Morris et al. BMC Pediatrics 2012, 12:20
http://www.biomedcentral.com/1471-2431/12/20

DEBATE

Open AccessA ‘snip’ in time: what is the best age tocircumcise?
Brian J Morris1*, Jake H Waskett2, Joya Banerjee3, Richard G Wamai4, Aaron AR Tobian5, Ronald H Gray5,
Stefan A Bailis6, Robert C Bailey7, Jeffrey D Klausner8, Robin J Willcourt9, Daniel T Halperin10, Thomas E Wiswell11
and Adrian Mindel12

Abstract
Background: Circumcision is a common procedure, but regional and societal attitudes differ on whether there is aneed for a male to be circumcised and, if so, at what age. This is an important issue for many parents, but also
pediatricians, other doctors, policy makers, public health authorities, medical bodies, and males themselves.
Discussion: We show here that infancy is an optimal time for clinical circumcision because an infant’s low mobility
facilitates the use of local anesthesia, sutures are not required, healing is quick, cosmetic outcome is usually
excellent, costs are minimal, and complications are uncommon. The benefits of infant circumcision include
prevention of urinary tract infections (a cause of renal scarring), reduction in risk of inflammatory foreskinconditions such as balanoposthitis, foreskin injuries, phimosis and paraphimosis. When the boy later becomessexually active he has substantial protection against risk of HIV and other viral sexually transmitted infections suchas genital herpes and oncogenic human papillomavirus, as well as penile cancer. The risk of cervical cancer in his
female partner(s) is also reduced. Circumcision in adolescence or adulthood may evoke a fear of pain, penile
damage or reduced sexual pleasure, even though unfounded. Time off work or school will be needed, cost ismuch greater, as are risks of complications, healing is slower, and stitches or tissue glue must be used.
Summary: Infant circumcision is safe, simple, convenient and cost-effective. The available evidence strongly
supports infancy as the optimal time for circumcision.
Keywords: Circumcision, Public health, Surgery, Infant health, Adolescent health, Foreskin, Urinary tract infections,Sexually transmitted infections, Penile cancer, Cervical cancer, Dermatology, Psychology

Background
The English proverb “A stitch in time saves nine” teaches that to avoid a bigger problem later immediate
effort is preferable to procrastination. Thus fixing asmall hole in a sock with one stitch will avoid the needfor nine stitches later when the hole becomes bigger. In
the present article we consider whether this applies to
medical male circumcision (MC) - referred to colloquially as a “snip”.
Worldwide 1 in 3 males are circumcised [1,2], totaling
an estimated 1.2 billion [2]. In the USA, medical MC is
performed on 1.2 million newborns (56% of baby boys)* Correspondence: brian.morris@sydney.edu.au
1
School of Medical Sciences, University of Sydney, Sydney, NSW 2006,
Australia
Full list of author information is available at the end of the article

in community hospitals annually [3,4]. The true number
is higher because some boys are circumcised in ambulatory facilities, a physician’s clinic or in a private home.
In other developed countries infancy is also the mostcommon time for performing MC, whereas in non-Muslim developing countries MC is usually part of comingof-age ceremonies where risks are usually greater [5].
The largest number of circumcised males are Muslims(approx. 70% of circumcised males globally) [1].
Circumcision predates human history, with evidenceof MC from art forms of the Upper Paleolithic period inEurope (38,000 to 11,000 years BCE) [6]. Rather thanarising independently in diverse cultures globally [7], thepractice more logically arose prior to the migration of
Homo sapiens out of Africa [8]. If it had no survival
advantage, it is unlikely that it would have persisted,© 2012 Morris et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.

Morris et al. BMC Pediatrics 2012, 12:20
http://www.biomedcentral.com/1471-2431/12/20

and, as hypothesized by Cox & Morris, subsequent cessation of MC in some populations was perhaps a resultof behavioral changes caused by environmental stressors
or new religious philosophies such as Hinduism andBuddhism [8]. Such factors could explain why circumcision is relatively low in European, South and Central
America, southern Africa, and non-Muslim Asian
countries.
The awareness during Victorian times of a wide arrayof medical benefits from MC, including prevention ofsyphilis and better hygiene, led to a rise in its popularity
in Anglo-Saxon populations in the 19th century [7,9],
continuing today in the USA in particular, where themajority of infant boys are circumcised [3,4]. In the UK
circumcision is more common in the wealthier upperclasses, marking the fact that a doctor attended thebirth rather than a mid-wife.
The advent of the AIDS epidemic in the 1980s refocused interest on MC as a means of prevention of notjust HIV, but other sexually transmitted infections(STIs) and adverse medical conditions. This has led to
MC programs in high-HIV prevalence settings of subSaharan Africa focused on men for more immediate
reductions in HIV incidence, but considerable interest
has also been given to encouraging infant MC for
longer-term gains [10,11]. There have as well been
recent calls for the promotion of infant MC in the USA[12,13], the UK [14], Australia [15] and sub-SaharanAfrica [16,17].
Despite the advantages of MC, few studies havedirectly compared the relative merits of MC at different
ages. Here we present our findings after reviewing theliterature, and document the relative pros and cons ofinfant MC versus MC in later childhood, adolescence or
adulthood ("later circumcision”). We compare medical
and surgical issues for infant versus later MC, attitudes
and barriers, ethical issues, as well as cost-effectiveness.
Our analysis has relevance to all countries, both developed and developing. Nevertheless, it should be recognized that a decision about circumcision is subject tovarying considerations depending on the particularsocial and cultural context involved.

Discussion
Is infancy the best time medically?

Although an abundance of evidence exists about thebenefits of MC [9,12,13,18], it is reasonable to ask
whether these dictate infant MC rather than MC laterin life when a boy can make up his own mind [19,20].
Some of the advantages of MC in infancy were featured
in a report arising from an expert consultation conducted by the US Centers for Disease Control and Prevention (CDC) in 2007 [13]. Here we discuss several

Page 2 of 15

compelling reasons for infancy being the optimum timefor MC.
An immediate medical benefit is the greatly reduced
risk of a urinary tract infection (UTI), which is higher in
infancy than any other year of life, and 10 times greater if
the infant male is uncircumcised [21-26]. UTIs are common in uncircumcised infant boys [22-26] and cause
severe pain. UTI as a cause of a fever at this age is often
undiagnosed [27,28]. Bacteriuria in febrile boys presenting at hospital emergency departments occurs in 36% of
uncircumcised boys, pointing to a UTI as the likely causeof fever, compared with only 1.6% of boys who are circumcised [29]. Antibiotic resistance in pathogenic bacteria under the foreskin is a growing problem [30]. The
younger the infant, the more likely and severe the UTI
will be, and the greater the risk of sepsis and death [31].
In the still-growing pediatric kidney [26,32] a UTI can
result in permanent kidney damage in 34-86% of cases[33,34], thus exposing the boy to serious, life-threatening
conditions later in life [26], including end-stage renal disease in 10% of cases [35]. In men, risk of UTI is over 5fold higher if they are uncircumcised [36]. Thus infant
MC offers protection against UTI over the lifetime.
Infant MC also offers immediate protection against
inflammatory penile skin conditions such as balanitis,
posthitis and balanoposthitis that are usually caused by
Candida spp. [37]. Balanitis affected 5.9% of uncircumcised boys in one study [38] and 14% in another [39]. In
male dermatology patients, balanitis was present in 13%of those who were uncircumcised compared to 2.3% of
the circumcised [40]. After reviewing relevant studies[38-46] we conducted a meta-analysis to determine thelevel of protection against balanitis. This yielded an ORof 0.32 (95% CI 0.20-0.52) (Figure 1). Balanoposthitis
was a cause of 26% of cases of acquired phimosis [47],in which the foreskin orifice is so narrow that the foreskin cannot be retracted. Lichen sclerosis, a chronic
inflammatory dermatosis that results in white plaquesand epidermal atrophy, is a disease of the uncircumcised
male. It occurs in 35% [48] to 55% [49] of uncircumcised men with type 2 diabetes and peaks in the 30s[50]. Although most effectively cured by MC [50], it
would be preferable to prevent it by MC in infancy.
Delaying circumcision therefore results in greater exposure of the male to risk of penile inflammation.
All boys are born with phimosis. This resolves by
about age 3 in all but approximately 10% of males, who
as a result experience problems with micturition, ballooning of the foreskin, and painful difficulties witherections (see review [9]). Paraphimosis can similarly be
prevented by infant MC.
Circumcision in infancy also means that by the timethe male becomes sexually active, he has partial

Morris et al. BMC Pediatrics 2012, 12:20
http://www.biomedcentral.com/1471-2431/12/20

Page 3 of 15

Herzog 1986
Fergusson 1988
Fakjian 1990
O'Farrell 2005
Wilson 1947
Taylor 1975
Mallon 2000
Krieger 2008

Random effects model

0.00

0.01

0.10

1.00

10.00

Odds ratio
Figure 1 Forest plot showing association between circumcision and penile inflammation in 8 studies [38-45]. The meta-analysis shown
does not include an anomalous outlier study [46], which when included led to significant between-study heterogeneity (P = 0.03), but whenexcluded no significant heterogeneity remained (P = 0.40).

protection against those STIs known to be more prevalent in uncircumcised men [9,12,18,51,52]. Meta-analyses of observational studies show MC protects against
oncogenic human papillomavirus (HPV) [53,54], genital
herpes (HSV-2) [51], syphilis [51] and HIV [55]. The
protective effect demonstrated by meta-analyses of theobservational data [51,55] has, with the curious exception of syphilis, been reinforced by randomized controlled trials (RCTs) [55-61]). The trials also
demonstrated increased efficacy to prevent HIV infection the longer the follow-up period after surgery. The
protective effect is greater when MC is performed prior
to sexual debut [51]. In men who have sex with men(MSM), while MC offers little protection against STIs
acquired from receptive anal intercourse, MC does
appear to protect men who are insertive-only, and to asimilar degree as for vaginal heterosexual intercourse[62-64].

If the male is circumcised, his reduced vulnerability tocarriage of several STIs means his female partner is lesslikely to become infected. The female partners of circumcised men are at reduced risk of HPV infection, themain cause of cervical cancer [53,65-67], as well as Trichomonas vaginalis [68] and bacterial vaginosis [68,69].
While RCT data were not as clear, observational studies
have indicated that MC reduces female HSV-2 [70],
Chlamydia trachomatis [71], and HIV [72-74].
MC timing has the same implications for all STIs prevented by MC. If a male becomes sexually active before
he is circumcised, he is exposed to a period of increased
risk of infection from several STIs. The length of thisperiod varies according to the age at which circumcision
is eventually performed. In countries with a high prevalence of STIs, the risk of infection before a male undergoes adult MC may be considerable. HPV and HSV-2
are an epidemic in virtually all countries worldwide

Morris et al. BMC Pediatrics 2012, 12:20
http://www.biomedcentral.com/1471-2431/12/20[75,76]. Importantly, if a male has been circumcised ininfancy or childhood, preceding sexual debut, the issue
of infection with an STI during the post-MC healing
period does not arise.
The risk of penile cancer is very much higher if a man
is uncircumcised [54,77]. Many of the conditions above
predispose to penile cancer. For example, meta-analyses
found phimosis increases risk of penile cancer 12-fold (8studies), balanitis 3.8-fold (4 studies) and smegma 3.0fold (4 studies) [54]. These conditions are more common in or restricted to uncircumcised men. At least halfof all penile cancers contain high-risk HPV types [78,79]
and these can be an important predisposing factor [54].
A meta-analysis [53,54] and data from RCTs [60,80-85]
have shown that MC protects against HPV infection. A
very conservative meta-analysis noted that there were
two-thirds fewer penile cancer cases in men circumcisedin childhood [77]. It found the protective effect of MC
may be greater for invasive than in situ penile cancer[77]. Because of lead-time bias and earlier diagnosis in acircumcised man, it was stated that the analysis was
likely to have under-estimated the true protective effectof circumcision [77]. An association found between
adult MC and penile cancer could be due to the factthat MC when performed in adulthood is frequently toremove cancerous lesions or to treat conditions such as
phimosis and recurring balanoposthitis that themselves
are associated with predisposition to penile cancer.
Therefore the association does not necessarily imply
that delaying MC to adulthood increases the risk ofpenile cancer.
There is also some evidence that MC protects against
prostate cancer, a malignancy associated with a historyof STIs (see reviews [9,54,86]).
Arguments that benefits and risks of MC are evenly
matched are not supported by an analysis of the frequency of each, as shown in Table 1, which also indicates grade of quality of the evidence [87]. Even though
MC in adults still provides many benefits, and is currently a crucial intervention in the high-HIV-prevalence
epidemics of sub-Saharan Africa, where many men areat considerable risk of acquiring HIV, when considering
all of the conditions MC protects against, the benefits ofperforming this procedure in infancy predominate overlater circumcision (Table 2). When aggregating the frequency of each condition that is higher in uncircumcised males, it has been calculated that as many as halfof uncircumcised males will, over their lifetime, require
medical attention for at least one of these conditions(Table 1). Thus immediate, as well as assured lifetime
protection against a range of adverse medical conditions
and infections supports infancy as the optimum time toperform circumcision.

Page 4 of 15

While the medical evidence supports infancy as being
the optimum time to circumcise, it is recognized that
instituting infant circumcision might present a challenge
to individuals in cultures in which circumcision is an
important part of coming-of-age ceremonies or that are
traditionally opposed to circumcision, particularly incountries in which circumcision is a mark of religious
affiliation (e.g., Hindu versus Muslim).
Is infancy the best time surgically?

Evidence clearly shows that circumcision in infancy carries fewer risks of complications than circumcisions performed in childhood or later in life. In infancy, surgicalcomplications for large published series range from 0.2%
to 0.6% [23,88-90]. Higher rates of 2-10% have beenreported in much older and smaller studies [91-93]. A
recent systematic review found a median complication
frequency of 1.5% among studies of neonatal or infant
circumcision, compared to 6% among studies of children
aged one year or older [94]. Almost all of such complications are minor and can be easily - and completely treated. In both infants and older children, severe complications (as compared to mild complications) wererare, with a median frequency close to zero [94].
While excluded from systematic review, the frequency
of complications among adult MC patients was noted tobe higher than the frequency of complications from MC
in children older than 1 year [94]. In the large RCTs ofadult MC, complications were seen in 1.7-3.8%; thesewere virtually all mild or moderate and were effectively
treated [56-58] (Table 3).
Another issue is a fear of complications - whether realor imagined - when circumcision is performed later.
Such fears can be a significant barrier to uptake of adult
MC. In a US study, 59% of men expressed worries
about risks of bleeding and infections [95]. A study in
China found that 12.5% of men were concerned about
infection [96]. Education about the actual low frequency
of complications is thus necessary to allay such fears.
Other desirable features of infant MC are the surgicalease of performing a circumcision on an immobile newborn, the speed of the operation, absence of any need touse sutures, quick healing, and good cosmetic outcome[97,98]. Further information is provided in an extensive
recent review of instrumentation and techniques for
infant and later circumcision [99].
When the frequency and severity of complications
from the procedure itself are compared with the frequency and severity of medical conditions, including
deaths, that can result from not circumcising, the evidence strongly favors the argument for MC in infancy[9] (Table 1). Nevertheless, circumcision later is far better than no circumcision at all.

Morris et al. BMC Pediatrics 2012, 12:20
http://www.biomedcentral.com/1471-2431/12/20

Page 5 of 15

Table 1 A comprehensive risk-benefit analysis of infant MC
Risks from not circumcising
Fold increase

NNT†

Urinary tract infection (infants)

1++

10

50

Urinary tract infections (lifetime)

2+

5

4

Pyelonephritis (infants)

2+

10

100

- with concurrent bacteraemia

2+

200

1000

- childhood hypertension

2

-

1500

- end-stage renal disease (lifetime)

2+

-

500

Candidiasis
Prostate cancer

2
2

2
1.5-2

10
6

Balanitis

2++

3

10

Phimosis1++

infinite10

High-risk HPV

1++

3

2

Genital herpes (HSV-2)

1+

1.35

Syphilis

1+

3

200

HIV infection

1++

3-8

1000

Penile cancer
In female partner:

1++

> 20

1000

Cervical cancer

1++

4

-

Chlamydia

2+

4

-

HSV-2

2+

2

-

Bacterial vaginosis

1+

2

-

Thus risk in an uncircumcised male of developing a condition requiring medical attention over their lifetime = 1 in 2
Risk associated with medical MC in infancy
Condition
Local bruising at site of injection of local anesthetic (if dorsal penile nerve block used)

Fold increase
0.25*

NNH††
4

Infection, local

0.002

600

Infection, systemic

0.0002

4000

Excessive bleeding

0.001

1000

Need for repeat surgery (if skin bridges or too little prepuce removed)

0.001

1000

Loss of penis

close to 0

1 million

Deathclose to 0

Over 1 million

Loss of penile sensitivity
Thus risk of an easily-treatable condition = 1 in 500 and of a true complication = 1 in 5000

Low

High

*As per Scottish Intercollegiate Guidelines Network (SIGN) grading system for evidence-based guidelines [87], which ranges from 1++ (highest) to 4 (lowest).
Values shown are based on statistics for USA (for source data see review [18] and references cited in the present article)
Abbreviations:†
NNT number needed to treat - i.e., approximate number of males who need to be circumcised to prevent one case of each condition associated with lack of
circumcision.
††
NNH number needed to harm, i.e., approximate number of males that need to be circumcised to see one of each particular (mostly minor) adverse effect. *The
minor bruising (from this method only) disappears naturally without any need for medical intervention, so is not included in overall calculation of easily-treatable
risks

Table 2 Approximate figures for benefits of circumcision in infancy versus circumcision later
Condition

Infancy

Later

Critical age for maximum benefit

UTI

10 ×

5×

birth, highest risk in 1st year of life

Phimosis5-infinity

5-infinity

birth

Balanitis

3×

3×

birth, higher risk after onset of sexual activity

Hygiene
HIV

n/a
3-8 ×

n/a
3-8 ×

birth
onset of sexual activity

HPV

2×

2×

onset of sexual activity

HSV-2

1.3 ×

1.3 ×

onset of sexual activity

Thrush2×2×onset of sexual activity

Penile cancer

3-22 ×less

protection level unclear if performed after childhood

See main text for references to each condition

Morris et al. BMC Pediatrics 2012, 12:20
http://www.biomedcentral.com/1471-2431/12/20

Page 6 of 15

Table 3 Complications and their frequency for medical
MC of men in RCTs in South Africa (3.8%, all mild or
moderate), Kenya (1.7%, all mild or moderate) and
Uganda (4% mild, 3% moderate [breakdown notdisclosed] and 1% severe [shown])
Condition

South Africa

Kenya

UgandaBleeding post-op

0.6%

0.4%

0.08%

Infection
Wound disruption

0.2%
0%

0.4%
0.3%

0.04%
0.04%

Delayed healing

0.1%

0.2%

-†

Swelling or hematoma

0.6%

0.1%

-

Severe pain

0.8%

0%*

-

Appearance problem

0.6%

0%

-

Damage to the penis

0.3%

0%

-

Too much skin removed

0%

0%

-

Too little skin removed
Anesthesia-related event

0.3%
0.06%

0%
0.1%

-

Problem urinating

0%

0%

-

Other

0.3%

0.4%

-

Death

0%

0%

-

Refs: [56-58], respectively*At the 3-day post-operative visit pain was zero in 48% of men, mild in 52%
and severe in none
†Dashes indicate that the item was not reported in the publication

Parental acceptability of MC in infancy

Despite infancy having a favorable risk-benefit ratio for
MC, parents must make the ultimate decision overwhether to circumcise infant sons or not. A survey in
the USA found that 88% of participants were willing tocircumcise a son [100]. A review of 13 studies in 9 subSaharan African countries found a median of 81%(range 70-90%) of women would choose to circumcise
their sons [101]. After an informational session about
MC, 74% of men in the Dominican Republic expressed
a willingness to have their sons circumcised [102]. In
India, a study of women, 78% of whom were Hindu (areligious group that does not traditionally circumcise),found that after being informed about risks and benefits,
81% said they would definitely have their boy(s) circumcised if the procedure were offered in a safe hospital setting, free of charge [103]. Only 1% said they would
definitely not have their boy circumcised [103]. In general, when choosing when it should be carried out, theneonatal period or childhood appears to be more acceptable than MC later.
Unfortunately, in a survey in California, 40% of parents believed they had not been provided with enoughinformation about MC to make an informed choice[104]. For parents of boys who were not circumcised,
the doctor had not discussed circumcision with them, as
opposed to 15% of parents of boys who were circumcised. Twice as many parents would, in retrospect, havewanted their boy to have been circumcised had theyknown more. After reading information about MC, 86%of parents were in favor of neonatal circumcision [105].
Overall, support was higher among parents born in theUSA, but lower among Hispanic parents.
The reasons for MC given by Australian parents
include family tradition, improved hygiene and reduced
risk of diseases and other conditions that MC protects
against [106]. A study of African-American parents
found that 96% strongly believed pediatric circumcision
to be healthy, and 73% considered it essential [107].
Interestingly, the study found that it was the mothers
who most often made the final decision. This demonstrates the need to engage and educate mothers andpregnant women about MC for their infant boys.
Acceptability of adult MC

MC does have benefits at later ages, but a man must be
willing to avail himself of these by getting circumcised.
It is therefore important to examine the acceptability of
MC by adult males. In the USA, only 13% of uncircumcised heterosexual men indicated that they would be
willing to become circumcised to lower their risk of
HIV [108]. In sub-Saharan Africa, however, where HIV
is an epidemic, an extensive review of 13 studies foundthat a median of 65% (range 29-87%) of heterosexual
men were willing to be circumcised [101]. Men andwomen in a Kenyan study exhibited a good understanding of the need to maintain safe sexual practices [109].
In India, of 467 uncircumcised heterosexual men in ahigh-HIV prevalence region, 93% agreed that men
should consider MC for HIV prevention, and 58%
would accept free medical MC [110]. Facilitators of
acceptability included improved penile hygiene (97%),
reduced HIV/STIs (91%), lower risk of penile cancer(90%) and of cervical cancer in their female partner(86%) [110]. In Kenya, perceived improvement in sexualpleasure was a facilitator [109,111]. In the Dominican
Republic willingness was only 29% initially, but after an
information session explaining the risks and benefits ofthe procedure, this figure increased to 67% [102].
Acceptability in Thailand was 14%, rising to 25% after
an information session [112]. In a Chinese study, 39%
were willing to be circumcised to protect themselvesfrom infection, and 46% would consider it to protect
their partner as well [113]. In other samples of mostly
heterosexual Chinese men, 41% were willing to be circumcised in one study [114] and 25% in another [115].
In studies of MSM, a US study found that 53% of participants were willing to be circumcised in one survey[95], whereas another, conducted in San Francisco,found 28% of the uncircumcised were willing to get circumcised if there was evidence of efficacy, but only 0.9%of those for whom MC would be a relevant intervention(mostly those who engaged in insertive anal intercourseMorris et al. BMC Pediatrics 2012, 12:20
http://www.biomedcentral.com/1471-2431/12/20

not using condoms) were willing [116]. In Scotland, only
14% of MSM indicated their willingness to take part in acircumcision trial [117]. One study in China found 43%
of MSM were willing to be circumcised [96], and inanother, 8% were willing initially, but this rose to 31%
after an information session [118]. The lower rates of
acceptability among MSM compared to heterosexual
men could be due to the fact that recent studies of MC
have not shown a benefit for most MSM in protection
against HIV [63,119]. However, these studies included
men who were both receptive and insertive anal sex
partners, and MC only offers protective benefits for
MSM who are mostly or exclusively insertive [63,119].
Even if a man is willing to be circumcised this does
not mean he will end up having the procedure done.
On the other hand, a lack of willingness to be circumcised should not be interpreted as a preference to be
uncircumcised. This is because a large number of obstacles have been documented, such as fear of pain orcomplications, embarrassment, inconvenience and cost.
The obstacles are discussed in the following sections. It
is reasonable to suppose that, if these barriers could be
addressed through the provision of correct informationand financial assistance, the fraction of men willing to
be circumcised would increase significantly. Better education of parents before or soon after their baby is bornabout actual risks should, by helping to ensure a circumcision in infancy, avoid later deliberations and barriers to circumcision in adolescence and adulthood.
Barriers
Pain

Since not all men are willing to be circumcised, evenwhen their infection risk from not doing so may behigh, there are clearly barriers to an affirmative decision,
particularly in high HIV prevalence settings where MC
is being rolled-out to reduce infections.
In a review of 13 acceptability studies of heterosexual
men in sub-Saharan Africa, concern about possible pain
was “the major barrier” to agreeing to be circumcised[101]. As well as pain, the long healing period, meaning
no sex, and MC not being part of the local culture, wereother impediments to getting a circumcision [109,111].
In Pune, India 71% of men expressed this concern [110].
Amongst MSM, fear of pain was a barrier for 62% of
men in the USA [95] and was 47% for Chinese men[96]. An acceptability study among African-Americanparents found that despite high (88%) perception of painin their child, 73% strongly believed that MC was necessary [107].
In practice, the pain associated with medical MC is far
less than men anticipate, and many are not aware that
local anesthesia is recommended. In the large RCTs,
severe pain was reported in only 0.8% of 1,568

Page 7 of 15

participants in the South African trial [56], 0.3% of
2,326 HIV-negative men and 0.2% of 420 HIV positivemen in the Ugandan trial [120], and in the Kenyan trial,of 1,334 men, “very mild” pain was reported in 52% at
postoperative day 3 and 11% at day 8, with none of themen reporting pain more severe than “very mild” [57].
In a small trial of the “Shang Ring” device used to circumcise 40 men, pain scores (graded from 0 = no pain
to 10 = worst possible pain) averaged 3.5 during erections [121]. Since erections would place the most tension on the wound during healing, erections likely
contribute maximally to pain scores.
It is instructive to consider here the issue of pain associated with an infant circumcision. In infancy, local
anesthesia is effective in reducing or almost eliminating
pain during and after circumcision [122], although gauging the level of pain experienced is more subjective
than what can be ascertained from communications byolder children or men. Of interest is that neonates exhibit lower pain scores than older infants [123]. Their
response to pain in general is less when delivered vaginally than by cesarian section [124]. As an aside, early
exposure to noxious or stressful stimuli decreases pain
sensitivity and behavior in adult life [125,126]. While
there may be some short-term memory of pain [127],
no credible study has been conducted into long-term
memory of pain experienced in infancy. Irrespective ofsuch considerations we strongly support a recommendation of adequate pain control as being essential during
and after a circumcision at any age.
Thus, although pain is overall minor and should not
be seen as a major barrier, the fear of pain for later circumcision does represent a significant barrier.
Cost

Acceptability studies show cost to be a frequent barrier
to adult MC [101], although willingness is higher if
costs are borne by others. The barrier of cost, especiallyfor poor families, has not been helped by an unscientific(but successful) lobbying campaign by MC opponentsthat led 18 states in the USA to eliminate coverage forcircumcision by Medicaid, the public insurance programthat insured 50.3 million people as of June 2010, or
about one of every six Americans [128-130], and that
led to a ban on elective MC in public hospitals in all
but one state in Australia. While immediate costs to thehealth system might have been reduced, the longer-termcosts for medical need and conditions caused by lack of
circumcision can only be greater [131,132].
The cost of a neonatal circumcision is far lower thancircumcision later [98]. Cost estimates in the USA for acircumcision are approximate $165 [131] to $257 [133]in infancy, compared with approx. US$1,800-2,000 for
circumcision in adolescence or adulthood [131,134].
Even if the adolescent or adult male wants to beMorris et al. BMC Pediatrics 2012, 12:20
http://www.biomedcentral.com/1471-2431/12/20

circumcised, the cost can be prohibitive. Cost can be
reduced by insisting on a local anesthetic, since a general anesthesiologist’s fees can be considerable. In developing countries, the cost of a circumcision is typically
US$59 for adults or adolescents, and US$15 for newborns [11].
Although the costs are greater in developed nations,when represented as a fraction of GDP per capita [135],
the figures are comparable between each: 0.4%-1.4% of
GDP per capita for neonatal and 4.2%-5.4% for MC inadolescents or adults. Health interventions are considered highly cost-effective at a threshold below 1% of
GDP per capita [136]. Thus the cost of adult MC represents a significant sum. Affordability of MC is nothelped by the lower earnings typical of younger men. In
developing countries, the extreme poverty of many people means any cost is unaffordable by most of the
population.
While MC protects against numerous conditions andinfections, in the case of HIV, in locations where HIVprevalence is high and MC rates are low, increasing
adult MC should be regarded as an urgent objective,
while increasing infant MC should be an important
objective. In populations where HIV prevalence is still
low and MC rates are low, increasing infant MC should
be a priority.
Cost-effectivenessIn a cost-benefit analysis in the USA it was found that,for a range of medical conditions, “much of the initialcost of neonatal circumcision is eventually recovered
when disease and the medical need [in 9.6% of males]for post-neonatal circumcision are prevented” [131].
This analysis was criticized as being overly conservative[132].
In the case of HIV reduction, modeling in high-prevalence settings such as sub-Saharan Africa has shownthat adult MC would be highly cost-effective [137,138].
Similarly, neonatal MC was calculated to provide enormous cost savings in populations where HIV prevalence
is high [11]. Net cost per HIV infection averted in
Rwanda was US$3,932 for adolescent circumcision and
US$4,949 for adult circumcision [11]. Reviews of 21[139] and 5 [140] cost-effectiveness studies found adult
MC to be very cost-effective, the cost per HIV infection
averted ranging from US$174 to US$2,808 [140]. MC
was particularly cost-saving after due consideration of
the cost of HIV treatment, treatment cost being estimated as US$2.3B over 20 years [141].
In low prevalence settings it has been argued that MC
is a waste of money as it will have little impact on HIV[142-144]. This may not be true, however, as shown by
CDC calculations that found infant MC to be cost-saving for future HIV prevention in Black and Hispanic

Page 8 of 15

males in the USA, although not in non-Hispanic White
males, perhaps because the latter have the highest MC
rates and much lower HIV prevalence [133].
Cosmetic outcome

When circumcision is performed in infancy the ability of
the inner and outer foreskin layers to adhere to eachother means sutures are rarely needed and the scar that
results is virtually invisible [98]. Other factors include
the more rapid healing at this time of life, contributedby age-associated differences in pro-inflammatory factors that might affect scar formation [145].
In studies on adult MC, both men and their partners
preferred the new appearance of the penis post-circumcision [146,147]. In the case of MSM, in a Chinese
study, only 2.5% of men expressed concern about cosmetic outcome [96]. Despite the fact that MC rarely
causes permanent disfigurement from scarring when
performed properly, the fear of a poor cosmetic outcome is a documented deterrent of acceptability. For
example, a study in the South American Andes foundthat MSM identified the risk of scarring as a significant
barrier to MC [148].
Sexual function and activity

The effect of an infant circumcision on sexual function
and activity cannot be determined directly, but can beinferred from studies of men circumcised as adults.
Numerous studies show that MC has no adverse effecton sexual function [147,149-152]. This finding is supported by data from the large RCTs in sub-SaharanAfrica [45,153] which included more than 10,000 participants. A study in Turkey found no relationshipbetween age of childhood circumcision and overall sexual function in men aged 22-44 [154]. Since all men are
circumcised, mostly in childhood, in this Muslim country there was no control group of uncircumcised men tocompare with. Of seven areas of sexual function examined (frequency of intercourse, communication, degreeof satisfaction, avoidance, sensuality, ejaculatory functionand erectile function), the only difference was lower
avoidance in those circumcised between the ages of 0-2,
compared to the 3-5 and 6-12 age groups [154]. A studyof MSM in Sydney reported that later circumcision was
associated with erectile dysfunction and premature ejaculation difficulties in some men [155]. Such difficulties
were not seen in men who had been circumcised ininfancy. In developed countries, most later circumcisions
tend to be for treatment of a medical condition and this
could offer a partial explanation for the finding. Since
men circumcised later were less likely to engage in
insertive anal intercourse, psychological effects after MC
for medical need, at an age where the male has cognitiveawareness of his previous painful penile problems, asMorris et al. BMC Pediatrics 2012, 12:20
http://www.biomedcentral.com/1471-2431/12/20

well as the surgery itself, seemed a probable explanation.
In a large Danish study in which circumcision, mostly
for medical reasons, accounted for the small proportionof circumcised men surveyed, there were no differences
in a range of sexual measures, apart from a statisticallyquestionable [156] difference in ability to reach orgasm
during intercourse in a minority of 10 circumcised men[157].
When circumcision is delayed beyond the onset of
sexual activity, the impact of a period of abstinencemust be considered. Analysis of data from three RCTs
found that relatively few men engaged in sexual intercourse within 42 days of circumcision [158]. It has beensuggested, not unreasonably, that this period of complete abstinence (from both intercourse and masturbation) is “often daunting and serves as a disincentive formen to undertake the procedure” [159], and the recommended post-surgical abstinence period was found to bea significant barrier to MC uptake in Kenya [111]. Circumcision in infancy, or indeed at any time before puberty, eliminates such an obstacle.
Sexual pleasure

A range of beliefs exists about the effect of MC on sexual pleasure and function. A comprehensive review of
acceptability studies in sub-Saharan Africa noted thatmen who were willing to be circumcised considered that
MC would not adversely affect sexual pleasure [101].
Subsequent surveys support this, with many men considering that MC will enhance their sexual performanceand satisfaction [111]. However, a belief that MC might
reduce their sexual pleasure was the reason 46% of men
in a Dominican Republic study were reluctant to be circumcised [102], as was also the case for 14% of men in
an Indian study [110], and 5.3% of men in a Chinesesurvey [96]. In the latter study approximately threetimes as many men thought circumcision would
increase, rather than diminish, their sexual pleasure[96]. In the USA, 18% of men said they would consider
circumcision because it might increase sexual pleasure,
this being associated with willingness to be circumcised[95]. In another US study, 35% of African American parents thought circumcision increases pleasure, although
this was not a significant factor in deciding on circumcision for their boys [107].
Fears and anxieties about sexual pleasure appear to be
substantial. This may be especially problematic in developed countries with widespread Internet access, as thismedium is dominated by anti-circumcision websites,
many of which spuriously claim that MC severely harms
the sexual experience. This was documented in a surveyof 73 Internet sites devoted to MC [160].
Scientific evidence regarding the sexual effects of MC
does not substantiate the purported harms to sexual

Page 9 of 15

pleasure. The better-quality studies (in terms of sample
size, rigor of methodology, accuracy of analysis of findings, and generalizability of results) have found noadverse effect of MC on penile sensitivity [151,161-163],
sensation during arousal [164], sexual satisfaction[146,151], premature ejaculation [165], intravaginal ejaculatory latency time [166,167], or erectile function[147,149-152]. Two RCTs found MC does not adversely
affect sexual function, sensitivity or satisfaction [45,153],
with one of these studies showing that the sexual
experience of most men was enhanced after circumcision [45]. Some studies have found that MC reduced
the risk of premature ejaculation [168,169].
In several studies, perceptions about partners’ sexualpleasure and preferences were also important predictorsof willingness to be circumcised [101]. A study of Chinese MSM found that 15% thought MC would improve
the partner’s sexual pleasure, while 4% thought it would
decrease it, and 68% were unsure [96]. In sub-SaharanAfrica, 69% (range 47-79%) of women preferred circumcision for their partners because of its perceived aesthetic value [101], consistent with credible studies indeveloped countries [170,171].
Credible studies of the female partners of adult MCpatients have found no adverse effect on sexual experience. For example, data from 455 women in a Ugandan
RCT indicated no change (57%) or an improvement(40%) in sexual satisfaction after their male partner had
been circumcised [172] and a Mexican study found nochange in sexual satisfaction, desire, pain during vaginal
penetration or orgasm [173]. A study in Sydney of MSM
found no overall differences between the circumcisedand uncircumcised in participation in insertive or receptive anal intercourse, difficulty in using condoms, or
sexual problems such as loss of libido [155]. A survey of
US women found 82% preferred the circumcised penis
for fellatio, with only 2% preferring the uncircumcised
penis [170].
The fact that circumcision does not impair - and formany may enhance - a man’s sensation and sexual pleasure, should reassure men considering whether to get
circumcised [174]. It should also reassure parents who
may wonder about this issue when deciding to havetheir infant son circumcised.
Psychological consequences

Very few credible studies have examined psychologicalfactors associated with MC.
A study of Californian boys in their early teenage
years found that circumcised boys - the majority ofwhom were circumcised neonatally - were more satisfied
with their circumcision status than were uncircumcisedboys [175]. A study in Sweden, where MC is uncommon, found no serious psychological disorders amongst

Morris et al. BMC Pediatrics 2012, 12:20
http://www.biomedcentral.com/1471-2431/12/20

boys circumcised in childhood, although shyness in thechange-room was noted in 7% [176].
An acceptability study conducted in the Sichuan province of China found 53% of men were concerned that
MC would be “too sensitive and embarrassing” [114].
Concerns were also expressed that men might bemocked for undertaking the surgery.
In India, where MC is a mark of religious affiliation,
41% of mostly Hindu men were concerned that MC was
not part of their culture, while 30% were afraid of
stigma or rejection [110]. MC has historic implicationsin India, where Muslim men were targeted for violence
based on their circumcision status during the Hindu
fundamentalist, anti-Muslim pogroms of 2002 and subsequent riots [177]. It has been suggested that MC in
India might be more acceptable to STI clinic attendees
than others [178].
Psychological effects were the probable explanation forfindings in MSM that later circumcision, usually performed to treat a medical problem, was associated withlower insertive anal intercourse [155]. As referred toearlier, this is likely because, when older, the male has
cognitive awareness of his previous painful penile problems, as well as the surgery itself.
There is some concern about risk-compensation (thetendency to stop using condoms and increase the number of sexual partners) following MC, although in moststudies in which men were counseled this was not seen
[179,180]. It has been suggested that neonatal MC may
reduce the chances of a change in behavior due to circumcision status, as the male will not perceive anychange in risk compared to what might transpire if thecircumcision had taken place at an age when he might
be sexually active [181].
While these various psychological problems should be
mitigated by making MC normative in a community,
just as with most fears and anxieties, the prospect ofsuch concerns would be largely eliminated if MC were
performed in infancy.
Absence from work or school

Unlike the convenience of circumcising a baby thatsleeps most of the time and is a dependent in society,circumcision during productive work or school years
will typically require taking time off, although theamount of time off required is typically small. In one
study of men circumcised with the Shang Ring device,
men took an average of 1.1 days off work; 80% wereback at work by day 2, with only 20% requiring morethan 2 days, and little disruption to activities or discomfort was reported for the week the ring was in place[121]. Eighteen percent of men in the study reported
disruption to their work while the device was present,
and 30% had not resumed routine leisure activities by 7

Page 10 of 15days. In the large Kenyan RCT, only 4% of men required
3 days or more before they could return to normal
activities [57]. In a study of childhood MC, mediantimes of 5 days to return to normal activity and 7 toreturn to school have been reported [182]. This may
have been because children are usually more active thanadults, thus increasing the chances of injury and so
prolonging the healing period.
Ethical considerations

Nowhere is MC illegal. Concern has, however, been
expressed by some authors about the ethical implications of circumcising boys who are too young to giveconsent [19,20]. The “autonomy-centered” argument ofthese authors is that MC should be delayed until theindividual can decide for himself. But it has been
pointed out that this argument is not consistent withthe rationale behind other interventions, such as vaccinations, which are similarly performed before the childis old enough to consent and which carry similar risksof complications [183-185]. The authors of one bioethical analysis concluded that MC is appropriate for parental discretion [184]. Other bioethicists have argued that
MC in the face of high risk of infection and disease is
ethically imperative, as to do otherwise would risk
human lives [17] and under such circumstances MCshould be regarded as a justifiable public health measure[185]. Given the high infection and disease risk overall
to the male and his female partners (Table 1) there
would be few populations in the world that would notbenefit from MC.

Conclusions
Infancy presents a “window of opportunity” for circumcision. It is associated with substantially lower costs,
lower risk of complications when performed by anexperienced operator in a clinical or other appropriate
setting, and lower lifetime risk of a variety of adverse
conditions and infections [186]. The health benefits
include protection against urinary tract infection andthus permanent damage to the still-growing kidney,
reduced likelihood of penile inflammation, and elimination of risk of phimosis, which impedes micturition andresults in difficult and painful erections in adolescenceand adulthood. It also means tearing of the fragile foreskin and frenulum is avoided. Circumcision means anassurance of greatly reduced risk of penile cancer laterin life, no smegma, better hygiene, and lower risk of various STIs. These not only include HIV that is an epidemic in some locations, but also oncogenic HPVs andgenital herpes that are an epidemic worldwide. In the
future female sexual partners of males, infant MCmeans they too will be at reduced risk of STIs and cervical cancer.

Morris et al. BMC Pediatrics 2012, 12:20
http://www.biomedcentral.com/1471-2431/12/20

Some of the arguments against waiting until later tocircumcise are:
• Protection against UTIs and damage to the fragile
pediatric kidney is lost.
• Infant MC eliminates risk of phimosis and balanitis
in childhood and after puberty.
• If circumcision is performed after boys become
sexually active benefits associated with STI prevention
are delayed.
• The risk of complications is higher for latercircumcisions.
• The cost (to the individual or the public purse) ismuch higher, and often unaffordable, for latercircumcision.
• Educational resources for boys to make an informed
decision are quite limited.
• Large-scale adolescent circumcision would strain
medical resources.
• Boys who later choose circumcision will likely wish
it had been performed in infancy.
• Many older boys and men may not want to face anoperation even though they wish to be circumcised.
• The momentum amongst major international andAmerican health and medical organizations towards
encouraging circumcision, especially in infancy.
Circumcision in infancy avoids any embarrassment of
having it done later, as well as anxieties about pain,
complications and adverse sexual effects, even thoughthese are minimal or not supported by evidence. It also
avoids arguments about whether there might be adverse
psychological consequences for MC performed later inchildhood. And absence from work or school is avoided.
There are fewer barriers to MC in infancy. The infant
is less mobile, so facilitating the use of local anesthesia,
the procedure is simpler, healing is quicker, the cosmetic outcome is superior, and cost-effectiveness ishigh, as is acceptability. The neonatal period should
therefore be regarded as the optimal time to perform
circumcision. It is viewed as a vital component of publichealth strategies aimed at realizing high levels of MC in
the population [187]. The procedure should be performed by a trained professional using appropriate local
anesthesia in a clean environment. Circumcision outsideof such a setting is ill-advised, so explaining why clinical
MC is increasingly being made available in European
countries to Muslim families.
We recommend that evidence-based policies be developed regarding the availability of infant MC in all countries worldwide. It has been suggested that policies
surrounding neonatal MC should be integrated into
existing health systems as part of postnatal care [183],
with adolescent and adult MC constituting “catch-up”
campaigns that would be phased out over time [11].
This should not detract from the immediate urgent

Page 11 of 15

need for safe voluntary adult medical MC services inhigh-HIV-prevalence regions in particular.
Author details
1
School of Medical Sciences, University of Sydney, Sydney, NSW 2006,
Australia. 2Circumcision Independent Reference and Commentary Service,
157 Stand Lane, Radcliffe, Manchester M26 1JR, UK. 3Global Youth Coalition
on HIV/AIDS, Pretoria, South Africa. 4Department of African-American Studies,
Northeastern University, Boston, MA 02115, USA. 5Department of Pathology,
School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA.
6
Research & Education Association on Circumcision Health Effects,
Bloomington, MN 55425, USA. 7Division of Epidemiology and Biostatistics,
University of Illinois at Chicago, Chicago, IL, USA. 8Divisions of AIDS &Infectious Diseases, University of California, San Francisco, CA 94122, USA.
9
Pregnancy Advisory Centre, The Queen Elizabeth Hospital, Adelaide, SA
5011, Australia. 10Department of Education and Behavior, University of North
Carolina School of Public Health, Chapel Hill, NC 27599, USA. 11Center for
Neonatal Care, Orlando, FL 32804, USA. 12Sexually Transmitted Infections
Research Centre, Westmead Hospital and University of Sydney, Sydney, NSW
2145, Australia.
Authors’ contributions
BJM and JHW drafted the manuscript. JHW performed the statistical analyses
shown in Figure 1. BJM, JHW, JB, RGM, AART, RHG, SAB, RCB, JDK, RJW, DTH,
TEW and AM made substantial contributions to successive drafts andthereby to the intellectual content of this article. All authors read andapproved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 2 September 2011 Accepted: 28 February 2012
Published: 28 February 2012
References
1. World Health Organization/UNAIDS: Male circumcision: Global trends anddeterminants of prevalence, safety and acceptability. World HealthOrganization, Geneva; 2007 [http://whqlibdoc.who.int/publications/2007/
9789241596169_eng.pdf].
2. Waskett JH: Global circumcision rates. 2011 [http://www.circs.org/index.
php/Reviews/Rates/Global].
3. Merrill CT, Nagamine M, Steiner C: Circumcisions Performed in U.S.
Community Hospitals, 2005: Statistical Brief #45. Healthcare Cost andUtilization Project 2008, 1-9[http://www.ncbi.nlm.nih.gov/books/NBK56311/].
4. Healthcare Cost and Utilization Project (HCUP): Statistical Brief #118.
Agency for Healthcare Research and Quality, Rockville, MD; 2011 [http://
www.hcup-us.ahrq.gov/reports/statbriefs/sb118.jsp].
5. Wilcken A, Keil T, Dick B: Traditional male circumcision in eastern andsouthern Africa: a systematic review of prevalence and complications.
Bull World Health Organ 2010, 88:907-914.
6. Angulo JC, García-Díez M: Male genital representation in Paleolithic art:
erection and circumcision before history. Urology 2009, 74:10-14.
7. Kaicher DC, Swan KG: A cut above: Circumcision as an ancient status
symbol. Urology 2010, 76:18-20.
8. Cox G, Morris BJ: Why circumcision - From pre-history to the 21st
century. In Surgical Guide to Circumcision. Edited by: Bolnick DA, Koyle MA,
Yosha A. Springer, London; 2012:.
9. Morris BJ: Why circumcision is a biomedical imperative for the 21st
century. Bioessays 2007, 29:1147-1158.
10. Hargreave T: Male circumcision: towards a World Health Organisation
normative practice in resource limited settings. Asian J Androl 2010,
12:628-638.
11. Binagwaho A, Pegurri E, Muita J, Bertozzi S: Male circumcision at different
ages in Rwanda: a cost-effectiveness study. PLoS Med 2010, 7:e1000211.
12. Tobian AA, Gray RH, Quinn TC: Male circumcision for the prevention of
acquisition and transmission of sexually transmitted infections: the casefor neonatal circumcision. Arch Pediatr Adolesc Med 2010, 164:78-84.
13. Smith DK, Taylor A, Kilmarx PH, Sullivan P, Warner L, Kamb M, Bock N,
Kohmescher B, Mastro TD: Male circumcision in the United States for theMorris et al. BMC Pediatrics 2012, 12:20
http://www.biomedcentral.com/1471-2431/12/20

14.

15.

16.

17.

18.

19.

20.
21.

22.
23.

24.
25.

26.
27.

28.

29.

30.
31.
32.
33.
34.

35.

36.

37.
38.
39.
40.

prevention of HIV infection and other adverse health outcomes: Reportfrom a CDC consultation. Public Health Rep 2010, 125(Suppl 1):72-82.
Macdonald A, Humphreys J, Jaffe HW: Prevention of HIV transmission in
the United Kingdom: what is the role of male circumcision? Sex Transm
Infect 2008, 84:158-160.
Cooper DA, Wodak AD, Morris BJ: The case for boosting infant malecircumcision in the face of rising heterosexual transmission of HIV. Med J
Aust 2010, 193:318-319.
Weiss HA, Dickson KE, Agot K, Hankins CA: Male circumcision for HIV
prevention: current research and programmatic issues. AIDS 2010,
24(Suppl 4):S61-S69.
Clark PA, Eisenman J, Szapor S: Mandatory neonatal male circumcision in
Sub-Saharan Africa: medical and ethical analysis. Med Sci Monit 2007,
12:205-213.
Morris BJ: Circumcision: an evidence-based appraisal - medical, healthand sexual (a review with 1,023 references). 2010 [http://www.circinfo.
net].
Perera CL, Bridgewater FH, Thavaneswaran P, Maddern GJ: Nontherapeutic
male circumcision: tackling the difficult issues. J Sex Med 2009,
6:2237-2243.
MacDonald N: Male circumcision: get the timing right. CMAJ 2011,
183:872.
Singh-Grewal D, Macdessi J, Craig J: Circumcision for the prevention ofurinary tract infections in boys: a systematic review of randomized trials
and observational studies. Arch Dis Child 2005, 90:853-858.
Wiswell TE, Smith FR, Bass JW: Decreased incidence of urinary tract
infections in circumcised male infants. Pediatrics 1985, 75:901-903.
Wiswell TE, Geschke DW: Risks from circumcision during the first monthof life compared with those for uncircumcised boys. Pediatrics 1989,
83:1011-1015.
Wiswell TE: Circumcision circumspection. N Engl J Med 1997, 36:1244-1245.
Schoen EJ, Colby CJ, Ray GT: Newborn circumcision decreases incidence
and costs of urinary tract infections in the first year of life. Pediatrics
2000, 105:789-793.
Wiswell TE: The prepuce, urinary tract infections, and the consequences.
Pediatrics 2000, 105:8602.
Zorc JJ, Levine DA, Platt SL, Dayan PS, Macias CG, Krief W, Schor J, Bank D,
Shaw KN, Kuppermann N: Clinical and demographic factors associatedwith urinary tract infection in young febrile infants. Pediatrics 2005,
116:644-648.
Shaikh N, Morone NE, Bost JE, Farrell MH: Prevalence of urinary tract
infection in childhood: a meta-analysis. Pediatr Infect Dis J 2008,
27:302-308.
Hsiao AL, Chen L, Baker MD: Incidence and predictors of serious bacterial
infections among 57- to 180-day-old infants. Pediatrics 2006,
117:1695-1701.
Ladhani S, Gransden W: Increasing antibiotic resistance among urinary
tract isolates. Arch Dis Child 2003, 88:445-445.
Schoen EJ: Circumcision for preventing urinary tract infections in boys:
North American view. Arch Dis Child 2005, 90:772-773.
Shortliffe LM, McCue JD: Urinary tract infection at the age extremes:
pediatrics and geriatrics. Am J Med 2002, 113(Suppl 1A):55-66.
Zorc JJ, Kiddoo DA, Shaw KN: Diagnosis and management of pediatricurinary tract infections. Clin Microbiol Rev 2005, 18:417-422.
Rushton HG, Majd M: Dimercaptosuccinic acid renal scintigraphy for theevaluation of pyelonephritis and scarring: a review of experimental andclinical studies. J Urol 1992, 148:1726-1732.
Jacobson SH, Eklof O, Eriksson CG, Lins LE, Tidgren B, Winberg J:
Development of hypertension and uraemia after pyelonephritis inchildhood: 27 year follow up. Brit Med J 1989, 16:703-706.
Spach DH, Stapleton AE, Stamm WE: Lack of circumcision increases therisk of urinary tract infections in young men. J Am Med Assoc 1992,
267:679-681.
Edwards S: Balanitis and balanoposthitis: a review. Genitourin Med 1996,
72:155-159.
Herzog LW, Alvarez SR: The frequency of foreskin problems in
uncircumcised children. Am J Dis Child 1986, 140:254-256.
Fergusson DM, Lawton JM, Shannon FT: Neonatal circumcision and penile
problems: an 8-year longitudinal study. Pediatrics 1988, 81:537-541.
Fakjian N, Hunter S, Cole GW, Miller J: An argument for circumcision.
Prevention of balanitis in the adult. Arch Dermatol 1990, 126:1046-1047.

Page 12 of 15

41. O’Farrell N, Quigley M, Fox P: Association between the intact foreskin andinferior standards of male genital hygiene behaviour: a cross-sectional
study. Int J STD AIDS 2005, 16:556-559.
42. Wilson RA: Circumcision and venereal disease. Can Med Ass J 1947,
56:54-56.
43. Taylor PK, Rodin P: Herpes genitalis and circumcision. Brit J Ven Dis 1975,
51:274-277.
44. Mallon E, Hawkins D, Dinneen M, Francis N, Fearfield L, Newson R,
Bunker C: Circumcision and genital dermatoses. Arch Dermatol 2000,
136:350-354.
45. Krieger JN, Mehta SD, Bailey RC, Agot K, Ndinya-Achola JO, Parker C,
Moses S: Adult male circumcision: effects on sexual function and sexual
satisfaction in Kisumu, Kenya. J Sex Med 2008, 5:2610-2622.
46. Van Howe RS: Neonatal circumcision and penile inflammation in young
boys. Clin Pediatr (Phila) 2007, 46:329-333.
47. Bromage SJ, Crump A, Pearce I: Phimosis as a presenting feature ofdiabetes. BJU Int 2007, 101:338-340.
48. Kohn F-M, Pflieger-Bruss S, Schill W-B: Penile skin diseases. Andrologia
1999, 31(suppl 1):3-11.
49. Verma SB, Wollina U: Looking through the cracks of diabetic candidalbalanoposthitis. Int J Gen Med 2011, 4:511-513.
50. Edmonds EV, Hunt S, Hawkins D, Dinneen M, Francis N, Bunker CB: Clinicalparameters in male genital lichen sclerosus: a case series of 329
patients. J Eur Acad Dermatol Venereol 2011.
51. Weiss HA, Thomas SL, Munabi SK, Hayes RJ: Male circumcision and risk ofsyphilis, chancroid, and genital herpes: a systematic review and metaanalysis. Sex Transm Infect 2006, 82:101-109.
52. Morris BJ, Castellsague X: The role of circumcision in the prevention of
STIs. In Sexually Transmitted Infections and Sexually Transmitted Diseases.
Edited by: Gross GE, Tyring S. Heidelberg: Springer; 2011:715-739.
53. Bosch FX, Albero G, Castellsagué X: Male circumcision, humanpapillomavirus and cervical cancer: from evidence to intervention. J Fam
Plann Reprod Health Care 2009, 35:5-7.
54. Morris BJ, Gray RH, Castellsague X, Bosch FX, Halperin DT, Waskett JH,
Hankins CA: The strong protection afforded by circumcision against
cancer of the penis. Adv Urol 2011, Article ID 812368(21pages).
55. Weiss HA, Halperin D, Bailey RC, Hayes RJ, Schmid G, Hankins CA: Malecircumcision for HIV prevention: from evidence to action? (Review). AIDS
2008, 22:567-574.
56. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A:
Randomized, controlled intervention trial of male circumcision for
reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med 2005,
2(e298):1112-1122.
57. Bailey RC, Moses S, Parker CB, Agot K, Maclean I, Krieger JN, Williams CF,
Campbell RT, Ndinya-Achola JO: Male circumcision for HIV prevention inyoung men in Kisumu, Kenya: a randomised controlled trial. Lancet 2007,
369:643-656.
58. Gray RH, Kigozi G, Serwadda D, Makumbi F, Watya S, Nalugoda F,
Kiwanuka N, Moulton LH, Chaudhary MA, Chen MZ, Sewankambo NK,
Wabwire-Mangen F, Bacon MC, Williams CF, Opendi P, Reynolds SJ,
Laeyendecker O, Quinn TC, Wawer MJ: Male circumcision for HIV
prevention in men in Rakai, Uganda: a randomised trial. Lancet 2007,
369:657-666.
59. Siegfried N, Muller M, Deeks JJ, Volmink J: Male circumcision forprevention of heterosexual acquisition of HIV in men. Cochrane Database
Syst Rev 2009, 2, CD003362(38pages).
60. Tobian AAR, Serwadda D, Quinn TC, Kigozi G, Gravitt PE, Laeyendecker O,
Charvat B, Ssempijja V, Riedesel M, Oliver AE, Nowak RG, Moulton LH,
Chen MZ, Reynolds SJ, Wawer MJ, Gray RH: Male circumcision for theprevention of HSV-2 and HPV infections and syphilis. N Engl J Med 2009,
360:1298-1309.
61. Tobian AAR, Charvat B, Ssempijja V, Kigozi G, Serwadda D, Makumbi F,
Iga B, Laeyendecker O, Riedesel M, Oliver A, Chen MZ, Reynolds SJ,
Wawer MJ, Gray RH, Quinn TC: Factors associated with the prevalence
and incidence of herpes simplex virus type 2 infection among men in
Rakai, Uganda. J Infect Dis 2009, 199:945-949.
62. Templeton DJ, Jin F, Prestage GP, Donovan B, Imrie JC, Kippax SC,
Cunningham PH, Kaldor JM, Mindel A, Cunningham AL, Grulich AE:
Circumcision and risk of sexually transmissible infections in acommunity-based cohort of HIV-negative homosexual men in Sydney,
Australia. J Infect Dis 2009, 200:1813-1819.

Morris et al. BMC Pediatrics 2012, 12:20
http://www.biomedcentral.com/1471-2431/12/20

63. Wiysonge CS, Kongnyuy EJ, Shey M, Muula AS, Navti OB, Akl EA, Lo YR:
Male circumcision for prevention of homosexual acquisition of HIV inmen. Cochrane Database Syst Rev 2011, 6, CD007496(46pages).
64. Jameson DR, Celum CL, Manhart L, Menza TW, Golden MR: The association
between lack of circumcision and HIV, HSV-2, and other sexuallytransmitted infections among men who have sex with men. Sex Transm
Dis 2010, 37:147-152.
65. Castellsague X, Bosch FX, Munoz N, Meijer CJLM, Shah KV, de Sanjose S,
Eluf-Neto J, Ngelangel CA, Chichareon S, Smith JS, Herrero R, Franceschi S:
Male circumcision, penile human papillomavirus infection, and cervicalcancer in female partners. N Engl J Med 2002, 346:1105-1112.
66. Drain PK, Halperin DT, Hughes JP, Klausner JD, Bailey RC: Malecircumcision, religion, and infectious diseases: an ecologic analysis of
118 developing countries. BMC Infect Dis 2006, 6, 172(10pages).
67. Wawer MJ, Tobian AAR, Kigozi G, Kong X, Gravitt PE, Serwadda D,
Nalugoda F, Makumbi F, Ssempiija V, Sewankambo N, Watya S, Eaton KP,
Oliver AE, Chen MZ, Reynonds SJ, Quinn TC, Gray RH: Effect of
circumcision of HIV-negative men on transmission of humanpapillomavirus to HIV-negative women: a randomised trial in Rakai,
Uganda. Lancet 2011, 377:209-218.
68. Gray RH, Kigozi G, Serwadda D, Makumbi F, Nalugoda F, Watya S,
Moulton L, Chen MZ, Sewankambo NK, Kiwanuka N, Sempijja V, Lutalo T,
Kagayii J, Wabwire-Mangen F, Ridzon R, Bacon M, Wawer MJ: The effects ofmale circumcision on female partners’ genital tract symptoms andvaginal infections in a randomized trial in Rakai, Uganda. Am J Obstet
Gynecol 2009, 200:e1-e7.
69. Cherpes TL, Hillier SL, Meyn LA, Busch JL, Krohn MA: A delicate balance:risk factors for acquisition of bacterial vaginosis include sexual activity,
absence of hydrogen peroxide-producing lactobacilli, black race, andpositive herpes simplex virus type 2 serology. Sex Transm Dis 2008,
35:78-83.
70. Cherpes TL, Meyne LA, Krohn MA, Hiller SL: Risk factors for infection withherpes simplex virus type 2: role of smoking, douching, uncircumcised
males, and vaginal flora. Sex Transm Dis 2003, 30:405-410.
71. Castellsague X, Peeling RW, Franceschi S, de Sanjose S, Smith JS, Albero G,
Diaz M, Herrero R, Munoz N, Bosch FX: Chlamydia trachomati infection infemale partners of circumcised and uncircumcised adult men. Am J
Epidemiol 2005, 162:907-916.
72. Hallett TB, Alsallaq RA, Baeten JM, Weiss H, Celum C, Gray R, Abu-Raddad L:
Will circumcision provide even more protection from HIV to women andmen? New estimates of the population impact of circumcisioninterventions. Sex Transm Infect 2011, 87:88-93.
73. Weiss HA, Hankins CA, Dickson K: Male circumcision and risk of HIV
infection in women: a systematic review and meta-analysis. Lancet Infect
Dis 2009, 9:669-677.
74. Baeten JM, Donnell D, Kapiga SH, Ronald A, John-Stewart G, Inambao M,
Manongi R, Vwalika B, Celum C: Male circumcision and risk of male-tofemale HIV-1 transmission: a multinational prospective study in African
HIV-1-serodiscordant couples. AIDS 2010, 24:737-744.
75. Bruni L, Diaz M, Castellsagué X, Ferrer E, Bosch FX, de Sanjosé S: Cervicalhuman papillomavirus prevalence in 5 continents: meta-analysis of 1
million women with normal cytological findings. J Infect Dis 2010,
202:1789-1799.
76. Centers for Disease Control and Prevention: Seroprevalence of herpes
simplex virus type 2 among persons aged 14-49 years-United States,
2005-2008. MMWR Morb Mortal Wkly Rep 2010, 59:456-459.
77. Larke NL, Thomas SL, Dos Santos Silva I, Weiss HA: Male circumcision andpenile cancer: a systematic review and meta-analysis. Cancer Causes
Control 2011, 22:1097-1110.
78. Gross G, Pfister H: Role of human papillomavirus in penile cancer, penile
intraepithelial squamous cell neoplasias and in genital warts. Med
Microbiol Immunol 2004, 193:35-44.
79. Madsen BS, van den Brule AJ, Jensen HL, Wohlfahrt J, Frisch M: Risk factors
for squamous cell carcinoma of the penis-population-based case-control
study in Denmark. Cancer Epidemiol Biomarkers Prev 2008, 17:2683-2691.
80. Tobian AAR, Kong X, Gravitt PE, Eaton KP, Kigozi G, Serwadda D, Oliver AE,
Nalugoda F, Makumbi F, Chen MZ, Wawer MJ, Quinn TC, Gray RH: Malecircumcision and anatomic sites of penile human papillomavirus in
Rakai, Uganda. Int J Cancer 2011, 129:2970-2975.
81. Gray RH: Infectious disease: Male circumcision for preventing HPV
infection. Nat Rev Urol 2009, 6:298-299.

Page 13 of 15

82. Gray RH, Serwadda D, Kong X, Makumbi F, Kigozi G, Gravitt PE, Watya S,
Nalugoda F, Ssempijja V, Tobian AA, Kiwanuka N, Moulton LH,
Sewankambo NK, Reynolds SJ, Quinn TC, Iga B, Laeyendecker O, Oliver AE,
Wawer MJ: Male circumcision decreases acquisition and increases
clearance of high-risk human papillomavirus in HIV-negative men: arandomized trial in Rakai, Uganda. J Infect Dis 2010, 201:1455-1462.
83. Serwadda D, Wawer MJ, Makumbi F, Kong X, Kigozi G, Gravitt P, Watya S,
Nalugoda F, Ssempijja V, Tobian AA, Kiwanuka N, Moulton LH,
Sewankambo NK, Reynolds SJ, Quinn TC, Oliver AE, Iga B, Laeyendecker O,
Gray RH: Circumcision of HIV-infected men: effects on high-risk humanpapillomavirus infections in a randomized trial in Rakai, Uganda. J Infect
Dis 2010, 201:1463-1469.
84. Viscidi RP, Shah KV: Adult male circumcision: will it reduce diseasecaused by human papillomavirus? J Infect Dis 2010, 201:1447-1449.
85. Auvert B, Sobngwi-Tambekou J, Cutler E, Nieuwoudt M, Lissouba P,
Puren A, Taljaard D: Effect of male circumcision on the prevalence ofhigh-risk human papillomavirus in young men: results of a randomized
controlled trial conducted in orange farm, South Africa. J Infect Dis 2009,
199:14-19.
86. Morris BJ, Waskett J, Bailis SA: Case number and the financial impact of
circumcision in reducing prostate cancer. BJU Int 2007, 100:5-6.
87. Harbour R, Miller J: A new system for grading recommendations inevidence based guidelines. BMJ 2001, 323:334-336.
88. Cilento BGJ, Holmes NM, Canning DA: Plastibell complications revisited.
Clin Pediatr 1999, 38:239-242.
89. Christakis DA, Harvey E, Zerr DM, Feudtner C, Wright JA, Connell FA: A
trade-off analysis of routine newborn circumcision. Pediatrics 2000,
105:246-249.
90. Ben Chaim J, Livne PM, Binyamini J, Hardak B, Ben-Meir D, Mor Y:
Complications of circumcision in Israel: a one year multicenter survey. Isr
Med Assoc J 2005, 7:368-370.
91. Frank R: Comment on “Christakis DA et al. A trade-off analysis of routine
newborn circumcision. Pediatrics 2000; 105 (Part 3): 246-249”. Pediatrics
2000, 106:954.
92. Griffiths DM, Atwell JD, Freeman NV: A prospective survey of theindications and morbidity of circumcision in children. Eur Urol 1985,
11:184-187.
93. Kaplan GW: Complications of circumcision. Urol Clin North Am 1983,
10:543-549.
94. Weiss HA, Larke N, Halperin D, Schenker I: Complications of circumcisionin male neonates, infants and children: a systematic review. BMC Urol
2010, 10:2, (13pages).
95. Begley EB, Jafa K, Voetsch AC, Heffelfinger JD, Borkowf CB, Sullivan PS:
Willingness of men who have sex with men (MSM) in the United States
to be circumcised as adults to reduce the risk of HIV infection. PLoS One
2008, 3:e2731.
96. Ruan Y, Qian HZ, Li D, Shi W, Li Q, Liang H, Yang Y, Luo F, Vermund SH,
Shao Y: Willingness to be circumcised for preventing HIV among
Chinese men who have sex with men. AIDS Patient Care STDS 2009,
23:315-321.
97. Schoen EJ: Male circumcision. In Male Sexual Dysfunction. Pathophysiology
and Treatment. Edited by: Kandeel FR, Lue TF, Pryor JL, Swerdloff RS. New
York: Informa; 2007:95-107.
98. Schoen EJ: Should newborns be circumcised? Yes. Can Fam Physician
2007, 53:2096-2097.
99. Morris BJ, Eley C: Male circumcision: an appraisal of current
instrumentation. In Biomedical Engineering - From Theory to Applications.
Volume 14. Edited by: Fazel-Rezai R. InTech, Rijeka, Croatia; 2011:315-354.
100. Gust DA, Kretsinger K, Gaul Z, Pals S, Heffelfinger JD, Begley E, Chen RT,
Kilmarx PH: Acceptability of newborn circumcision to prevent HIV
infection in the United States. Sex Transm Dis 2011, 52:270-273.
101. Westercamp N, Bailey RC: Acceptability of male circumcision forprevention of HIV/AIDS in sub-Saharan Africa: a review. AIDS Behav 2007,
11:341-355.
102. Brito MO, Caso LM, Balbuena H, Bailey RC: Acceptability of malecircumcision for the prevention of HIV/AIDS in the Dominican Republic.
PLoS One 2009, 4:e7687, (6pages).
103. Madhivanan P, Krupp K, Chandrasekaran V, Karat SC, Reingold AL,
Klausner JD: Acceptability of male circumcision among mothers withmale children in Mysore, India. AIDS 2008, 22:983-988.

Morris et al. BMC Pediatrics 2012, 12:20
http://www.biomedcentral.com/1471-2431/12/20

104. Adler R, Ottaway S, Gould S: Circumcision: we have heard from theexperts; now let’s hear from the parents. Pediatrics 2001, 107: [http://
www.pediatrics.org/cgi/content/full/107/102/e120.].
105. Wang ML, Macklin EA, Tracy E, Nadel H, Catlin EA: Updated parental
viewpoints on male neonatal circumcision in the United States. Clin
Pediatr (Phila) 2010, 49:130-136.
106. Xu B, Goldman H: Newborn circumcision in Victoria, Australia: reasonsand parental attitudes. ANZ J Surg 2008, 78:1019-1022.
107. Ahaghotu C, Okafor H, Igiehon E, Gray E: Psychosocial factors influenceparental decision for circumcision in pediatric males of African American
decent. J Natl Med Assoc 2009, 101:325-330.
108. Gust DA, Kretsinger K, Pals SL, Gaul ZJ, Hefflefinger JD, Begley EB, Chen RT,
Kilmarx PH: Male circumcision as an HIV prevention intervention in the
U.S.: influence of health care providers and potential for risk
compensation. Prev Med 2011, 52:270-273.
109. Westercamp M, Agot KE, Ndinya-Achola J, Bailey RC: Circumcisionpreference among women and uncircumcised men prior to scale-up ofmale circumcision for HIV prevention in Kisumu, Kenya. AIDS Care 2012,24:157-166.
110. Madhivanan P, Krupp K, Kulkarni V, Kulkarni S, Klausner JD: Acceptability of
male circumcision for HIV prevention among high-risk men in Pune,
India. Sex Transm Dis 2011, 38:571.
111. Herman-Roloff A, Otieno N, Agot K, Ndinya-Achola JO, Bailey RC:
Acceptability of medical male circumcision among uncircumcised men
in Kenya one year after the launch of the national male circumcision
program. PLoS One 2010, 6:e19814, (6pages).
112. Tieu HV, Phanuphak N, Ananworanich J, Vatanparast R, Jadwattanaku LT,
Pharachetsakul N, Mingkwanrungrueng P, Buajoom R, Teeratakulpisarn S,
Teeratakulpisarn N, Methajittiphun P, Hammer SM, Ann Chiasson M,
Phanuphak P: Acceptability of male circumcision for the prevention of
HIV among high-risk heterosexual men in Thailand. Sex Transm Dis 2010,
37:352-355.
113. Sullivan SG, Ma W, Duan S, Li F, Wu Z, Detels R: Attitudes towards
circumcision among Chinese men. J Acquir Immune Defic Syndr 2009,
50:238-240.
114. Feng N, Lü F, Zeng G, Nan L, Wang XY, Xu P, Zhang JX, Zhang SE:[Acceptability and related factors on male circumcision among young
men with Yi ethnicity in one county of Sichuan province] (In Chinese).
Zhonghua Liu Xing Bing Xue Za Zhi 2010, 31:281-285.
115. Hao L, Xu L, Jian C, Xiao-Bo Y, Jun-Jun J, Wei D: [Acceptability of malecircumcision among male miners in Baise of Guangxi] (In Chinese).
Zhongguo Yi Xue Ke Xue Yuan Xue Bao 2011, 33:313-317.
116. Wei C, Raymond HF, McFarland W, Buchbinder S, Fuchs JD: What is thepotential impact of adult circumcision on the HIV epidemic among men
who have sex with men in San Francisco? Sex Transm Dis 2010,
38:353-355.
117. McDaid LM, Weiss HA, Hart GJ: Circumcision among men who have sex
with men in Scotland: limited potential for HIV prevention. Sex Transm
Infect 2010, 86:404-406.
118. Lau JT, Zhang J, Yan H, Lin C, Choi KC, Wang Z, Hao C, Huan X, Yang H:
Acceptability of circumcision as a means of HIV prevention among men
who have sex with men in China. AIDS Care 2011, 23:1472-1482.
119. Millett GA, Flores SA, Marks G, Reed JB, Herbst JH: Circumcision status andrisk of HIV and sexually transmitted infections among men who havesex with men: a meta-analysis. JAMA 2008, 300:1674-1684.
120. Kigozi G, Gray RH, Wawer MJ, Serwadda D, Makumbi F, Watya S,
Nalugoda F, Kiwanuka N, Moulton LH, Chen MZ, Sewankambo NK,
Wabwire-Mangen F, Bacon MC, Ridzon R, Opendi P, Sempijja V, Settuba A,
Buwembo D, Kiggundu V, Anyokorit M, Nkale J, Kighoma N, Charvat B: The
safety of adult male circumcision in HIV-infected and uninfected men in
Rakai, Uganda. PLoS Med 2008, 5:e116, (8pages).
121. Barone MA, Ndede F, Li PS, Masson P, Awori Q, Okech J, Cherutich P,
Muraguri N, Perchal P, Lee R, Kim HH, Goldstein M: The Shang Ring device
for adult male circumcision: A proof of concept study in Kenya. J Acquir
Immune Defic Syndr 2011, 57:e7-e12.
122. Russell CT, Chaseling J: Topical anaesthesia in neonatal circumcision: astudy of 208 consecutive cases. Aust Fam Physician 1996, 25(suppl
1):30-34.
123. van Dijk M, de Boer JB, Koot H, Duivenvoorden HJ, Passchier J,
Boowmeester N, Tibboel D: The association between physiological andPage 14 of 15

behavioral pain measures in 0- to 3-year-old infants after major surgery.
J Pain Symptom Mgt 2001, 22:600-609.
124. Bergqvist LL, Katz-Salamon M, Hertegård S, Anand KJ, Lagercrantz H: Modeof delivery modulates physiological and behavioral responses toneonatal pain. J Perinatol 2009, 29:44-50.
125. Sternberg WF, Scorr L, Smith LD, Ridgway CG, Stout M: Long-term effects
of neonatal surgery on adulthood pain behavior. Pain 2005, 113:347-353.
126. Laprairie JL, Murphy AZ: Neonatal injury alters adult pain sensitivity byincreasing opioid tone in the periaqueductal gray. Front Behav Neurosci
2009, 3(article 31):1-11.
127. Taddio A, Stevens B, Craig K, Rastogi P, Bendavid S, Shennan A, Mulligan P,
Koren G: Efficacy and safety of lidocaine-prilocaine cream for pain
during circumcision. N Engl J Med 1997, 336:1197-1201.
128. Potetz L, Cubanski J, Neuman T: Medicare spending and financing. A
primer. Helath Policy Alternatives Inc and The Henry J. Kaiser Family
Foundation. 2011 [http://www.kff.org/medicare/upload/7731-03.pdf].
129. Leibowitz AA, Desmond K, Belin T: Determinants and policy implicationsof male circumcision in the United States. Am J Public Health 2009,
99:138-145.
130. Morris BJ, Bailis SA, Waskett JH, Wiswell TE, Halperin DT: Medicaid coverageof newborn circumcision: a health parity right of the poor. Am J Public
Health 2009, 99:969-971.
131. Schoen EJ, Colby CJ, To TT: Cost analysis of neonatal circumcision in alarge health maintenance organization. J Urol 2006, 175:1111-1115.
132. Morris BJ, Castellsague X, Bailis SA: Re: Cost analysis of neonatal
circumcision in a large health maintenance organization. E. J. Schoen, C.
J. Colby and T. T. To. J Urol, 175: 1111í1115, 2006. J Urol 2006,
176:2315-2316.
133. Sansom SL, Prabhu VS, Hutchinson AB, An Q, Hall HI, Shrestha RK, Lasry A,
Taylor AW: Cost-effectiveness of newborn circumcision in reducing
lifetime HIV risk among U.S. males. PLoS One 2010, 5:8723.
134. Anderson J, Wilson D, Templeton DJ, Grulich A, Carter R, Kaldor J: Costeffectiveness of adult circumcision in a resource-rich setting for HIV
prevention among men who have sex with men. J Infect Dis 2009,
200:1803-1812.
135. Central Intelligence Agency: Country Comparison: GDP - per capita (PPP).
2004, Retrieved from: https://www.cia.gov/library/publications/the-worldfactbook/rankorder/2004rank.html.
136. World Health Organization: CHOosing Interventions that are Cost
Effective (WHOCHOICE). 2011, Retrieved from: http://www.who.int/choice/en/.
137. Williams BG, Lloyd-Smith JO, Gouws E, Hankins C, Getz WM, Hargrove J, deZoysa I, Dye C: The potential impact of male circumcision on HIV in SubSaharan Africa. PLoS Med 2006, 3(e262):1032-1040.
138. Gray RH, Li X, Kigozi G, Serwadda D, Nalugoda F, Watya S, Reynolds SJ,
Wawer M: The impact of male circumcision on HIV incidence and cost
per infection prevented: a stochastic simulation model from Rakai,
Uganda. AIDS 2007, 21:845-850.
139. Galárraga O, Colchero MA, Wamai RG, Bertozzi SM: HIV prevention costeffectiveness: a systematic review. BMC Public Health 2009, 9(Suppl 1):S5.
140. Uthman OA, Popoola TA, Uthman MM, Aremu O: Economic evaluations ofadult male circumcision for prevention of heterosexual acquisition of
HIV in men in sub-Saharan Africa: a systematic review. PLoS One 2010, 5:
e9628, (7pages).
141. Lissouba P, Taljaard D, Rech D, Doyle S, Shabangu D, Nhlapo C, OtchereDarko J, Mashigo T, Matson C, Lewis D, Billy S, Auvert B: A model for theroll-out of comprehensive adult male circumcision services in African
low-income settings of high HIV incidence: the ANRS 12126 Bophelo
Pele Project. PLoS Med 2010, 7:e1000309, (13pages).
142. Green LW, Travis JW, McAllister RG, Peterson KW, Vardanyan AN, Craig A:
Male circumcision and HIV prevention insufficient evidence andneglected external validity. Am J Prev Med 2010, 39:479-482.
143. Garenne M: Long-term population effects of male circumcision in
generalized HIV epidemics in sub-Saharan Africa. Afr J AIDS Res 2008,
7:1-8.
144. Connolly C, Simbayi LC, Shanmugam R, Nqeketo A: Male circumcision andits relationship to HIV infection in South Africa: results of a national
survey in 2002. S Afr Med J 2008, 98:789-794.
145. Bermudez DM, Canning DA, Liechty KW: Age and pro-inflammatory
cytokine production: Wound-healing implications for scar-formation andthe timing of genital surgery in boys. J Pediatr Urol 2011, 7:324-331.

Morris et al. BMC Pediatrics 2012, 12:20
http://www.biomedcentral.com/1471-2431/12/20

146. Fink KS, Carson CC, de Vellis RF: Adult circumcision outcomes study:
Effect on erectile function, penile sensitivity, sexual activity andsatisfaction. J Urol 2002, 167:2113-2116.
147. Masood S, Patel HRH, Himpson RC, Palmer JH, Mufti GR, Sheriff MKM: Penile
sensitivity and sexual satisfaction after circumcision: are we informing
men correctly? Urol Int 2005, 75:62-66.
148. Goicochea P, Sanchez J, Morales M, Celum C: Feasibility, acceptability andwillingness to participate in a male circumcision trial for the preventionof HIV acquisition in men who have sex with men in the Andes. 5th IAS
Conference on HIV Pathogenesis and Treatment 2009, Abstract#TUPEC068.
149. Laumann EO, Maal CM, Zuckerman EW: Circumcision in the United States.
Prevalence, prophyactic effects, and sexual practice. J Am Med Assoc
1997, 277:1052-1057.
150. Richters J, Smith AM, de Visser RO, Grulich AE, Rissel CE: Circumcision inAustralia: prevalence and effects on sexual health. Int J STD AIDS 2006,
17:547-554.
151. Collins S, Upshaw J, Rutchik S, Ohannessian C, Ortenberg J, Albertsen P:
Effects of circumcision on male sexual function: Debunking a myth? J
Urol 2002, 167:2111-2112.
152. Ferris JA, Richters J, Pitts MK, Shelley JM, Simpson JM, Ryall R, Smith AMA:
Circumcision in Australia: further evidence on its effects on sexual
health and wellbeing. Aust N Z J Publ Hlth 2010, 34:160-164.
153. Kigozi G, Watya S, Polis CB, Buwembo D, Kiggundu V, Wawer MJ,
Serwadda D, Nalugoda F, Kiwanuka N, Bacon MC, Ssempijja V, Makumbi F,
Gray RH: The effect of male circumcision on sexual satisfaction andfunction, results from a randomized trial of male circumcision forhuman immunodeficiency virus prevention, Rakai, Uganda. BJU Int 2008,
101:65-70.
154. Aydur E, Gungor S, Ceyhan ST, Taiimaz L, Baser I: Effects of childhood
circumcision age on adult male sexual functions. Int J Impot Res 2007,
19:424-431.
155. Mao LM, Templeton DJ, Crawford J, Imrie J, Prestage GP, Grulich AE,
Donovan B, Kaldor JM, Kippax SC: Does circumcision make a difference tothe sexual experience of gay men? Findings from the Health in Men(HIM) Cohort. J Sex Med 2008, 5:2557-2561.
156. Morris BJ, Waskett JH, Gray RH: Does sexual function survey in Denmark
offer any support for circumcision having an adverse effect? Int J
Epidemiol 2012, 41:310-312.
157. Frisch M, Lindholm M, Grønbeck M: Male circumcision and sexualfunction in men and women: a survey-based-cross-sectional study inDenmark. Int J Epidemiol 2011, 40:1367-1381.
158. Mehta SD, Gray RH, Auvert B, Moses S, Kigozi G, Taljaard D, Puren A,
Agot K, Serwadda D, Parker CB, Wawer MJ, Bailey RC: Does sex in the early
period after circumcision increase HIV-seroconversion risk? Pooled
analysis of adult male circumcision clinical trials. AIDS 2009, 23:1557-1564.
159. Shelton JD: Masturbation: breaking the silence. Int Perspect Sex Reprod
Health 2010, 36:157-158.
160. Okino BM, Yamamoto LG: Survey of Internet web sites on circumcision.
Clin Pediatr (Phila) 2004, 43:667-669.
161. Masters WH, Johnson VE: Human Sexual Response Boston: Little Brown;
1966.
162. Bleustein CB, Fogarty JD, Eckholdt H, Arezzo JC, Melman A: Effect of
neonatal circumcision on penile neurological sensation. Urology 2005,
65:773-777.
163. Schober JM, Meyer-Bahlburg HF, Dolezal C: Self-ratings of genital
anatomy, sexual sensitivity and function in men using the ‘SelfAssessment of Genital Anatomy and Sexual Function, Male’questionnaire. BJU Int 2009, 103:1096-1103.
164. Payne K, Thaler L, Kukkonen T, Carrier S, Binik Y: Sensation and sexual
arousal in circumcised and uncircumcised men. J Sex Med 2007,
4:667-674.
165. Son H, Song SH, Kim SW, Paick JS: Self-reported premature ejaculation
prevalence and characteristics in Korean young males: communitybased data from an Internet survey. J Androl 2010, 31:540-546.
166. Waldinger MD, Quinn P, Dilleen M, Mundayat R, Schweitzer DH, Boolell M:
A multinational population survey of intravaginal ejaculation latency
time. J Sex Med 2005, 2:492-497.
167. Waldinger MD, McIntosh J, Schweitzer DH: A five-nation survey to assessthe distribution of the intravaginal ejaculatory latency time among thegeneral male population. J Sex Med 2009, 6:2888-2895.

Page 15 of 15168. Senol MG, Sen B, Karademir K, Sen H, Saraçoğlu M: The effect of malecircumcision on pudendal evoked potentials and sexual satisfaction.
Acta Neurol Belg 2008, 108:90-93.
169. Senkul T, Iseri C, Sen B, Karademir K, Saracoglu F, Erden D: Circumcision in
adults: effect on sexual function. Urology 2004, 63:155-158.
170. Williamson ML, Williamson PS: Women’s preferences for penile
circumcision in sexual partners. J Sex Educ Ther 1988, 14:8-12.
171. Wildman RW, Wildman RW II, Brown A, Trice C: Note on males’ andfemales’ preferences for opposite sex body parts, bust sizes, and bustrevealing clothing. Psychol Rep 1976, 38:485-486.
172. Kigozi G, Lukabwe I, Kagaayi J, Wawer MJ, Nantume B, Kigozi G,
Nalugoda F, Kiwanuka N, Wabwire-Mangen F, Serwadda D, Ridzon R,
Buwembo D, Nabukenya D, Watya S, Lutalo T, Nkale J, Gray RH: Sexual
satisfaction of women partners of circumcised men in a randomized
trial of male circumcision in Rakai, Uganda. BJU Int 2009, 104:1698-1701.
173. Cortés-González JR, Arratia-Maqueo JA, Gómez-Guerra LS: [Doescircumcision has an effect on female’s perception of sexual satisfaction?](In Spanish). Rev Invest Clin 2008, 60:227-230.
174. Sharlip I: Circumcision and the risk of HIV transmission in Africa. J Sex
Med 2008, 5:2481-2484.
175. Schlosberger NM, Turner RA, Irwin CE Jr: Early adolescent knowledge andattitudes about circumcision: methods and implications for research. J
Adolescent Hlth 1992, 13:293-297.
176. Stenram A, Malmfors G, Okmian L: Circumcision for phimosis: a follow-up
study. Scand J Urol Nephrol 1986, 20:89-92.
177. Sen R, Wagner W: History, emotions and hetero-referential
representations in inter-group conflict: the example of Hindu-Muslim
relations in India. Paper Soc Representations 2005, 14:2.1-2.23.
178. Chandhiok N, Gangakhedkar RR: The new evidence on male circumcision:an Indian perspective. Reprod Health Matters 2007, 15:53-56.
179. Mattson CL, Campbell RT, Bailey RC, Agot K, Ndinya-Achola JO, Moses S:
Risk compensation is not associated with male circumcision in Kisumu,
Kenya: a multi-faceted assessment of men enrolled in a randomized
controlled trial. PLoS One 2008, 3:e2443, (9pages).
180. Peltzer K, Simbayi L, Banyini M, Kekana Q: HIV risk reduction intervention
among medically circumcised young men in South Africa: a randomized
controlled trial. Int J Behav Med 2011.
181. Kalichman SC: Neonatal circumcision for HIV prevention: cost, culture,and behavioral considerations. PLoS Med 2010, 7:e1000219.
182. de la Hunt MN: Paediatric day care surgery: a hidden burden for primarycare? Ann R Coll Surg Engl 1999, 81:179-182.
183. Rennie S, Muula AS, Westreich D: Male circumcision and HIV prevention:
ethical, medical and public health tradeoffs in low-income countries. J
Med Ethics 2007, 33:357-361.
184. Benatar M, Benatar D: Between prophylaxis and child abuse: the ethics of
neonatal male circumcision. Am J Bioeth 2003, 3:35-48.
185. Vawda YA, Maqutu LN: Neonatal circumcision - violation of children’s
rights or public health necessity? S Afr J Bioethics Law 2011, 4:36-42.
186. UNAIDS/WHO/SACEMA Expert Group on Modelling the Impact and Cost ofMale Circumcision for HIV Prevention: Male circumcision for HIV
prevention in high HIV prevalence settings: what can mathematicalmodelling contribute to informed decision making? PLoS Med 2009, 6:
e1000109.
187. Bateman C: Male circumcision roll-out certain - now for ‘the how’. S Afr
Med J 2010, 100:84-86.
Pre-publication history
The pre-publication history for this paper can be accessed here:
http://www.biomedcentral.com/1471-2431/12/20/prepub
doi:10.1186/1471-2431-12-20
Cite this article as: Morris et al.: A ‘snip’ in time: what is the best age tocircumcise? BMC Pediatrics 2012 12:20.