Circumcision

  

Circumcision knife from the Congo;
wood, iron; late 19th/early 20th century[1]

Male circumcision is the surgical removal of the foreskin from the human penis.[1][2][3][4]

The oldest documented evidence for circumcision comes from ancient Egypt.[1][5] The Egyptian Book of the Dead describes the sun god Ra as having circumcised himself.[1][6][7]

British and American doctors began recommending circumcision in the late 19th century, primarily as a deterrent to masturbation.[1][8][9] 

Prior to the 20th century, masturbation was believed to be the cause of a wide range of physical and mental illnesses including epilepsy, paralysis, impotence, gonorrhea, tuberculosis, feeble-mindedness, and insanity.[1][10][11]

Approximately one-third of males worldwide are circumcised, most often for non-medical reasons.[1][5][13] 

Prevalence of circumcision by country.[1]

A 2010 review of literature worldwide found circumcisions performed by medical practitioners to have a median complication rate of 1.5% for newborns and 6% for older children, with few cases of severe complications.[1][13][14][15]

A 2013 systematic review found that circumcision did not appear to affect sexual desire, pain with intercourse, premature ejaculation, time to ejaculation, erectile dysfunction or difficulties with orgasm.[1][16]

Circumcision surgery with hemostats and scissors.[1]

The procedure is most often elected for religious or cultural reasons,[1][5] but may be indicated as a treatment option for pathological phimosis (inability to retract the foreskin over the glans penis)  and chronic urinary tract infections (UTIs).[1][2][12][13][30][32][33] 

Circumcision is associated with a reduced prevalence of oncogenic types of Human papillomavirus (HPV) infection.[35]

• The procedure is associated with increased clearance of the papillomavirus by the body,[26][27] which may account for the finding of reduced prevalence.[27] 

• There is no statistically significant relationship between being circumcised and the presence of genital warts.[1][19][19][20][21]

Important risk factors for penile cancer include phimosis and HPV infection, both of which are mitigated by circumcision.[1][13][25][34][35][36]

Yeast infections are the most common penile infection and are rarely identified in samples taken from circumcised males.[1][31]

***

The World Health Organization (WHO) and the Joint United Nations Program on HIV/AIDS (UNAIDS) state that male circumcision is an efficacious intervention for HIV prevention, but should be carried out by well-trained medical professionals and under conditions of informed consent.[1][5][17][18][21]

• The joint WHO/UNAIDS recommendation also notes that circumcision only provides partial protection from HIV and should not replace known methods of HIV prevention (ex: condoms).[1][5][17]  

• As HIV/AIDS is an incurable disease that is expensive to manage, significant effort has been spent studying the cost-effectiveness of circumcision to reduce its spread in parts of Africa that have a relatively high infection rate and low circumcision prevalence.[1][22] 

• In Rwanda, circumcision has been found to be cost-effective across a wide range of age groups from newborn to adult,[1][19] with the greatest savings achieved when the procedure is performed in the newborn period due to the lower cost per procedure and greater time-frame for HIV infection protection.[1][20] 

• Circumcision for the prevention of HIV transmission in adults has also been found to be cost-effective in South Africa, Kenya and Uganda, with cost savings estimated in the billions of US dollars over 20 years.[1][22][23] 

***

In 2014, the Centers for Disease Control and Prevention released, "Draft CDC Recommendations for Providers Counseling Male Patients and Parents Regarding Male Circumcision and the Prevention of HIV Infection, STIs, and Other Health Outcomes." 

These draft guidelines suggested that the benefits of male circumcision outweigh the risks. 
The following is their summary of beneficial versus adverse effects:[24]

Health benefits of elective male circumcision in adults and adolescents:

• Male circumcision reduces the risk of acquiring HIV infection through penile-vaginal sex by 50-60%, as demonstrated in three well-conducted clinical trials among adult men living in sub-Saharan Africa.
• In clinical trials involving heterosexual males living in sub-Saharan Africa, male circumcision reduces the risk of some sexually transmitted infections.
• HSV-2 (herpes simplex virus type 2): circumcised men were approximately 30%-45% less likely to acquire HSV-2 infection than were uncircumcised men.
• HPV (human papillomavirus): circumcised men were approximately 30% less likely to be infected with high-risk strains of HPV associated with cancers than were uncircumcised men.

Adverse events and risks associated with elective male circumcision of adults: 

• For adult male circumcision performed by clinicians, the rate of adverse events is between 2% and 4%, with pain, bleeding, infection and unsatisfactory post-surgical appearance most commonly reported. While severe and/or long-term complications have been reported, they are so rare that they have not been precisely established.
• Adult men who undergo circumcision generally report minimal or no change in sexual satisfaction or function. 

Health benefits of neonatal male circumcision:

• The estimated annual rate of urinary tract infections (UTIs) in uncircumcised male infants is 0.70%. Male circumcision reduces the risk for infant UTIs by about 80%.
• In the U.S., the estimated lifetime risk of penile cancer for males is about 1 in 1,400 (0.07%) and that of prostate cancer is about 15%. Neonatal male circumcision reduces the risk of penile carcinoma by about 90% and may reduce the risk of prostate cancer by 15% compared to men who are uncircumcised. 

Adverse events and risks associated with neonatal male circumcision:

• Adverse events: For male circumcision performed by clinicians, the rate of reported adverse events is as follows:
• 0.4% in infants (age through 12 mo.)
• 9.1% in children (age 1-9 years)

***
Fin

References:

[1] http://en.wikipedia.org/wiki/Circumcision

[2] Lissauer T, Clayden G (October 2011). Illustrated Textbook of Paediatrics, Fourth edition. Elsevier. pp. 352–353. ISBN 978-0-7234-3565-5.

[3] Rudolph C, Rudolph A, Lister G, First L, Gershon A (18 March 2011). Rudolph's Pediatrics, 22nd Edition. McGraw-Hill Companies, Incorporated. p. 188. ISBN 978-0-07-149723-7.

[4] Sawyer S (November 2011). Pediatric Physical Examination & Health Assessment. Jones & Bartlett Publishers. pp. 555–556. ISBN 978-1-4496-7600-1.

[5] "Male circumcision: Global trends and determinants of prevalence, safety and acceptability" (PDF). World Health Organization. 2007.

[6] Alanis MC, Lucidi RS (May 2004). "Neonatal circumcision: a review of the world's oldest and most controversial operation". Obstet Gynecol Surv 59 (5): 379–95.doi:10.1097/00006254-200405000-00026. PMID 15097799.

[7] Gollaher (2001), ch. 1, The Jewish Tradition, pp. 1-30

[8] Matthew, H. C. G. (2004). Oxford dictionary of national biography : in association with the British Academy : from the earliest times to the year 2000. Oxford New York: Oxford University Press. ISBN 978-0-19-861411-1.

[9] Siegfried N, Muller M, Volmink J et al. (2003). Siegfried, Nandi, ed. "Male circumcision for prevention of heterosexual acquisition of HIV in men". Cochrane Database of Systematic Reviews (3): CD003362. doi:10.1002/14651858.CD003362.PMID 12917962.

[10] Boyle GJ, Hill G (2011). "Sub-Saharan African randomised clinical trials into male circumcision and HIV transmission: methodological, ethical and legal concerns". J Law Med19 (2): 316–34. PMID 22320006.

[11] Dowsett GW, Couch M (May 2007). "Male circumcision and HIV prevention: is there really enough of the right kind of evidence?". Reproductive Health Matters 15 (29): 33–44.doi:10.1016/S0968-8080(07)29302-4. PMID 17512372.

 [12] Hay W, Levin M (25 June 2012). Current Diagnosis and Treatment Pediatrics 21/E. McGraw Hill Professional. pp. 18–19. ISBN 978-0-07-177971-5.

[13] Weiss HA, Larke N, Halperin D, Schenker I; Larke; Halperin; Schenker (2010). "Complications of circumcision in male neonates, infants and children: a systematic review". BMC Urol 10: 2. doi:10.1186/1471-2490-10-2. PMC 2835667.PMID 20158883.

[14] American Academy of Pediatrics Task Force on Circumcision (2012). "Technical Report". Pediatrics 130 (3): e756–e785.doi:10.1542/peds.2012-1990. ISSN 0031-4005. PMID 22926175.

[15] "Circumcision: Position Paper on Neonatal Circumcision". American Academy of Family Physicians. 2007. 

[16]Ko MC, Liu CK, Lee WK, Jeng HS, Chiang HS, Li CY (April 2007). "Age-specific prevalence rates of phimosis and circumcision in Taiwanese boys". Journal of the Formosan Medical Association=Taiwan Yi Zhi 106 (4): 302–7. doi:10.1016/S0929-6646(09)60256-4. PMID 17475607.

[17]  "WHO and UNAIDS announce recommendations from expert consultation on male circumcision for HIV prevention". World Health Organization. March 2007.

[18] "New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications" (PDF). World Health Organization. March 28, 2007.

[19] Albero G, Castellsagué X, Giuliano AR, Bosch FX (February 2012). "Male Circumcision and Genital Human Papillomavirus: A Systematic Review and Meta-Analysis".Sex Transm Dis 39 (2): 104–113. doi:10.1097/OLQ.0b013e3182387abd.PMID 22249298.

[20] Kim H, Li PS, Goldstein M, Howard H; Li, Philip S; Goldstein, Marc (November 2010). "Male circumcision: Africa and beyond?". Current Opinion in Urology 20 (6): 515–9.doi:10.1097/MOU.0b013e32833f1b21. PMID 20844437.

[21] Siegfried N, Muller M, Deeks JJ, Volmink J; Muller; Deeks; Volmink (2009). Siegfried, Nandi, ed. "Male circumcision for prevention of heterosexual acquisition of HIV in men". Cochrane Database of Systematic Reviews (2): CD003362.doi:10.1002/14651858.CD003362.pub2. PMID 19370585.

[22] Doyle S, Kahn J, Hosang N, Carroll P (2010). "The Impact of Male Circumcision on HIV Transmission". Journal of Urology 183 (1): 21–26. doi:10.1016/j.juro.2009.09.030.PMID 19913816.

[23]  Hankins C, Forsythe S, Njeuhmeli E (Mar 2012). Sansom, Stephanie L, ed. "Voluntary medical male circumcision: an introduction to the cost, impact, and challenges of accelerated scaling up". Arch Pediatr Adolesc Med 8 (11): e1001127.doi:10.1371/journal.pmed.1001127. PMC 3226452. PMID 22140362
[24] http://www.regulations.gov/#!documentDetail;D=CDC-2014-0012-0003

[25] Larke et al. "Male circumcision and human papillomavirus infection in men: a systematic review and meta-analysis" (2011), Albero et al. "Male Circumcision and Genital Human Papillomavirus: A Systematic Review and Meta-Analysis" (2012), Rehmeyer "Male Circumcision and Human Papillomavirus Studies Reviewed by Infection Stage and Virus Type" (2011).

[26] Larke N, Thomas SL, Dos Santos Silva I, Weiss HA (November 2011). "Male circumcision and human papillomavirus infection in men: a systematic review and meta-analysis". J. Infect. Dis. 204 (9): 1375–90. doi:10.1093/infdis/jir523. PMID 21965090.

[27] Rehmeyer C, CJ (2011). "Male Circumcision and Human Papillomavirus Studies Reviewed by Infection Stage and Virus Type". J Am Osteopath Assoc 111 (3 suppl 2): S11–S18. PMID 21415373.

[28]Templeton DJ, Millett GA, Grulich AE; Millett; Grulich (February 2010). "Male circumcision to reduce the risk of HIV and sexually transmitted infections among men who have sex with men". Current Opinion in Infectious Diseases 23 (1): 45–52.doi:10.1097/QCO.0b013e328334e54d. PMID 19935420.

[29] Millett GA, Flores SA, Marks G, Reed JB, Herbst JH (October 2008). "Circumcision status and risk of HIV and sexually transmitted infections among men who have sex with men: a meta-analysis". JAMA 300 (14): 1674–84. doi:10.1001/jama.300.14.1674.PMID 18840841.

[30] Becker K (January 2011). "Lichen sclerosus in boys". Dtsch Arztebl Int 108 (4): 53–8.doi:10.3238/arztebl.2011.053. PMC 3036008. PMID 21307992.

[31] Aridogan IA, Izol V, Ilkit M (August 2011). "Superficial fungal infections of the male genitalia: a review". Crit. Rev. Microbiol. 37 (3): 237–44.

[32] Jagannath VA, Fedorowicz Z, Sud V, Verma AK, Hajebrahimi S (2012). Fedorowicz, Zbys, ed. "Routine neonatal circumcision for the prevention of urinary tract infections in infancy". Cochrane Database of Systematic Reviews 11: CD009129.doi:10.1002/14651858.CD009129.pub2. PMID 23152269.

[33] Jagannath VA, Fedorowicz Z, Sud V, Verma AK, Hajebrahimi S (2011). Fedorowicz, Zbys, ed. "Routine neonatal circumcision for the prevention of urinary tract infections in infancy (Protocol)". Cochrane Database of Systematic Reviews (5): CD009129.doi:10.1002/14651858.CD009129.

[34] Hayashi Y, Kojima Y, Mizuno K, Kohri K (2011). "Prepuce: phimosis, paraphimosis, and circumcision". ScientificWorldJournal 11: 289–301. doi:10.1100/tsw.2011.31.PMID 21298220.

[35] Larke NL, Thomas SL, Dos Santos Silva I, Weiss HA (August 2011). "Male circumcision and penile cancer: a systematic review and meta-analysis". Cancer Causes Control 22 (8): 1097–110. doi:10.1007/s10552-011-9785-9. PMC 3139859.PMID 21695385.

[36] "Can penile cancer be prevented?". Learn About Cancer: Penile Cancer: Detailed Guide. American Cancer Society. 

Additional Resources:

http://www.webmd.com/sexual-conditions/guide/circumcision

http://www.scientificamerican.com/article/male-circumcision-benefits-outweigh-risks-cdc-says/?WT.mc_id=SA_HLTH_20141209

http://www.theguardian.com/us-news/2014/dec/02/guidelines-male-circumcision
American Academy of Pediatrics Task Force on Circumcision (2012). "Technical Report". Pediatrics 130 (3): e756–e785.doi:10.1542/peds.2012-1990. ISSN 0031-4005. PMID 22926175.

Image Credits:

"Mangbetu Beschneidungsmesser Museum Rietberg RAC 15" by Photograph: Andreas Praefcke - Own work (own photograph). Licensed under Public Domain via Wikimedia Commons - http://commons.wikimedia.org/wiki/File:Mangbetu_Beschneidungsmesser_Museum_Rietberg_RAC_15.jpg#mediaviewer/File:Mangbetu_Beschneidungsmesser_Museum_Rietberg_RAC_15.jpg

"Global Map of Male Circumcision Prevalence at Country Level" by Emilfaro - The World Health Organization report of 14 December 2007. Male circumcision: global trends and determinants of prevalence, safety and acceptability. This report is the result of collaborative work between the London School of Hygiene and Tropical Medicine, the World Health Organization and the Joint United Nations Programme on HIV/AIDS (UNAIDS). Based on:13. Demographic and health surveys. MEASURE DHS, 2006 (http://www.measuredhs.com, accessed 21 September 2006).53. Drain PK et al. Male circumcision, religion and infectious diseases: an ecologic analysis of 118 developing countries. BMC Infect Dis, 2006, 6(1):172.54. Williams BG et al. The potential impact of male circumcision on HIV in sub-Saharan Africa. PLoS Med, 2006, 3(7):262.55. International religious freedom report for 2004. U.S. Department of State (http://www.state.gov/g/drl/rls/irf/2004/index.htm, accessed 21 September 2006).. Licensed under Public Domain via Wikimedia Commons - http://commons.wikimedia.org/wiki/File:Global_Map_of_Male_Circumcision_Prevalence_at_Country_Level.png#mediaviewer/File:Global_Map_of_Male_Circumcision_Prevalence_at_Country_Level.png

"Circumcision illustration" by MrArifnajafov - File:Sünnət_circumcision_əməliyyatı.gif. Licensed under CC BY-SA 1.0 via Wikipedia - http://en.wikipedia.org/wiki/File:Circumcision_illustration.jpg#mediaviewer/File:Circumcision_illustration.jpg