Male circumcision: pain, trauma and psychosexual sequelae

Genital Modifications in Prepubescent Minors: When May Clinicians Ethically Proceed?

When is it ethically permissible for clinicians to surgically intervene into the genitals of a legal minor? We distinguish between voluntary and nonvoluntary procedures and focus on nonvoluntary procedures, specifically in prepubescent minors ("children"). We do not address procedures in adolescence or adulthood. With respect to children categorized as female at birth who have no apparent differences of sex development (i.e., non-intersex or "endosex" females) there is a near-universal ethical consensus in the Global North. This consensus holds that clinicians may not perform any nonvoluntary genital cutting or surgery, from "cosmetic" labiaplasty to medicalized ritual "pricking" of the vulva, insofar as the procedure is not strictly necessary to protect the child's physical health. All other motivations, including possible psychosocial, cultural, subjective-aesthetic, or prophylactic benefits as judged by doctors or parents, are seen as categorically inappropriate grounds for a clinician to proceed with a nonvoluntary genital procedure in this population. We argue that the main ethical reasons capable of supporting this consensus turn not on empirically contestable benefit-risk calculations, but on a fundamental concern to respect the child's privacy, bodily integrity, developing sexual boundaries, and (future) genital autonomy. We show that these ethical reasons are sound. However, as we argue, they do not only apply to endosex female children, but rather to all children regardless of sex characteristics, including those with intersex traits and endosex males. We conclude, therefore, that as a matter of justice, inclusivity, and gender equality in medical-ethical policy (we do not take a position as to criminal law), clinicians should not be permitted to perform any nonvoluntary genital cutting or surgery in prepubescent minors, irrespective of the latter's sex traits or gender assignment, unless urgently necessary to protect their physical health. By contrast, we suggest that voluntary surgeries in older individuals might, under certain conditions, permissibly be performed for a wider range of reasons, including reasons of self-identity or psychosocial well-being, in keeping with the circumstances, values, and explicit needs and preferences of the persons so concerned. Note: Because our position is tied to clinicians' widely accepted role-specific duties as medical practitioners within regulated healthcare systems, we do not consider genital procedures performed outside of a healthcare context (e.g., for religious reasons) or by persons other than licensed healthcare providers working in their professional capacity.

Neonatal Male Circumcision: Clearly Beneficial for Public Health or an Ethical Dilemma? A Systematic Review

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.

Factors influencing satisfaction with male circumcision in Taiwan

We aimed to investigate patient satisfaction with male circumcision in Taiwan. An online, questionnaire-based, cross-sectional study involving 376 circumcised men 20 to 40 years of age in Taiwan was conducted. Circumcision-related satisfaction was defined as a visual analogue scale score ≥ 6 (range, 1-10). Pearson's chi-square test was performed to compare differences between satisfied and unsatisfied participants. Factors predictive of participant satisfaction were analysed using multivariate logistic regression. Statistical significance was set at P < 0.05. Among 376 circumcised men, 249 (66.2%) reported satisfaction with circumcision. Satisfied participants had higher levels of education, underwent circumcision for phimosis or balanitis, underwent circumcision during adulthood, reported a larger penile size, and had fewer long-term complaints. Furthermore, 89.4% had various long-term complaints, including skin colour mismatch, changes in masturbation methods, hypertrophic scarring, excessive shortening of the prepuce, and redundant prepuce. Multivariate analysis revealed that adult circumcision and the absence of long-term conditions were predictive of satisfaction. Two-thirds of participants were satisfied with their circumcision outcome, especially those who underwent circumcision for phimosis or balanitis during adulthood. Proper preoperative patient selection and postoperative symptom prevention would improve patient satisfaction.

How does circumcision performed under regional anesthesia affect sleep, feeding, and maternal attachment in babies aged 0-4 months?

BACKGROUND

There is no consensus whether circumcision performed in the first months of life has negative effects on feeding, sleep, and maternal attachment in babies. This prospective study aimed to investigate this relation in the first months of life. This study is the first to investigate the effects of circumcision on feeding, sleep, and maternal attachment simultaneously.

METHODS

The study group consisted of 75 families with their babies aged 0-4 months. Surgical circumcision procedure under regional anesthesia was applied to all patients. The questionnaires were used to evaluate the babies' feeding and sleeping habits, and the Maternal Attachment Inventory (MAI) was used to assess mother-baby attachment level. All assessments were performed before and one month after the circumcision.

RESULTS

The mean age of the patients when circumcision was performed was 75 (74.52 ± 37.03) (3-120) days. The mean ages of mothers were 32 (32.51 ± 4.05) years. There was no statistically significant change in the sleep habits and feeding status of babies before and after circumcision. The mean maternal attachment value before circumcision was 101 (98.89 ± 6.77) points, while it was 103 (101.36 ± 4.21) points after circumcision. This result indicates that the maternal attachment score increased significantly after circumcision (p < 0.001).

CONCLUSIONS

The circumcision performed under regional anesthesia between 0 and 4 months did not have any negative effect on sleep, feeding, and maternal attachment in babies.

Critical evaluation of contrasting evidence on whether male circumcision has adverse psychological effects: A systematic review

OBJECTIVE

To conduct the first systematic review critically examining evidence on whether early male circumcision has short- and long-term adverse psychological effects.

METHODS

We searched PubMed, EMBASE, SCOPUS, Cochrane Library, and Google Scholar.

RESULTS

Twenty-four studies with original data met the inclusion criteria. These comprised 11,173 total males, 4340 circumcised in infancy and 6908 uncircumcised. Nineteen were rated 1+, 2++ or 2+, and 5 were rated 2- by SIGN criteria. Neonatal circumcision, particularly without anesthetic, increased vaccination pain response, but had little effect on breastfeeding or cognitive ability. Studies reporting associations with sudden infant death syndrome, autism, alexithymia and impaired sexual function and pleasure had design flaws and were rated 2-. Sexual arousal, touch, pain, and warmth thresholds measured by quantitative sensory testing were not diminished in neonatally circumcised men. Neonatal circumcision was not associated with empathy in men, contradicting the hypothesis that procedural pain causes central nervous system changes. After correcting all associations with socioaffective processing parameters for multiple testing only higher sociosexual desire, dyadic sexual libido/drive, and stress remained significant. The relatively greater sexual activity found in circumcised men might reflect reduced sexual activity in uncircumcised men overall owing to pain and psychological aversion in those with foreskin-related medical conditions (reverse causality). Most studies employed case-control designs with limited follow-up. Studies beyond childhood were prone to confounding.

CONCLUSION

The highest quality evidence suggest that neonatal and later circumcision has limited or no short-term or long-term adverse psychological effects.

Psychological, psychosocial, and psychosexual aspects of penile circumcision

Policy statements on penile circumcision have focused primarily on disease, dysfunction, or sensation, with relatively little consideration of psychological and psychosocial implications of the procedure. There has also been minimal consideration of potential qualitative changes in the subjective experience of sexual activity following changes in penile anatomy (foreskin removal) or associated sexual biomechanics. We present a critical overview of literature on the psychological, psychosocial, and psychosexual implications of penile circumcision. We give consideration to differences among circumcisions performed in infancy, childhood, or adulthood. We also discuss potential psychosocial effects on parents electing, or failing to elect, circumcision for their children. We propose a framework for policy considerations and future research, recognizing that cultural context is particularly salient for the narratives individuals construct around penile circumcision, including both affected individuals and medical professionals who perform the surgeries. We argue that additional attention should be paid to the potential for long-term effects of the procedure that may not be properly considered when the patient is an infant or child.

Pediatric Circumcision in the 21st Century National Health Service: A Snapshot of Practice in a United Kingdom Center

Introduction  Pediatric circumcision is a commonly performed operation, yet outcomes related to procedures performed for medical indications remain underreported.

Aim  The aim of this study was to report outcomes of therapeutic circumcision from our center.

Methods  Prospective registry of elective circumcisions was maintained and analyzed at a single institution in the United Kingdom. Data collected included information on complications (early and late), emergency presentations, and referrals back from primary care services.

Results  Between August 2015 and June 2019, 300 patients (mean age: 9 years; range: 3–16 years) underwent therapeutic circumcision. The average length of follow-up data available was 2.1 years (range: 6 months to 4 years). The overall complication rate was 4.7% ( n  = 16). There were no unplanned admissions and no cases returned to the operating room as emergency. Only 1% ( n  = 3) of patients presented with an early complication (minor bleeding, pain, urinary retention), and 3.7% ( n  = 11) suffered a late complication (meatal stenosis [2.7%]). All cases of meatal stenosis had lichen sclerosus confirmed on histology. Cosmetic satisfaction was 99%.

Conclusion  Therapeutic circumcision is an effective procedure in the pediatric population, which carries a low risk of early and late complications. Our study found that meatal stenosis only occurred in those patients with confirmed lichen sclerosus histology.

Current critiques of the WHO policy on female genital mutilation

In recent years, the dominant Western discourse on "female genital mutilation" (FGM) has increasingly been challenged by scholars. Numerous researchers contest both the terminology used and the empirical claims made in what has come to be called "the standard tale" of FGM (also termed "female genital cutting" [FGC]). The World Health Organization (WHO), a major player in setting the global agenda on this issue, maintains that all medically unnecessary cutting of the external female genitalia, no matter how slight, should be banned as torture and a violation of the human right to bodily integrity. However, the WHO targets only non-Western forms of female-only genital cutting, raising concerns about gender bias and cultural imperialism. Here, we summarize ongoing critiques of the WHO's terminology, ethicolegal assumptions, and empirical claims, including the claim that non-Western FGC as such constitutes an extreme form of discrimination against women. To this end, we highlight recent comparative studies of medically unnecessary genital cutting of all types, including those affecting adult women and teenagers in Western societies, individuals with differences of sex development (DSD), transgender persons, and males. In so doing, we attempt to clarify the grounds for a growing critical consensus that current anti-FGM laws and policies may be ethically incoherent, empirically unsupportable, and legally unsustainable.

Critical evaluation of arguments opposing male circumcision: A systematic review

OBJECTIVE

To systematically evaluate evidence against male circumcision (MC).

METHODS

We searched PubMed, Google Scholar, EMBASE and Cochrane databases.

RESULTS

Database searches retrieved 297 publications for inclusion. Bibliographies of these yielded 101 more. After evaluation we found: Claims that MC carries high risk were contradicted by low frequency of adverse events that were virtually all minor and easily treated with complete resolution. Claims that MC causes psychological harm were contradicted by studies finding no such harm. Claims that MC impairs sexual function and pleasure were contradicted by high-quality studies finding no adverse effect. Claims disputing the medical benefits of MC were contradicted by a large body of high-quality evidence indicating protection against a wide range of infections, dermatological conditions, and genital cancers in males and the female sexual partners of men. Risk-benefit analyses reported that benefits exceed risks by 100-200 to 1. To maximize benefits and minimize risks, the evidence supported early infant MC rather than arguments that the procedure should be delayed until males are old enough to decide for themselves. Claims that MC of minors is unethical were contradicted by balanced evaluations of ethical issues supporting the rights of children to be provided with low-risk, high-benefit interventions such as MC for better health. Expert evaluations of case-law supported the legality of MC of minors. Other data demonstrated that early infant MC is cost-saving to health systems.

CONCLUSIONS

Arguments opposing MC are supported mostly by low-quality evidence and opinion, and are contradicted by strong scientific evidence.

From sameness to difference: Swedish Somalis' post-migration perceptions of the circumcision of girls and boys

In every society where non-therapeutic female circumcision (FC) occurs, so too does non-therapeutic male circumcision (MC). In the past few decades, the norm in Euro-American societies has been to distinguish between the practices: FC is banned, while MC is condoned or encouraged. We explored Somalis' post-migration perceptions of FC and MC, while considering that they once lived in a society where both practices were widely accepted and now live in a society where there is a legal ban on FC alongside acceptance of MC. Eighteen individual interviews and seven focus group discussions were conducted with Somali men and women in three Swedish cities. There seemed to be a continuity of values across male and female forms of genital cutting concerning being a good Muslim, not inflicting harm and upholding respectability. Following migration, however, a renegotiation of how these values relate to MC and FC resulted in a conceptual split between the two: MC was perceived as an unquestionably required practice, but FC was viewed as a practice that can be adapted or abandoned. In a new cultural context after migration, perceptions of ideal male and female genitals, and what kinds of inscriptions on the body are desired, seem to have changed.

Post-traumatic stress disorder (PTSD) among Filipino boys subjected to non-therapeutic ritual or medical surgical procedures: A retrospective cohort study

In the Philippines, non-therapeutic genital cutting is viewed as a culturally sanctioned rite of passage from boyhood to manhood. Strong social and peer pressure is exerted on boys aged between 8-16years to submit to destructive genital cutting, despite the fact that many men who have been subjected to genital cutting during infancy or childhood often describe their experiences in the language of violence, torture, mutilation, and sexual assault. Among a group of 505 Filipino boys subjected to ritual genital cutting (Tuli), 69% fulfilled the DSM-IV criteria for a diagnosis of PTSD, while among 1072 boys circumcised by medical operators or their assistants, 51% exhibited PTSD symptoms. Pursuant to ritual genital cutting, almost 3 out of every 4 boys exhibited PTSD-like symptoms.

False beliefs predict increased circumcision satisfaction in a sample of US American men

Critics of non-therapeutic male and female childhood genital cutting claim that such cutting is harmful. It is therefore puzzling that 'circumcised' women and men do not typically regard themselves as having been harmed by the cutting, notwithstanding the loss of sensitive, prima facie valuable tissue. For female genital cutting (FGC), a commonly proposed solution to this puzzle is that women who had part(s) of their vulvae removed before sexual debut 'do not know what they are missing' and may 'justify' their genitally-altered state by adopting false beliefs about the benefits of FGC, while simultaneously stigmatising unmodified genitalia as unattractive or unclean. Might a similar phenomenon apply to neonatally circumcised men? In this survey of 999 US American men, greater endorsement of false beliefs concerning circumcision and penile anatomy predicted greater satisfaction with being circumcised, while among genitally intact men, the opposite trend occurred: greater endorsement of false beliefs predicted less satisfaction with being genitally intact. These findings provide tentative support for the hypothesis that the lack-of-harm reported by many circumcised men, like the lack-of-harm reported by their female counterparts in societies that practice FGC, may be related to holding inaccurate beliefs concerning unaltered genitalia and the consequences of childhood genital modification.

The development of a decellularized extracellular matrix-based biomaterial scaffold derived from human foreskin for the purpose of foreskin reconstruction in circumcised males

The circumcision of males is emphatically linked to numerous sexual dysfunctions. Many of the purported benefits do not hold up to the scrutiny of extensive literature surveys. Involuntary circumcision, particularly when not medically warranted, is also associated with many psychological and emotional traumas. Current methods to reconstruct the ablated tissue have significant drawbacks and produce a simple substitute that merely imitates the natural foreskin. Extracellular matrix-based scaffolds have been shown to be highly effective in the repair and regeneration of soft tissues; however, due to the unique nature of the foreskin tissue, commercially available biomaterial scaffolds would yield poor results. Therefore, this study discusses the development and evaluation of a tissue engineering scaffold derived from decellularized human foreskin extracellular matrix for foreskin reconstruction. A chemicophysical decellularization method was applied to human foreskin samples, sourced from consenting adult donors. The resulting foreskin dermal matrices were analyzed for their suitability for tissue engineering purposes, by biological, histological, and mechanical assessment; fresh frozen foreskin was used as a negative control. Sterility of samples at all stages was ensured by microbiological analysis. MTT assay was used to evaluate the absence of viable cells, and histological analysis was used to confirm the maintenance of the extracellular matrix structure and presence/integrity of collagen fibers. Bioactivity was determined by submitting tissue extracts to enzyme-linked immunosorbent assay and quantifying basic fibroblast growth factor content. Mechanical properties of the samples were determined using tensile stress tests. Results found foreskin dermal matrices were devoid of viable cells (p < 0.0001) and the matrix of foreskin dermal matrices was maintained. Basic fibroblast growth factor content doubled within after decellularization (p < 0.0001). Tensile stress tests found no statistically significant differences in the mechanical properties (p < 0.05). These results indicate that the derived foreskin dermal matrix may be suitable in a regenerative approach in the reconstruction of the human foreskin.

Circumcision does not alter long-term glucocorticoids accumulation or psychological effects associated with trauma- and stressor-related disorders

Male infants and boys through early adolescence can undergo circumcision either for the sake of upholding religious traditions or for medical reasons. According to both, Jewish as well as Islamic tenets, circumcision is a religious rite symbolizing the bond with God. The World Health Organization (WHO), the United Nations Council (UNC) as well as the American Academy of Pediatrics (AAP), and the Centers for Disease Control and Prevention (CDC) strongly recommend circumcision to promote hygiene and prevent disease. This procedure has frequently been criticized by various communities claiming that circumcision in infancy and early adolescence were psychologically traumatizing with medical implications up into old age. Due to the lack of evidence concerning an alleged increase in vulnerability, we measured objective and subjective stress and trauma markers, including glucocorticoids from hair samples, in circumcised and non-circumcised males. We found no differences in long-term limbic-hypothalamic-pituitary-adrenal axis activity, subjective stress perception, anxiety, depressiveness, physical complaints, sense of coherence and resilience. Rather, an increase in the glucocorticoid levels indicated a healthy lifestyle and appropriate functioning. Thus, our findings provide evidence that male circumcision does not promote psychological trauma. Moreover, a qualitative approach, the ambivalence construct, was used for the discussion, aiming at a discourse devoid of biases.

The role of Xhosa traditional circumcision in constructing masculinity

Ulwaluko is a Xhosa word that refers to an initiation ritual. The purpose is to transform boys into men. Circumcision is one of the rituals performed. The ritual aims to instil good moral and social values. Due to socio-cultural shifts, the practice of Ulwaluko has changed and this has culminated in instances of criminal activity, drug abuse, risky sexual behaviours, and inhumane behaviours among some of the initiates. There has been a recent upsurge in research on Ulwaluko in South Africa. While many studies examined Ulwaluko from a constructionist framework, very few have focused on subject positions and how Ulwaluko contributes to the construction of masculinity in Xhosa men. Using social constructionist theory, the study employed a qualitative exploratory design and semi-structured interviews that were analysed using thematic decomposition analysis and positioning theory. Seven participants, from a university in Cape Town, aged from 19 to 32 were recruited using purposive sampling. The results of the study reflect the fluidity of masculinity as reported in literature. First, in some of the participants, Ulwaluko created an idealised masculine identity that was chiefly characterised by upholding ritual teachings and yet the same men were burdened by a prescriptive set of masculine role expectations. Second, through self-reflection and critical engagement, some men contested Ulwaluko resulting in the creation of rival masculinities and thus the study created spaces to rethink masculine identities.

Addressing polarisation in science

Ploug and Holm argue that polarisation in scientific communities can generate conflicts of interest for individual researchers. Their proposed solution to this problem is that authors should self-report whether they are polarised on conflict of interest disclosure forms. I argue that this is unlikely to work. This is because any author with the self-awareness and integrity to identify herself as polarised would be unlikely to conduct polarised research to begin with. Instead, I suggest that it is the role of (associate-level) editors of journals to detect and report on polarisation. One consequence of this view is that they need to be sufficiently familiar with the field of research they are evaluating to know whether polarisation is at stake.

On the impermissibility of infant male circumcision: a response to Mazor (2013)

This is a response to Dr Joseph Mazor's paper 'The child's interests and the case for the permissibility of male infant circumcision.' I argue that Dr Mazor fails to prove that bodily integrity and self-determination are mere interests as opposed to genuine rights in the case of infant male circumcision. Moreover, I cast doubt on the interest calculus that Dr Mazor employs to arrive at his conclusions about circumcision.

A review of the current state of the male circumcision literature

INTRODUCTION

Male circumcision is one of the most commonly performed surgical procedures worldwide and a subject that has been the center of considerable debate. Recently, the American Association of Pediatrics released a statement affirming that the medical benefits of neonatal circumcision outweigh the risks. At present, however, the majority of the literature on circumcision is based on research that is not necessarily applicable to North American populations, as it fails to take into account factors likely to influence the interpretability and applicability of the results.

AIMS

The purpose of this review is to draw attention to the gaps within the circumcision literature that need to be addressed before significant changes to public policy regarding neonatal circumcision are made within North America.

METHODS

A literature review of peer-reviewed journal articles was performed.

MAIN OUTCOME MEASURES

The main outcome measure was the state of circumcision research, especially with regard to new developments in the field, as it applies to North American populations.

RESULTS

This review highlights considerable gaps within the current literature on circumcision. The emphasis is on factors that should be addressed in order to influence research in becoming more applicable to North American populations. Such gaps include a need for rigorous, empirically based methodologies to address questions about circumcision and sexual functioning, penile sensitivity, the effect of circumcision on men's sexual partners, and reasons for circumcision. Additional factors that should be addressed in future research include the effects of age at circumcision (with an emphasis on neonatal circumcision) and the need for objective research outcomes.

CONCLUSION

Further research is needed to inform policy makers, health-care professionals, and stakeholders (parents and individuals invested in this debate) with regard to the decision to perform routine circumcision on male neonates in North America.

Paediatric male circumcision and penile hygiene: a Japanese mothers' view

This paper analyses the views of 20 Japanese mothers concerning paediatric male circumcision and penile hygiene. In Japan, routine male circumcision has never been implemented for newborns and children, and adult males are mostly circumcised at aesthetic clinics. However, media reports indicate a trend of Japanese mothers willing to have their sons circumcised. In discussing penile hygiene and male circumcision, the construct of a 'sexual script' becomes relevant to understanding how linguistic and gender barriers made references to male genitalia and penile hygiene largely appear as 'vulgar' and 'unfeminine' in daily life conversations. Peers were often identified as the main source of information and only mothers who have struggled with their children's penile infections have learnt about male genital hygiene, a domain of knowledge largely transmitted by men. Male circumcision becomes a double-edged sword that could help prevent penile infections but also an embarrassing conversational topic that could elicit discrimination because most Japanese children are uncircumcised.

Gender, pride and medical circumcision in contemporary Japan

The outcome of interviews with 26 Japanese men is analysed to identify their views concerning male circumcision and their implications in terms of embodiment, gender and sexuality. Data were collected as part of a larger ethnographic investigation of circumcision, masculinity, sexual behaviour and health matters for Japanese men. Participants in the investigation offered their views in relation to male circumcision by deploying arguments that commodify male genitalia and stress masculinity and sexual prowess. Male circumcision was thought of as a medical technology oriented towards boosting the gender identity of adolescent and/or 'incomplete' men. Male circumcision may also be also promoted as a medical strategy to help heterosexual couples conceive. References to circumcision as a procedure for disease prevention were almost completely absent.

Circumcision of neonates and children without appropriate anaesthesia is unacceptable practice

Circumcision is painful surgery and appropriate intraoperative anaesthesia and postoperative analgesia is required. This is recognised in the policies of the Royal Australasian College of Physicians and the majority of Australian State Health Departments. Nevertheless, anecdotal evidence exists that neonatal circumcision continues to be performed in Australia with either no anaesthesia or with inadequate anaesthesia. This paper presents the evidence that neonatal circumcision is painful and reviews the available anaesthetic techniques. The authors conclude that general anaesthesia is arguably the most reliable way of ensuring adequate anaesthesia, although this may mean deferment of the procedure until the child is older. Local or regional anaesthesia for neonatal circumcision ideally requires a separate skilled anaesthetist (other than the proceduralist) to monitor the patient and intervene if the anaesthesia is inadequate. Topical anaesthesia with lignocaine-prilocaine (EMLA) cream is insufficient.

Correlates of risky sexual behaviors in recently traditionally circumcised men from initiation lodges in the Eastern Cape, South Africa

This exploratory quantitative study examines past risky sexual behaviors among young men who were circumcised as part of a rite of passage to adulthood embedded within a cultural and traditional belief system in the Eastern Cape Province in South Africa. Following permission from the Eastern Cape House of Traditional Leaders (ECHOTL), individual face-to-face interviews using a structured questionnaire were conducted among 114 initiates. The mean age of the participants was 18.9 years, ranging from 15 to 32 years old. About 79.8% reported already having had sex with a woman prior to initiation. Of those, 89% reported that they ever used condoms when having sex, and 61% reported consistent use. Logistic regression analysis showed that consistent condom use increased with higher educational levels. Those involved in other risky health behaviors (specifically, smoking) were also more likely to report inconsistent condom use. Most participants had positive beliefs about male circumcision and STI/HIV transmission. This study provides a first look at the sexual behaviors of young men at the time of their initiation in adulthood, a process that is intended to make it socially acceptable to initiate sexual relations and highlights a major public health challenge in integrating the protective health benefits of circumcision with indigenous cultural practices.

Nontherapeutic male circumcision: tackling the difficult issues

INTRODUCTION

Male circumcision is the most commonly performed surgical procedure in the world. Circumcision may be performed to treat an underlying pathological process ("therapeutic circumcision"). However there may be religious, cultural, and social indications.

AIM

This article addresses the religious, cultural, social, and ethical issues surrounding nontherapeutic male circumcision (NTMC).

MAIN OUTCOME MEASURES

Any religious, social, cultural, or ethical issues relating to NTMC.

METHODS

Because of the absence of high level evidence, a concise literature review was undertaken to identify articles published between January 1990 and February 2009 summarizing current knowledge on NTMC.

RESULTS

There are complex religious, cultural, social, and prophylactic incentives for NTMC. The procedure may have associated clinical and psychosocial adverse events and raises such ethical issues as bodily integrity and consent. Because of the strength of the incentives for NTMC, there may be important implications in denying patients the procedure. Several important issues must be considered when introducing mass circumcision as a preventative strategy for HIV/AIDS.

CONCLUSION

When assessing whether NTMC will benefit or harm a patient, clinicians must take his religious, cultural, and social circumstances into account. Males requiring mandatory religious or cultural NTMC are likely to suffer significant harm if they do not receive circumcision and should be considered separately to males in general.

Circumcision status and risk of sexually transmitted infection in young adult males: an analysis of a longitudinal birth cohort

OBJECTIVES

Previous research suggests that male circumcision may be a protective factor against the acquisition of sexually transmitted infections; however, studies examining this question have produced mixed results. The aim of this study was to examine the association between circumcision status and sexually transmitted infection risk using a longitudinal birth cohort study.

METHODS

Data were gathered as part of the Christchurch Health and Development Study, a 25-year longitudinal study of a birth cohort of New Zealand children. Information was obtained on: (1) the circumcision status of males in the cohort before 15 years old, (2) measures of self-reported sexually transmitted infection from ages 18 to 25 years, and (3) childhood, family, and related covariate factors.

RESULTS

Being uncircumcised had a statistically significant bivariate association with self-reported sexually transmitted infection. Adjustment for potentially confounding factors, including number of sexual partners and unprotected sex, as well as background and family factors related to circumcision, did not reduce the association between circumcision status and reports of sexually transmitted infection. Estimates of the population-attributable risk suggested that universal neonatal circumcision would have reduced rates of sexually transmitted infection in this cohort by 48.2%.

CONCLUSIONS

These findings suggest that uncircumcised males are at greater risk of acquiring sexually transmitted infection than circumcised males. Male circumcision may reduce the risk of sexually transmitted infection acquisition and transmission by up to one half, suggesting substantial benefits accruing from routine neonatal circumcision.

Circumcision policy: A psychosocial perspective

The debate about the advisability of circumcision in English-speaking countries has typically focused on the potential health factors. The position statements of committees from national medical organizations are expected to be evidence-based; however, the contentiousness of the ongoing debate suggests that other factors are involved. Various potential factors related to psychology, sociology, religion and culture may also underlie policy decisions. These factors could affect the values and attitudes of medical committee members, the process of evaluating the medical literature and the medical literature itself. Although medical professionals highly value rationality, it can be difficult to conduct a rational and objective evaluation of an emotional and controversial topic such as circumcision. A negotiated compromise between polarized committee factions could introduce additional psychosocial factors. These possibilities are speculative, not conclusive. It is recommended that an open discussion of psychosocial factors take place and that the potential biases of committee members be recognized.

Penile and testicular disorders

Circumcision, priapism, phimosis, Peyronie's disease, orchitis, epididymitis, and testicular torsion are conditions of the male penis and testicles that warrant increased attention by health care providers in practice. Healthy outcomes for penile and testicular disorders can be achieved through education, enhanced screening, and adequate comprehensive treatment. Penile and testicle disorders provide researchers and clinicians with many opportunities for research and practice that can improve the condition of men's health.