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Morris B, Rivin BE, Sheldon M, Krieger JN. Neonatal Male Circumcision: Clearly Beneficial for Public Health or an Ethical Dilemma? A Systematic Review. Cureus 2024; 16:e54772. [PMID: 38405642 PMCID: PMC10889534 DOI: 10.7759/cureus.54772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2024] [Indexed: 02/27/2024] Open
Abstract
Contrasting ethical and legal arguments have been made concerning neonatal male circumcision (NMC) that merit the first systematic review on this topic. We performed PRISMA-compliant keyword searches of PubMed, EMBASE, SCOPUS, LexisNexis, and other databases and identified 61 articles that met the inclusion criteria. In the bibliographies of these articles, we identified 58 more relevant articles and 28 internet items. We found high-quality evidence that NMC is a low-risk procedure that provides immediate and lifetime medical and health benefits and only rarely leads to later adverse effects on sexual function or pleasure. Given this evidence, we conclude that discouraging or denying NMC is unethical from the perspective of the United Nations Convention on the Rights of the Child, which emphasizes the right to health. Further, case law supports the legality of NMC. We found, conversely, that the ethical arguments against NMC rely on distortions of the medical evidence. Thus, NMC, by experienced operators using available safety precautions, appears to be both legal and ethical. Consistent with this conclusion, all of the evidence-based pediatric policies that we reviewed describe NMC as low-risk and beneficial to public health. We calculated that a reduction in NMC in the United States from 80% to 10% would substantially increase the cases of adverse medical conditions. The present findings thus support the evidence-based NMC policy statements and are inconsistent with the non-evidence-based policies that discourage NMC. On balance, the arguments and evidence reviewed here indicate that NMC is a medically beneficial and ethical public health intervention early in life because it reduces suffering, deaths, cases, and costs of treating adverse medical conditions throughout the lifetimes of circumcised individuals.
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Affiliation(s)
- Brian Morris
- Faculty of Medicine and Health, The University of Sydney, Sydney, AUS
| | - Beth E Rivin
- Schools of Medicine and Public Health, Department of Global Health, University of Washington, Seattle, USA
- Bioethics, Uplift International, Seattle, USA
| | - Mark Sheldon
- Medical Humanities and Bioethics Program, Feinberg School of Medicine, Chicago, USA
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Moreton S, Cox G, Sheldon M, Bailis SA, Klausner JD, Morris BJ. Comments by opponents on the British Medical Association's guidance on non-therapeutic male circumcision of children seem one-sided and may undermine public health. World J Clin Pediatr 2023; 12:244-262. [PMID: 38178933 PMCID: PMC10762604 DOI: 10.5409/wjcp.v12.i5.244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/07/2023] [Accepted: 09/25/2023] [Indexed: 12/08/2023] Open
Abstract
The British Medical Association (BMA) guidance on non-therapeutic circumcision (NTMC) of male children is limited to ethical, legal and religious issues. Here we evaluate criticisms of the BMA's guidance by Lempert et al. While their arguments promoting autonomy and consent might be superficially appealing, their claim of high procedural risks and negligible benefits seem one-sided and contrast with high quality evidence of low risk and lifelong benefits. Extensive literature reviews by the American Academy of Pediatrics and the United States Centers for Disease Control and Prevention in developing evidence-based policies, as well as risk-benefit analyses, have found that the medical benefits of infant NTMC greatly exceed the risks, and there is no reduction in sexual function and pleasure. The BMA's failure to consider the medical benefits of early childhood NTMC may partly explain why this prophylactic intervention is discouraged in the United Kingdom. The consequence is higher prevalence of preventable infections, adverse medical conditions, suffering and net costs to the UK's National Health Service for treatment of these. Many of the issues and contradictions in the BMA guidance identified by Lempert et al stem from the BMA's guidance not being sufficiently evidence-based. Indeed, that document called for a review by others of the medical issues surrounding NTMC. While societal factors apply, ultimately, NTMC can only be justified rationally on scientific, evidence-based grounds. Parents are entitled to an accurate presentation of the medical evidence so that they can make an informed decision. Their decision either for or against NTMC should then be respected.
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Affiliation(s)
| | - Guy Cox
- Australian Centre for Microscopy & Microanalysis and School of Aeronautical, Mechanical and Mechatronic Engineering, University of Sydney, Sydney 2006, New South Wales, Australia
| | - Mark Sheldon
- Medical Humanities and Bioethics Program, Feinberg School of Medicine, Northwestern University, Chicago, IL 60661, United States
| | - Stefan A Bailis
- Cornerstone Therapy & Recovery Center, St. Paul, MN 55101, United States
| | - Jeffrey D Klausner
- Department of Medicine, Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA 90089, United States
| | - Brian J Morris
- School of Medical Sciences, University of Sydney, Sydney 2006, New South Wales, Australia
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Morris BJ, Katelaris A, Blumenthal NJ, Hajoona M, Sheen AC, Schrieber L, Lumbers ER, Wodak AD, Katelaris P. Evidence-based circumcision policy for Australia. JOURNAL OF MEN'S HEALTH 2022; 18:132. [PMID: 36034719 PMCID: PMC9409339 DOI: 10.31083/j.jomh1806132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The aim was (1) to perform an up-to-date systematic review of the male circumcision (MC) literature and (2) to determine the number of adverse medical conditions prevented by early MC in Australia. Searches of PubMed using "circumcision" with 39 keywords and bibliography searches yielded 278 publications meeting our inclusion criteria. Early MC provides immediate and lifetime benefits, including protection against: urinary tract infections, phimosis, inflammatory skin conditions, inferior penile hygiene, candidiasis, various STIs, and penile and prostate cancer. In female partners MC reduces risk of STIs and cervical cancer. A risk-benefit analysis found benefits exceeded procedural risks, which are predominantly minor, by approximately 200 to 1. It was estimated that more than 1 in 2 uncircumcised males will experience an adverse foreskin-related medical condition over their lifetime. An increase in early MC in Australia to mid-1950s prevalence of 85% from the current level of 18.75% would avoid 77,000 cases of infections and other adverse medical conditions over the lifetime for each annual birth cohort. Survey data, physiological measurements, and the anatomical location of penile sensory receptors responsible for sexual sensation indicate that MC has no detrimental effect on sexual function, sensitivity or pleasure. US studies found that early infant MC is cost saving. Evidence-based reviews by the AAP and CDC support early MC as a desirable public health measure. Although MC can be performed at any age, early MC maximizes benefits and minimises procedural risks. Parents should routinely be provided with accurate, up-to-date evidence-based information in an unbiased manner early in a pregnancy so that they have time to weigh benefits and risks of early MC and make an informed decision should they have a son. Parental choice should be respected. A well-trained competent practitioner is essential and local anaesthesia should be routinely used. Third party coverage of costs is advocated.
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Affiliation(s)
- Brian J. Morris
- School of Medical Sciences, University of Sydney, Sydney, NSW 2006, Australia
| | - Athos Katelaris
- Department of Urology, St George Hospital, Sydney, NSW 2217, Australia
| | - Norman J. Blumenthal
- Department of Obstetrics and Gynaecology, SAN Clinic, Wahroonga, NSW 2076, Australia
| | - Mohamed Hajoona
- Victoria Circumcision Clinic, The Regent Medical Group, Preston, VIC 3072, Australia
| | | | - Leslie Schrieber
- Department of Medicine, Royal North Shore Hospital, St Leonards, NSW 2065, Australia
| | - Eugenie R. Lumbers
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Pregnancy and Reproduction Program, Hunter Medical Research Institute, New Lambton Heights; Priority Research Centre for Reproductive Sciences, University of Newcastle, Callaghan, NSW 2308, Australia
| | - Alex D. Wodak
- St Vincent’s Hospital, Australian Tobacco Harm Reduction Association and Australia21, Darlinghurst, NSW 2010, Australia
| | - Phillip Katelaris
- Katelaris Urology, North Shore Private Hospital, St Leonards, NSW 2065, Australia
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Lee SWH, Gottlieb SL, Chaiyakunapruk N. Healthcare resource utilisation pattern and costs associated with herpes simplex virus diagnosis and management: a systematic review. BMJ Open 2022; 12:e049618. [PMID: 34983754 PMCID: PMC8728455 DOI: 10.1136/bmjopen-2021-049618] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 10/28/2021] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES Little is known about the economic burden of herpes simplex virus (HSV) across countries. This article aims to summarise existing evidence on estimates of costs and healthcare resource utilisation associated with genital and neonatal HSV infection. DESIGN Systematic literature review. DATA SOURCES Seven databases were searched from inception to 31 August 2020. A focused search was performed to supplement the results. ELIGIBILITY CRITERIA Studies which reported either healthcare resource utilisation or costs associated with HSV-related healthcare, including screening, diagnosis and treatment of genital HSV infection and neonatal herpes prevention and treatment. DATA EXTRACTION AND SYNTHESIS Two independent reviewers extracted data and assessed the risk of bias using the Larg and Moss's checklist. All data were summarised narratively. RESULTS Out of 11 443 articles, 38 were included. Most studies (35/38, 94.6%) were conducted in high-income countries, primarily the United States, and were more often related to the prevention or management of neonatal herpes (n=21) than HSV genital ulcer disease (n=17). Most analyses were conducted before 2010. There was substantial heterogeneity in the reporting of HSV-related healthcare resource utilisation, with 74%-93% individuals who sought care for HSV, 11.6%-68.4% individuals who received care, while neonates with herpes required a median of 6-34 hospitalisation days. The costs reported were similarly heterogeneous, with wide variation in methodology, assumptions and outcome measures between studies. Cost for screening ranged from US$7-100, treatment ranged from US$0.53-35 for an episodic therapy, US$240-2580 yearly for suppressive therapy, while hospitalisation for neonatal care ranged from US$5321-32 683. CONCLUSIONS A paucity of evidence exists on healthcare resource utilisation and costs associated with HSV infection, especially among low-income and middle-income countries. Future research is needed on costs and healthcare utilisation patterns to improve overall understanding of the global economic burden of HSV.
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Affiliation(s)
- Shaun Wen Huey Lee
- School of Pharmacy, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia
- School of Pharmacy, Taylor's University Lakeside Campus, Subang Jaya, Malaysia
- Center of Global Health, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sami L Gottlieb
- Department of Reproductive Health and Research, World Health Organization, Geneve, Switzerland
| | - Nathorn Chaiyakunapruk
- School of Pharmacy, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia
- Department of Pharmacotherapy, University of Utah, Salt Lake City, Utah, USA
- School of Pharmacy, University of Wisconsin, Madison, WI, USA
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Macho-Aizpurua M, Imaz-Pérez M, Álava-Menica JÁ, Hernández-Ragpa L, López-de-Munain-López MJ, Cámara-Pérez MM, Bilbao-González A, Díaz-de-Tuesta-Del Arco JL, Muñoz-Sánchez J, Basaras-Ibarzabal M, Cisterna-Cancér R. Characteristics of genital herpes in Bilbao (Northern Spain): 12-year retrospective study. Enferm Infecc Microbiol Clin 2020; 39:234-240. [PMID: 32563583 DOI: 10.1016/j.eimc.2020.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 04/25/2020] [Accepted: 04/28/2020] [Indexed: 01/20/2023]
Abstract
BACKGROUND Herpes simplex virus type 2 (HSV-2) is the most common cause of genital herpes (GH), but genital infection by herpes simplex virus type 1 (HSV-1) is increasing. The aim of this study was to analyze and compare epidemiological characteristics of patients with GH. METHODS Retrospective study conducted from January 2004 to December 2015 in patients with GH attended at two Sexually Transmitted Diseases (STDs) medical consultation of Bilbao-Basurto Integrated Health Organisation in Northern Spain. Patient's medical history was reviewed and data of interest was analyzed. RESULTS One thousand three patients (524 male and 479 female) were reviewed. HSV-2 was detected in 74%. The proportion of HSV-1 increased during the study period, significantly in men (28% in 2004-2007 vs. 50% in 2012-2015). More female than male had HSV-1 infection (56% vs. 44%). The proportion of primary infection was higher among HSV-1 compared to HSV-2 (79% vs. 21%). Among the patients with HSV-1, primary infection was higher among men (86%) and in younger than 30 years. Recurrent GH was higher among HSV-2 infections (63%). In a multivariate model older age, geographic origin outside Spain, recurrent infection, prior contact with a partner's genital herpetic lesions, previous N. gonorrhoeae infection and prostitution were significantly associated with HSV-2 infection. CONCLUSIONS HSV-2 was the most common causative agent of GH, but the proportion of HSV-1 increased. Overall, antecedent of STD and sexual risk behaviors were more frequent in patients with genital HSV-2 infection.
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Affiliation(s)
- Mikele Macho-Aizpurua
- Osakidetza, Hospital Universitario Basurto, Servicio de Microbiología Clínica y Control de Infección, Avenida Montevideo 18, 48013 Bilbao, Spain.
| | - Manuel Imaz-Pérez
- Osakidetza, Hospital Universitario Basurto, Servicio de Microbiología Clínica y Control de Infección, Avenida Montevideo 18, 48013 Bilbao, Spain
| | - José Ángel Álava-Menica
- Osakidetza, Hospital Universitario Basurto, Servicio de Microbiología Clínica y Control de Infección, Avenida Montevideo 18, 48013 Bilbao, Spain
| | - Leonora Hernández-Ragpa
- Osakidetza, Hospital Universitario Basurto, Servicio de Microbiología Clínica y Control de Infección, Avenida Montevideo 18, 48013 Bilbao, Spain
| | | | - Mari-Mar Cámara-Pérez
- Osakidetza, Hospital Universitario Basurto, Servicio de Enfermedades Infecciosas, Avenida Montevideo 18, 48013 Bilbao, Spain
| | - Amaia Bilbao-González
- Osakidetza, Hospital Universitario Basurto, Unidad de Investigación, Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Avenida Montevideo 18, 48013 Bilbao, Spain
| | - José-Luis Díaz-de-Tuesta-Del Arco
- Osakidetza, Hospital Universitario Basurto, Servicio de Microbiología Clínica y Control de Infección, Avenida Montevideo 18, 48013 Bilbao, Spain
| | - Josefa Muñoz-Sánchez
- Osakidetza, Hospital Universitario Basurto, Servicio de Enfermedades Infecciosas, Avenida Montevideo 18, 48013 Bilbao, Spain
| | - Miren Basaras-Ibarzabal
- Universidad del País Vasco (UPV/EHU), Departamento de Inmunología, Microbiología y Parasitología, Facultad de Medicina y Enfermería, Barrio Sarriena s/n, 48940 Leioa, Spain
| | - Ramon Cisterna-Cancér
- Universidad del País Vasco (UPV/EHU), Departamento de Inmunología, Microbiología y Parasitología, Facultad de Medicina y Enfermería, Barrio Sarriena s/n, 48940 Leioa, Spain
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