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A snip in time
by Professor Brian J. Morris, University of Sydney (Australia)

Background
The English proverb "A stitch in time saves nine" teaches that to avoid a bigger problem later immediate effort is preferable to procrastination. Thus fixing a small hole in a sock with one stitch will avoid the need for nine stitches later when the hole becomes bigger. In the present article we consider whether this applies to medical male circumcision (MC) - referred to colloquially as a "snip".

Worldwide 1 in 3 males are circumcised [1,2], totaling an estimated 1.2 billion [2]. In the USA, medical MC is performed on 1.2 million newborns (56% of baby boys) in community hospitals annually [3,4]. The true number is higher because some boys are circumcised in ambulatory facilities, a physician's clinic or in a private home. In other developed countries infancy is also the most common time for performing MC, whereas in non-Muslim developing countries MC is usually part of coming-of-age ceremonies where risks are usually greater [5]. The largest number of circumcised males are Muslims (approx. 70% of circumcised males globally) [1].

Circumcision predates human history, with evidence of MC from art forms of the Upper Paleolithic period in Europe (38,000 to 11,000 years BCE) [6]. Rather than arising independently in diverse cultures globally [7], the practice more logically arose prior to the migration of Homo sapiens out of Africa [8]. If it had no survival advantage, it is unlikely that it would have persisted, and, as hypothesized by Cox & Morris, subsequent cessation of MC in some populations was perhaps a result of behavioral changes caused by environmental stressors or new religious philosophies such as Hinduism and Buddhism [8]. Such factors could explain why circumcision is relatively low in European, South and Central America, southern Africa, and non-Muslim Asian countries.

The awareness during Victorian times of a wide array of medical benefits from MC, including prevention of syphilis and better hygiene, led to a rise in its popularity in Anglo-Saxon populations in the 19th century [7,9], continuing today in the USA in particular, where the majority of infant boys are circumcised [3,4]. In the UK circumcision is more common in the wealthier upper-classes, marking the fact that a doctor attended the birth rather than a mid-wife.

The advent of the AIDS epidemic in the 1980s re-focused interest on MC as a means of prevention of not just HIV, but other sexually transmitted infections (STIs) and adverse medical conditions. This has led to MC programs in high-HIV prevalence settings of sub-Saharan Africa focused on men for more immediate reductions in HIV incidence, but considerable interest has also been given to encouraging infant MC for longer-term gains [10,11]. There have as well been recent calls for the promotion of infant MC in the USA [12,13], the UK [14], Australia [15] and sub-Saharan Africa [16,17].

Despite the advantages of MC, few studies have directly compared the relative merits of MC at different ages. Here we present our findings after reviewing the literature, and document the relative pros and cons of infant MC versus MC in later childhood, adolescence or adulthood ("later circumcision"). We compare medical and surgical issues for infant versus later MC, attitudes and barriers, ethical issues, as well as cost-effectiveness. Our analysis has relevance to all countries, both developed and developing. Nevertheless, it should be recognized that a decision about circumcision is subject to varying considerations depending on the particular social and cultural context involved.
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