Article Figures & Data
Figures
- Figure 1.
Flow chart of studies included in review of nontherapeutic male circumcision.
- Figure 2.
Efficacy of circumcision in preventing HIV infection in men who were HIV-negative at randomization.
CI = confidence interval; HIV = human immunodeficiency virus; M-H = Mantel-Haenszel odds ratio.
Tables
Databases Searched Search Terms Bris, milah, and mohel are terms associated with Jewish religious circumcision; khitan is a term for Islamic religious circumcision; and dhapi, djapi, madiwa, and mandiyala are terms for Australian Aboriginal circumcision. The truncation symbol (*) is used in many databases to allow retrieval of search terms with common word stems, eg, circumcis* will retrieve circumcise, circumcised, circumcision, etc. The York (UK) Centre for Reviews and Dissemination (CRD) Medical subject heading (MeSH): circumcision, male The Cochrane Library Textword terms: PubMed circumcis* EMBASE bris milah* mohel* khitan* dhapi* djapi* mandiwa* mandiyala* Study Location Outcomes Analyzed Study Groups No. of Patients Randomized Age at Circumcision EMLA = EMLA Cream, a proprietary cream of 2.5% lidocaine and 2.5% prilocaine; HIV/AIDS = human immunodeficiency virus/acquired immune deficiency syndrome. a Mattson 2008 reported further outcomes for the Bailey 2007 cohort. b Kigozi 2008 reported further outcomes for the Gray 2007 cohort. c Kigozi 2008a reported further outcomes for the Gray 2007 cohort. Adult circumcision Auvert et al,13 2005 South Africa HIV/AIDS incidence, adverse events associated with circumcision Immediate circumcision 1,546 Median 21 y Delayed circumcision 1,582 Median 21 y Bailey et al,14 2007 Kenya HIV/AIDS incidence, adverse events associated with circumcision Immediate circumcision 1,391 Median 20 y Delayed circumcision 1,393 Median 20 y Mattson et al,15 2008a Kenya Unique data on sexual risk behavior only Immediate circumcision 1,391 Median 20 y Delayed circumcision 1,393 Median 20 y Gray et al,16 2007 Uganda HIV/AIDS incidence, adverse events associated with circumcision Immediate circumcision 2,474 Range 15–49 y Delayed circumcision 2,522 Range 15–49 y Kigozi et al,17 2008b Uganda Unique data on sexual satisfaction and function only Immediate circumcision 2,474 Range 15–49 y Delayed circumcision 2,522 Range 15–49 y Kigozi et al,18 2008ac Uganda Unique data on safety outcomes only Immediate circumcision 2,474 Range 15–49 y Delayed circumcision 2,522 Range 15–49 y Neonatal circumcision Macke,19 2001 USA Pain distress, mother-infant bonding Circumcised with acetaminophen 29 Mean 29.57±9.18 h Circumcised with placebo 31 Mean 26.82±6.37 h Taddio et al,8 1997 Canada Subsequent pain response during vaccination Uncircumcised 32 Mean 133±12.9 d Circumcised with EMLA 20 Mean 140±23.7 d Circumcised with placebo 26 Mean 143±29.4 d Study Randomization Technique Outcome Assessors Blinded Inclusion/Exclusion Criteria Provided Operator Baseline Characteristics Power Calculations Follow-Up Lost to Follow-Up No. (%) HIV=human immunodeficiency virus; NR = not reported; STI = sexually transmitted infection. a Study identifier where more than 1 report for a single study exists. b Note: this cohort was originally randomly assigned to receive lidocaine-prilocaine or placebo cream prior to circumcision.20 Adult circumcision Auvert et al,13 2005 Opaque, sealed envelopes Yes Yes General practitioners experienced in male circumcision Patients in both groups well matched for age, religion, ethnic group, and educational level; authors did not provide information on statistical significance 3,035 patients required to obtain power of 80% to detect 50% reduction in HIV 21 mo 251 (8) 100 (6.5%) in circumcision group 151 (9.5) in control group (P=.0016). Bailey et al,14 2007a Opaque, sealed envelopes Yes Yes Clinicians Patients in both groups well matched for demographic and physical characteristics, prevalence of STI, and reported sexual history with women; authors did not provide information on statistical significance 2,776 patients required to detect 50% difference in 2-y HIV seroincidence 24 mo 240 (8.6) 126 (9.1) in circumcision group 114 (8.2) in control group Mattson et al,15 2008 Gray et al,16 2007a Opaque, sealed envelopes NR Yes Trained and certified physicians Patients in both groups well matched for sociodemographic characteristics, sexual risk behaviors, rates of self-reported symptoms of STI; authors did not provide information on statistical significance Study had 80% power to detect rate ratio of 0.5 for incident HIV in intervention group relative to control group 24 mo 229 (10.4) 114 (10.4) in circumcision group 115 (10.4) in control group Kigozi et al,17 2008 Kigozi et al,18 2008a Previous receipt of voluntary counselling and testing slightly higher in intervention than control groups (no figures provided) Neonatal circumcision Macke 19 2001 Groups determined by pharmacy staff Yes Inclusion criteria only Private and resident physicians No significant differences between the groups for maternal or newborn variables NR 1-h post circumcision NR Taddio et al,8 1997 NRb Yes No Pediatricians No significant differences between groups for demographic characteristics 30 infants per group needed 20 sec before, 20 sec during, and 20 sec after vaccination NR - Table 4.
Adverse Events Reported in Men Aged 15 to 49 Years Who Received Circumcision (N=5,228)
Adverse Events No. (%) Postoperative bleeding 69 (1.32) Infection 77 (1.47) Wound disruptions 34 (0.65) Delayed healing 5 (0.10) Swelling or hematoma 12 (0.23) Anesthesia-related 2 (0.04) Damage to the penis 4 (0.08) Insufficient skin removed 4 (0.08) Problems with appearance 9 (0.17) Difficulty voiding 7 (0.13) Other causes 28 (0.54) Total 251 (4.8)
The Article in Brief
Safety and Efficacy of Nontherapeutic Male Circumcision: A Systematic Review
Guy J. Maddern , and colleagues
Background Male circumcision, a commonly performed surgical procedure, can be performed for therapeutic (medical) reasons or nontherapeutic (religious, cultural, or social) reasons. This study examines existing research to determine the safety and effectiveness of nontherapeutic male circumcision.
What This Study Found There is little evidence showing clinical benefit from nontherapeutic male circumcision. Although evidence does show that adult male circumcision is effective in preventing HIV/AIDS in sub-Saharan African men, these findings cannot necessarily be applied to men in other countries. Current evidence is unclear on the effectiveness of adult circumcision in preventing sexually transmitted infections, urinary tract infections, and penile cancer. Furthermore, there is no current evidence that circumcision in infants prevents HIV/AIDS, sexually transmitted infections, urinary tract infections, and penile cancer.
Implications
- Patients who request circumcision for clinical reasons should be informed of the lack of consensus surrounding the procedure, the lack of strong evidence regarding its benefits, and the potential medical and psychosocial harms of the procedure.
- The authors call for additional research to strengthen the evidence base and allow for more informed conclusions on nontherapeutic male circumcision.
