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doi:10.1111/jpc.12825
VIEWPOINT
Circumcision: Is it worth it for 21st-century Australian boys? Angelika F Na,1 Sharman PT Tanny1 and John M Hutson1,2 1 F. Douglas Stephens Surgical Research Laboratory, Murdoch Childrens Research Institute and 2Department of Urology, Royal Children’s Hospital, Melbourne, Victoria, Australia
Key words:
HIV; male circumcision; newborn; sexually transmitted disease; urinary tract infection.
Male circumcision is a centuries-old medical practice imbued with rich historical, religious and cultural tradition. Circumcision presumably started as a religious and social tradition to maintain hygiene, reduce infection and provide cultural identity. In the modern era, circumcision is a part of paediatric surgical practice to treat phimosis, balanitis and paraphimosis when medical interventions fail.1 However, non-therapeutic circumcision in infants and boys has always been a debated, controversial and minority practice. Data from research studies are often coloured by the authors’ personal belief of what should be the male norm – circumcised or uncircumcised. Although most of the research on circumcision have sound scientific basis, its findings are usually only applicable to the specific socio-cultural context in which the study was conducted. Yet many authors tend to prematurely extrapolate the data in an attempt to set national and international standards on circumcision in infants. The 2012 American Academy of Paediatrics policy statement on circumcision2 departed from their earlier 1999 policy. Although the statement did not recommend circumcision, it stated that health benefits of circumcision in the newborn outweigh the risks, in particular for urinary tract infection (UTI) prevention, human immunodeficiency virus (HIV) acquisition and transmission of sexually transmitted diseases (STDs). In addition, the policy concluded that significant acute complications are rare. Coming from such an influential body, it revived the international controversy of the topic.3 In Australia, the 2010 Royal Australasian College of Physicians’ policy4 concluded that there is currently insufficient evidence to recommend routine newborn circumcision. Other medical societies such as Canadian Paediatric Society5 and British Medical Association6 also cited lack of consistent data to recommend non-therapeutic circumcision. Royal Dutch Medical Association stated that the practice ‘is a violation of children’s rights to autonomy and physical integrity’.7
Correspondence: Prof. John M Hutson, F. Douglas Stephens Surgical Research Laboratory, Murdoch Childrens Research Institute, 9th floor, Royal Children’s Hospital 50 Flemington Road, Parkville, Melbourne, Vic. 3052, Australia. Fax: 61 03 9345 7997; email: [email protected] Conflict of interest: The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication. Accepted for publication 21 November 2014.
580
Global estimates in 2006 suggest that about 30% of males are circumcised. Male circumcision is almost universal in the Middle East, Central Asia, Bangladesh, Indonesia and Pakistan. Male circumcision is common in many African countries, yet the rate varies from 15% to 70% depending on the countries.8 Circumcision is prevalent in these societies because they are largely Islamic, or for tribal and cultural reasons such as in African countries. During the 20th century, male circumcision gained popularity for perceived health benefits and social reasons in North America, New Zealand and Britain, but not elsewhere in Europe. In the United States, neonatal and childhood circumcision incidence rate peaked at 85% in 1965. The trend persisted, then declined to 56% in 2006 and most recently 32% in 2009, although the validity of these percentages varies depending on the source of data collection.9,10 The only developed countries in which non-therapeutic circumcision remains common are the United States and South Korea, though it lingers in Canada and Australia. Even in these places, habit and tradition play a major role in parental preferences. In the 1970s, the Australian newborn circumcision rate decreased from 50% to 40%. In the 1980s and 1990s, less than 10% of babies were circumcised. In 2003, the infant circumcision rate in Australia was 13%.8,11,12 Most circumcisions in Australia are now attributable to the cultural or religious adherence of the parents mainly and increasingly Muslim these days. In 2006–2007, most Australian states withdrew circumcision from the range of free services provided in public hospitals through Medicare funding system. The result is that most nontherapeutic circumcisions are now performed by general practitioners and in private clinics. World-wide trends of circumcision are affected by religious views (Islam, Judaism and Christianity) and cultures. In subSaharan Africa, cultural identity plays as important a role as religion during circumcision. In the developed countries, the popularity of circumcision often depends on the society’s current perceptions of the health benefits of the practice. In Australia, male circumcision was popularised during the world wars,13 presumably to treat recurrent balanitis.14 Anecdotally, circumcision was thought to improve hygiene by reducing sand accumulation under the foreskin. As these returning soldiers became fathers, circumcised newborns became the norm, aiming to prevent balanitis and allow their boys to fit in with the norm at that time. There was also the argument that newborn
Journal of Paediatrics and Child Health 51 (2015) 580–583 © 2015 The Authors Journal of Paediatrics and Child Health © 2015 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
AF Na et al.
circumcision was less complicated and less costly compared with adult circumcision. However, in the 1960–1970s, as the number of newborn circumcisions increased, so did the number of reported complications. Most of these were minor complications, such as bleeding and infection. However, catastrophic complications such as cases of glans amputation15 and deaths have been reported.16 After the initial circumcision, some boys require more procedures for cosmetic revision. In Australia, the decline in newborn circumcision rate may be related to the increased parental education on maintaining penile hygiene without removing the foreskin. UTI is more common in the first year of life and affects up to 1–2% of boys and 4% of girls by age 12.17,18 The risk is higher in uncircumcised boys with underlying renal tract abnormalities,19,20 which can be diagnosed with antenatal or post-natal ultrasound. Although circumcision reduces the risk of childhood UTI by about 10-fold,18 UTI is a medical condition treated effectively with antibiotics. For most Australian newborns, there is a good access to early antibiotic treatment. Antenatal and post-natal ultrasound scanning can be used to identify those newborns at higher risk of recurrent UTI. So, rather than recommending circumcision to all newborns, clinicians can selectively offer circumcision for those with higher risk. One hundred and eleven newborns would need to be circumcised to prevent one UTI because of the low baseline risk of infection. However, when targeted at higher-risk newborns, the number needed to treat is only 11.18 Despite emerging data from sub-Saharan Africa of the benefit of circumcision in reducing male HIV acquisition via heterosexual contact,21–23 there is a decline in the proportion of circumcised adults in Australia. Circumcision was less common among younger males (32% aged
doi:10.1111/jpc.12825
VIEWPOINT
Circumcision: Is it worth it for 21st-century Australian boys? Angelika F Na,1 Sharman PT Tanny1 and John M Hutson1,2 1 F. Douglas Stephens Surgical Research Laboratory, Murdoch Childrens Research Institute and 2Department of Urology, Royal Children’s Hospital, Melbourne, Victoria, Australia
Key words:
HIV; male circumcision; newborn; sexually transmitted disease; urinary tract infection.
Male circumcision is a centuries-old medical practice imbued with rich historical, religious and cultural tradition. Circumcision presumably started as a religious and social tradition to maintain hygiene, reduce infection and provide cultural identity. In the modern era, circumcision is a part of paediatric surgical practice to treat phimosis, balanitis and paraphimosis when medical interventions fail.1 However, non-therapeutic circumcision in infants and boys has always been a debated, controversial and minority practice. Data from research studies are often coloured by the authors’ personal belief of what should be the male norm – circumcised or uncircumcised. Although most of the research on circumcision have sound scientific basis, its findings are usually only applicable to the specific socio-cultural context in which the study was conducted. Yet many authors tend to prematurely extrapolate the data in an attempt to set national and international standards on circumcision in infants. The 2012 American Academy of Paediatrics policy statement on circumcision2 departed from their earlier 1999 policy. Although the statement did not recommend circumcision, it stated that health benefits of circumcision in the newborn outweigh the risks, in particular for urinary tract infection (UTI) prevention, human immunodeficiency virus (HIV) acquisition and transmission of sexually transmitted diseases (STDs). In addition, the policy concluded that significant acute complications are rare. Coming from such an influential body, it revived the international controversy of the topic.3 In Australia, the 2010 Royal Australasian College of Physicians’ policy4 concluded that there is currently insufficient evidence to recommend routine newborn circumcision. Other medical societies such as Canadian Paediatric Society5 and British Medical Association6 also cited lack of consistent data to recommend non-therapeutic circumcision. Royal Dutch Medical Association stated that the practice ‘is a violation of children’s rights to autonomy and physical integrity’.7
Correspondence: Prof. John M Hutson, F. Douglas Stephens Surgical Research Laboratory, Murdoch Childrens Research Institute, 9th floor, Royal Children’s Hospital 50 Flemington Road, Parkville, Melbourne, Vic. 3052, Australia. Fax: 61 03 9345 7997; email: [email protected] Conflict of interest: The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication. Accepted for publication 21 November 2014.
580
Global estimates in 2006 suggest that about 30% of males are circumcised. Male circumcision is almost universal in the Middle East, Central Asia, Bangladesh, Indonesia and Pakistan. Male circumcision is common in many African countries, yet the rate varies from 15% to 70% depending on the countries.8 Circumcision is prevalent in these societies because they are largely Islamic, or for tribal and cultural reasons such as in African countries. During the 20th century, male circumcision gained popularity for perceived health benefits and social reasons in North America, New Zealand and Britain, but not elsewhere in Europe. In the United States, neonatal and childhood circumcision incidence rate peaked at 85% in 1965. The trend persisted, then declined to 56% in 2006 and most recently 32% in 2009, although the validity of these percentages varies depending on the source of data collection.9,10 The only developed countries in which non-therapeutic circumcision remains common are the United States and South Korea, though it lingers in Canada and Australia. Even in these places, habit and tradition play a major role in parental preferences. In the 1970s, the Australian newborn circumcision rate decreased from 50% to 40%. In the 1980s and 1990s, less than 10% of babies were circumcised. In 2003, the infant circumcision rate in Australia was 13%.8,11,12 Most circumcisions in Australia are now attributable to the cultural or religious adherence of the parents mainly and increasingly Muslim these days. In 2006–2007, most Australian states withdrew circumcision from the range of free services provided in public hospitals through Medicare funding system. The result is that most nontherapeutic circumcisions are now performed by general practitioners and in private clinics. World-wide trends of circumcision are affected by religious views (Islam, Judaism and Christianity) and cultures. In subSaharan Africa, cultural identity plays as important a role as religion during circumcision. In the developed countries, the popularity of circumcision often depends on the society’s current perceptions of the health benefits of the practice. In Australia, male circumcision was popularised during the world wars,13 presumably to treat recurrent balanitis.14 Anecdotally, circumcision was thought to improve hygiene by reducing sand accumulation under the foreskin. As these returning soldiers became fathers, circumcised newborns became the norm, aiming to prevent balanitis and allow their boys to fit in with the norm at that time. There was also the argument that newborn
Journal of Paediatrics and Child Health 51 (2015) 580–583 © 2015 The Authors Journal of Paediatrics and Child Health © 2015 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
AF Na et al.
circumcision was less complicated and less costly compared with adult circumcision. However, in the 1960–1970s, as the number of newborn circumcisions increased, so did the number of reported complications. Most of these were minor complications, such as bleeding and infection. However, catastrophic complications such as cases of glans amputation15 and deaths have been reported.16 After the initial circumcision, some boys require more procedures for cosmetic revision. In Australia, the decline in newborn circumcision rate may be related to the increased parental education on maintaining penile hygiene without removing the foreskin. UTI is more common in the first year of life and affects up to 1–2% of boys and 4% of girls by age 12.17,18 The risk is higher in uncircumcised boys with underlying renal tract abnormalities,19,20 which can be diagnosed with antenatal or post-natal ultrasound. Although circumcision reduces the risk of childhood UTI by about 10-fold,18 UTI is a medical condition treated effectively with antibiotics. For most Australian newborns, there is a good access to early antibiotic treatment. Antenatal and post-natal ultrasound scanning can be used to identify those newborns at higher risk of recurrent UTI. So, rather than recommending circumcision to all newborns, clinicians can selectively offer circumcision for those with higher risk. One hundred and eleven newborns would need to be circumcised to prevent one UTI because of the low baseline risk of infection. However, when targeted at higher-risk newborns, the number needed to treat is only 11.18 Despite emerging data from sub-Saharan Africa of the benefit of circumcision in reducing male HIV acquisition via heterosexual contact,21–23 there is a decline in the proportion of circumcised adults in Australia. Circumcision was less common among younger males (32% aged
