk of becoming infected with HIV, but does not provide complete protection | accessdate = 2006-07-20 | date = [[December 13]], [[2006]] | publisher = World Health Organization }} </ref><ref>{{cite web | url = http://news.bbc.co.uk/2/hi/health/4371384.stm | title = Circumcision 'reduces HIV risk' | date = [[October 25]], [[2005]] | publisher = BBC News }} </ref> 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.<ref>{{cite web | url =http://www.aidsmap.com/en/news/3CBF12A3-A1AC-4A0E-A79C-54FC6EF93E28.asp | author = Virginia Differding | title = Women may be at heightened risk of HIV infection immediately after male partner is circumcised | accessdate = 2007-03-14 | date = [[March 12]], [[2007]] | publisher = Aidsmap News}} </ref> In assessing the impact of circumcision on the spread of sexually transmitted infections including HIV it must always be borne in mind that there are other risk factors. Thus, the United States has a high rate of STD infection and a high rate of circumcision compared with other advanced countries. [http://www.medicinenet.com/script/main/art.asp?articlekey=41672] ====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<ref>{{cite journal | last = Hussain LA | first = LA | authorlink = | coauthors = T. Lehner | year = 1995 | month = July | title = Comparative investigation of Langerhans' cells and potential receptors for HIV in oral, genitourinary and rectal epithelia | journal = Immunology | volume = 85 | issue = 3 | pages = 475&ndash;484 | doi = | pmid = 7558138 | url = | format = Abstract | accessdate = 2006-07-09 }} </ref><ref>{{cite journal | last = Patterson | first = Bruce K. | authorlink = | coauthors = Alan Landay, Joan N. Siegel, Zareefa Flener, Dennis Pessis, Antonio Chaviano, and Robert C. Bailey | year = 2002 | month = | title = Susceptibility to Human Immunodeficiency Virus-1 Infection of Human Foreskin and Cervical Tissue Grown in Explant Culture | journal = American Journal of Pathology | volume = 161 | issue = 3 | pages = 867&ndash;873 | doi = | pmid = 12213715 | url = http://ajp.amjpathol.org/cgi/reprint/161/3/867.pdf | format = PDF | accessdate = 2006-07-09 }} </ref><ref>{{cite journal | last = Donoval | first = BA | authorlink = | coauthors = AL Landay, S Moses, K Agot, JO Ndinya-Achola, EA Nyagaya, I MacLean, and RC Bailey | year = 2006 | month = March | title = HIV-1 target cells in foreskins of African men with varying histories of sexually transmitted infections | journal = American Journal of Clinical Pathology | volume = 125 | issue = 3 | pages = 386&ndash;391 | doi = 10.1309/JVHQ-VDJD-YKM5-8EPH | pmid = 16613341 | url = http://ajcp.metapress.com/link.asp?id=jvhqvdjdykm58eph | format = Abstract | accessdate = 2006-07-09 }} </ref> and Szabo and Short suggested that the Langerhans cells in the foreskin may provide an entry point for viral infection.<ref name = "Szabo">{{cite journal | last = Szabo | first = Robert | coauthors = Roger V. Short | year = 2000 | month = June | title = How does male circumcision protect against HIV infection? | journal = BMJ | volume = 320 | issue = 7249 | pages = 1592&ndash;1594 | doi = 10.1136/bmj.320.7249.1592 | pmid = 10845974 | url = http://bmj.bmjjournals.com/cgi/reprint/320/7249/1592 | format = PDF | accessdate = 2006-07-09 }} </ref> McCoombe, Cameron, and Short also found that the keratin is thinnest on the foreskin and frenulum.<ref>{{cite paper |author= McCoombe SG, Cameron PU, Short RV |date= [[July 7]], [[2002]] |url= http://www.aegis.com/conferences/iac/2002/WePeA5739.html |format= Abstract |title= The distribution of HIV-1 target cells and keratin in the human penis. |publisher= International AIDS Society |version= |accessdate= 2006-07-09 }} </ref> Fleiss, Hodges and Van Howe had previously stated a belief that the prepuce has an immunological function.<ref name=Fleiss>{{cite journal | last = Fleiss | first = PM | authorlink = | coauthors = FM Hodges, RS Van Howe | year = 1998 | month = October | title = Immunological functions of the human prepuce | journal = Sexually Transmitted Infections | volume = 74 | issue = 5 | pages = 364&ndash;367 | doi = | pmid = 10195034 | url = http://sti.bmjjournals.com/cgi/reprint/74/5/364.pdf | format = PDF | accessdate = 2006-07-09 }} </ref> While their specific hypothesis was criticised on technical grounds.<ref>{{cite web | url = http://sti.bmj.com/cgi/eletters/74/5/364#112 | title = Apocrine glands in inner prepuce doubtful | accessdate = 2006-07-09 | last = Waskett | first = Jake H. | date = [[June 20]], [[2005]] | work = Electronic letters | publisher = BMJ Publishing Group Ltd }} </ref> a study published in 2007 by de Witte and others said that [[langerin]], produced by Langerhans cells, is a natural barrier to HIV-1 transmission by Langerhans cells.<ref>{{cite web | url =http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17334373&query_hl=4&itool=pubmed_docsum | title = Langerin is a natural barrier to HIV-1 transmission by Langerhans cells | accessdate = 2007-03-19 | last = de Witte | first = L. | date = [[March 4]], [[2007]] | work = Abstract | publisher = www.Pubmed.gov }} </ref> === Epididymitis in children === [[Epididymitis]] is inflammation of the [[epididymis]]. It can be very painful, and become a chronic condition, but medical treatment is well accepted and effective. [http://www.duj.com/epididymitis.html] [http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Epididymitis?OpenDocument]. One [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9783972&dopt=Abstract 1998 study] found the rate of epididymitis in boys with foreskins was significantly higher than in those without; that an intact foreskin is an important etiological factor in boys with epididymitis. ===Penile problems in boys up to 8 years of age=== A 1988 New Zealand study of penile problems by Fergusson ''et al'', in a birth cohort of more than 500 children from birth to 8 years of age found that: :''By 8 years, circumcised children had a rate of 11.1 problems per 100 children, and uncircumcised children had a rate of 18.8 per 100. The majority of these problems were for penile [[inflammation]] including [[balanitis]], [[meatitis]], and inflammation of the [[prepuce]]. However, the relationship between risks of penile problems and circumcision status varied with the child's age. During infancy, circumcised children had a significantly higher risk of problems than uncircumcised children, but after infancy the rate of penile problems was significantly higher among the uncircumcised. These associations were not changed when the results were adjusted statistically for the effects of a series of potentially confounding social and perinatal factors. [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=3353186] The authors of this study acknowledged certain problem with the data: :''It is important to recognize that the data on medical attendance for penile problems was collected as part of a much larger longitudinal study of child health and development in which the primary concern was not with the issue of the longterm consequences of circumcision. This feature of the data collection process places a number of restrictions on the quality of the collected data. Specifically, data relating to immediate postcircumcision problems and penile problems that were treated at home without medical attention were not available. Also, diagnostic details of medical attendances for penile problems were limited. The net result of these imprecisions in the data collection process is that the incidence and prevalence of penile problems probably underestimated and the problems can only be described in terms of broad diagnostic categories. Nonetheless, we believe that the trends that emerge from the analysis are likely to reflect general differences in the medical histories of circumcised and uncircumcised children.[http://www.circs.org/library/fergusson/index.html]'' Van Howe observed that Fergusson ''et al.'' used parental complaints rather than direct examination in their retrospective study, so the study may have understated the number of boys with penile problems.[http://www.cirp.org/library/complications/vanhowe/] ===Paraphimosis=== The American Academy of Family Physicians says: :"[[Paraphimosis]] is a urologic emergency, occurring in uncircumcised males, in which the [[foreskin]] becomes trapped behind the corona and forms a tight band of constricting tissue. Often iatrogenically induced, paraphimosis can be prevented by returning the prepuce to cover the glans following penile manipulation. Treatment often begins with reduction of edema, followed by a variety of options, including mechanical compression, pharmacologic therapy, puncture technique and dorsal slit. Prevention and early intervention are key elements in the management of paraphimosis. (Am Fam Physician 2000;62:2623-6,2628.)"[http://aafp.org/afp/20001215/2623.html] The article goes on to say that the cause is most often iatrogenic (caused by doctors). It further stated: :"Rare causes of paraphimosis include self-inflicted injury to the penis (such as piercing a penile ring into the glans) and paraphimosis secondary to penile erections." In children, it is sometimes caused by a caregiver trying to [[forcible retraction of the foreskin|forcibly retract the infant foreskin]].<ref name = "Gairdner" /> Several techniques to treat paraphimosis are listed in an article in the American Family Physician, and in the anti-circumcision web site CIRP. [http://www.cirp.org/library/treatment/paraphimosis/] One procedure is minor surgery to make a small slit in the foreskin without removing any tissue.[http://www.cirp.org/library/treatment/phimosis/saxena1/] Another is called the "Dundee technique." [http://www.cirp.org/library/treatment/phimosis/reynard1/] The Royal Children's Hospital in Melbourne, Australia, says, "Once reduced, a single episode of paraphimosis is not an indication for circumcision." [http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=5153#paraphimosis] but an article in the American Family Physician says that paraphimosis is one of the medical indications for circumcision [http://www.aafp.org/afp/990315ap/1514.html]. Images of paraphimosis. [http://www.aafp.org/afp/20001215/2623_f1.jpg][http://www.circlist.com/anatterms/anatimages/tcer015.jpg] ===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.”<ref name="AAP1999" /><ref>Although the Academy's 1975 statement asserted that "A program of education leading to continuing good personal hygiene would offer all the advantages of circumcision without the attendant surgical risk," the 1999 statement cites a study which found that "appropriate hygiene decreased significantly the incidence of phimosis, adhesions, and inflammation, but did not eliminate all problems."</ref> 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 the penis of an uncircumcised infant requires no special care and should be left alone. It states that attempts to [[forcible retraction of the foreskin|forcibly retract the foreskin]], e.g. to clean it, are painful, often injure the foreskin, and can lead to scarring, infections and pathologic phimosis.<ref name = "RACPAnat">{{cite web | url = http://www.racp.edu.au/hpu/paed/circumcision/anatomy.htm | title = Care Of The Foreskin | accessdate = 2006-07-13 | year = 2004 | month = October | work = Paediatric Policy - Circumcision | publisher = The Royal Australasian College of Physicians }} </ref> [[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 is common to all [[mammals]]—male and female. In rare cases, accumulating smegma may help cause [[balanitis]].<ref>{{cite journal |first=C |last=Sonnex |coauthors=Croucher, PE; Dockerty WG |title=Balanoposthitis associated with the presence of subpreputial "smegma stones" |journal=Genitourin Med |year=1997 |month=Dec |volume=73 |issue=6 |pages=567}}</ref> Hutson speculated 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.<ref>{{cite journal |last = Hutson |first = J.M. |year = 2004 |month = June |title = Circumcision: a surgeon’s perspective |journal = Journal of Medical Ethics |volume = 30 |issue = 3 |pages = 238&ndash;240 |doi = 10.1136/jme.2002.001313 |pmid = 15173354 |url = http://jme.bmjjournals.com/cgi/reprint/30/3/238.pdf |format = PDF |accessdate = 2006-07-09}}</ref> 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.”<ref>{{cite journal | last = Darby | first = Robert | year = 2005 | month = July | title = The riddle of the sands: circumcision, history, and myth | journal = The New Zealand Medical Journal | volume = 118 | issue = 1218 | pages = 76&ndash;82 | doi = | id = {{ISSN|11758716}} PMID 16027753 | url = http://www.nzma.org.nz/journal/118-1218/1564/content.pdf | format = PDF | accessdate = 2006-07-09 }} </ref> ===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.<ref name = "Ferg">{{cite journal | last = Fergusson | first = DM | coauthors = JM Lawton and FT Shannon | year = 1988 | month = April | title = Neonatal circumcision and penile problems: an 8-year longitudinal study | journal = Pediatrics | volume = 81 | issue = 4 | pages = 537&ndash;541 | doi = | pmid = 3353186 | url = http://www.circs.org/library/fergusson/index.html | format = | accessdate = 2007-07-18 }}</ref><ref>{{cite journal |last=Fakjian |first=N |coauthors=S Hunter, GW Cole and J Miller |year=1990 |month=August |title=An argument for circumcision. Prevention of balanitis in the adult |journal=Arch Dermatol |volume=126 |issue=8 |pages=1046&ndash;7 |pmid=2383029 |doi=10.1001/archderm.126.8.1046 }}</ref><ref>{{cite journal |last=Herzog |first=LW |coauthors=SR Alvarez |year=1986 |month=March |title=The frequency of foreskin problems in uncircumcised children |journal=Am J Dis Child |volume=140 |issue=3 |pages=254&ndash;6 |pmid=3946358}}</ref> The reasons are unclear, but several hypotheses have been suggested: *The foreskin may harbor bacteria and become infected if it is not cleaned properly.<ref>{{cite journal | last = O’Farrel | first = Nigel | coauthors = Maria Quigley and Paul Fox | year = 2005 | month = August | title = Association between the intact foreskin and inferior standards of male genital hygiene behaviour: a cross-sectional study | journal = International Journal of STD & AIDS | volume = 16 | issue = 8 | pages = 556–588(4) | doi = 10.1258/0956462054679151 | pmid = 16105191 | url = http://www.ingentaconnect.com/content/rsm/std/2005/00000016/00000008/art00008 | format = Abstract | accessdate = 2006-08-20 }} <small>'''Editor’s note: I cannot confirm that the article substantiates the claim as I cannot access the full article.</small></ref> *The foreskin may become inflamed if it is cleaned too often with soap.<ref name="birley" /> *The [[forcible retraction of the foreskin]] in boys can lead to infections.<ref name ="CMAJ" /> ===Balanitis=== {{main|Balanitis}} '''Balanitis''', an inflammation of the [[glans penis]], has several causes.<ref name = "HKhandbook">{{cite book | last = Au | first = T.S. | coauthors = K.H. Yeung | editor = Pedro Sá Cabral, Luís Leite, and José Pinto (eds.) | title = HANDBOOK OF DERMATOLOGY & VENEREOLOGY | origdate = | origyear = | origmonth = | url = http://www.hkmj.org.hk/skin/cover.htm | accessdate = 2006-09-04 | edition = 2nd ed. | year = 2003 | publisher = Department of Dermatology—Hospital Pulido Valente | location = [[Lisbon, Portugal]] | id = ISBN 978-962-334-030-4 | chapter = Balanitis, Bacterial Vaginosis and Other Genital Conditions | chapterurl = http://www.hkmj.org.hk/skin/balaniti.htm }} </ref> Some of these, such as anaerobic infection, occur more frequently in uncircumcised men.<ref name = "EdwardsGU">{{cite journal | last = Edwards | first = Sarah | year = 1996 | month = June | title = Balanitis and balanoposthitis: a review | journal = Genitourinary Medicine | volume = 72 | issue = 3 | pages = 155–159 | doi = | pmid = 8707315 | url = http://www.cirp.org/library/disease/balanitis/edwards1/ | accessdate = 2006-09-04 }} </ref> [[Balanitis]] involving the foreskin is called balanoposthitis. The usual treatment for balanoposthitis is to use topical antibiotics (metronidazole cream) and antifungals (clotrimazole cream) or low-potency steroid creams.<ref>{{cite web | url = http://www.emedicine.com/derm/topic615.htm | title = Balanoposthitis | accessdate = 2006-11-20 | last = Osipov | first = Vladimir O. | authorlink = | coauthors = Scott M. Acker | date = [[November 14]], [[2006]] | work = Reactive and Inflammatory Dermatoses | publisher = [[EMedicine]] }} </ref> One study found that uncircumcised men had more than five times the rate of balanitis [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=2383029&dopt=Abstract]. The most common complication of balanitis is phimosis, or inability to retract the foreskin from the glans penis.[http://www.emedicine.com/emerg/topic51.htm]. EMedicine says: "Uncircumcised men with poor personal hygiene are most affected by balanitis. Lack of aeration and irritation because of smegma and discharge surrounding the glans penis causes inflammation and edema. Adherence of the foreskin to the inflamed and edematous glans penis causes phimosis."[http://www.emedicine.com/emerg/topic51.htm] O'Farrell ''et al.'' noted inferior hygiene among uncircumcised men attending a sexually transmitted infections (STI) clinic at Ealing Hospital, London.[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16105191&query_hl=3&itool=pubmed_docsum] The researchers also reported an association between balanitis and inferior hygiene. Balanitis has many causes, including irritation by environmental substances, physical trauma, and infection by a wide variety of pathogens, including bacteria, virus, yeast, or fungus &mdash; each of which require a particular treatment. Good medical practice includes careful diagnosis with the aid of a good patient history, swabs and cultures, and pathologic examination of a biopsy. Only then can the proper treatment be prescribed.[http://www.cirp.org/library/disease/balanitis/edwards1/] Many studies of balanitis do not examine the subjects' genital washing habits. A 1993 study by Birley ''et al.'' did so and found that excessive genital washing with soap may be a strong contributing factor to balanitis. <ref name="birley">{{cite journal | last = Birley | initial = HDL | year = 1993 | month = October | title = Clinical Features and management of recurrent balanitis; association with atopy and genital washing | journal = Genitourinary Medicine | volume = 69 | issue = 5 | pages = 400&ndash;403 | doi = 10.1136/jme.2002.001313 | pmid = 8244363 | url = http://www.cirp.org/library/disease/balanitis/birley/ | accessdate = 2007-08-19 }} </ref> Fakjian ''et al.'' studied 398 patients at a dermatology clinic in a cross-sectional study. 213 (53.5%) had been circumcised. "Balanitis was diagnosed in 2.3% of circumcised men and in 12.5% of uncircumcised men. In patients with diabetes mellitus, balanitis occurred with a prevalence of 34.8% in the uncircumcised population, compared with 0% in the circumcised population. Balanitis did occur with increased frequency in the diabetic population (16%), regardless of circumcision status, compared with the nondiabetic population (5.8%)." [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=2383029&dopt=Abstract] Treatments that are less invasive than circumcision are effective in treating most mild cases of balanitis.<ref name = "HKhandbook" /> 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 et atrophicus|lichen sclerosus]] and plasma cell balanitis.”<ref name = "birley" /> The, less invasive procedures are not as successful in treating [[balanitis xerotica obliterans]], or '''BXO''',<ref>{{cite journal | last = Vincent | first = Michelle Valerie | coauthors = Ewan MacKinnon | year = 2005 | month = April | title = The response of clinical balanitis xerotica obliterans to the application of topical steroid-based creams | journal = Journal of Pediatric Surgery | volume = 40 | issue = 4 | pages = 709–712 | doi = 10.1016/j.jpedsurg.2004.12.001 | pmid = 15852285 | url = http://www.jpedsurg.org/article/PIIS002234680400867X/abstract | format = Abstract | accessdate = 2006-09-21 }} </ref><ref>{{cite journal | last = Wright | first = J.E. | year = 1994 | month = May | title = The treatment of childhood phimosis with topical steroid | journal = The Australian and New Zealand journal of surgery | volume = 64 | issue = 5 | pages = 327–328 | pmid = 8179528 | url = http://www.cirp.org/library/treatment/phimosis/wright/ | accessdate = 2006-09-21 | doi = 10.1111/j.1445-2197.1994.tb02220.x }} </ref><ref>{{cite journal | last = Webster | first = T.M. | coauthors = M.P. Leonard | year = 2002 | month = April | title = Topical steroid therapy for phimosis | journal = The Canadian journal of urology | volume = 9 | issue = 2 | pages = 1492–1495 | pmid = 12010594 | url = http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12010594&query_hl=5 | format = Abstract | accessdate = 2006-09-21 }} </ref> which is much less common but harder to treat.<ref>{{cite web | url = http://www.emedicine.com/derm/topic46.htm | title = http://www.emedicine.com/derm/topic46.htm | accessdate = 2006-09-21 | last = Scheinfeld | first = Noah S. | authorlink = | coauthors = George C. Keough, Daniel Lehman | date = [[January 11]], [[2006]] | work = Diseases Of The Dermis | publisher = [[EMedicine]] }} </ref> [[Balanitis xerotica obliterans]] is a skin condition causing white, atrophic patches on the glans or foreskin. It is much more common among uncircumcised males. Circumcision is believed to reliably reduce the threat of BXO.<ref>{{cite journal | last = Mattioli | first = G. | coauthors = P. Repetto, C. Carlini, C. Granata, C. Gambini, and V. Jasonni | year = 2002 | month = May | title = Lichen sclerosus et atrophicus in children with phimosis and hypospadias | journal = Pediatric Surgery International | volume = 18 | issue = 4 | pages = 273–275 | doi = 10.1007/s003830100699 | pmid = 12021978 | url = http://www.springerlink.com/content/dy5cgm3h11prdy76/ | format = Abstract | accessdate = 2006-09-21 }} </ref> [[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]]. '''Zoon's Balanitis''', illustrated [http://www.meddean.luc.edu/lumen/MedEd/medicine/dermatology/melton/zoon1.htm here], also know as ''Balanitis Circumscripta Plasmacellularis'' or ''plasma cell balanitis'' (PCB) is an idiopathic, rare, benign penile dermatosis, usually of a middle-aged or older man [http://www.emedicine.com/derm/topic45.htm]. Circumcision is the usual treatment of choice but fusidic acid cream 2% has been curative in some cases. [http://www.emedicine.com/derm/topic45.htm] [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10101891&dopt=Abstract] '''Balanitis in childhood.''' Balanitis afflicts young boys generally only where a difficult to retract tight foreskin is present. Two studies found that uncircumcised boys were at approximately twice the risk of developing balanitis[http://www.circs.org/library/herzog/][http://www.circs.org/library/fergusson/] Escala and Rickwood, in a 1989 examination of 100 cases of balanitis in childhood, concluded: "[T]he risk in any individual, uncircumcised boy appears to be no greater than 4%." [http://www.cirp.org/library/disease/balanitis/escala1/], They recommend circumcision as a last resort only in cases of recurrent balanitis.[http://www.cirp.org/library/disease/balanitis/escala1/] Images of balanitis [http://zdravi.004.cz/z-balanitis/balanitis-cand.jpg] [http://www.stdservices.on.net/images/std/balanitis/slide10.jpg] [http://www.atlasdermatologico.com.br/ListaImagens/Balanitis_Candidomycetica1.JPG] ===Skin diseases=== Researchers from the Imperial College School of Medicine, Chelsea & Westminster Hospital, London, England in a study [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10724196&dopt=Abstract Circumcision and genital dermatoses]reported the results of their study of 357 patients referred for genital skin disease: : Most cases of inflammatory dermatoses were diagnosed in uncircumcised men, suggesting that circumcision protects against inflammatory dermatoses. The presence of the foreskin may promote inflammation by a koebnerization phenomenon, or the presence of infectious agents, as yet unidentified, may induce inflammation. The data suggest that circumcision prevents or protects against common infective penile dermatoses. Some American military doctors have recommended prophylactic circumcision because of the difficult conditions during wartime. For example, a United States Army report regarding [[World War II]] noted that in case of penile lesions, the foreskin may "invite secondary infection". The sexually transmitted disease [[chancroid]], now very uncommon, was also associated with phimosis, which could hardly occur in circumcised males, and "soldiers in combat were seldom able to practice personal hygiene". (Source: JF Patton, Medical Department, United States Army, Surgery in World War II, Urology, p. 64) There are a few cases of skin diseases such as staphyloccal scalded skin syndrome or impetigo following circumcision. [http://www.cirp.org/library/complications/annunziato1/][http://www.cirp.org/library/complications/stranko1/]. One study found a difference in infection rates between circumcised and uncircumcised boys (p < 0.10) that was not statistically significant, "perhaps due to the relatively small number.." . [http://www.cirp.org/library/complications/enzenauer1/] ===Other Sexually transmitted infections=== A recent systematic review [http://sti.bmjjournals.com/cgi/content/full/82/2/101] has suggested that there is strong evidence for a protective effect of circumcision against [[Syphilis]] or [[Chancroid]] infection, but only weak evidence for a protective effect against [[Herpes Simplex]]. ==Costs and Benefits== The American Academy of Pediatrics (1999) said: :"Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In the case of circumcision, in which there are potential benefits and risks, yet the procedure is not essential to the child's current well-being, parents should determine what is in the best interest of the child." [http://pediatrics.aappublications.org/cgi/content/full/103/3/686 Policy Statement, 1999] Clarifying their statement in 2000, the authors explained: :The Task Force found the evidence of low incidence, high-morbidity problems not sufficiently compelling to recommend circumcision as a routine procedure for all newborn males. However, the Task Force did recommend making all parents aware of the potential benefits and risks of circumcision and leaving it to the family to decide whether circumcision is in the best interests of their child. ... Circumcision falls into that group of procedures that have potential medical benefits and some risks and should be evaluated by each family in the context of their personal beliefs and values as well as their ethnic, cultural, and religious practices. The Task Force respects the role of parents as decision-makers for their newborns and recommends that physicians discuss with parents the potential benefits as well as risks of circumcision so that parents can decide whether circumcision is in the child's best interests. In June 2004 the College of Physicians and Surgeons of British Columbia said: :"Infant male circumcision was once considered a preventive health measure and was therefore adopted extensively in Western countries. Current understanding of the benefits, risks and potential harm of this procedure, however, no longer supports this practice for prophylactic health benefit. Routine infant male circumcision performed on a healthy infant is now considered a non-therapeutic and medically unnecessary intervention."[https://www.cpsbc.ca/cps/physician_resources/publications/resource_manual/malecircum] Several cost-benefit analyses of infant circumcision have been published. :Cadman ''et al.'' (1984) concluded that the expense of circumcision outweighed any money that might be saved by reducing the risk of penile cancer. Therefore, they argued, public funds should not pay for it [http://www.cmaj.ca/cgi/content/abstract/131/11/1353]. :Lawler ''et al.'' (1991) [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=1794670] reported a net cost of $25.00 and a benefit of ten days of life. They concluded that there was no medical indication for or against circumcision. :Ganiats ''et al.'' (1991) [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=1766331] reported a net cost of $102 and a loss of 14 hours of healthy life. They found no medical reason to recommend for or against circumcision. :Chessare (1992) weighed the risks of circumcision against the prevention of urinary tract infections [http://www.cirp.org/library/disease/UTI/chessare/]. He concluded that non-circumcision produced the “highest expected utility”, provided that the probability of developing a UTI was less than 0.29%. :Christakis ''et al.'' (2000) report that "Circumcision remains a relatively safe procedure. However, for some parents, the risks we report may outweigh the potential benefits." [http://www.circs.org/library/christakis/index.html] :Van Howe <ref>{{cite journal |last=Van Howe |first=R.S. |authorlink= |coauthors= |year=2004 |month= |title=A Cost-Utility Analysis of Neonatal Circumcision |journal=Medical Decision Making |volume=24 |issue=6 |pages=584–601 |pmid=15534340 |url=http://mdm.sagepub.com/cgi/reprint/24/6/584.pdf |accessdate=|doi=10.1177/0272989X04271039 }} Van Howe is a fierce opponent of circumcision. In 1999 a detractor accused him of bias, distortions and misrepresentation of the literature [http://www.ncbi.nlm.nih.gov/pubmed/9726361].</ref>(2004) reported that the overall effect of male neonatal non-therapeutic circumcision on health is more likely to be negative rather than positive. :Schoen et al. (2006) concluded: "Multiple lifetime medical benefits of neonatal circumcision can be achieved at little or no cost. Because postneonatal circumcision is so expensive, its rate is the most important factor determining future cost savings from newborn circumcision." <ref>{{cite journal |last=Schoen |first=E.J. |authorlink= |coauthors=C.J. Colby CJ and T.T. To |year=2006 |month=March |title=Cost analysis of neonatal circumcision in a large health maintenance organization |journal=Journal of Urology |volume=175 |issue=3, Part 1 |pages=1111–1115 |pmid=16469634 |url= |accessdate= |quote= |doi=10.1016/S0022-5347(05)00399-X }}E.J. Schoen, the principal author of the above study, is an 'outspoken proponent' of circumcision.{{Fact|date=April 2008}}</ref> Some public and private health insurance providers have deleted coverage of elective non-therapeutic circumcision. In such cases, the cost falls on the person electing the procedure. ==See also== *[[Bioethics of neonatal circumcision]] *[[Circumcision advocacy]] *[[Genital integrity]] (opponents of circumcision) *[[Circumcision and law]] *[[Foreskin]] *[[Foreskin restoration]] *[[Male circumcision]] *[[Female circumcision]] ==References== {{reflist|2}} ==External links== *American Academy of Pediatrics. [http://aappolicy.aappublications.org/cgi/content/full/pediatrics;103/3/686 Circumcision Policy Statement (RE9850)]. March 1999. *American Medical Association. [http://www.ama-assn.org/ama/pub/category/13585.html Report 10 of the Council on Scientific Affairs (I-99), Neonatal Circumcision]. Dec 1999. *British Medical Association. [http://web.bma.org.uk/ap.nsf/Content/malecircumcision2003 The Law & Ethics of Male Circumcision - Guidance for Doctors]. March 2003. *Canadian Paediatric Society. [http://www.cps.ca/english/statements/FN/fn96-01.htm Neonatal Circumcision Revisited]. 1996 (reaffirmed March 2002) *The Royal Australasian College of Physicians. [http://www.racp.edu.au/hpu/paed/circumcision/summary.htm Policy Statement On Circumcision]. Sep 2002. * Remondino, Peter Charles. ''[http://www.gutenberg.org/etext/23135 History of Circumcision from the Earliest Times to the Present].'' Philadelphia and London; F. A. Davis; 1891. ==Further reading== *Apt A. Circumcision and prostatic cancer. ''Acta Med Scand'' 1965; 178: 493-504. *Bailis, S. & Halperin, D.. Male circumcision: time to re-examine the evidence. ''studentBMJ'' May 2006;14:179-180. *Reddy DG, Baruah IK. Carcinogenic Action of Human Smegma. ''Arch Pathol'' 1963; 75(4): 414-420. [[Category:Circumcision debate]]