title: Early infant male circumcision: Systematic review, risk-benefit analysis, and progress in policy.
abstract: OBJECTIVE
  To determine whether recent evidence-based United States policies on male circumcision (MC) apply to comparable Anglophone countries, Australia and New Zealand.
  
  
  METHODS
  Articles in 2005 through 2015 were retrieved from PubMed using the keyword "circumcision" together with 36 relevant subtopics. A further PubMed search was performed for articles published in 2016. Searches of the EMBASE and Cochrane databases did not yield additional citable articles. Articles were assessed for quality and those rated 2+ and above according to the Scottish Intercollegiate Grading System were studied further. The most relevant and representative of the topic were included. Bibliographies were examined to retrieve further key references. Randomized controlled trials, recent high quality systematic reviews or meta-analyses (level 1++ or 1+ evidence) were prioritized for inclusion. A risk-benefit analysis of articles rated for quality was performed. For efficiency and reliability, recent randomized controlled trials, meta-analyses, high quality systematic reviews and large well-designed studies were used if available. Internet searches were conducted for other relevant information, including policies and Australian data on claims under Medicare for MC.
  
  
  RESULTS
  Evidence-based policy statements by the American Academy of Pediatrics (AAP) and the Centers for Disease Control and Prevention (CDC) support infant and later age male circumcision (MC) as a desirable public health measure. Our systematic review of relevant literature over the past decade yielded 140 journal articles that met our inclusion criteria. Together, these showed that early infant MC confers immediate and lifelong benefits by protecting against urinary tract infections having potential adverse long-term renal effects, phimosis that causes difficult and painful erections and "ballooning" during urination, inflammatory skin conditions, inferior penile hygiene, candidiasis, various sexually transmissible infections in both sexes, genital ulcers, and penile, prostate and cervical cancer. Our risk-benefit analysis showed that benefits exceeded procedural risks, which are predominantly minor, by up to 200 to 1. We estimated that more than 1 in 2 uncircumcised males will experience an adverse foreskin-related medical condition over their lifetime. Wide-ranging evidence from surveys, physiological measurements, and the anatomical location of penile sensory receptors responsible for sexual sensation strongly and consistently suggested that MC has no detrimental effect on sexual function, sensitivity or pleasure. United States studies showed that early infant MC is cost saving. The evidence supporting early infant MC has further strengthened since the positive AAP and CDC reviews.
  
  
  CONCLUSIONS
  Affirmative MC policies are needed in Australia and New Zealand. Routine provision of accurate, unbiased education, and access in public hospitals, will maximize health and financial benefits.
authors.affiliation: Brian J Morris, Adrian Mindel, School of Medical Sciences and Bosch Institute, University of Sydney, Sydney, NSW 2006, Australia.
authors.forename: Brian J
authors.initials: BJ
authors.lastname: Morris
authors.affiliation: Brian J Morris, Adrian Mindel, School of Medical Sciences and Bosch Institute, University of Sydney, Sydney, NSW 2006, Australia.
authors.forename: Sean E
authors.initials: SE
authors.lastname: Kennedy
authors.affiliation: Brian J Morris, Adrian Mindel, School of Medical Sciences and Bosch Institute, University of Sydney, Sydney, NSW 2006, Australia.
authors.forename: Alex D
authors.initials: AD
authors.lastname: Wodak
authors.affiliation: Brian J Morris, Adrian Mindel, School of Medical Sciences and Bosch Institute, University of Sydney, Sydney, NSW 2006, Australia.
authors.forename: Adrian
authors.initials: A
authors.lastname: Mindel
authors.affiliation: Brian J Morris, Adrian Mindel, School of Medical Sciences and Bosch Institute, University of Sydney, Sydney, NSW 2006, Australia.
authors.forename: David
authors.initials: D
authors.lastname: Golovsky
authors.affiliation: Brian J Morris, Adrian Mindel, School of Medical Sciences and Bosch Institute, University of Sydney, Sydney, NSW 2006, Australia.
authors.forename: Leslie
authors.initials: L
authors.lastname: Schrieber
authors.affiliation: Brian J Morris, Adrian Mindel, School of Medical Sciences and Bosch Institute, University of Sydney, Sydney, NSW 2006, Australia.
authors.forename: Eugenie R
authors.initials: ER
authors.lastname: Lumbers
authors.affiliation: Brian J Morris, Adrian Mindel, School of Medical Sciences and Bosch Institute, University of Sydney, Sydney, NSW 2006, Australia.
authors.forename: David J
authors.initials: DJ
authors.lastname: Handelsman
authors.affiliation: Brian J Morris, Adrian Mindel, School of Medical Sciences and Bosch Institute, University of Sydney, Sydney, NSW 2006, Australia.
authors.forename: John B
authors.initials: JB
authors.lastname: Ziegler
keywords: Adults; Adverse events; Cost-benefit; Evidence-based policy; Genital cancers; Infants; Male circumcision; Risk-benefit analysis; Sexually transmitted infections; Urinary tract infections