1. The Case for CIRCUMCISION in the Interests of Better Genital Health, Public Health & Individual Well-being School of Medical Sciences and Bosch Institute The University of Sydney Brian J. Morris www.circinfo.net

3. World’s oldest surgical procedure xxxx Egypt 2,300 BC

4. World’s most common surgical procedure 34% circ’d worldwide (W.H.O.) Middle East (all Muslim, Jewish, many Christian) Africa (tribal differences; 65% overall) Indigenous: Australians, Pacific Islanders, Mexicans, Kalahari. Asia: Philippines, South Korea Worldwide: All Muslims and Jews USA: 88% whites, 73% blacks, 42% Hispanic. Australia: 69% of Aust-born men (32% for ages 16–20) UK: 16% of men (12% 16-24 y, 16% 25-34 y, 26% 35-45 y), London 44% Canada: 50% (regional variation) Most other countries: 1–20%

5. Statements by US experts Dr Tom Wiswell: “As a pediatrician and neonatologist, I am a child advocate and try to do what is best for children. For many years I was an outspoken opponent of circumcision … I have gradually changed my mind.” Dr Edgar Schoen: (Chairman 1989 AAP Task Force on Circumcision) “ Current newborn circumcision may be considered a preventative measure analogous to immunization in that side effects and complications are immediate and usually minor, but benefits accrue for a lifetime.” Derides ‘NOCIRC’ and other anti-circ groups for “use of distortions, anecdotes and testimonials to try to influence professional and legislative bodies and the public …. have become increasingly desperate and outrageous as the medical literature has documented the benefits.”

6. Its anatomy makes the uncircumcised penis a health hazard Uncircumcised Circumcised

7. Parents’ reasons for circ in Australia, USA, etc Most: Hygiene, appearance, family (be like ‘dad’). But growing awareness of medical benefits Medical necessity: 1–2% Religion: 3% [Donovan et al. 1994: Sydney Hospital study]

8. HYGIENE Nonexistent in schoolboys and poor in uncirc’d men Smegma (shed cells, dirt, bacteria, yeast, offensive odour) Soap & water not the answer – bacteria quickly return after washing – dermatological problems from soap Inferior genital hygiene – 26% of uncirc’d vs. 4% of circ’d Possible reason: medical conditions that make retracting foreskin difficult and painful Wash > once per day – 19% of uncirc’d vs. 37% of circ’d [Study in London – O’Farrell et al. Int J STD AIDS 2005;16:556-9]

9. GENERAL PROBLEMS Affect 18% of the uncirc’d by age 8 PHIMOSIS (Inability to retract foreskin) After age 5, seen in 10% of those not circ’d PARAPHIMOSIS (Can’t return foreskin back) Inflammatory dermatoses (5-fold higher in uncirc’d. 1 in 10 affected; diabetics 1 in 3) BALANITIS (Inflammation of glans) POSTHITIS (Inflammation of foreskin) BALANOPOSTHITIS (in UNCIRC’d diabetics) Other: ZIPPER INJURIES BATHROOM ‘SPLATTER’ URINARY DRAINAGE APPLIANCE (Quadraplegic, Senile) HYGIENE IN ELDERLY (Carers in nursing homes)

10. URINARY TRACT INFECTIONS (UTIs) In the first year of life: UNCIRC – 1 in 50 (~1M annually worldwide) CIRC’d – 1 in 500 (FEMALE – 1 in 200) META-ANALYSIS: 12 X HIGHER in uncirc’d (range: 5–89 X ) LIFETIME: UTI affects ~20% of uncirc’d UTI is the cause in 22% of febrile uncirc’d boys (only 1% of circ’d). 40% get PYELONEPHRITIS and RENAL SCARRING Recurrent UTIs affect 19% of uncirc’d boys Death possible: kidney failure, meningitis, bone marrow infection

11. UTIs — Biological support Uropathogens under the foreskin of over 90%: Fimbriated E. coli (pyelonephritogenic) – adhere to foreskin – form impenetrable ‘pods’ on bladder wall Enterococcus spp Proteus spp Pseudomonas spp Klebsiella spp Staphylococci

12. SEXUALLY TRANSMITTED INFECTIONS (STIs) USA: 19M cases in 2006. Enormous increase this decade. Many early studies showed uncircumcised men had higher: syphilis chlamydia gonorrhoea non-gonococcal urethritis herpes (30% higher in recent RCT) warts Most recent studies in western (hygienic) settings: ≥ 2x higher syphilis, chancroid, thrush; 4 x HPV Little difference in gonorrhoea and chlamydia. Longitudinal studies (NZ): 3x higher STIs to age 25 No difference in the other

13. Penile Carcinoma penis can be transformed into a solid mass

14. INVASIVE PENILE CANCER >22 higher in uncirc’d men. Rarely seen in men circumcised at birth. LIFETIME RISK in uncirc’d: 1 in 600 (USA) In USA: 0.2% of all malignancies 0.1% of cancer deaths Australia: 60–70 cases per year High mortality (1 in 2 dead by 5 y ) and morbidity Treatment: Penile amputation (total or partial) Radiation

15. Cause of penile cancer High-risk (oncogenic) HPV Present in 20% of uncirc’d men but only 5.5% of circ’d men (Adjusted OR = 0.37) 100% of PIN grade III In high-risk men, circ reduces penile HPV 14-fold Distribution of HPV is highest in foreskin Sexual transmission Phimosis Smegma (Stallions: erections clear smegma cf. Geldings, no erections, 10x higher CaP) Not hygiene

16. PROSTATE CANCER Correlates with history of STIs Incidence 1.5–2 fold higher in uncircumcised men Circ rate inversely correlated with prostate cancer rate in 51 countries. In USA lifetime risk (for 70% circ rate of men born 1930s) uncirc’d = 1 in 4.2–4.6 circ’d = 1 in 7.4–8.4 Extra cases: 24–40% more (ie, 40–67,000 more) Extra cost: $0.8–1.1 Billion cf. cost of circ (today) @ $195 = $390M per year [Morris et al. BJU Int 2007; 100: 5-6]

17. CERVICAL CANCER Caused by high-risk HPVs (16, 18, etc) Low in populations where men are circ’d Sexually-transmitted cancer PIN & CIN Smegma

18. Castellsague X et al. N Engl J Med 2002; 346: 1105-12  Male circumcision reduced the risk of cervical cancer in wives by: 1.4-fold (overall) 1.4-fold (overall) 5.6-fold (monogamous wives of high-risk males) 5.6-fold (monogamous wives of high-risk males) [i.e., >5 partners … = most men] UNAIDS data from 117 developing countries: CC incidence of 35 per 100,000 women per year in 51 countries with a low (<20%) circumcision prevalence and 20 in 52 with a high (>80%) circumcision prevalence (P <0.001) {Drain, 2006 #1524}. Of all factors examined, male circumcision had the strongest association with cervical cancer incidence. CONDOMS DON’T HELP MUCH OR 0.83 vs. 0.67 (users vs. non-users)

19. Education (circumcised – higher education) Age at first sexual intercourse Genital washing after intercourse (circumcised, less often) Physician-examined penile hygiene (circumcised, better hygiene) Circumcision associated with: No association with: Age Number of sexual partners Contacts with prostitutes Condom use Wife’s number of sexual partners

20. Cervical cancer UNAIDS data from 117 developing countries Low circ (<20%): 35 cases per 100,000 women per year (51 countries) High circ (>80%): 20 cases per 100,000 women per year (52 countries) (P <0.001) Of all factors examined, male circumcision had the strongest association with lower cervical cancer incidence.

21. BREAST CANCER HPV present (10 studies) Same type as in cervix of each woman Support: Women with HPV-positive breast tumours YOUNGER than women with HPV-negative breast tumours Sexual transmission? – Direct? – or from cervix (via bloodstream or lymphatic system)

22. HERPES SIMPLEX TYPE 2 (genital herpes) IN WOMEN If male partner uncirc’d: 2.2 times higher in female partner (Pittsburg: age 18–30; HSV-2 seroprev 25%) 2.0 times higher (Africa: randomized controlled trial. BMJ 2008)

23. CHLAMYDIA TRACHOMATIS IN WOMEN 5.6 times higher if male partner uncirc’d (i.e., circ reduced risk by 82%) Women had only ever had 1 partner. 5 countries. No difference in C. pneumoniae HOW?: Foreskin traps infections longer, so increasing urethral infection and subsequent transmission to the vagina during sex?

24. Late 1980s first evidence that circumcision reduces HIV risk Sub-Saharan Africa HIV / AIDS

25. Foreskin increases risk to man during insertive sex INCREASED RISK = 1.5–9.6 (> 40 observational studies) ALL studies show lack of circ increased risk Sub-Saharan Africa (UNAIDS data) Low circ (< 20%): 0.76% (11 countries) High circ (> 80%): 0.09% (17 countries) DIFFERENCE = 8-fold USA (heterosexual) Uncirc’d: 2.1% of men infected Circ’d: 0.6% of men infected DIFFERENCE = 4-fold

26. Randomized controlled trials (gold standard) 50–60% reduction in ‘circ group’. But per-protocol shows 60–76% protection Auvert et al. PLoS Med 2005: South Africa 76% Bailey et al. Lancet 2007: Kenya 60% Gray et al. Lancet 2007: Uganda 60% Protection so striking that ALL were stopped early. 28 Mar 2007 circ endorsed by WHO and UNAIDS Circ added to the old ‘ABC’ (abstinence, be faithful, condoms). New ‘ABC’: antivirals, barriers, circumcision Could avert 4M infections and 3M deaths over 10 y Cost-effective Could ‘abort the epidemic’

27. USA Seattle: 2.2-fold higher HIV in the uncirc’d (15% of men) 6 US cities: 2-fold higher in uncirc’d Black & Hispanice: No difference Failed HIV vaccine trial stopped in 2007: more uncirc’d became infected! MSM (HOMOSEXUAL) Australia Sydney: No association

28. Lifetime treatment cost, discounted to time of birth = $113,381 Neonatal circumcision reduces expected lifetime cost of HIV among ALL males by 14% Absolute cost difference: $102 (white) $1,134 (black) HIV/AIDS: COST in USA

29. MUCOSAL SURFACE OF INNER FORESKIN HAS A THINNER KERATIN BARRIER

30. xx INNER FORESKIN IS RICH IN HIV TARGET CELLS

31. LIVE HIV-1 CAN INFECT INNER, BUT NOT OUTER, FORESKIN IN EXPLANT CULTURE

32. HIV infects via inner foreskin: mucosal epithelium low keratin barrier rich in immune system target cells

33. xx The vulnerable inner foreskin becomes exposed during an erection HIV entry No HIV entry

34. IN GENERAL: WHY FORESKIN REPRESENTS A RISK Thinner epidermal barrier of inner lining of foreskin Langerhan’s (immune) cells take up HIV directly. They lie just beneath the surface, so easily infected. Greater microtrauma during sex Large surface area Traps infectious agents, e.g., HIV, HPV, etc Favours growth of micro-organisms Pathogenic E. coli, Proteus, Pseudomonas, Klebsiella, Serratia - bind to foreskin “Cesspool for infection”

35. SEX Australia (first ever survey was by a USyd academic in 1989) 18% circumcised later 21% of uncirc’d wanted to be circumcised No difference in sexual performance Slight increase in sexual activity in circ’d Frequency of sex same for older circ’d vs uncirc’d Men circ’d as adults – no difference in sensitivity of penis, better sex Simultaneous climax more likely for circ’d (29% vs. 17%) Women with uncirc’d lovers 3 x less likely to orgasm Circ favoured by women for appearance & hygiene (Some women nauseated by smell of uncirc’d men) Circ preferred for oral sex

36. National Health & Social Life Survey (USA) 1410 men 18–59 y [Laumann et al. JAMA 1997; 277: 1052-57] Uncirc’d – More sexual dysfunctions Circ’d – More elaborate set of sexual practices, rec’d more fellatio, masturbated more Australia-wide survey [Richters et al., Int J STD AIDS 2006] 10,000 men aged 16–60 y Uncirc’d – More problems: pain at any age, erectile dysfunction in 27% aged >50 Circ’d – More liberal attitudes These and other studies: Circ’d: higher socio-economic-educated groups in society

37. Sensitivity of the flaccid penis – Little or no difference Sensation **during sexual arousal** – No difference (lower sensitivity in each during arousal) [Thermal imaging by Payne et al. J Sex Med 2007; 4: 667-74] Satisfaction Same or better Time to ejaculation No difference – circ’d 6.7 min uncirc’d 6.0 min 500 couples: USA, UK, Netherlands, Spain, Turkey [J Sex Med 2005]

38. Women’s Preferences [Williamson & Williamson. J Sex Educ Hlth 1988; 14: 8-12] 92% Cleaner 90% Sexier 85% Felt nicer 82% Preferred for oral sex (cf. 2% for uncirc’d) 75% Manual stimulation (NB: Appearance of circ’d penis preferred by women who had only ever had uncirc’d partners!) Many studies in Africa, etc –> circ preferred by women & men Magazine surveys –> circ favoured The only study to differ: [O’Hare & O’Hare. BJU Int 1999; 83 (suppl): 93-102] INVALID – survey by anti-circs of members of anti-circ organization

39. Mothers’ preferences Hygiene Appearance So son will attract a ‘better’ partner. Thus better offspring (grandchildren).

40. THE PROCEDURE ITSELF Greatly reduced by local anaesthetic – ring block – dorsal penile nerve block – EMLA cream (2 h prior –> pain-free) No memory if prior to age 1–2 y No adverse psychological aftermath cf. pain of birth itself + many others in childhood * ANAESTHETIC SHOULD ALWAYS BE USED * A general anaesthetic is rarely necessary –> risk PAIN

41. DEVICES USED FOR INFANT CIRCS Various sizes OTHERS: Gomco clamp Mogen clamp Plastibell

42. RISKS (INFANT CIRCS) 1 in 500 MOSTLY MINOR + IMMEDIATELY & EASILY TREATABLE Excess bleeding 1 in 1000 Local infection 1 in 1000 Re do 1 in 1000 Injury to penis 1 in 15,000 Loss of penis 1 in 1,000,000 (never for medical circs today) Anaesthetic If dorsal penile nerve block, 1 in 4 may get small bruise that will disappear. Death USA 1954–89: 3 deaths from 50 million circs (cf: 11,000 deaths from penile cancer) No deaths today from medical circs

43. BREASTFEEDING OUTCOMES NOT DISRUPTED Longitudinal study in NZ Circ not associated with: breastfeeding outcomes in infancy health in infancy (except 2x higher lower resp tract inf in uncirc’d: 21% vs. 11%) cognitive ability outcomes in later childhood [Fergusson et al. J Paed Child Hlth 2007: 1000 men born 1977]

44. ADULT CIRC Local anaesthetic + mild sedative General anaesth preferred for sleeve-resection technique Risks: 2–3% (but <1% after 400 circs) … mostly minor Stitches (but tissue glue and tape now available) Healing complete when sutures dissolve (4 weeks) No sex until then Less convenient (time off work or school) Resume normal activities after 1–3 days Swelling resolves in a few weeks Final cosmetic result can take several months Cost = 10x higher than in infancy (can be > $1000)

45. WHOSE RESPONSIBILITY? Parental: over-rides ‘rights of child’ cf. immunization, education, etc Max. benefits if done soon after birth (+ simpler, cheaper, more convenient) Also: What adolescent or young adult will: be informed enough? be mature enough to request it be able to afford it? (10x higher costs cf. neonatal)

46. ANALOGOUS TO IMMUNIZATION RISKS – immediate BENEFITS – lifetime Eliminates phimosis, balanitis, posthitis Decreases UTI Prevents penile cancer Decreases cervical cancer in female partner Decreases chlamydia & herpes in female partner Decreases HIV infection Decreases penile problems Better hygiene Better sex

47. SUMMARY NOT CIRCUMCISING MEANS 1 in 3 will need medical attention for a problem arising 12 x increased risk of UTI (Risk = 1 in 20–1 in 50) Increased risk of death in 1st year of life and beyond ~1 in 600 will get cancer of penis (deadly); prostate cancer Physical & inflammatory problems in 18% by age 8 Is biggest risk factor for heterosexual HIV infection; other STIs Increased cervical cancer & chlamydia risk in female partner May need circumcision later in life Risk = 1 in 50 (cf. = 1 in 500 in newborn) + cost = 10 x higher if done later (Better cosmetic result if circ done earlier in life) More sexual problems (especially with age and diabetes)

48. 500,000–750,000 problems averted (many deaths) BENEFIT OUTWEIGHS THE RISKS 4,300 complications (mostly minor) by over 100 to 1

49. 1 in 3 uncircumcised men will have a problem as a result of not being circumcised and some of these will die as a result BENEFITS OF CIRCUMCISION EXCEED RISKS BY OVER 100 TO 1

50. Yes! …. a circumcision please!