Systematic Reviews
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Pediatr. Feb 8, 2017; 6(1): 89-102
Published online Feb 8, 2017. doi: 10.5409/wjcp.v6.i1.89
Early infant male circumcision: Systematic review, risk-benefit analysis, and progress in policy
Brian J Morris, Sean E Kennedy, Alex D Wodak, Adrian Mindel, David Golovsky, Leslie Schrieber, Eugenie R Lumbers, David J Handelsman, John B Ziegler
Brian J Morris, Adrian Mindel, School of Medical Sciences and Bosch Institute, University of Sydney, Sydney, NSW 2006, Australia
Sean E Kennedy, School of Women’s and Children’s Health, University of New South Wales, Sydney, NSW 2052, Australia
Alex D Wodak, St Vincent’s Hospital and Kirby Institute for Infection and Immunity in Society, University of New South Wales, Sydney, NSW 2010, Australia
David Golovsky, IVF Australia, Sydney, NSW 2000, Australia
Leslie Schrieber, Department of Medicine, Sydney Medical School, Royal North Shore Hospital, Sydney, NSW 2060, Australia
Eugenie R Lumbers, School of Biomedical Sciences and Pharmacy, Mothers and Babies Research Centre, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW 2305, Australia
David J Handelsman, Department of Medicine and ANZAC Research Institute, Concord Hospital, Sydney, NSW 2139, Australia
John B Ziegler, Department of Immunology and Infectious Diseases, Sydney Children’s Hospital, Randwick, Sydney, NSW 2031, Australia
Author contributions: All authors contributed to this manuscript.
Conflict-of-interest statement: Authors are members of the Circumcision Academy of Australia, a medical body formed to provide accurate, evidence-based information on male circumcision to parents, practitioners and others, as well as contact details of doctors who perform the procedure.
Data sharing statement: The technical appendix, statistical code, and dataset are available from the first author at brian.morris@sydney.edu.au.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: John B Ziegler, AM, MD, MB, BS, DipHEd, FRACP, FAAAAI, Professor, Department of Immunology and Infectious Diseases, Sydney Children’s Hospital, High St, Randwick, Sydney, NSW 2031, Australia. j.ziegler@unsw.edu.au
Telephone: +61-2-93821515 Fax: +61-2-93821580
Received: May 31, 2016
Peer-review started: June 6, 2016
First decision: July 25, 2016
Revised: November 17, 2016
Accepted: December 27, 2016
Article in press: December 28, 2016
Published online: February 8, 2017
Abstract
AIM

To determine whether recent evidence-based United States policies on male circumcision (MC) apply to comparable Anglophone countries, Australia and New Zealand.

METHODS

Articles in 2005 through 2015 were retrieved from PubMed using the keyword “circumcision” together with 36 relevant subtopics. A further PubMed search was performed for articles published in 2016. Searches of the EMBASE and Cochrane databases did not yield additional citable articles. Articles were assessed for quality and those rated 2+ and above according to the Scottish Intercollegiate Grading System were studied further. The most relevant and representative of the topic were included. Bibliographies were examined to retrieve further key references. Randomized controlled trials, recent high quality systematic reviews or meta-analyses (level 1++ or 1+ evidence) were prioritized for inclusion. A risk-benefit analysis of articles rated for quality was performed. For efficiency and reliability, recent randomized controlled trials, meta-analyses, high quality systematic reviews and large well-designed studies were used if available. Internet searches were conducted for other relevant information, including policies and Australian data on claims under Medicare for MC.

RESULTS

Evidence-based policy statements by the American Academy of Pediatrics (AAP) and the Centers for Disease Control and Prevention (CDC) support infant and later age male circumcision (MC) as a desirable public health measure. Our systematic review of relevant literature over the past decade yielded 140 journal articles that met our inclusion criteria. Together, these showed that early infant MC confers immediate and lifelong benefits by protecting against urinary tract infections having potential adverse long-term renal effects, phimosis that causes difficult and painful erections and “ballooning” during urination, inflammatory skin conditions, inferior penile hygiene, candidiasis, various sexually transmissible infections in both sexes, genital ulcers, and penile, prostate and cervical cancer. Our risk-benefit analysis showed that benefits exceeded procedural risks, which are predominantly minor, by up to 200 to 1. We estimated that more than 1 in 2 uncircumcised males will experience an adverse foreskin-related medical condition over their lifetime. Wide-ranging evidence from surveys, physiological measurements, and the anatomical location of penile sensory receptors responsible for sexual sensation strongly and consistently suggested that MC has no detrimental effect on sexual function, sensitivity or pleasure. United States studies showed that early infant MC is cost saving. The evidence supporting early infant MC has further strengthened since the positive AAP and CDC reviews.

CONCLUSION

Affirmative MC policies are needed in Australia and New Zealand. Routine provision of accurate, unbiased education, and access in public hospitals, will maximize health and financial benefits.

Keywords: Male circumcision, Evidence-based policy, Infants, Adults, Urinary tract infections, Adverse events, Sexually transmitted infections, Genital cancers, Risk-benefit analysis, Cost-benefit

Core tip: Australia and New Zealand should follow the lead of the American Academy of Pediatrics and the United States Centers for Disease Control and Prevention in facilitating education, provider training, patient access and affordability of circumcision of male infants and boys. Our systematic review of the current scientific evidence finds the protection afforded by early infant male circumcision against infections and other adverse medical conditions exceed risks by 200 to 1 and that over their lifetime over 1 in 2 uncircumcised males will suffer an adverse medical condition caused by their foreskin. Strong evidence shows no adverse effect on penile function, sexual sensitivity or pleasure. Circumcision is a desirable public health intervention. It is moreover cost-saving.