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Public Health: Male Circumcision

Rate of male circumcision by country: Red = >80% prevalence; Orange = 20-80% prevalence; Yellow = <20% prevalence; Gray Not available


Graphic credit: AHC300 – PLoS Med, 2006, 3(7):262.55. International religious freedom report for 2004. U.S. Department of State; Wikipedia Commons


An article about male circumcision, published this past week in the New York Times, appeared to have intentionally overlooked much of the interesting medical evidence regarding this issue, probably because the Times piece focused mainly on social and religious points of view. We became interested and read additional sources.


In 2014, the American Academy of Pediatrics announced its first major shift on circumcision in more than a decade, concluding that the health benefits of the procedure clearly outweigh any 1) ___. Then this year, 2017, the CDC took a stand, recommending male circumcision, as a key public health measure. Then, after an extensive evaluation of the scientific evidence, the 2) ___ ___ ___ and ___ released draft policy recommendations in December 2014 affirming male circumcision (MC) as an important public health measure. The CDC’s summary was accompanied by a 61-page literature review. The CDC supported the American Academy of Pediatrics (AAP) infant MC policy and recommended that providers: a) give parents of newborn boys comprehensive counseling about the benefits and risks of MC; b) inform all uncircumcised adolescent and adult 3) ___ who engage in intimate relations about the significant, but partial, efficacy of MC in reducing the risk of acquiring HIV and some STIs, as well as about the potential harms of MC; and c) inform men who have sex with men (MSM) that while it is biologically plausible that MC could be beneficial, MC has not been proven to reduce the risk of acquiring HIV or other STIs.


The CDC made it clear that their recommendations are intended to assist health care providers in the United States who are counseling men and parents of male infants, children and adolescents in decision-making about male circumcision. Such decision-making is made in the context of not only health considerations, but also other social, cultural, ethical, and religious factors. Although data have been accumulating about infant male circumcision for many years, clinical trials conducted between 2005-2010 have demonstrated safety and significant efficacy of voluntary adult male circumcision performed by clinicians for reducing the risk of acquisition of human immunodeficiency virus (HIV). Three randomized clinical trials showed that adult male circumcision reduced HIV infection risk by 50-60% over time. These trials also found that adult circumcision reduced the risk of men acquiring two common STIs, herpes simplex virus type-2 (HSV-2) and types of human papilloma virus (HPV) by 30%. Since the release of these trial data, various organizations have updated their recommendations about adult male and infant male 4) ___.


The conclusions of the Circumcision Policy Statement by the American Academy of Pediatrics Task Force on Circumcision, are as follows: Systematic evaluation of English-language peer-reviewed literature from 1995 through 2010 indicates that preventive health 5) ___ of elective circumcision of male newborns outweigh the risks of the procedure. Benefits include significant reductions in the risk of urinary tract infection in the first year of life and, subsequently, in the risk of acquisition of HIV and the transmission of other STIs. Both the CDC and the AAP agree that the procedure is well tolerated when performed by trained professionals under sterile conditions with appropriate pain management. Complications are infrequent; most are minor, and severe complications are rare. Male circumcision performed during the newborn period has considerably lower complication rates than when performed later in 6) ___. These agencies also agree It is important that clinicians routinely inform parents of the health benefits and risks of male newborn circumcision in an unbiased and accurate manner. The American College of Obstetricians and Gynecologists has endorsed the conclusions of the CDC and the AAP.


Research shows that the cumulative lifetime benefit is greatest if circumcision is performed early in infancy since early infant circumcision is simpler, more convenient, and carries lower risk than when performed later, and circumcision confers immediate protection against 7) ____ tract infections, phimosis, balanitis, and, when older, specific STIs and l cancers. MC also protects the female partners, as confirmed in randomized controlled trials. While procedural pain can occur during circumcision, the evidence cited by the CDC indicates that, with use of local anesthetic, pain is negligible in the first week of a boy’s life, especially when the local is preceded with topical anesthetic ointment.


A cost-benefit study by authors from the Johns Hopkins University, found that if infant MC prevalence in the United States decreased from the current 80% prevalence to the levels of 10% typical in Europe, the additional direct medical costs in infancy and later for treatment of UTIs and STIs would exceed $4.4 billion over 10 annual birth cohorts, after accounting for the cost of the MC procedure and treatment of MC complications. If early infant MC rates decreased to 10%, lifetime prevalence of infant UTIs would increase by 211.8%, high- and low-risk human HPV by 29.1%, HSV-2 by 19.8%, and HIV by 12.2%. Among females, lifetime prevalence of bacterial vaginosis would increase by 51.2%, trichomoniasis by 51.2%, high-risk HPV by 18.3%, and low-risk HPV by 12.9%. The U.S. state of Florida provides an illustrative case study of the cost-savings benefits of MC. In 2003, the state withdrew Medicaid health insurance coverage for infant MC. That resulted in a 6-fold increase in medical costs for publicly funded MCs for medical indications, because later MCs are substantially more expensive than early infant MCs. In response, Florida restored 8) ___ coverage in 2014.


Pain could occur during injection of local anesthetics, but it can be reduced by prior application of readily available topical 9) ___ creams containing lidocaine and prilocaine (EMLA, or the more potent LMX4). In a clinical trial, application of EMLA cream 2 hours prior to treatment, MC resulted in near absence of evidence of pain during and for 4 hours after infant MC, by which time nerves at the ablation site would have died, meaning a pain-free MC. Besides vaccination, newborn MC is the most common pediatric procedure among males in the United States. The policy statements by the CDC and AAP have raised the bar. Policy statements on MC by medical bodies should follow their lead and rely on a thorough evaluation of the medical evidence to support their conclusions. Policy statements on male circumcision by medical bodies should rely on medical evidence. Convincing arguments have been made that it would be unethical to withhold information about the risks and benefits of MC from parents of boys, as recommended by the AAP and CDC. Adoption of the draft CDC recommendations into formal policy should improve public 10) ___ in the United States.

Morris BJ, Krieger JN, Klausner JD. CDC’s male circumcision recommendations represent a key public health measure. Glob Health Sci Pract. 2017;5(1):15-27. https://doi.org/10.9745/GHSP-D-16-00390; This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/. When linking to this article, please use the following permanent link: https://doi.org/10.9745/GHSP-D-16-00390http://www.npr.org


ANSWERS: 1) risks; 2) The United States Centers For Disease Control and Prevention; 3) males; 4) circumcision; 5) benefits; 6) life; 7) urinary; 8) Medicaid; 9) anesthetic; 10) health



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