Circumcision rates differ between countries

Editor-I read with interest the article on male circumcision by Bailis and Halperin.¹ Circumcision rates in the United States have long been greater than those in the United Kingdom. Rates of circumcision in newborns in the US have increased recently: from 48% in 1988-91 to 61% in 1997-2000.² About 15% of men in the UK are circumcised.³ The rate fell from 35% in the 1930s to 6.5% by the mid-1980s¹ and is still falling.⁵

The differences in rates are associated with preferences of clinicians for circumcision as fuelled by historical trends and the demand of society. In the 1890s circumcision became popular as a treatment for male infants and was urged as a preventive of “congenital phimosis,” masturbation, syphilis, epilepsy, hip diseases, bed wetting, and many more disorders. Evidence based medicine has proved many of these indications to be false, but further benefits of the procedure have been explored.

As the article states, 90% of boys have a retractable foreskin at the age of 5, but studies show that only 0.6-1% have non-retractable foreskins at age 16-17.⁶ Of those individuals with a physiological phimosis for this period there is no evidence of obstructed voiding⁷ and associated renal impairment.

Evidence is emerging that implies a biological advantage of circumcision in preventing HIV-1 infection, but not other sexually transmitted infections.⁸ European views of circumcision and urinary tract infection show that the number of circumcisions needed to prevent one infection is 111 in normal boys. In those with recurrent infections, this number drops-so circumcision should be reserved for those with recurrent infections.⁹

The article also highlighted penile cancer as an indication for circumcision-but its rate is falling in Europe despite the decline in circumcision rates.¹⁰

In the US there is a view to increase the rate of circumcision, but in Europe this seems to be the opposite. In Denmark, the rate is 1.6%, and a UK paper says that a rate of 0.6% should be the target¹¹-with an increase in the use of surgery that preserves the foreskin, such as preputioplasty, should it be even lower?

Given the operative morbidity, cost, and benefit to only a small percentage of the population, is mass circumcision really justified?

1. Bailis SA, Halperin DT. Male circumcision: time to re-examine the evidence. studentBMJ 2006;14:179. (May.)
2. Nelson CP, Dunn R, Wan J, Wei JT. The increasing incidence of newborn circumcision: data from the nationwide inpatient sample. J Urol 2005;173:978-81.
3. Dave SS, Fenton KA, Mercer CH, Erens B, Wellings K. Johnson AM. Male circumcision in Britain: findings from a national probability sample survey. Sex Transm Infect 2003;79:499-500.
4. Rickwood AMK, Walker J. Is phimosis over diagnosed in boys and are too many circumcisions performed in consequence? Ann R Coll Surg Engl 1989;71:275-7.
5. Quaba O, MacKinlay GA. Changing trends in a decade of circumcision in Scotland. J Pediatr Surg 2004;39:1037-9.
6. Shankar KR, Rickwood AM. The incidence of phimosis in boys. BJU Int 1999;84:101-2.
7. Babu R, Harrison SK, Hutton KA. Ballooning of the foreskin and physiological phimosis: is there any objective evidence of obstructed voiding? BJU Int 2004;94:384-7.
8. Reynolds SJ, Shepherd ME, Risbud AR, Gangakhedkar RR, Brookmeyer RS, Divekar AD, et al. Male circumcision and risk of HIV-1 and other sexually transmitted infections in India. Lancet 2004;363:1039-40.
9. Singh-Grewal D, Macdessi J, Craig J. Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomised trials and observational studies. Arch Dis Child 2005;90:853-8.
10. Frisch M, Friis S, Krüger Kjaer S, Melbye M. Falling incidence of penile cancer in an uncircumcised population (Denmark 1943-90). BMJ 1995;311:1471.
11. Rickwood AMK, Kenny SE, Donnell SC. Towards evidence based circumcision of English boys: survey of trends in practice. BMJ 2000;321:792-3.

       

           

	LETTERS Circumcision rates differ between countries       Daniel C Perry (July 2006)
	Raghesh varot kangath (August 21st, 2006)       lecturer, DR SMCSI Medical College hospital drraghesh@yahoo.com
	Prophylactic circumcision has ethical concerns also in addition to economical concerns and efficacy. The question is whether circumcision can be limited to those with increased risk of developing urinary tract infections and those prone to develop penile carcinomas. Also many children might find the experience traumatic to their young minds and are not capable to take fully informed decisions. It will be better if the procedure can be postponed to a higher age when the children can decide for themselves.