Occasional ReviewNon-therapeutic male circumcision
Introduction
Victorian Britain considered nontherapeutic male circumcision (NTMC) to offer protection against syphilis, balanitis, inferior hygiene and phimosis. As a consequence, NTMC became popular in Anglophone countries. In 1949, however, Gairdner noted 16 deaths annually in children undergoing NTMC, mostly resulting from crude anaesthetics used at the time. This led to a decline in NTMC in the UK.
Recent guidelines from the UK (The 2019 BMA Guidance on NTMC) is consistent with this generally negative approach. It recognizes the wide spectrum of views within both society and the medical profession in the UK.
The guidance states, ‘It should be noted that although representing doctors, the BMA is not a clinical organisation. We would welcome a more comprehensive review of the literature on this issue from an impartial clinical organisation.’ Since the guidance states that the ‘BMA's specialists in science and public health’ obtained, ‘good evidence from international studies that male circumcision can reduce the chances of acquiring HIV,’ a comprehensive review should be within the purview of BMA specialists.
Our primary aim is to assist in establishing such an evidence-based position in response to the BMA's statement that, ‘those wishing to authorize the procedure for their children need to demonstrate that it is in the child's best interests.’ Our secondary aim is to provide a risk-benefit analysis applicable to the UK.
Section snippets
How prevalent is NTMC?
Historical estimates of 30% for global prevalence of male circumcision have been superseded by a detailed compilation of prevalence data for every country and territory that estimated a global circumcision prevalence of 38–39% for males aged ≥15 years. In the UK circumcision rates are lower than this. Britain's third National Survey of Sexual Attitudes and Lifestyles (Natsal-3) of a nationally representative sample of 4,816 men aged 16–74 found that 20.7% were circumcised.1
Function of the foreskin
Not unreasonably, many paediatricians take the view that the foreskin must have a role or function. Otherwise, why would we have evolved to have one? Whilst there is debate about the role of the foreskin, with possible functions that include keeping the glans moist, protecting the developing penis in utero, or enhancing sexual pleasure due to the presence of nerve receptors. However, these purported functions remain contentious and its sexual functions are now contradicted by strong scientific
Why is NTMC controversial?
A paradigm shift in attitude to NTMC occurred in 2007 when the WHO endorsed the procedure for HIV reduction in epidemic settings. This has led to a divergent policy position by different countries. The American Academy of Pediatrics (AAP) advises that, ‘the current evidence suggests that the health benefits of NTMC outweigh the risks’ (see Box 1 for AAP recommendations). The AAP's recommendations followed an extensive review of the medical literature. The largest review by far on NTMC was by
Is NTMC of overall benefit or harm to a child's health?
This question may depend upon context. In the ‘Health risks and benefits’ subsection the recent BMA guidance it states that there is, ‘good evidence from international studies that male circumcision can reduce the chances of acquiring HIV in some circumstances,’ but warns ‘caution must be taken about how this can be extrapolated to the UK.’ In contrast, the CDC cited US and sub-Saharan African data in concluding that circumcised males in the US are at reduced risk of heterosexual acquisition of
Condoms
Data show that condoms, when used consistently and correctly, provide protection against HIV infection ranging from 71 to 80%. However, they are not a certain prophylactic in any sense. Condoms may of course break or slip off. Genital contact with an infected partner may take place during foreplay, prior to application of the condom. A Cochrane systematic review and meta-analysis of RCTs of condom use (two in the US, one in England and four in Africa) found, ‘little clinical evidence of
NTMC and sexual problems
Compelling data suggest that NTMC has virtually no adverse effect on sexual function, including erectile function, premature ejaculation, ejaculatory latency, orgasm difficulties, and pain during penetration. The evidence is summarized in a recent systematic review.3 It includes two randomized clinical trials, four systematic reviews (by authors in Australia, the US, China, and Denmark where NTMC is uncommon), two meta-analyses from China, a longitudinal cohort study and the British Natsal-3
NTMC and sexual pleasure
Other studies, including RCTs, found NTMC had no adverse effect on sexual pleasure. In fact, the RCTs found a net increase in sexual pleasure in circumcised men and their female partners.
A systematic review of histological correlates of sexual sensitivity found that the neuroreceptors responsible for sexual pleasure are concentrated in the glans and underside of the shaft, there being none in the foreskin, thus supporting the survey findings above. Claims that NTMC diminishes sexual pleasure
Procedural risks from NTMC
A 2014 study by CDC researchers of 1.3 million medical infant NTMCs in the US, based on inpatient data as well as data from more than 870,000 unique outpatient medical providers, found an adverse event frequency of 0.4%. Adverse events were 20-times higher for ages 1–9 years, and 10-times higher for ages ≥10 years. A large California study found adverse event frequency was 0.5% in neonates, but 18.5 times higher in non-neonates. The AAP policy gave adverse event figures of 0.19%–0.34% for
Benefits
The AAP and CDC reviews found that prophylactic early infant NTMC confers immediate and long-term benefits that include protection against infant and lifetime urinary tract infections, phimosis, inflammatory foreskin conditions, and, in sexually mature males, STIs (see above), penile cancer and prostate cancer. In addition, male circumcision partially protects female partners against various STIs and cervical cancer.
Risk-benefit analysis for the UK
The BMA's guidance acknowledges that NTMC, ‘is generally considered a low-risk procedure.’ While recognizing that, ‘usually risks of surgery are offset by the medical benefits that ensue,’ the BMA equivocates as to whether there are clear medical benefits from NTMC, and if not, whether, ‘some other justification is needed for exposing children to this risk.’ But no data were provided.
We therefore performed a risk-benefit analysis using the most relevant data obtained from key articles
Circumcision for medical purposes
The BMA guidance recognizes that circumcision may be required for medical indications. It lists these as including phimosis, paraphimosis, recurrent balanitis, lichen sclerosis (‘balanitis xerotica obliterans (BXO)’), prophylaxis of urosepsis in those with underlying structural urological abnormalities, traumatic injury (citing ‘zipper’ injury), and foreskin removal for penile malignancy. The risk of each of these is reduced by neonatal NTMC. It nevertheless cautions against therapeutic
The law and ethics
In the UK NTMC is generally assumed to be lawful if:
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it is believed to be in the child's best interests;
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there is valid consent (noting the role of both parents); and
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it is performed competently.
Nevertheless, in the UK, ‘lawfulness is not, however, grounded in statute and despite this common law assumption, the legality is not uncontroversial’. In 1995 the Law Commission concluded that, ‘although in its view ritual circumcision is lawful, law reform to ‘put the lawfulness of ritual male
Intactivism (opposition to NTMC of minors)
Just as there are anti-vaccination lobby groups there are anti-NTMC lobby groups. The BMA guidance rightly states that it, ‘abhors the harassment of individual doctors through intimidating and threatening behaviour on the basis of their involvement in the provision of NTMC.’ The same should be said for attacks on parents who choose to protect their sons' health by infant NTMC. Policy criticisms by NTMC opponents were repudiated by the AAP and CDC. For a comprehensive critical evaluation
Our views on NTMC
In public health, all effective disease prevention measures should be recommended, provided risk of the intervention is low, as is the case for NTMC.
Since prevention is an important aspect of advice on all health-related matters, wouldn't it be more sensible to recommend neonatal NTMC to reduce risk of the above conditions in the first place? This advice is also favoured by cost-benefit analyses.4
Conclusions
NTMC is a one-off procedure that is most conveniently performed in early infancy using local anaesthesia. In early infancy it is simpler, safer, quicker, cheaper, more convenient, cosmesis is optimum, and healing is faster than later circumcision, which presents multiple other challenges (Table 2). Recent UK guidance deals mostly with religious and cultural factors in minorities.
Given the evidence, it is our view that infant NTMC might be considered in a similar manner as childhood vaccination.
References (4)
- et al.
Examining the association between male circumcision and sexual function: evidence from a British probability survey
AIDS
(2015) - et al.
Male circumcision and STI acquisition in Britain: evidence from a national probability sample survey
PLoS One
(2015)