This was successfully posted to your pofile.
This box will close automatically in a few seconds. Close this window
We don't have an e-mail address on file for you. To use AAFP Connection, you must have an e-mail address in our records. Click Here
Circumcision: Position Paper on Neonatal Circumcision
Neonatal circumcision is one of the most common surgical procedures performed in the United States. However, little is known about the long-term risks and benefits. There have been few methodologically generalizable prospective studies concerning medical outcomes.
The AAFP Commission on Science has reviewed the literature regarding neonatal circumcision. Evidence from the literature is often conflicting or inconclusive. Most parents base their decision whether or not to have their newborn son circumcised on nonmedical preferences (i.e. religious, ethnic, cultural, cosmetic). The American Academy of Family Physicians recommends physicians discuss the potential harms and benefits of circumcision with all parents or legal guardians considering this procedure for their newborn son.
Contraindications to Neonatal Circumcision
Complications of Neonatal Circumcision
Urinary Tract Infections
Sexually Transmitted Diseases and Human Immunodeficiency Virus
Most of the studies on the relationship between acquiring HIV and being circumcised have been conducted in developing countries, particularly those in Africa. Because of the challenges with maintaining good hygiene and access to condoms, these results are probably not generalizable to the U.S. population. These studies did, however, find an association between contracting HIV and being uncircumcised. Based on two of the African prospective studies, an estimated 10 to 20 circumcisions are needed to prevent one infection of HIV. (4) A literature review estimated that the risk ratios of HIV sero-conversion for uncircumcised men compared to circumcised men ranged from 2.3 to 8.1. (18) Limitations to the studies from which these risk ratios are derived include poor sampling, a low rate of acquiring the disease, and not controlling for confounders such as the number of sexual partners or other sexual practices. Because ulcerative STDs are more common in uncircumcised men than circumcised men, one hypothesis is that these lesions increase the probability of one becoming infected if exposed to HIV. (19)
Cancer of the Penis
Cancer of the Cervix
Sexual Functioning and Penile Problems
Future Need for Circumcision
Informed Consent and the Medical Ethics of Circumcision
While routine circumcision is widely practiced, the small medical benefits of circumcision lead many to consider routine circumcision to be a cosmetic procedure. This leads to questions regarding medical ethics and whether and how to present to a parent a balanced discussion of the relative benefits and harms of the procedure. Key to the ethical discussion is respect of the parent’s religious, ethnic, or other cultural beliefs for which circumcision is practiced.
The evidence indicates that neonatal circumcision prevents UTIs in the first year of life with an absolute risk reduction of about 1% and prevents the development of penile cancer with an absolute risk reduction of less than 0.2%. The evidence suggests that circumcision reduces the rate of acquiring an STD, but careful sexual practices and hygiene may be as effective. Circumcision appears to decrease the transmission of HIV in underdeveloped areas where the virus is highly prevalent. No study has systematically evaluated the utility of routine neonatal circumcision for preventing all medically-indicated circumcisions in later life. Evidence regarding the association between cervical cancer and a woman’s partner being circumcised or uncircumcised, and evidence regarding the effect of circumcision on sexual functioning is inconclusive. If the decision is made to circumcise, anesthesia should be used.
The American Academy of Family Physicians recommends physicians discuss the potential harms and benefits of circumcision with all parents or legal guardians considering this procedure for their newborn son. (2001)
- Robson WL. The circumcision question. Postgraduate Medicine 1992;91:237-243.
- Laumann EO et al. Circumcision in the United States. JAMA 1997;277:1052-7.
- Christakis DA et al. A trade-off analysis of routine newborn circumcision. Pediatrics 2000; 105:246-9.
- Learman LA. Neonatal circumcision: a dispassionate analysis. Clinical Obstetrics and Gynecology 1999;42:849-859.
- Kaplan GW. Complications of Circumcision. Urol Clin North Am 1983;10:543-9.
- Harkavy KL. The circumcision debate (Letter). Pediatrics 1987;79:649.
- Anderson GF. Circumcision. Pediatric Annals 1989;18:205-213.
- Fergusson DM et al. Neonatal circumcision and penile problems. Pediatrics 1988;81:537-541.
- Niku SD et al. Neonatal circumcision. Urol Clin North Am 1995;22:57-65.
- King LR. Neonatal circumcision in the United States in 1982. J Urol 1982;128:1135-6.
- Ginsburg CM et al. Urinary tract infections in young infants. Pediatrics 1982;69:409-412.
- Wiswell TE. Urinary tract infection and the uncircumcised state: an update. Clin Pediatrics 1993;32:130-134.
- Rushton HG. The evaluation of acute pyelonephritis and renal scarring with technetium 99m-dimercaptosuccinic acid renal scintigraphy: evolving concepts and future directions. Urological Review 1997;11:108-120.
- Roberts JA. Neonatal circumcision: an end to the controversy. South Med J 1996;89:167-171.
- Moses S et al. The association between lack of male circumcision and risk for HIV infection. Sexually Transmitted Diseases 1994;21:201-210.
- Parker SW et al. Circumcision and sexually transmissible disease. Med J Australia 1983;2:288-290.
- Cook LS. Circumcision and sexually transmitted diseases. Am J Public Health 1994;84:197-201.
- Moses S et al. Male circumcision: an assessment of health benefits and risks. Sexually Transmitted Infections 1998;74:368-373.
- Caldwell JC et al. The African AIDS epidemic. Scientific American 1996;274:62-68.
- Maden C et al. History of circumcision, medical conditions, and sexual activity and risk of penile cancer. J Natl Cancer Inst 1993;85:19-24.
- Kochen M et al. Circumcision and the risk of cancer of the penis. Am J Dis Child 1980;134:484-6.
- Burger R et al. Why circumcision? Pediatrics 1974;54:362-2.
- Preston EN. Whither the foreskin? JAMA 1970;213:1853-8.
- Masters WH et al. Human Sexual Response. Little, Brown and Company. Boston 1966.
- Lander J et al. Comparison of ring block, dorsal penile nerve block, and topical anesthesia for neonatal circumcision. JAMA 1997;278:2157-2162.
- Snellman LW et al. Prospective evaluation of complications of dorsal penile nerve block for neonatal circumcision. Pediatrics 1995;95:705-708.
- Fontaine P et al. The safety of dorsal penile nerve block for neonatal circumcision. J Fam Prac. 1994;39:243-248.
- Gairdner D. The fat of the foreskin. Brit Med J 1949;2:1433.
- Herzog LW et al. The frequency of foreskin problems in uncircumcised children. Am J Dis Child 1986;140:254-6.
- Lawler FH et al. Circumcision: a decision analysis of its medical value. Fam Med 1991;23:587-593.
- Ganiats TG et al. Routine neonatal circumcision: a cost-utility analysis. Med Decis Making 1991;11:282-293.
|Author and study type||Outcome||Comment|
|Crain , Case [n=22], Control [n=177].||*.21 [.07-.60]odds of being circumcised if a case
*based on reported data: 82% of cases were not circumcised vs. 48% of controls [p
|Infants who presented to ER with fever.|
|Craig , Case [n=144], Control [n=742].||OR, controlled for age =.18 [.05-.7] Authors estimate 79.2% of UTIs attributable to no circumcision in boys less than 5 years of age||Boys
|Rushto , Case [n=23], Control [n=63].||*OR =.076 [.016-.353] *based on reported percentage of cases without circumcision [91.3% vs. controls 44%] [p
||Based on infants admitted with UTI and fever. No significant differences between race and socioeconomic status or between cases and controls|
|Bennett , Case [n=36], Control [n=200].||OR = .20 [.09-.44]
Based on reported 72% of cases having been uncircumcised vs. 35% of controls
|Boys <18 years of age diagnosed with epididymitis.
Controls based on consecutive hospital admissions for nonurological problems
|To  Cohort of 30,105 boys who were circumcised and 38,995 who were not circumcised.||Relative risk for hospitalization if uncircumcised: 3.7 (2.8-5.0) Attributable risk of admission over one year per 1,000 boys: 5.14. 195 circumcisions needed to prevent one hospitalization||Hospital admission data only. Controlled for socioeconomic status. Did not account for outpatient circumcisions.|
|Wiswell . Cohort of 80,274 infants who were circumcised and 27,319 who were not circumcised||Percentage circumcised boys with UTI: .14%, Uncircumcised: 1.4%||U.S. Military Hospital record review of infants born between Jan. 1985 to Dec. 1990|
|Wiswell . Meta-analysis of 9 papers.||Odds ratio of being uncircumcised if a case [UTI]: 12.0 [10.6-13.6]|
|Chessare  Decision analysis.||Probability of UTI had to be greater than .29 in order to favor circumcision||Analysis very sensitive to utilities assigned to minor complications of bleeding and or pain. Utility assigned to pain had to be .9867 or higher in order to favor circumcision|
|Cameron Case[N=293], Kenya.||RR=8.1 (3.4-19.7)||*Only crude proxies to control for sexual practices. Most Muslims|
|Tyndall Case [N=413], Kenya.||RR=4.5 (2.6-7.7)||Are circumcised and difficult to control for other lifestyle patterns associated with religion. Circumcision based on self report often mis-classified and up to 16% are functionally not circumcised. Ulcerative diseases (esp. chancroid) are common and chancroid is more common in men who are not circumcised|
|Telzac Case [N=758], USA.||3.5 (.8-15.8)||Very low incidence of HIV. Insufficient power|
|Mehendale Case [N=721], India.||RR=2.9 (p=.11)||Low number of circumcised men in sample|
|Lavreys Case [N=746], Kenya.||RR=2.3 (1.0-5.1)||*Adjusted for potential confounders|
|Kapiga Case [N= 471], Women attending a family planning clinic.||RR=3.4 (1.03-11.3)||*Adjusted for potential confounders|
|Grosskurth Case [N=12,534], Prevalence study.||OR=1.24 (p=.14)||Authors speculate that they have missed controlling for lifestyle factors that may be associated with circumcision|
|Learman||10-20 circumcisions to prevent one HIV infection||Based on prospective studies from Rwanda and Tanzania. Because of hygiene and very low prevalence of chancroid in the U.S., probably not applicable to the U.S.|
|SEXUALLY TRANSMITTED DISEASES|
|Cook .||OR (syphilis)= 4.0 (1.9-8.4)||Adjusted for race, number of partners, place of residence, and other STDs. No association with nongonnoccal urethritis, chlamydia, and genital herpes. Only identified cases by positive cultures. Will miss many cases of asymptomatic genital herpes|
|Learman||Absolute risk reduction: .31 cases of penile carcinoma per 100,000 males a year. 322,000 circumcisions to prevent one case of penile carcinoma a year||Virtually all cases of penile cancer occur in uncircumcised men. Incidence, however is very low (2 per 100 000 uncircumcised men per year). Other public health strategies such as hygiene are much more effective|
|Agarwal . Case control.||OR=4.1||Recent mutivariate analysis of data did not support this association. (Learman) Age at initiation of sexual activity, number of partners, and smoking are much more important risk factors|
|SAFETY OF LOCAL ANESTHESIA|
|Snellman . Prospective follow-up of 491 infants who had DPB.||11% had bruising at time of discharge, all of which resolved at two weeks||Relied on returned questionnaires from pediatrician’s office. Only a two-week follow-up|
|Fontaine  Record review 1,022 charts.||1.2% had minor complications (11 minor bruising at site, one with “excessive bleeding”)|
These recommendations are provided only as an assistance for physicians making clinical decisions regarding the care of their patients. As such, they cannot substitute for the individual judgment brought to each clinical situation by the patient’s family physician. As with all reference resources, they reflect the best understanding of the science of medicine at the time of publication, but they should be used with the clear understanding that continued research may result in new knowledge and recommendations.