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

Conclusions
Infancy presents a "window of opportunity" for circumcision. It is associated with substantially lower costs, lower risk of complications when performed by an experienced operator in a clinical or other appropriate setting, and lower lifetime risk of a variety of adverse conditions and infections [186]. The health benefits include protection against urinary tract infection and thus permanent damage to the still-growing kidney, reduced likelihood of penile inflammation, and elimination of risk of phimosis, which impedes micturition and results in difficult and painful erections in adolescence and adulthood. It also means tearing of the fragile foreskin and frenulum is avoided. Circumcision means an assurance of greatly reduced risk of penile cancer later in life, no smegma, better hygiene, and lower risk of various STIs. These not only include HIV that is an epidemic in some locations, but also oncogenic HPVs and genital herpes that are an epidemic worldwide. In the future female sexual partners of males, infant MC means they too will be at reduced risk of STIs and cervical cancer.

Some of the arguments against waiting until later to circumcise are:
  • Protection against UTIs and damage to the fragile pediatric kidney is lost.
  • Infant MC eliminates risk of phimosis and balanitis in childhood and after puberty.
  • If circumcision is performed after boys become sexually active benefits associated with STI prevention are delayed.
  • The risk of complications is higher for later circumcisions.
  • The cost (to the individual or the public purse) is much higher, and often unaffordable, for later circumcision.
  • Educational resources for boys to make an informed decision are quite limited.
  • Large-scale adolescent circumcision would strain medical resources.
  • Boys who later choose circumcision will likely wish it had been performed in infancy.
  • Many older boys and men may not want to face an operation even though they wish to be circumcised.
  • The momentum amongst major international and American health and medical organizations towards encouraging circumcision, especially in infancy.

Circumcision in infancy avoids any embarrassment of having it done later, as well as anxieties about pain, complications and adverse sexual effects, even though these are minimal or not supported by evidence. It also avoids arguments about whether there might be adverse psychological consequences for MC performed later in childhood. And absence from work or school is avoided.

There are fewer barriers to MC in infancy. The infant is less mobile, so facilitating the use of local anesthesia, the procedure is simpler, healing is quicker, the cosmetic outcome is superior, and cost-effectiveness is high, as is acceptability. The neonatal period should therefore be regarded as the optimal time to perform circumcision. It is viewed as a vital component of public health strategies aimed at realizing high levels of MC in the population [187]. The procedure should be performed by a trained professional using appropriate local anesthesia in a clean environment. Circumcision outside of such a setting is ill-advised, so explaining why clinical MC is increasingly being made available in European countries to Muslim families.

We recommend that evidence-based policies be developed regarding the availability of infant MC in all countries worldwide. It has been suggested that policies surrounding neonatal MC should be integrated into existing health systems as part of postnatal care [183], with adolescent and adult MC constituting "catch-up" campaigns that would be phased out over time [11]. This should not detract from the immediate urgent need for safe voluntary adult medical MC services in high-HIV-prevalence regions in particular.

Authors' contributions
BJM and JHW drafted the manuscript. JHW performed the statistical analyses shown in Figure 1. BJM, JHW, JB, RGM, AART, RHG, SAB, RCB, JDK, RJW, DTH, TEW and AM made substantial contributions to successive drafts and thereby to the intellectual content of this article. All authors read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests. Manuscript disposed: September, 2. 2011. Accepted: February, 28. 2012. Published: February, 28. 2012.
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