Circumcision: Is it worth it for 21st‐century <scp>A</scp>ustralian boys?

Male circumcision is a centuries-old medical practice imbued with rich historical, religious and cultural tradition. Circumcision presumably started as a religious and social tradition to maintain hygiene, reduce infection and provide cultural identity. In the modern era, circumcision is a part of paediatric surgical practice to treat phimosis, balanitis and paraphimosis when medical interventions fail.1 However, non-therapeutic circumcision in infants and boys has always been a debated, controversial and minority practice. Data from research studies are often coloured by the authors’ personal belief of what should be the male norm – circumcised or uncircumcised. Although most of the research on circumcision have sound scientific basis, its findings are usually only applicable to the specific socio-cultural context in which the study was conducted. Yet many authors tend to prematurely extrapolate the data in an attempt to set national and international standards on circumcision in infants. The 2012 American Academy of Paediatrics policy statement on circumcision2 departed from their earlier 1999 policy. Although the statement did not recommend circumcision, it stated that health benefits of circumcision in the newborn outweigh the risks, in particular for urinary tract infection (UTI) prevention, human immunodeficiency virus (HIV) acquisition and transmission of sexually transmitted diseases (STDs). In addition, the policy concluded that significant acute complications are rare. Coming from such an influential body, it revived the international controversy of the topic.3 In Australia, the 2010 Royal Australasian College of Physicians’ policy4 concluded that there is currently insufficient evidence to recommend routine newborn circumcision. Other medical societies such as Canadian Paediatric Society5 and British Medical Association6 also cited lack of consistent data to recommend non-therapeutic circumcision. Royal Dutch Medical Association stated that the practice ‘is a violation of children's rights to autonomy and physical integrity’.7 Global estimates in 2006 suggest that about 30% of males are circumcised. Male circumcision is almost universal in the Middle East, Central Asia, Bangladesh, Indonesia and Pakistan. Male circumcision is common in many African countries, yet the rate varies from 15% to 70% depending on the countries.8 Circumcision is prevalent in these societies because they are largely Islamic, or for tribal and cultural reasons such as in African countries. During the 20th century, male circumcision gained popularity for perceived health benefits and social reasons in North America, New Zealand and Britain, but not elsewhere in Europe. In the United States, neonatal and childhood circumcision incidence rate peaked at 85% in 1965. The trend persisted, then declined to 56% in 2006 and most recently 32% in 2009, although the validity of these percentages varies depending on the source of data collection.9, 10 The only developed countries in which non-therapeutic circumcision remains common are the United States and South Korea, though it lingers in Canada and Australia. Even in these places, habit and tradition play a major role in parental preferences. In the 1970s, the Australian newborn circumcision rate decreased from 50% to 40%. In the 1980s and 1990s, less than 10% of babies were circumcised. In 2003, the infant circumcision rate in Australia was 13%.8, 11, 12 Most circumcisions in Australia are now attributable to the cultural or religious adherence of the parents mainly and increasingly Muslim these days. In 2006–2007, most Australian states withdrew circumcision from the range of free services provided in public hospitals through Medicare funding system. The result is that most non-therapeutic circumcisions are now performed by general practitioners and in private clinics. World-wide trends of circumcision are affected by religious views (Islam, Judaism and Christianity) and cultures. In sub-Saharan Africa, cultural identity plays as important a role as religion during circumcision. In the developed countries, the popularity of circumcision often depends on the society's current perceptions of the health benefits of the practice. In Australia, male circumcision was popularised during the world wars,13 presumably to treat recurrent balanitis.14 Anecdotally, circumcision was thought to improve hygiene by reducing sand accumulation under the foreskin. As these returning soldiers became fathers, circumcised newborns became the norm, aiming to prevent balanitis and allow their boys to fit in with the norm at that time. There was also the argument that newborn circumcision was less complicated and less costly compared with adult circumcision. However, in the 1960–1970s, as the number of newborn circumcisions increased, so did the number of reported complications. Most of these were minor complications, such as bleeding and infection. However, catastrophic complications such as cases of glans amputation15 and deaths have been reported.16 After the initial circumcision, some boys require more procedures for cosmetic revision. In Australia, the decline in newborn circumcision rate may be related to the increased parental education on maintaining penile hygiene without removing the foreskin. UTI is more common in the first year of life and affects up to 1–2% of boys and 4% of girls by age 12.17, 18 The risk is higher in uncircumcised boys with underlying renal tract abnormalities,19, 20 which can be diagnosed with antenatal or post-natal ultrasound. Although circumcision reduces the risk of childhood UTI by about 10-fold,18 UTI is a medical condition treated effectively with antibiotics. For most Australian newborns, there is a good access to early antibiotic treatment. Antenatal and post-natal ultrasound scanning can be used to identify those newborns at higher risk of recurrent UTI. So, rather than recommending circumcision to all newborns, clinicians can selectively offer circumcision for those with higher risk. One hundred and eleven newborns would need to be circumcised to prevent one UTI because of the low baseline risk of infection. However, when targeted at higher-risk newborns, the number needed to treat is only 11.18 Despite emerging data from sub-Saharan Africa of the benefit of circumcision in reducing male HIV acquisition via heterosexual contact,21-23 there is a decline in the proportion of circumcised adults in Australia. Circumcision was less common among younger males (32% aged <20) compared with older males (50–65% aged 20–59).12 It remains unknown what proportion of the adult males elected to be circumcised as an adult. The transmission of STDs, including HIV, is greatly affected by the sexual practices of the community. The results from African communities do not directly translate to Australians due to demographic differences. HIV is much more prevalent in Africa, compared with Australia,24 and the main mode of HIV transmission in Africa is through heterosexual contacts, while in Australia, it is more common through homosexual contacts.25 Among homosexual couples, the prophylactic value of circumcision to prevent HIV transmission is not statistically significant.26 Furthermore, Australians have a higher level of safe sex education, access to STDs screening and treatment, including antiretroviral medications, compared with those living in sub-Saharan Africa. These public health interventions are effective in Australia and do not involve permanent loss of foreskin. Indeed, even after a boy is circumcised as a newborn, he is not immune to STDs transmission and still needs to wear condoms. In fact, in an Australian study, circumcised men were found to have more liberal sexual attitudes.12 There are no studies showing an association between infant circumcision and reduced risk of HIV infection. There is emerging evidence that circumcision confers protection from STD, especially ulcerative disease.27 However, evidence remains contradictory and uncertain in developed countries on whether circumcision provides risk reduction for STD.28, 29 Even if circumcision did reduce the risk, all STDs except HIV and genital herpes are readily treated with antibiotics. In studies from the United States and United Kingdom, circumcision was found to have no protective effect for STD.30, 31 In a Sydney study conducted in a sexual health clinic, circumcision had no significant effect on the incidence of common STDs.32 A survey of ∼10 000 Australian men found that there was no significant protective effect of circumcision for genital warts, Chlamydia, genital herpes, gonorrhoea, non-specific urethritis or pubic lice. Circumcision only appears to exert a protective effect for penile candidiasis, which occurs under the foreskin.12 In the United States, the percentage of boys circumcised varies by regions and ethnic groups.30 By comparison, Australia has a unique socio-cultural demographic. Our living standards, access to health care and education match those of other developed countries. Yet our community is ethnically diverse with high proportion of migrants. In Australia, migrants from Asia, America and Africa had proportionally larger young (0–14 years) populations compared with those from Europe.33 Within Australia, circumcision rates also vary between states. The highest rates are in Queensland (19%), followed by New South Wales (16%) and South Australia (14%), with the lowest in Tasmania (4%).34 A 2006 survey of adult Australian men found that 59% of the men were circumcised. Compared with uncircumcised men, circumcised men were likely to be older, to speak English at home and to have been born in Australia. While 74% of Muslim respondents were circumcised, only 26% of Buddhist and 34% of other non-Christian respondents were circumcised. In addition, circumcision was somewhat more common among those with post-secondary education, those living in regional (but not remote areas) and those in managerial or professional occupations.12 We need to study parental and clinicians’ decision-making about circumcision in the context of our multicultural society. Migration into Australia and interaction with families from different cultures may change these parents’ attitude on non-therapeutic circumcision. In Australia, as less children are being circumcised, parents’ priorities might have changed from making the boy to look like his father to allowing the boy to look more like the other uncircumcised boys at school. The important question is whether circumcision to reduce a low temporary risk of childhood UTI and future risk of HIV justifies the immediate surgical complications and permanent foreskin loss. After considering the available research data, if some Australian adult males choose non-therapeutic circumcision for themselves, then this consent would be considered informed and autonomous. However, it is difficult to argue the same ethical principles for infants. Parents have legal rights to consent for a medical procedure if it is in the child's best interest. Yet the risk of sexually-transmitted HIV is more real and immediate for adults compared with infants. How can we justify circumcision as being in the best interest of the infant when most uncircumcised Australian adult males themselves, despite the available evidence, are reluctant to undergo adult circumcision? Infants and children are not at risk of HIV transmission via their foreskin until they commence sexual activity much later in life. At puberty, the issue of circumcision can then be discussed, taking into account available research data and the adolescent's sexual practices. While currently HIV remains an incurable disease, there is a time lag of ∼10–15 years before the current generation of newborns reach puberty. By then, more effective antiretroviral medication and potentially an HIV vaccine might have been developed. Given that no one can accurately predict the future, as a community, we should defer a highly personal yet permanent decision, such as removing the foreskin, until our newborns become autonomous young adults. Perhaps our roles as clinicians and parents are to give our boys this freedom of choice and educate them on safe sex practices. For paediatric surgeons, most requests for non-therapeutic circumcision are from parents who wish for their newborns to be part of their religious and cultural norm. Parents can make informed decision based on the child's best interest from a family and socio-cultural point of view.35 Therefore, at Australian national policy level, while guided by international data, our clinicians and parents need more data relevant to our unique socio-cultural milieu. The role of circumcision in reducing HIV transmission in Australia, where most of the transmission is among homosexual individuals, remains unclear. Some of the questions that remain to be answered in Australia include the following: the effect of circumcision status on STDs/HIV heterosexual transmission; the long-term effect on psychological and sexual function of males circumcised in infancy; and community perception on prophylactic adult male circumcision. In conclusion, although there is a benefit of circumcision in those with urogenital tract anomalies, in a healthy newborn, the disease in the foreskin is non-existent. There is insufficient scientific evidence to support routine newborn circumcision in Australia done for UTI risk and HIV transmission issues alone. Therefore, any surgical complication and financial cost of routine newborn circumcision for these reasons in Australia currently cannot be justified. From a medical point of view, the ‘price’ is still too high.

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