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Positions of major health organizations United States “Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In the case of circumcision, in which there are potential benefits and risks, yet the procedure is not essential to the child’s current well-being, parents should determine what is in the best interest of the child. To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision. It is legitimate for parents to take into account cultural, religious, and ethnic traditions, in addition to the medical factors, when making this decision. Analgesia is safe and effective in reducing the procedural pain associated with circumcision; therefore, if a decision for circumcision is made, procedural analgesia should be provided. If circumcision is performed in the newborn period, it should only be done on infants who are stable and healthy.” The American Medical Association defines “non-therapeutic” circumcision as the non-religious, non-ritualistic, not medically necessary, elective circumcision of male newborns. It states that medical associations in the US, Australia, and Canada do not recommend the routine non-therapeutic circumcision of newborns. It supports the general principles of the 1999 Circumcision Policy Statement of the American Academy of Pediatrics. The American Urological Association (2007) recommends "that circumcision should be presented as an option for health benefits." 3 Canada and "Neonatal circumcision revisited" in 1996. The 1996 position statement says that "circumcision of newborns should not be routinely performed," (a statement with which the Royal Australasian College of Physicians concurs,) and the 2004 advice to parents says it "does not recommend circumcision for newborn boys. Many paediatricians no longer perform circumcisions." “We undertook this literature review to consider whether the CPS should change its position on routine neonatal circumcision from that stated in 1982. The review led us to conclude the following. There is evidence that circumcision results in an approximately 12-fold reduction in the incidence of UTI during infancy. The overall incidence of UTI in male infants appears to be 1% to 2%. The incidence rate of the complications of circumcision reported in published articles varies, but it is generally in the order of 0.2% to 2%. Most complications are minor, but occasionally serious complications occur. There is a need for good epidemiological data on the incidence of the surgical complications of circumcision, of the later complications of circumcision and of problems associated with lack of circumcision. Evaluation of alternative methods of preventing UTI in infancy is required. More information on the effect of simple hygienic interventions is needed. Information is required on the incidence of circumcision that is truly needed in later childhood. There is evidence that circumcision results in a reduction in the incidence of penile cancer and of HIV transmission. However, there is inadequate information to recommend circumcision as a public health measure to prevent these diseases. When circumcision is performed, appropriate attention needs to be paid to pain relief. The overall evidence of the benefits and harms of circumcision is so evenly balanced that it does not support recommending circumcision as a routine procedure for newborns. There is therefore no indication that the position taken by the CPS in 1982 should be changed. When parents are making a decision about circumcision, they should be advised of the present state of medical knowledge about its benefits and harms. Their decision may ultimately be based on personal, religious or cultural factors. United Kingdom The British Medical Association's position (June 2006) was that male circumcision for medical purposes should only be used where less invasive procedures are either unavailable or not as effective. The BMA specifically refrained from issuing a policy regarding “non-therapeutic circumcision,” stating that as a general rule, it “believes that parents should be entitled to make choices about how best to promote their children’s interests, and it is for society to decide what limits should be imposed on parental choices.” Australasia CIRCUMCISION PROCEDURES Clamps are designed to cut the blood supply to the foreskin, stop any Bleeding and protect the glans. Before using a clamp, the foreskin and the glans are separated with a blunt probe and/or curved hemostat.
POSSIBLE COMPLICATIONS OF CIRCUMCISION The complications listed here are known to have occurred at least once, and have been reported in medical journals. They ''may or may not'' occur in a particular operation. The immediate complications may be classified as surgical mishap, Hemorrhage , Infection and Anesthetic Risk . Immediate Complications Infection and bleeding are by far the most common complications. According to the AMA, Blood Loss and Infection are the most common complications. Bleeding is mostly minor; applying pressure will stop it.
: Infections are usually minor and local, but in some cases they have led to Urinary Tract Infection 28, life-threatening Systemic Infections 29, Meningitis 30 or death 31. ''1 Studies investigating several forms of pain relief have one entry for each form.'' Howard ''et al'' report that neonatal circumcision without Anaesthesia and using Acetaminophen (Tylenol) results in deteriorated breast-feeding immediately after circumcision. {Link without Title} They commented: :Numerous studies have shown that circumcision causes severe pain. This is shown by measures of crying, heart rate, respiratory rate, transcutaneous PO2, and cortisol levels ... {Link without Title} ... Neonatal circumcision are often performed on the day of discharge with many neonates leaving the hospital 3 to 6 hours postoperatively. Thus the observed deterioration in ability to Breast-feed may potentially contribute to breast-feeding failure. Furthermore some neonates in this study required formula supplementation because of maternal frustration with attempts at breast-feeding, or because the neonate was judged unable to breast-feed postoperatively. This finding is disconcerting because early formula supplementation is associated with decreased breast-feeding duration. Howard ''et al.'' concluded that: :Acetaminophen was not found to ameliorate either the intra-operative or the immediate postoperative pain of circumcision, although it seems that it may provide some benefit after the postoperative period. {Link without Title} Many other studies have investigated the pain caused by circumcision, and the effectiveness of different forms of analgesia and anaesthesia. Taddio ''et al'' reported behavioural changes (heightened pain responses) during vaccinations in children circumcised with EMLA cream and with no anaethesia at the 99.9+% statistical confidence level (p<0.001) four to six months after their circumcision, suggesting a persistent effect on pain response. {Link without Title} The researchers commented: : "Study of the vaccination pain response of infants who had received more effective circumcision pain management (i.e., dorsal penile nerve block and adequate postoperative pain management) would be interesting." Kirya and Werthmann investigated the effect of Dorsal Penile Nerve block (DPNB), describing it as "painless". However, Lander ''et al'' found that DPNB is less effective than ring block.[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9417009&query_hl=1 Marshall ''et al'' report that the stress of Neonatal Circumcision may alter feeding behaviour and some male infants may be unable to breastfeed after circumcision. {Link without Title} They commented: :Despite differences between control and experimental infants shortly after surgery, by 24 h post-operatively no significant differences were observed between the groups. The behavioral effects of circumcision in the present study were immediate but brief. This should be comforting information to those who provide care for newborns and for their parents. {Link without Title} Marshall ''et al'' did not report whether anaesthesia was used. Fergusson ''et al.'' found no evidence in their study of an association between neonatal circumcision and breastfeeding. They concluded that "the findings do not support the view that neonatal circumcision disrupts breastfeeding."46 Emotional consequences POSSIBLE PROTECTIONS GAINED BY CIRCUMCISION Prostate cancer is least common in Asian men, more common in European men and most common in Black men [http://www.hsc.stonybrook.edu/som/urology/urology_cp_prostatecancer.cfm . However, these high rates may reflect increased detection rates [http://jama.ama-assn.org/cgi/content/abstract/273/7/548]. Neither the American Cancer Society nor the professional medical organizations' policy statements on circumcision that are cited in this article mention a relationship between prostate cancer and circumcision status. Early obtained results as follows: Ross ''et al.'' of the National Cancer Institute. 1987 May;78(5):869-74 reported on two case-control studies, both in Southern California. Both studies included 142 cases. In both studies, circumcised men were at reduced risk (relative risk of 0.5 in whites and 0.6 in blacks).[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=3471995] Mandel & Schuman Gerontology. 1987 May;42(3):259-64 .reported on a case-control study with 250 cases. When compared to controls drawn from their neighborhood, circumcised men were less likely to develop prostate cancer (odds ratio 0.82). [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=3553301] Ewings & Bowie J Cancer. 1996 Aug;74(4):661-6 performed a case-control study of 159 cases of prostate cancer, and found that circumcised men were at a reduced risk (odds ratio 0.62) [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8761387]. They noted: ''"...some statistically significant associations were found, although these can only be viewed as hypothesis generating in this context."'' Human Papilloma Virus (HPV) and That study was criticized on methodological grounds. [http://www.cirp.org/library/disease/cancer/vanhowe2006b/ but Baldwin ''et al'' (2004) [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15388997] also found less HPV infection in circumcised men in their sample. HPV and cervical cancer Several studies were performed to investigate whether smegma had Carcinogenic Properties . Pratt-Thomas ''et al.'' in 1956, found that horse smegma had a carcinogenic effect on laboratory mice and Heins ''et al,'' 1958 found that human smegma also had a carcinogenic effect on these mice. However, when Reddy and Baruah did a study in 1963, they were unable to reproduce this effect, leading them to conclude that the carcinogenic effect must be weak. Wynder (1964) was uncertain about the connectiion between male circumcision, smegma and cervical cancer [http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1816029 . In 2006 Van Howe and Hodges described and discussed human smegma, asserting that the claims of harm in it were a myth that "has evolved over time and with retelling."[http://www.cirp.org/library/disease/cancer/vanhowe2006/] Some medical researchers have found evidence of a link between a higher incidence of Cervical Cancer in female partners of uncircumcised men and a higher incidence of penile human papillomavirus (HPV) in uncircumcised men. [http://sti.bmjjournals.com/cgi/content/full/78/3/215 Stern and Neely (1962) observed no protective effect of male circumcision in female partners. Punyaratabandhu ''et al.'' (1982) reported a protective effect in Thai women [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=7119622 , Kjaer ''et al.'' (1991) reported an apparently protective effect in Dutch women, that failed to achieve statistical significance. and Agarwal ''et al.'' (1993) observed a significantly protective effect among Indian women.[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8348498 . The role of male circumcision in female infection with HPV remains controversial. As Castellsagué (2002) said, "...it would not make sense to promote circumcision as a way to control cervical cancer in the United States, where Pap Smear s usually detect it at a treatable stage." Now an HPV vaccine that is effective against the two strains of HPV that are responsible for 70% of the cases of cervical cancer is being distributed {Link without Title} . In 2000, cervical cancer deaths in Great Britain were 3.9 per 100,000 patient-years, 3.3 in the USA, 2.8 in Canada, and 2.4 in Australia. In Great Britain, cancer deaths in women under 35 had tripled between 1967 and 1987. Gilham ''et al'' found that national cervical screening prevented many deaths from cervical cancer by reversing that trend. In their estimation, one in 65 of all British women born since 1950 would have died from cancer of the cervix without the screenings [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15262102 . Penile cancer See Also: Penile cancer Penile Cancer is a rare form of Cancer . Annually, there is one case in 100 000 men in Developed Countries . [http://www.cancer.org/docroot/CRI/content/CRI_2_4_1X_What_are_the_key_statistics_for_penile_cancer_35.asp?sitearea= The overall five-year survival rate for all stages of penile cancer is about 50 per cent. One 1980 study estimated that the lifetime risk of an uncircumcised man developing invasive penile cancer (IPC) is one in 600 This was more than 3 times higher than for males neonatally circumcised. [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11144896&dopt=Abstract [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8260177&dopt=Abstract Most cases of penile cancer occur in men over the age of 70. Childhood circumcision has been associated with a reduced incidence of penile cancer in numerous studies. [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11144896&dopt=Abstract [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11405332&dopt=Abstract [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10699138&dopt=Abstract Boczko and Freed (1979) stated that since Wolbarst's 1932 review, "there have been only eight documented cases of penile carcinoma in an individual circumcised in infancy." They described the ninth reported case, concluding that "performing it in infancy continues to be the most effective prophylactic measure against penile carcinoma."54 {Link without Title} The AMA remarked that in six case series published from 1932 and 1986, "all penile cancers occurred in uncircumcised individuals." Maden ''et al'' (1993) reported that the risk of penile cancer was 3.2 times greater in men who were never circumcised and 3 times greater among those who were circumcised after the neonatal period.55 An editorial by Holly and Palefsky complimented the study for noting other risk factors for penile cancer, and also for providing corroborating evidence as to the association between a lack of neonatal circumcision and the development of penile cancer. However, they criticised include the study for combining data from invasive and ''in situ'' cancers. They concluded that as Maden reported that 20% of the men with penile cancer were circumcised at birth, the recommendation of circumcision for medical indications remained somewhat controversial and the risks and benefits must be weighed.56 The American Academy of Pediatrics made similar criticism, also noting the possibly inaccurate use of self-report to determine circumcision status. Schoen ''et al'' studied the association between neonatal circumcision and invasive penile cancer in 2000, and found that the relative risk for uncircumcised men was 22 times that of circumcised men.57 The American Academy Of Pediatrics (1999) stated that studies suggest that neonatal circumcision confers some protection from penile cancer, but circumcision at a later age does not seem to confer the same level of protection. Further, penile cancer is a rare disease and the risk of penile cancer developing in an uncircumcised man, although increased compared with a circumcised man, remains low. Similarly, the American Medical Association states that although neonatal circumcision seems to lower the risk of contracting penile cancer, because it is rare and occurs later in life, the use of circumcision as a preventive practice is not justified. They estimated a rate of 1 in 600, or 0.167% in uncircumcised males, with a median age of occurrence of 67 years. They stated, “Since the uncircumcised male is uniquely susceptible, virtually all of these cancers are preventable by neo-natal circumcision. The number of lifetime incident cancers that could be prevented annually by circumcision can be estimated with birth statistics available for 1971. In that year, there were 1,822,910 recorded live male births. If none had been neonatally circumcised, our analysis predicts that one in 600, or more than 3,000 would have penile cancer in their lifetimes.” The Medical College of Georgia is now studying the impact of the new vaccine against "HPV types 16 and 18, the two most common causes of cervical and penile cancer" {Link without Title} Positions of medical organisations The American Medical Association , American Academy Of Pediatrics , American Association Of Family Physicians , Royal Australasian College Of Physicians , and the Canadian Paediatric Society state that circumcision reduces the risk of penile cancer. The American Medical Association and the Royal Australasian College Of Physicians both stated that the use of infant circumcision to prevent Penile Cancer alone in adulthood is not justified. [http://www.racp.edu.au/hpu/paed/circumcision/print.htm The American Cancer Society stated:: :In the past, circumcision has been suggested as a way to prevent penile cancer. This suggestion was based on studies that reported much lower penile cancer rates among circumcised men than among uncircumcised men. However, most researchers now believe those studies were flawed because they failed to consider other factors that are now known to affect penile cancer risk {Link without Title} . : (last revised 10 March 2006 ) Elsewhere, the ACS stated: :Whether circumcision actually reduces risk is uncertain. :One line of reasoning is based on comparisons of risk across countries. Penile cancer is much less common in Israel, where nearly everyone is circumcised, than in the United States where only some men are. However, this comparison does not take into account other known risk factors such as the number of sexual partners, smoking, or personal hygiene. Furthermore, the risk of penile cancer in Denmark, where very few men are circumcised, is no higher than that in the United States {Link without Title} . And: :Recent studies have found that circumcised men are less likely to be infected with HPV, even after this risk is adjusted for differences in sexual behavior. Other studies suggest that circumcision may reduce the risk of more invasive forms of penile cancer. However, it is important that the issue of circumcision not distract the public's attention from avoiding known penile cancer risk factors – poor hygiene, having unprotected sex with multiple partners (increasing the likelihood of human papillomavirus infection), and cigarette smoking. {Link without Title} : (last revised 10 March 2006 ) Phimosis , and Rickwood ''et al.'' write in their 2000 paper "Towards evidence based circumcision of English boys" in the ''British Medical Journal'' {Link without Title} : Too many English boys, especially those under 5 years of age, are still being circumcised because of misdiagnosis of phimosis. What is phimosis? At birth, the foreskin is almost invariably non-retractable, but this state is transient and resolves in nearly all boys as they mature through puberty. Such normality, with an unscarred and pliant preputial orifice, is clearly distinguishable from pathological phimosis, a condition unambiguously characterised by secondary cicatrisation of the orifice, usually due to Balanitis Xerotica Obliterans . This problem, the only absolute indication for circumcision, affects some 0.6% of boys, peaks in incidence at 11 years of age, and is rarely encountered before the age of 5. (...) Strictly, only some 0.6% of boys with pathological phimosis need to be circumcised, although more relaxed criteria would allow for a similar proportion affected by recurrent balanoposthitis. A 1968 Danish study of 9,545 boys, which distinguished between phimosis and preputial adhesion, found that both conditions steadily declined with age. Phimosis was 8% among 6-7 year olds but only 1% among 16-17 year olds. Similarly, preputial adhesion was 63% among 6-7 year olds but only 3% among 16-17 year olds. The author, Jakob Øster, concluded: Phimosis is seen to be uncommon in schoolboys, and the indications for operation even rarer if the normal development of the prepuce is patiently awaited. When this policy is pursued, in the majority of cases of phimosis, it is seen to be a physiological condition which gradually disappears as the tissues develop. {Link without Title} The AAP state that the true frequency of problems such as phimosis is unknown. Several researchers have described less invasive treatments for phimosis than circumcision, and recommend that they be tried first. 6364 Several studies have identified phimosis as a risk factor for penile cancer. A letter to the British Medical Journal stated it would be irresponsible to expose a patient to risk for longer than necessary.Robin J Willcourt, "Re: Circumcision is a last resort - to be avoided, whenever possible" - letters to the editor, ''British Medical Journal'' http://bmj.bmjjournals.com/cgi/eletters/321/7264/792#110919 Phimosis is also a complication of circumcision, that can occur when too little foreskin is removed. {Link without Title} Images of phimosis. {Link without Title} {Link without Title} {Link without Title} {Link without Title} Circumcision and Urinary tract infection (UTI) A 1998 Canadian population based cohort study by To et al. {Link without Title} , for example, reported a relative risk of 3.7. The overall incidence of UTIs in infants was low, 1.88 and 7.02 per 1000 respectively. According to the American Medical Association, "There is little doubt that the uncircumcised infant is at higher risk for urinary tract infection (UTI)." Some of these studies have nevertheless been extensively criticized for their methodology. The American Academy Of Pediatrics noted in its 1999 circumcision policy statement: : Few of the studies that have evaluated the association between UTI in male infants and circumcision status have looked at potential confounders (such as prematurity, breastfeeding, and method of urine collection) in a rigorous way. For example, because premature infants appear to be at increased risk for UTI, the inclusion of hospitalized premature infants in a study population may act as a confounder by suggesting an increased risk of UTI in uncircumcised infants. Premature infants usually are not circumcised because of their fragile health status. In another example, breastfeeding was shown to have a threefold protective effect on the incidence of UTI in a sample of uncircumcised infants. However, breastfeeding status has not been evaluated systematically in studies assessing UTI and circumcision status. (Studies have found that 1 in 10 premature infants will have a urinary tract infection during the first month of life. {Link without Title} ) More recently, however, randomized controlled trials and other studies have confirmed the protective effect of circumcision[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11772190 [http://pediatrics.aappublications.org/cgi/content/full/105/4/789 . UTIs are usually detected through urine tests. Depending on the method of urine collection, there is a varying risk of false positives through contamination. The bacteria detected may in fact come from the foreskin itself, not the urinary tract. In spite of this, an increased risk of UTI in uncircumcised males is generally considered plausible, a higher likelihood of bacterial colonization being the proposed mechanism. However, studies of UTI and circumcision do not classify groups of circumcised males according to their mothers' handling of the foreskin, making it impossible to infer any link with specific hygienic practices. It is generally recommended not to retract the foreskin of an infant during hygiene {Link without Title} . The Canadian Paediatric Society questions whether increased UTI and Balanitis rates in uncircumcised male infants may be caused by Forced Premature Retraction . Hodges and Fleiss claim that "it has been proven that retraction and washing of the infant foreskin can cause urinary tract infections by irritating the mucous membranes and destroying the naturally occurring beneficial flora which protects against pathogens." More recent research has shown that in fact fewer pathogens are present in circumcised males. {Link without Title} Lerman and Liao state that apart from its effects on UTI infection rates, "Most of the other medical benefits of circumcision probably can be realized without circumcision as long as access to clean water and proper penile hygiene are achieved."Lerman SE, Liao JC. Neonatal circumcision. ''Pediatr Clin North Am.'' 2001 December;48(6):1539-57. PMID 11732129 UTIs in boys are most common during the first years of life A Swedish study found that the cumulative incidence of UTIs in boys under 2 years of age was 2.2%.Jakobsson 1999, ''et al''. Minimum incidence and diagnostic rate of first urinary tract infection. ''Pediatrics.'' 1999 August;104 (2 Pt 1):222–6. ([http://pediatrics.aappublications.org/cgi/content/full/104/2/222 full text ) The AMA cites evidence that the incidence of UTI’s is “small (0.4%–1%)” in uncircumcised infants, and “depending on the model employed, approximately 100 to 200 circumcisions would need to be performed to prevent 1 UTI…One model of decision analysis concluded that the incidence of UTI would have to be substantially higher in uncircumcised males to justify circumcision as a preventive measure against this condition.” Based upon their data, To et al. estimate that 195 circumcisions would be needed to prevent one hospital admission for UTI in the first year of life. Circumcision and HIV/AIDS In 1989 the Cameron study 66 was published and reported an 8.2 times higher risk of HIV infection among uncircumcised men. Since then some 38 studies have covered the issue of the protective effect accruing through male circumcision against female-to-male HIV transmission through vaginal sex. A recent study in Rakai, Uganda also observed a 30% reduction in male-to-female HIV transmission {Link without Title} , suggesting some protective effect for the female partner as well. There is no evidence yet, however, of a protective effect against transmission from the active partner to the passive partner in homosexual oral or anal intercourse. Changedia and Gilada (2002) reported that "Though circumcision offers protection in acquisition of HIV infection, our findings reveal that it does not reduce transmission of HIV in conjugal settings." Hunter ''et al.'' (1994), however, report that "Women whose husband or usual sex partner was uncircumcised had a threefold increase in risk of HIV, and this risk was present in almost all strata of potential confounding factors."[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=8011242&query_hl=8&itool=pubmed_docsum Fonck ''et al.'' (2000) reported that "Partners of circumcised men had less-prevalent HIV infection."[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=10949433&query_hl=16&itool=pubmed_docsum] The USAID document Male Circumcision:Current Epidemiological and Field Evidence summarized research as at September 2002. It states: :A systematic review and meta-analysis of 28 published studies by the London School of Hygiene and Tropical Medicine, published in the journal AIDS in 2000, found that circumcised men are less than half as likely to be infected by HIV as uncircumcised men. A subanalysis of 10 African studies found a 71 percent reduction among higher-risk men. A September 2002 update considered the results of these 28 studies plus an additional 10 studies and, after controlling for various potentially confounding religious, cultural, behavioral, and other factors, had similarly robust findings. Recent laboratory studies in Chicago found HIV uptake in the inner foreskin tissue to be up to nine times more efficient than in a control sample of cervical tissue. {Link without Title} However, the Cochrane Library for Evidence-based Medicine's review of the data (2004) reported: :We found insufficient evidence to support an interventional effect of male circumcision on HIV acquisition in heterosexual men. The results from existing observational studies show a strong epidemiological association between male circumcision and prevention of HIV, especially among high-risk groups. However, observational studies are inherently limited by confounding which is unlikely to be fully adjusted for. In the light of forthcoming results from RCTs, the value of IPD analysis of the included studies is doubtful. The results of these trials will need to be carefully considered before circumcision is implemented as a public health intervention for prevention of sexually transmitted HIV. {Link without Title} (See the "Recent results" section below for results of these trials.) Both UNAIDS and the Centers for Disease Control of the United States Public Health Service recommend that male circumcision should now be recognized as an efficacious intervention for HIV prevention and they are promoting that male circumcision should be recognized as an additional, important strategy for the prevention of heterosexually acquired HIV infection in men. Connolly ''et al.'' (2004) studied the effects of circumcision in South Africa. They report that, among racial groups, "circumcised Blacks showed similar rates of HIV as uncircumcised Blacks, (OR: 0.8, p = 0.4) however other racial groups showed a strong protective effect, (OR: 0.3, p = 0.01)." They added "When the data are further stratified by age of circumcision, there is a slight protective effect between early circumcision and HIV among Blacks, OR: 0.7, p = 0.4." They conclude that "in general, circumcision offers slight protection." {Link without Title} Thomas ''et al.'' (2004) report that "male circumcision is not associated with HIV or STI prevention in a U.S. Navy population." {Link without Title} Other researchers have contested the findings which indicate that circumcision reduces HIV transmission. For example, Van Howe, a leading anti-circumcision campaigner, produced a meta-analysis which presented circumcised men at a greater risk for HIV infection. He further speculated that circumcision may be responsible for the increased number of partners, and therefore, the increased risk. Van Howe's work was reviewed by O'Farrell and Egger who found methodological flaws in his work. Weiss, Quigley and Hayes carried out a new meta-analysis on circumcision and HIV and found as follows: :Male circumcision is associated with a significantly reduced risk of HIV infection among men in sub-Saharan Africa, particularly those at high risk of HIV. These results suggest that consideration should be given to the acceptability and feasibility of providing safe services for male circumcision as an additional HIV prevention strategy in areas of Africa where men are not traditionally circumcised. There have been other studies of note. Kelly ''et al.'' reported in " Age of male circumcision and risk of prevalent HIV infection in rural Uganda " that where circumcision was carried out before the age of 12 it results in a reduction to 0.39 of the odds of an uncircumcised man. The degree of protection changed according to the age at which circumcision was performed, however, with those circumcised at between 13 and 20 years at an odds ratio of 0.46, and those circumcised after the age of 20 at an odds ratio of 0.78. They concluded: "Prepubertal circumcision is associated with reduced HIV risk, whereas circumcision after age 20 years is not significantly protective against HIV-1 infection." With regard to the effects of behaviour on infection risk Buvé in USAID funded multi-site study on behalf of UNAIDS found that "In conclusion, differences in the rate of HIV spread between the East African and West African cities studied cannot be explained away by differences in sexual behaviour alone. In fact, behavioural differences seem to be outweighed by differences in HIV transmission probability." Bailey found in his study {Link without Title} that: :These results suggest that differences between circumcised and uncircumcised men in their sex practices and hygienic behaviors do not account for the higher risk of HIV infection found among uncircumcised men. Further consideration should be given to male circumcision as a prevention strategy in areas of high prevalence of HIV and other sexually transmitted diseases. Studies of the feasibility and acceptability of male circumcision in traditionally noncircumcising societies are warranted. Kiwanuka ''et al.'' (1996) studied the relationship between religion and HIV in Rural Uganda and concluded : "Lower rates of HIV infection among Pentecostal s appear to be associated with less Alcohol consumption, Sexual Abstinence and fewer sexual partners, whereas the low HIV prevalence in Muslim s appears to be associated with low reported alcohol consumption and male circumcision." Muslims, despite having the lowest rate of sexual abstinence and the highest rate of having two or more sexual partners, had the lowest level of HIV infection compared with the other religious groups in the study ( Catholic s, Protestant s, and Pentecostals). The factor in common between the Muslims (14.5% seropositive) and the Pentecostals (14.6% seropositive) was the lower alcohol consumption rate in these two groups than amongst Protestants (19.2%) and Catholics (19.9%). Studies have also been carried out as to the acceptability of male circumcison within traditionally non-circumcising communities. Kebaabetswe found that: :Male circumcision appears to be highly acceptable in Botswana. The option for safe circumcision should be made available to parents in Botswana for their male children. Circumcision might also be an acceptable option for adults and adolescents, if its efficacy as an HIV prevention strategy among sexually active people is supported by clinical trials. Lagarde found that "More than 70% of the non-circumcised men (NCM) stated that they would want to be circumcised if MC were proved to protect against sexually transmitted diseases (STD)." Lagarde cautioned that "Our results strongly suggest that interventions including MC should carefully address the false sense of security that it may provide." Bailey in his study Adult male circumcision in Kenya: safety and patient satisfaction looked at the possible adverse effects of introducing male circumcision on a public health scale and the post operative satisfaction levels of 380 circumcsions on 18-24 year old consenting men. As to satisfaction; "At 30 days post-surgery, 99.3% of men reported being very satisfied and 0.7% somewhat satisfied with circumcision. None were dissatisfied." And with regard to adverse effects; "All were mild or moderate and resolved within hours or several days of detection." In a recently published study in this regard in The Lancet , Male circumcision and risk (2004) of HIV-1 and other sexually transmitted infections in India , Reynolds and Bollinger found that male circumcision was strongly protective against HIV-1 infection with circumcised men being almost seven times less at risk of HIV infection than uncircumcised men.[http://news.bbc.co.uk/1/hi/health/3570223.stm] They further state that: :"The specificity of this relation suggests a biological rather than behavioural explanation for the protective effect of male circumcision against HIV-1." Baeten ''et al'' in a study published in The ''Journal of Infectious Diseases'' in 2005 found that uncircumcised men were at a greater than two-fold increased risk of acquiring HIV per sex act when compared with circumcised men. They conclude as follows: :"Moreover, our results strengthen the substantial body of evidence suggesting that variation in the prevalence of male circumcision may be a principal contributor to the spread of HIV-1 in Africa." A World Health Organization AIDS Prevention Team official Tim Farley disagreed with the findings of the paper, while Chris Surridge, PLoS One's managing editor, defended its publication.73 In 1999 the American Medical Association had stated, "behavioral factors are far more important in preventing these infections than the presence or absence of a foreskin." Despite the strong evidence of a significant protective effect of infant male circumcision, "male circumcision should not be actively promoted for HIV prevention unless and until the RCTs (Randomized controlled trials) confirm MC to be effective in reducing HIV infection". {Link without Title} If proper hygienic procedures are not adhered to, the circumcision operation itself can spread HIV. Brewer et al. (2007)74 report, " {Link without Title} male and female virgins were substantially more likely to be HIV infected than uncircumcised virgins. Among adolescents, regardless of sexual experience, circumcision was just as strongly associated with prevalent HIV infection. However, uncircumcised adults were more likely to be HIV positive than circumcised adults." They concluded: "HIV transmission may occur through circumcision-related blood exposures in eastern and southern Africa." Recent Results Three Randomised Control Trials published since 2005 confirm that adult male circumcision results in a 50-60% reduction in risk of HIV transmission (from female to male) during heterosexual intercourse. One of the more rigorous RCTs was cancelled July 6, 2005 when the study's preliminary results, disclosed by the Wall Street Journal, showed that circumcision reduced the risk of contracting HIV by 70 percent -- a level of protection far better than the 30 percent risk reduction set as a target for an AIDS vaccine. According to the newspaper account, the study under way in Orange Farm township, South Africa, was stopped because the results were so favorable. It was deemed unethical to continue the trial after an early peek at data showed that the uncircumcised men were so much more likely to become infected. {Link without Title} In assessing the impact of circumcision on the spread of sexually transmatted infections including HIV it must always be borne in mind that there are other risk factors. Thus, the United States has a high rate of STD infection and a high rate of circumcision compared with other advanced countries. {Link without Title} The above conclusions drawm from the Orange Farm study have also been criticised by Michel Garenne (2006) of the Institut Pasteur . In his critique, published on the PLoS Journal of Medicine, he states: "Concluding that 'male circumcision should be regarded as an important public health intervention for preventing the spread of HIV' appears overstated. Even though large-scale male circumcision could avert a number of HIV infections, theoretical calculations and empirical evidence show that it is unlikely to have a major public health impact, apart from the fact that achieving universal male circumcision is likely to be more difficult than universal vaccination coverage or universal contraceptive use." {Link without Title} . Mills and Siegfried (2006) point out that trials that are stopped early tend to over estimate treatment effects. They argue that a meta-analysis should be done before further feasibility studies are done. {Link without Title} These studies were terminated early because "an interim review of trial data revealed that medically performed circumcision significantly reduces a man’s risk of acquiring HIV through heterosexual intercourse." {Link without Title} On Wednesday, March 28, 2007, the World Health Organisation (WHO) and UNAIDS issued joint recommendations concerning male circumcision and HIV/AIDS. 79 These recommendations are:
Kim Dickson, coordinator of the working group that authored the report, commented: {Link without Title}
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