Benefits From Being Systematic When Evaluating Circumcision for the Paediatric Patient

We congratulate Prabhakaran et al. for their recent narrative review on paediatric male circumcision (MC).1 The final CDC report2 mirrors the American Academy of Pediatrics (AAP)' review and recommendations. Prabhakaran et al. cite criticisms of the AAP policy but not the detailed responses by the AAP and other authorities. (See Morris et al.3 for reference.) Crucially, a risk–benefit analysis performed in a recent systematic review tailored to Australia found that benefits exceed risks by 200:1 and that, over their lifetime, half of uncircumcised males would suffer from a medical problem attributable to their foreskin.3 (The benefit:risk figure cited in the CDC guidelines was ‘100:1’.2) Cost–benefit analyses3 should also have been cited. While steroids can help resolve phimosis, twice-daily application for 4–8 weeks, low efficacy and prospect of return of phimosis in 3–11% of cases1 present challenges. By contrast, MC is a one-off, effective intervention with additional benefits, such as prevention of lichen sclerosus. Inflammation and infection leading to balanoposthitis are also largely prevented by MC. The decline in early infant MC in Australia would result in increased penile cancer rates, although universal human papillomavirus (HPV) vaccination should partially drive rates down, noting that, unlike cervical cancer, high-risk HPV types are the cause of half, not all, cases. Consequently, a combination of MC in early infancy and HPV vaccination in early adolescence should be advocated. Not mentioned in the review is that MC also reduces risk of prostate cancer, multiple other sexually transmitted infections in both men and women and cervical cancer.3 They dismiss early infant MC for human immunodeficiency virus prevention in Australia. However, in men who have sex with men (MSM), in Sydney, MC reduced the risk of HIV infection 10-fold in MSM who predominantly engaged in insertive anal intercourse3. Their assertion that ‘HIV prevention is not an indication for paediatric circumcision’ is not supported by the evidence. Prabhakaran et al. failed to cite three systematic reviews and a meta-analysis that found no difference in sexual function, sensitivity and sexual pleasure by MC status.3 Nor did they cite a 2014 study of 1.4 million circumcisions by CDC researchers which found that the frequency of adverse events is 0.4% for early infant MC.4 Frequency was 10–20-fold higher in older boys.4 Most adverse events were minor and easily treatable, with complete resolution. Their recommendation that paediatricians should provide parents with accurate information in an impartial manner is consistent with the AAP's recommendation1, 3 and an evaluation of legal and ethical arguments by professors of law, bioethics, urology and medical sciences.3

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