Fact sheet: the pros and cons of male circumcision

"Male circumcision is a complex and emotive health issue that continues to generate great debate in the community and the medical profession. Foremost is the baby's welfare. The current prevailing public policy in Australia suggests that there is no medical indication for routine neonatal circumcision. However, recent evidence does demonstrate a higher risk of some health problems in uncircumcised males. Ultimately, it is the parents' decision, which should be respected and based on balanced, well-informed, comprehensive information. If you do decide to have your son circumcised, ensure it's done by an appropriate and experienced practitioner." Dr Christine Bennett, MBF's Chief Medical Officer.

What is circumcision?

Circumcision in the male refers to the surgical removal of the foreskin (prepuce) of the penis. The foreskin is a redundant fold of skin, which overlaps the end of the glans penis.

At birth, it is normal for the inner surface of the foreskin to be fused to the glans and separation occurs during childhood. By five years of age most boys should be able to retract the foreskin however a small percentage of boys are unable to do this until after puberty.

By puberty, uncircumcised boys should be able to retract the foreskin and clean underneath it to avoid infection.

Gentle washing of the genital area is sufficient in newborns and infants and later, when the foreskin is fully retractable, boys should be taught the importance of washing beneath the foreskin on a regular basis. ¹

Why is it important?

Circumcision has been around for religious and cultural reasons for thousands of years. Originally it was most likely done as a hygienic measure in hot, dry and often sandy environments and is still an important ritual in some religious groups.

Circumcision has been associated with a number of medical benefits, including lower rates of urinary tract infections, penile cancer, penile inflammation, penile dermatoses and sexually transmitted diseases.

Parents of newborn males often face many questions in the decision-making process on circumcision with major factors concerning opinions of family and friends, conformity with their dad and medical issues.

It is important that parents are presented with unbiased, accurate information so that they can make an informed decision as well as consider that the magnitude of some benefits depends on the age that circumcision is performed. Talking to people they trust can be another important step for parents in the decision-making process.

General statistics

The rates of circumcision vary around the world and are subject to trends as medical and ethical issues are debated.

In recent years the rate of circumcision in Australia has fallen and it is now estimated that 10 - 20% of male infants are circumcised ¹
Urinary tract infections affect 1 - 2% of boys but may be 5 times less frequent in circumcised boys ¹
Circumcision has a complication rate of 1 - 5% and includes local infection, bleeding and damage to the penis. Serious complications such as bleeding and septicaemia may rarely even result in death ¹
Penile cancer is rare - it affects 1 in 100,000 men in developed countries ¹

What are the benefits?

Reduction in urinary tract infections: the prevalence is higher in infancy than in older males. The risk of urinary tract infection is higher in males with underlying renal tract abnormalities and it is likely that "a small group of boys" will benefit from circumcision. ¹
Reduction of cancer: compared to uncircumcised men, circumcised men appear to have a lower risk of penile cancer and their female sexual partners may have a lower risk of cervical cancer. ²
- Penile cancer - this is rare but the risk is increased three - to six fold in uncircumcised men;
- Cervical cancer - uncircumcised men may be more likely to acquire and transmit the human papillomavirus (HPV) that is responsible for most cervical cancers.
Reduction in penile inflammation and retractile disorders: penile inflammatory disorders are less common in circumcised men but can develop whether or not circumcision has been performed. Uncircumcised males who retract the foreskin while bathing are less likely to experience problems with inflammation. Acute and recurrent problems of the foreskin can sometimes be managed medically but surgical intervention may be required. ¹
Reduction in sexually transmitted diseases (eg syphilis, gonorrhoea, herpes, HPV, HIV): the literature shows that generally, circumcision protects against contracting and passing on these diseases. The prepuce can act as a reservoir for viral organisms. The uncircumcised penis is protected by the foreskin and does not become keratinised and so is more susceptible to irritation. The significant reduction in risk of acquiring sexually transmitted infections is an important medical benefit of circumcision and recent research has prompted the World Health Organisation to develop specific policy recommendations to expand and promote male circumcision as a method of HIV prevention as part of an HIV prevention package. Circumcision does not provide complete protection against HIV and should not replace safe sex practices. ^{2, 3}
Improved hygiene: genital hygiene is easier in the absence of a foreskin.

What are the risks?

The rate of procedure-related complications is about 1 - 5% with most of these problems readily treatable with no long-term effects. ¹

Pain and distress: surgical excision of the foreskin is painful. Safe and effective pain control exists and should be offered to all infants undergoing the procedure.
Bleeding and local infection: these are the most common, significant complications. The risk of severe bleeding is higher if there is an underlying problem such as haemophilia. Wound infection occurs infrequently and is usually mild enough to be treated with local treatment. ¹
Cosmetic reasons: too much or too little skin removal may present problems ²
Ulceration: irritation from wet nappies may cause ulceration in the first few weeks after circumcision. Ulceration may lead to stenosis or 'hardening' of the 'eye of the penis'. ²
Buried penis: refers to a penis that is buried under scar tissue that develops at the site of incision. It may occur if too much or too little skin is removed. Treatment is surgical. ²
Sexual dissatisfaction: Some literature indicates that the end of the penis becomes less sensitive when the foreskin is removed. However, most circumcised males do not describe psychological trauma or decreased sexual function as a result of being circumcised. ²

What's happening in Australia?

In Australia circumcision is currently restricted in public hospitals in NSW, Victoria, Western Australia and Tasmania, with South Australia said to follow. ⁴

Public hospitals will continue to provide circumcision where there is an identified need for surgery to improve the patient's physical health. The medical reasons for circumcision may include the following:

Phimosis: a condition that prevents the retraction of the foreskin, which is either congenital or the result of infection.
Recurrent Balanoposthitis: generalised inflammation of the penis occurring as a complication of bacterial or fungal infection.
Paraphimosis: a condition characterised by an inability to replace the foreskin in its normal position after it has been retracted, which is caused by a narrow or inflamed foreskin.

The Royal Australasian College of Physicians is reviewing its policy on neonatal circumcision with information to be released at the end of 2007. ¹

How to care for an uncircumcised foreskin

(source: Royal Australasian College of Physicians)

It is normal for the inner surface of the foreskin to be fused to the glans in newborn males. Separation of the foreskin from the glans occurs spontaneously during childhood. By five years of age most of boys are able to retract their foreskin. A small percentage of boys are unable to fully retract their foreskin until puberty.

The foreskin requires no special care during infancy. It should be left alone. Attempts to forcibly retract it are painful, often injure the foreskin, and can lead to scarring and phimosis (difficulty in retracting the foreskin).

Later in childhood, the foreskin can be gently retracted to the point where resistance is met and the distal portion of the penis and the urethral meatus become visible. The glans and the inner-surface of the foreskin can be cleaned along with the rest of the body once separation has occurred and the foreskin is fully retractable.

By around the time of puberty, all uncircumcised boys should be able to retract their foreskin and clean underneath it in the bath or shower. It is important that they always return the foreskin to its original position after they have finished. If the foreskin is left retracted behind the glans, it may swell up and become painful (paraphimosis).

As the foreskin separates from the glans, dead skin cells will collect between the two layers. These dead cells appear as white crumbly or cheesy material and have been termed smegma. Smegma may produce a noticeable (and often asymmetrical) swelling beneath the foreskin. This material rarely causes problems and usually discharges spontaneously. Accumulation of smegma assists the normal process of separation of the inner surface of the foreskin to the glans of the penis in the young boy. Infection of smegma as it is released may cause inflammation.

Although there is evidence that boys who are uncircumcised have a higher incidence of urinary tract infections, there is no evidence that the increased incidence of infection is due to poor hygiene.