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New Data Support Long-Term Health Benefits of Male Circumcision

From Medscape Medical News
New Data Support Long-Term Health Benefits of Male Circumcision
Fran Lowry
Authors and Disclosures

January 4, 2010 — The American Academy of Pediatrics (AAP) policy on newborn male circumcision, initiated in 1999 and reaffirmed in 2005, states that data are insufficient to recommend routine neonatal circumcision. However, recent results from 3 randomized trials showing that it prevents sexually transmitted infections suggest that it is time to revise this policy to fully reflect these benefits, according to a review published in the January 2010 issue of the Archives of Pediatric and Adolescent Medicine.

“During the past 4 years, substantial new data have been published on the health benefits of circumcision,” write Aaron A. R. Tobian, MD, from Johns Hopkins University School of Medicine, Baltimore, Maryland, and colleagues. “While the historical evidence strongly suggests that male circumcision reduces urinary tract infections and penile inflammatory disorders in infants, we reviewed the more recent evidence with regard to effects on sexually transmitted infections (STIs) in adulthood.”

To evaluate the effect of circumcision on HIV prevention, the researchers analyzed 3 randomized controlled trials of more than 10,000 men from South Africa, Kenya, and Uganda.

The trials enrolled HIV-negative men to circumcision on enrollment or after 21 to 24 months, and all 3 trials demonstrated that male circumcision significantly decreased male heterosexual HIV acquisition by 53% to 60%, despite differences in age eligibility criteria, urban or rural settings, and surgical procedure.

Results Prompted New WHO/UNAIDS Recommendations

Because of this new evidence, the World Health Organization (WHO), together with the Joint United Nations Program on HIV/AIDS (UNAIDS), recommended that male circumcision be provided as an important intervention to reduce heterosexually acquired HIV in men, the study authors report.

The trials also found that male circumcision decreased herpes simplex virus type 2 (HSV-2) acquisition by 28% to 34% and the prevalence of human papillomavirus (HPV) by 32% to 35% in men.

Among female partners of circumcised men, bacterial vaginosis was reduced by 40% and Trichomonas vaginalis infection was reduced by 48%, the study authors write.

The study authors note that the rates of neonatal circumcision complications are between 0.2% and 0.6% of operations performed. The most common complications are bleeding and local infection, which are controlled with pressure and wound care or antibiotics. Other complications, such as phimosis and concealed penis, adhesions, fistula, meatitis, meatal stenosis, and injury to the glans, are extremely rare.

They add that there was no evidence of change in sexual behavior after circumcision in the African randomized controlled trials. “Thus, there are risks to neonatal circumcision, but serious long-term complications are extremely rare,” the study authors write.

“The rare short-term risks of neonatal circumcision need to be weighed against the potential benefits accrued in infancy and childhood (eg, reduction of urinary tract infections), the longer-term benefits that may accrue in adolescence and adulthood (eg, reduced risks of HIV, HSV-2, and HPV), as well as possible benefits to female sexual partners of circumcised men (eg, reduced bacterial vaginosis and trichomonas),” Dr. Tobian and colleagues write.

Medicaid does not cover the cost of male circumcision in 16 states, and the lack of coverage particularly affects disadvantaged minorities, who have the highest risk for HIV and sexually transmitted diseases. “These socioeconomically disadvantaged groups could benefit most if Medicaid covered the costs of neonatal circumcision. Thus, the AAP’s policy has important implications for the health of disadvantaged minorities,” they write.

They conclude that it is time for the AAP policy to fully reflect current data.

Coverage for Circumcision

In an accompanying editorial, Michael T. Brady, MD, from Nationwide Children’s Hospital in Columbus, Ohio, writes that the study authors have provided a very objective review of the available data. Although the 3 randomized trials were performed in Africa, “it is clear that circumcision does offer health benefits, even in the United States,” he notes.

The current evidence on the health benefits of circumcision is adequate enough to include circumcision in medical coverage provided by Medicaid or commercial insurance providers, Dr. Brady points out. “This is particularly relevant since over the past decade many state Medicaid programs have discontinued payment for circumcision.”

He concludes that recommendations for routine newborn circumcision will need to wait for well-designed studies that verify its cost-effectiveness for the individual and/or society. “With available data, we are not there yet, but we may be getting closer.”

Dr. Tobian and Dr. Brady have disclosed no relevant financial relationships.

Arch Pediatr Adolesc Med. 2010;164:78-84, 94-96.

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Comment by DR. ARINDAM DUTTA on February 6, 2010 at 6:38am

Comment by Gina Tyler DHOM on January 18, 2010 at 9:00pm
And lets not forget FROM A HOMEOPATHIC point of view- Do we as practicioners cut off the foot if there might be a problem with this foot years later? Just in case? Homeopaths Do not look at diseases as isolated facts,We must take into consideration the Whole person (mental/physical/emotional) and then find the symptoms that may cause an imbalance in the 'vitalforce',thus prescribing the well indicated remedy. How does Circumcision fit into this homeopathic logic?This is pure Allopathic Logic.
Comment by David Quinn on January 14, 2010 at 5:25am
I fully agree with and support Gina in her efforts to clarify this issue. Circumcission is defined to be a surgical procedure of no health or medical benefit. In fact, only the reverse is true, that it is an invasive, deforming and probably most traumatising procedure carried out on a baby who with regard to the procedure is already in a perfect state of health.

Comment by Gina Tyler DHOM on January 13, 2010 at 8:57pm
To answer Dr. Nisanth's question,
Repertory of
of our Materia Medica


Prepuce :-

Aching, of inner surface :- Lyc.

Biting sensation :-

On inner surface :- Nux-v.

Urinating, on :- Calad.

Black, bluish, with hæmorrhage and gangrene (syphilis) :- Kreos.

Burning :- Ars-met., Cann-s., Sulph.

Between prepuce and glans :- Thuj.

Phimosis, in :- Sulph.

Rasping :- Berb.

Stool, after :- Sil.

Chancre :- (See Syphilis, Chancre.)

Coldness :- Berb.

Icy :- Sulph.

Moist :- Zing.

Discharge :-

Inner surface secretes a yellowish-green offensive matter :- Cor-r.

Yellowish pus, in drops :- MERC.

Yellowish-white liquid :- Jac-c.

Eruption :- Merc.

Blister, large round, that seemed about to burst (dropsy) :- Graph.

Blisters, little, containing pus burst and form round flat ulcers :- Ars-h.

Blister, long shaped, hangs from :- Rhus-t.

Blisters on inner surface forming chancre-like ulcers (gonorrhœa) :- Nit-ac.

Blotches, red, on inner surface :- Rhus-t.

Discolorations, several reddish-yellow :- Cinnb.

Herpes :- Caust., Merc., Sars.

Herpes, bleeding :- Dulc.

Herpes, brown :- Dulc.

Herpes, burning :- Sep.

Herpes, with chaps, with circular desquamation of :- Sep.

Herpes, corroding, itching :- Ph-ac.

Herpes, dry :- Dulc.

Herpes, furfuraceous :- Dulc.

Herpes, humid :- Dulc., Sep.

Herpes, itching :- Petr., Sep.

Herpes, preputialis, mercurial, itching :- Nit-ac.

Herpes, scurfy :- Sep.

Herpes, tingling, with :- Ph-ac.

Herpes, small vesicles in groups, whitish with red base and itching, sensitive to touch :- Hep.

Patches, 3 red, resembling in color eruptions of scarlatina on :- Cinnb.

Patches, white oval (syphilis) :- Sang.

Pimples, itching humid :- Sil.

Smallpox on inner surface, humid, suppurating, depressed on centre :- Thuj.

Spots, red, changing to an ulcer with scurf :- Thuj.

Spots, bright red, size of a pea :- Cann-s.

Vesicles :- Graph.

Vesicles (catarrh of bladder) :- Caust.

Vesicles, itching :- Calc.

Vesicles, small itching, open after a few days and become covered with small dry scabs or brown scurf :- NIT-AC.

Vesicles, pale red, from small ulcers, after breaking :- Merc.

Vesicles, successive creeps, very sore to touch, soon open at tip and leave a little ulcer-like sore, lasting a few days, a round clean cut, sharp edged elevation with depression, however, not filled with pus as in genuine chancre (retro-nasal catarrh benefited) :- # Med.

Vesicles, changing to suppurating ulcers :- Caust.

Erysipelas, after circumcision :- Apis.

Excoriation :-

Easy :- Nat-c.

Inner, on, and lower part :- Chin-b.

Itching, burning, with acrid discharge appearing upon inner surface as case improved (right-sided inguinal hernia) :- Psor.

Mechanical, of mucous surface, after coitus :- Calen.

Orifice, at, in diarrhœa :- Thuj.

Urine, by :- Hep.

Fissured :- Sep.

Frænum :-

Inflammation, yellow pus between frænum and glans :- Calc.

Itching :- Hep.

Painless lump, soft, smooth, having an abrasion on left side (gonorrhœa) :- Thuj.

Pain, attacks of (gleet) :- Sabin.

Secretions, humid :- Ph-ac.

Smarting :- Benz-ac.

Sore, as if pricked by needles :- Cor-r.

Tingling :- Ph-ac.

Ulcers :- Nit-ac.

Ulcers, painful, on both sides (chancre) :- Merc.

Tingling, oozing vesicles around, with feeling of heaviness in glans :- Ph-ac.

Heat :- Cann-s., Merc.

Gonorrhœa, in :- Merc.

Induration :-

Chancres, after :- Lach.

Board-like, red, swollen, with chancre :- Sulph.

Inflamed (See Sore, Swollen.) :- Calc., Cann-s., Merc., Nat-c.

Discharge, with acrid :- Sulph.

Inner surface, of, and its margins, with suppurating ulcers with flat edges looking like chancre, with sticking tearing, especially worse towards evening, lasting through night and preventing sleep, still worse by violent erections towards morning :- Nit-ac.

Pain, with burning :- Nit-ac.

Paraphimosis, in :- Coloc.

Redness, with, and burning :- Calc.

Redness of inner surface, painful sensitiveness :- Merc.

Skin :- Elaps.

Syphilis, in :- Apis.

Itching :- Agar., Aloe, CINNB., Colch., Gymno., Merc., Nit-ac., Sep., Sil., Sulph., Zing.

Biting, in inner and upper portion :- Puls.

Edges :- Ars-met.

Inner, on, side of :- Com.

Inner, on, surface :- Camph., Nux-v., Thuj.

Margin, in :- Cham., IGN., Jac-c.

Prostatic fluid, with discharge of, on every emotion :- CON.

Stinging, on inner surface :- Rhus-t.

Swelling, with :- Viol-t.

Voluptuous :- Euphor.

Numbness :- Berb.

Odor, fetid :- Cinnb.

Painful :- Calad., Osm.

Cannot retract it (gleet) :- Sabin.

As if a small bundle of fibres were seized :- Jac-c.

Paraphimosis :- Coloc., MERC., Merc-c., NIT-AC.

Gangrene threatened :- Ars., Canth., LACH., Merc-i-r.

Glans, with extensive swelling of :- Kali-i.

Gonorrhœal :- Cann-s., MERC-SUL.

Gonorrhœal, in its beginning :- Coloc.

Orchitis, in :- Nux-v.

Painful and swollen, after coition :- Calad.

Pains night and day :- Coloc.

Pains in penis, with :- Rhus-t.

Penis smaller :- Prun.

Retracted behind glans :- Nat-m.

Sleep, during :- Coloc.

Syphilitic :- MERC., Nit-ac., Sep., Thuj.

Phimosis :- Acon., Calc., Cann-s., Cycl., Ham., Jac-c., Lyc., Merc., NIT-AC., Sulph.

Burning, with, on urinating :- Dig.

Children, in :- Acon., Calc., Merc., Sulph.

Constipation, with :- Cann-s.

Discharge dirty and profuse (secondary syphilis) :- Cinnb.

Discharge fetid (secondary syphilis) :- Cinnb.

Discharge of pus, throbbing :- Hep.

Discharge of fetid pus :- Sulph.

Discharge pus-like :- Cinnb.

Friction, from :- ARN.

Induration, with :- Lach., Sep., Sulph.

Inflammation, with :- Acon., Arn., Euphr., Rhus-t.

The use of chemical, from, or poisonous substances :- Acon., Bell., Bry., Camph.

Suppuration, with :- Caps., Hep., Merc.

Swelling, with :- Nit-ac.

Syphilitic :- MERC., Nit-ac., Sep., Thuj.

Pricking :- Jac-c.

In margin :- Jac-c.

Purplish :- Cinnb.

Red :- Cann-s., CINNB., Cor-r., Merc., Sil., Sulph.

With dry heat of body :- Prun.

In phimosis :- Sulph.

Sensitive :- Cor-r.

Margin feels sore when linen touches it :- Cor-r.

To touch :- Cann-s.

To touch, and on walking :- Merc.

Skin, thick :- Elaps.

Smarting :- Lob.

As from excoriation of margin :- Cann-s.

On inner side :- Cann-s.

In outer edge, worse after urination :- Bell.

Sore (See Inflamed.) :- MERC.

Chancre, like incipient :- Ail.

Corrosive pain :- Calad.

Inner surface, on, and small ulcers secreting very offensive ichor, stains linen like bloody matter :- Nit-ac.

Margin, at :- IGN., Mur-ac.

Margin, at, in sycosis :- Cham.

Margin, at, or on mons veneris :- Nux-v.

Rubbing, from slight :- Cycl.

Stinging :-

On inner surface :- Camph.

In margin :- Cham.

Stitches :- Ang., NIT-AC.

Swollen :- Apis, Cann-s., Caps., CINNB., Cor-r., Nat-c., Sil., Thuj.

Blister, to a large water, without pain :- Graph.

Burning pain :- Nit-ac.

Circumference 3 times greater :- Ars-met.

Distended, like a bladder :- Rhod.

Distended, as if, with air or water to a blister :- Merc.

Dropsy :- Dig., Graph.

Drawn over glans, could not be, copious, yellowish green pus on attempting to do so (secondary syphilis) :- Jac-c.

Gonorrhœa, in :- Merc.

Itching, with :- Lac-c., Viol-t.

Margin, along :- CALAD.

Nodosities, edges covered with :- Lac-c.

Œdema :- Nat-s.

Œdematous, to completely hide orifice of urethra (affection of liver, with dropsy) :- Fl-ac.

Paraphimosis, in :- Coloc.

Phimosis, approaching :- Cann-s.

Phimosis, with :- Nit-ac.

Sensitiveness, with painful :- Merc.

Swelling, dark red, erysipelatous :- RHUS-T.

Hard, red, in front, appearing as thick and hard as a lead pencil, with hard chancre in centre, entirely painless :- Merc-i-r.

Sycosis, in :- Cham.

Tearing, in left side :- Chin.

Ulcerative pain, margin :- Ign.

Ulcers :- Aur-m-n., Chin-b., Cinnb., MERC., Phos., Sep.

Bowl-shaped, tallow-like coating :- Arg-n.

Chancre-like externally :- Hep.

Chancre-like, in retry-nasal catarrh :- # Med.

Grayish, with shaggy borders :- Arg-m.

Mercurio-syphilitic :- Phos.

Mild (gonorrhœa) :- MERC-C.

Red, flat, with profuse, yellow, ichorous discharge on inner surface :- Cor-r.

Small, covered with pus :- Arg-n.

Several, usually, at a time :- Nit-ac.

Several small, bleed easily so soon as prepuce moves, or handling parts (chancre) :- Merc.

Warts (See Genitals, Glans, and Penis Warts.) :- Aur-m.

Bleeding when touched, on frænum and inner surface :- CINNB.

Discharge of viscid fluid, slight, inner surface covered with small, pointed :- Thuj.

Edge, on, with itching and burning :- Psor.

Excrescence on inner surface, like fig warts :- Thuj.

4 white, pedunculated, dry condylomata, on mucous surface of, painless and not sensitive to touch, after mercury in gonorrhœa :- Lyc.

Growth, a red, like condylomata on inner surface :- Thuj.

7, large, moist, itching, burning on :- Psor.

Ulcers, around :- Aur-m-n.

Water, cold, caused pain as from excoriation :- Cann-s.
Comment by Gina Tyler DHOM on January 13, 2010 at 1:44pm
Hahnemann speaks:
Homoeopathy sheds not a drop of blood, administers no emetics, purgatives, laxatives or diaphoretics, drives off no external affection by external means, prescribes no warm baths or medicated clysters, applies no Spanish flies or mustard plasters, no setons, no issues, excites no ptyalism, burns not with moxa or red-hot iron to the very bone, and so forth, but gives with its own hand its own preparations of simple uncompounded medicines, which it is accurately acquainted with, never subdues pain by opium, etc.(circumcision)

Thus homoeopathy is a perfectly simple system of medicine, remaining always fixed in its principles as in its practice, which, like the doctrine whereon it is based, if rightly apprehended will be found to be so exclusive (and only in that way serviceable), that as the doctrine must be accepted in its purity, so it must be purely practised, and all backward straying* to the pernicious routine of the old school (whose opposite it is, as day to night) is totally inadmissible, otherwise it ceases to deserve the honourable name of homoeopathy.

* I am therefore sorry that I once gave the advice, savouring of allopathy, to apply to the back in psoric diseases a resinous plaster to cause itching, and to employ the finest electrical sparks in paralytic affections. For as both these appliances have seldom proved of service, and have furnished the mongrel homoeopathists with an excuse for their allopathic transgressions, I am grieved I should ever have proposed them, and I hereby solerunly retract them - for this reason also, that, since then, our homoeopathic system has advanced so near to perfection that they are now no longer required.

That some misguided physicians who would wish to be considered homoeopathists, engraft some, to them more familiar, allopathic malpractices upon their nominally homoeopathic treatment, is owing to ignorance of the doctrine, laziness, contempt for suffering humanity, and ridiculous conceit, and, besides showing unpardonable: negligence in searching for the best homoeopathic specific for each case of disease, has often a base love of gain and other sordid motives for its spring - and for its result? that they cannot cure all important and serious diseases (which pure and careful homoeopathy can), and that they send many of their patients to that place whence no one returns, whilst the friends console themselves with the reflection that everything (including very hurtful allopathic process!) has been done for the departed.

KOTHEN; March 28th, 1833
Comment by Dr. Nisanth Nambison MD on January 13, 2010 at 12:54pm
Dear Dr Katja & Dr Guillermo Zamora,
I fully agree with your views. We need to have open views & it is true, if Hahnemann were alive he would revised the organon.
Dr Nisanth
Comment by Gina Tyler DHOM on January 13, 2010 at 12:50pm
The Facts Behind Circumcision
Newborn male circumcision is the most common surgical procedure performed in the U.S. It's a common misconception that there are tangible health benefits to male circumcision, but the truth is no medical society in the world recommends it.

This invasive procedure carries serious health risks, including infection, hemorrhage, surgical mishap, and death.

Yet, despite these risks, the Centers for Disease Control (CDC) is developing public health recommendations that could mislead more parents into agreeing to circumcision for their newborn baby boys.-More on the CDC,FDA,AMA here;

Myth – Circumcising baby boys is a safe and harmless procedure.
Fact – As with any surgery, surgically removing part of a baby boy's healthy genitals causes pain, creates immediate health risks and can lead to serious complications. Risks include infection, hemorrhage, scarring, difficulty urinating, loss of part or all of the penis, and even death. More than 100 circumcision-related deaths are estimated to occur every year in the United States, but the number may be even higher. Circumcision complications can and do occur in even the best clinical settings.

Myth – Circumcision is just a little snip.
Fact – Surgically removing part of a baby boy's healthy penis is far more than "a snip." First, a doctor or nurse places the baby on his back, and straps his arms and legs onto a molded plastic board. In the most common method of infant circumcision, the doctor then attaches two hemostats to the foreskin, and inserts a metal instrument under the foreskin to forcibly separate it from the glans (head of the penis). The doctor then slits the foreskin in order to widen its opening for insertion of the circumcision device, against which the foreskin is crushed and then cut off. This operation takes up to fifteen minutes. The amount of skin removed from an infant in a typical circumcision is the equivalent of 15 square inches (the size of a 3 x 5 index card) in an adult male.

Myth – Circumcision is routinely recommended and endorsed by doctors and other health professionals.
Fact – No professional medical association in the United States or anywhere else in the world recommends routine circumcision as a medically necessary procedure. The American Medical Association calls it "non-therapeutic." At no time in its 75 years has the American Academy of Pediatrics ever recommended infant circumcision.

Myth – The baby does not feel any pain during circumcision.
Fact – Circumcision is painful. Babies are sensitive to pain, just like older children and adults. The younger the baby, the more intense the experience of pain. The analgesics used for circumcision only decrease pain; they do not eliminate it. Furthermore, the open wound left by the removal of the foreskin will continue to cause the baby pain and discomfort, especially during urination and defecation, for the 7-10 days it takes for the wound to heal.

Myth – If I don't circumcise my son, he will be ridiculed.
Fact – Times have changed and so has people's understanding of circumcision. Today, half of all baby boys born in the United States will leave the hospital "intact." The circumcision rate is already estimated to be as low as 30% in the Western United States, and the rate across the United States continues to decline as well. Most medically advanced nations do not "routinely" perform surgical operations to remove healthy flesh from newborn babies, and most have laws to protect girls from genital modification. Approximately 75 % of men in the world are not circumcised and remain intact.

Myth – A boy should look like his father. My husband is circumcised, so my son should also be circumcised.
Fact – Children differ from their parents in all kinds of ways, including eye and hair color, body type, and (of course) size and sexual development. If a parent were missing an eye or had a large birthmark, nobody would suggest that the baby's eye be removed at birth, or that he be tattooed with a "birthmark" to look like his parent. If a child asks why his penis looks different from that of his father (or a sibling), parents can offer a simple explanation such as, "Daddy (or brother) had a part of his penis removed when he was a baby, but now we know it’s not necessary and we decided not to let anyone do that to you."

Myth – Routine circumcision of baby boys cannot be compared to Female Genital Mutilation, either as a cultural or medical practice. Female genital cutting is an unjust and inhumane practice, but circumcising boys is justifiable.
Fact – The rationales offered in cultures that promote female genital cutting are similar to those offered in cultures that promote male circumcision. These include hygiene, disease prevention, improved appearance of the genitalia, and social acceptance. Whatever the rationale, forced removal of healthy genital tissue from any child – male or female – is unethical. Boys have the same right as girls to be spared this inhumane, unnecessary surgery.

Myth – To oppose male circumcision is religious and cultural bigotry.
Fact – Many who oppose the painful, risky and permanent alteration of babies' or children's genitalia do so precisely because they believe in universal human rights. People of many different religious and cultural traditions agree that all children – regardless of race, ethnicity, or culture of origin – have the right to be protected from bodily harm. In our society, parents have the right to raise their children in accordance with their own cultural and religious standards. However, that right is not limitless. Parents must not (directly, or through the agency of a medical or religious practitioner) inflict irreversible harm on a child.

Myth – Circumcising newborn baby boys produces health benefits in later life.
Fact – Despite common perception, there is NO conclusive link between circumcision and better health. In fact, performing medically unnecessary surgery on a baby boy's genitals creates immediate health risks. Circumcision-related risks include infection, hemorrhage, scarring, loss of part or all of the penis, and even death. These dangers exist in even the best clinical settings.

Myth – Male circumcision helps prevent HIV.
Fact – Only abstinence or the use of condoms can prevent the spread of sexually transmitted diseases, including HIV/AIDS. Moreover, condom usage protects women as well as men. Even if circumcision were effective for preventing disease, removing part of a baby boy's penis at birth to prevent the potential for disease in the future makes no more sense than "routinely" removing healthy gall bladders at birth to prevent the potential for gall stones in later life, or removing healthy teeth to prevent dental caries.
Comment by Katja Schütt on January 13, 2010 at 11:06am
Dear Dr.Nisanth,
I have given my interpretation from the homeopathic point of view with regard to infection and hygiene. Of course, I respect the freedom of choice and that there may be other reasons for doing circumcision (even if I do not agree).
Comment by Dr. Nisanth Nambison MD on January 13, 2010 at 9:29am
This is a data available to us in the form of statistics. It is upto you to use it or throw it. It is upto you to extract contents for your use. You can simply ignore & move forward.
Comment by Dr. Nisanth Nambison MD on January 13, 2010 at 9:27am
I think dear Debby has said it very clearly. I very much agree with this fact.
I am of the opinion that let the parents decide what is best for their wards.

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