Psychological, psychosocial, and psychosexual aspects of penile circumcision

Comments by opponents on the British Medical Association's guidance on non-therapeutic male circumcision of children seem one-sided and may undermine public health

The British Medical Association (BMA) guidance on non-therapeutic circumcision (NTMC) of male children is limited to ethical, legal and religious issues. Here we evaluate criticisms of the BMA's guidance by Lempert et al. While their arguments promoting autonomy and consent might be superficially appealing, their claim of high procedural risks and negligible benefits seem one-sided and contrast with high quality evidence of low risk and lifelong benefits. Extensive literature reviews by the American Academy of Pediatrics and the United States Centers for Disease Control and Prevention in developing evidence-based policies, as well as risk-benefit analyses, have found that the medical benefits of infant NTMC greatly exceed the risks, and there is no reduction in sexual function and pleasure. The BMA's failure to consider the medical benefits of early childhood NTMC may partly explain why this prophylactic intervention is discouraged in the United Kingdom. The consequence is higher prevalence of preventable infections, adverse medical conditions, suffering and net costs to the UK's National Health Service for treatment of these. Many of the issues and contradictions in the BMA guidance identified by Lempert et al stem from the BMA's guidance not being sufficiently evidence-based. Indeed, that document called for a review by others of the medical issues surrounding NTMC. While societal factors apply, ultimately, NTMC can only be justified rationally on scientific, evidence-based grounds. Parents are entitled to an accurate presentation of the medical evidence so that they can make an informed decision. Their decision either for or against NTMC should then be respected.

Age-incidence and prevalence of HIV among intact and circumcised men: an analysis of PHIA surveys in Southern Africa

The study investigates the statistical relationship between male circumcision and HIV prevalence in Africa, in the context of the Voluntary Medical Male Circumcision (VMMC) campaigns in place since 2008. Data from the Population-based HIV Impact Assessment (PHIA) surveys conducted in African countries in 2017-2018 were utilized. Six countries with high HIV prevalence, low traditional circumcision and large VMMC programs were selected: Eswatini, Lesotho, Malawi, Namibia, Zambia, Zimbabwe. The statistical analysis investigated the relative risk (RR) of HIV prevalence by circumcision status (circumcised vs intact) among men age 20-59, and the age-incidence of HIV in the two groups among men age 20-49, defined as the linear-logistic slope of the relationship between prevalence and age. Results show that the standardized RR was not different from 1 at older ages (50-59): RR = 0.923, 95% CI = 0.769-1.108, P = 0.390. Furthermore, the age-incidence was at least as high or higher among the circumcised groups than among the intact groups. The standardized RR was lower than 1 at younger ages, and this could be explained by selection biases. HIV prevalence at age 40-59 (27.3%) was also the same in the four groups of circumcision status (intact, traditional, medical, unknown). Results matched earlier observations made in South Africa that circumcised and intact men had similar levels of HIV infection. The study questions the current strategy of large scale VMMC campaigns to control the HIV epidemic. These campaigns also raise a number of ethical issues.

Newspaper Coverage of Violence Related to Initiation and Traditional Male Circumcision in South Africa

This study reports evidence of violence related to initiation and traditional male circumcision (ITMC) in South Africa. Our study conducted a search of the newspaper databases Newsbank and News24 from January 1, 2016, to August 31, 2023, and carried out a content analysis of newspaper articles that referenced violence in South African newspapers. Our initial search yielded 1796 articles; after screening for relevance and duplicates, 41 articles published in 16 South African newspapers and one online source were included in the analysis of the data. Most articles (41%) were published in 2016. Five major types of violence were identified at three unique stages of the ITMC process: (1) bullying; (2) mental and emotional abuse; (3) neglect; (4) physical violence; and (5) gender-based violence. At the pre-initiation stage, the articles reported that boys were forced, abducted, and trafficked into the initiation schools. While at the initiation schools, various forms of bullying, beating, fighting, slapping, assaulting, torturing, burning, neglecting, and physical, mental, and emotional abuse were reported. At the post-initiation stage, physical violence and mental abuse were reported. We noted that some articles reported violence prevention efforts during ITMC. Future research should examine readers' reception of newspaper information about violence associated with ITMC and their awareness of prevention measures. Our findings have implications for public health policy, including the Customary Initiation Act, which provides for the protection of life, the prevention of injuries, and the prevention of all forms of abuse that initiates may be subjected to as a result of initiation practices.

Foreskin restorers: insights into motivations, successes, challenges, and experiences with medical and mental health professionals - An abridged summary of key findings

Demographically diverse surveys in the United States suggest that 5-10% of non-voluntarily circumcised American males wish that they had not been circumcised. Similar data are unavailable in other countries. An unknown proportion of circumcised males experience acute circumcision-related distress; some attempt to regain a sense of bodily integrity through non-surgical foreskin restoration. Their concerns are often ignored by health professionals. We conducted an in-depth investigation into foreskin restorers' lived experiences. An online survey containing 49 qualitative and 10 demographic questions was developed to identify restorers' motivations, successes, challenges, and experiences with health professionals. Targeted sampling was employed to reach this distinctive population. Invitations were disseminated to customers of commercial restoration devices, online restoration forums, device manufacturer websites, and via genital autonomy organizations. Over 2100 surveys were submitted by respondents from 60 countries. We report results from 1790 fully completed surveys. Adverse physical, sexual, emotional/psychological and self-esteem impacts attributed to circumcision had motivated participants to seek foreskin restoration. Most sought no professional help due to hopelessness, fear, or mistrust. Those who sought help encountered trivialization, dismissal, or ridicule. Most participants recommended restoration. Many professionals are unprepared to assist this population. Circumcision sufferers/foreskin restorers have largely been ill-served by medical and mental health professionals.

A comprehensive comparison of the early and late complications of surgical circumcision in neonates and children: A cohort study

BACKGROUND AND AIMS

Major circumcision complications are rare; however, circumcision arouses distress in some special cases. The present study aimed to compare infancy and childhood regarding the frequency and relative risk of early and late complications of circumcision.

METHODS

This study was a retrospective cohort data analysis including 240 neonates and 240 children referred for circumcision from 2015 to 2021. All circumcisions were performed using the surgical dorsal-ventral slits method. A Cox proportional hazard model was used to assess the relative risk (RR) of complications at a confidence Interval of 95%.

RESULTS

The mean age was 19.32 ± 6.5 days for the neonates and 46.1 ± 8.8 months for the children. In general, complications occurred in 61 boys (12.7%), 40 neonates (8.3%), and 21 children (4.4%) (p˂0.001). Bleeding was the most common early complication in six neonates (2.5%) and three children (1.3%), and meatal stenosis was the most common late complication in 10 neonates (4.2%) and four children (1.6%). Meatal web was observed in 11 neonates (4.6%) and four children (1.6%), and the incomplete removal of the prepuce, as "not very satisfactory", was also noticed in nine neonates (3.75%) and three children (1.3%). The circumcision complications were significantly more frequent in neonates than in children (RR = 2.6, 95% CI 1.46-4.71, p<0.001). The neonatal circumcisions had a significant risk of the incomplete removal of the prepuce, meatal web, and meatal stenosis compared to children (RR = 3, 95% CI 5.83-10.81, p<0.04; RR = 2.75, 95% CI 0.9-8.3, p˂0.03; RR = 2.5, 95% CI 0.8-7.75, p<0.04, respectively).

CONCLUSION

The risk of complications is higher in neonates than children. The incomplete removal of prepuce, meatal web, and meatal stenosis are significantly higher in neonates than in children. Before prohibiting or recommending this procedure, practitioners should provide comprehensive information about its risks and benefits. Parents should weigh up the risks and benefits and make the best decision regarding their personal beliefs and customs.

Potentially under-recognized late-stage physical and psychosexual complications of non-therapeutic neonatal penile circumcision: a qualitative and quantitative analysis of self-reports from an online community forum

The removal of non-pathogenic foreskin from the penis of healthy neonates and infants for non-religious reasons is routinely practiced in many parts of the world. High level data from well-designed randomized controlled trials of circumcision in neonates and infants does not guide clinical practice. Reliable counts of immediate and short term circumcision complications are difficult to estimate. Emerging evidence suggests routine neonatal circumcision could lead to long term psychological, physical, and sexual complications in some men. The stigma associated with discussing circumcision complications creates a prevalence paradox where the presence of significant circumcision complications is higher than reported. Prior to the Internet, there were very few forums for men from diverse communities, who were troubled about their circumcision status, to discuss and compare stories. To investigate the long term consequences of circumcision, we reviewed 135 posts from 109 individual users participating in a circumcision grief subsection of Reddit, an internet discussion board. We identified three major categories of complications: physical such as pain during erections and lost sensitivity, psychological such as anxiety and violation of autonomy, and sexual such as feeling that the sexual experience was negatively altered or being unable to complete a sexual experience. We also identified a "discovery process" where some men described coming into awareness of their circumcision status. These findings suggest that neonatal circumcision can have significant adverse consequences for adult men. The removal of normal foreskin tissue should be limited to adult men who choose the procedure for cosmetic reasons or when medically indicated.

Genital Cutting as Gender Oppression: Time to Revisit the WHO Paradigm

The World Health Organization (WHO) condemns all medically unnecessary female genital cutting (FGC) that is primarily associated with people of color and the Global South, claiming that such FGC violates the human right to bodily integrity regardless of harm-level, degree of medicalization, or consent. However, the WHO does not condemn medically unnecessary FGC that is primarily associated with Western culture, such as elective labiaplasty or genital piercing, even when performed by non-medical practitioners (e.g., body artists) or on adolescent girls. Nor does it campaign against any form of medically unnecessary intersex genital cutting (IGC) or male genital cutting (MGC), including forms that are non-consensual or comparably harmful to some types of FGC. These and other apparent inconsistencies risk undermining the perceived authority of the WHO to pronounce on human rights. This paper considers whether the WHO could justify its selective condemnation of non-Western-associated FGC by appealing to the distinctive role of such practices in upholding patriarchal gender systems and furthering sex-based discrimination against women and girls. The paper argues that such a justification would not succeed. To the contrary, dismantling patriarchal power structures and reducing sex-based discrimination in FGC-practicing societies requires principled opposition to medically unnecessary, non-consensual genital cutting of all vulnerable persons, including insufficiently autonomous children, irrespective of their sex traits or socially assigned gender. This conclusion is based, in part, on an assessment of the overlapping and often mutually reinforcing roles of different types of child genital cutting—FGC, MGC, and IGC—in reproducing oppressive gender systems. These systems, in turn, tend to subordinate women and girls as well as non-dominant males and sexual and gender minorities. The selective efforts of the WHO to eliminate only non-Western-associated FGC exposes the organization to credible accusations of racism and cultural imperialism and paradoxically undermines its own stated goals: namely, securing the long-term interests and equal rights of women and girls in FGC-practicing societies.