Safety and Efficacy of Nontherapeutic Male Circumcision: A Systematic Review
Caryn L. Perera, BA, Grad Cert EBP, Franklin H. G. Bridgewater, MBBS, FRACS, Prema Thavaneswaran, BSc (Hons), PhD and Guy J. Maddern, PhD, FRACS

Annals of Family Medicine
Volume 8, Issue 1, January/February 2010

ABSTRACT

PURPOSE:  We wanted to assess the safety and efficacy of nontherapeutic male circumcision through a systematic review of the literature.

METHODS:  We systematically searched The York Centre for Reviews and Disseminations, Cochrane Library, PubMed, and EMBASE databases for randomized controlled trials published between January 1997 and August 2008. Studies reporting on circumcision in an operative setting in males of any age with no contraindications to or medical indications for circumcision were eligible for inclusion. The main comparator was intact genitalia. From 73 retrieved studies, 8 randomized controlled trials were ultimately included for analysis.

RESULTS:  Severe complications were uncommon. Analgesia/anesthesia during circumcision was promoted. The prevalence of self-reported genital ulcers was significantly lower in circumcised men than uncircumcised men (3.1% vs 5.8%; prevalence risk ratio 0.53; 95% confidence interval [CI], 0.43–0.64; P<.001). Circumcised sub-Saharan African men were at significantly lower risk of acquiring human immunodeficiency virus/acquired immune deficiency syndrome than were uncircumcised men (random effects odds ratio = 0.44, 95% CI, 0.32–0.59; P <.001). The evidence suggests that adult circumcision does not affect sexual satisfaction and function.

CONCLUSIONS:  Strong evidence suggests circumcision can prevent human immunodeficiency virus/acquired immune deficiency syndrome acquisition in sub-Saharan African men. These findings remain uncertain in men residing in other countries. The role of adult non-therapeutic male circumcision in preventing sexually transmitted infections, urinary tract infections, and penile cancer remains unclear. Current evidence fails to recommend widespread neonatal circumcision for these purposes.

Research Recommendation

Although approximately 30% of the global male population is circumcised, there is a paucity of high-quality evidence. Depending on the indication under investigation, prospective RCTs and case-control studies should be conducted to strengthen the evidence base and allow more informed conclusions on nontherapeutic male circumcision to be drawn.

Although the evidence for the efficacy of adult nontherapeutic male circumcision in preventing HIV/AIDS acquisition in sub-Saharan African men is strong, it is unclear whether these findings can be extrapolated to male populations in other countries. The role of adult nontherapeutic male circumcision in preventing sexually transmitted infection, urinary tract infection, and penile cancer is less clear, whereas the role of neonatal circumcision in preventing HIV/AIDS, sexually transmitted infection, urinary tract infection, and penile cancer is not presently supported by RCT evidence.

Patients who request circumcision in the belief that it bestows clinical benefits must be made aware of the lack of consensus and robust evidence, as well as the potential medical and psychosocial harms of the procedure. As the efficacy of prophylactic nontherapeutic male circumcision has not been comprehensively studied in neonates, it would be inappropriate to recommend widespread neonatal circumcision for this purpose.

Full text of the article may be read at Annals of Family Medicine

Comment

This level-headed article comes as a welcome breath of fresh air, and confirms the policy of the Royal Australasian College of Physicians to discourage medically unnecessary circumcision of minors. The bottom line is that (routine) preventive circumcision of minors offers no significant health benefit, carries significant risks, has an adverse effect on sexual sensation, and should not be performed.

There are two points that might be questioned.

First, the estimate of 30 per cent of men world-wide circumcised seems too high. Even allowing that most Muslims are circumcised (and there are probably many who are not), and that circumcision is common among tribal societies in Africa, it does not seem likely that the total could be much more than 25 per cent – though of course, fuelled by American dollars and those Microsoft millions, the World Health Organisation is certainly doing its best to make Africa foreskin-free. In fact, circumcision is rapidly becoming a practice confined to the underdeveloped world, where people who do not know any better have no choice but to obey those white witchdoctors.

Second, to conclude that “the evidence suggests that adult circumcision does not affect sexual satisfaction and function” suggests that the search for evidence has not been as thorough as it might have been. It is highly likely that circumcision in adulthood has a far less severe effect on sexual function and genital sensation than if it is done in infancy or childhood (for which reason maturity is a much better time to do it, if it must be done), but there are plenty of men, circumcised as adults, who report a significant loss of sexual feeling, and who bitterly regret their decision.