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Neonatal and child male circumcision:

a global review

UNAIDS/10.07E – JC1672E (English original, April 2010)

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WHO Library Cataloguing-in-Publication Data

Neonatal and child male circumcision: a global review.

«UNAIDS/10.07E».

1.Circumcision, Male - utilization. 2.Infant, Newborn. 3.Children. 4.HIV infections -

prevention and control. I.UNAIDS.

ISBN 978 92 9 173855 7

(NLM classiﬁcation: WC 503.6)

UNAIDS

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Neonatal and child male circumcision:

a global review

Infant from Nigeria following male circumcision

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UNAIDS

CONTENTS

ACKNOWLEDGEMENTS

SECTION 1. Summary

1.1. Background

1.2. Scope of the review

1.3. Findings

1.4. Conclusions

SECTION 2. Background

2.1. Introduction

2.2. Determinants of male circumcision

2.3. Global prevalence of male circumcision

2.4. Physiology of the foreskin in neonates and boys

2.5. Medical indications for circumcision

2.6. Paediatric circumcision by medically trained providers

2.6.1. Screening and consent for circumcision

2.6.2. Anaesthesia in paediatric circumcision

2.6.3. Surgical methods for paediatric circumcision

2.7. Adolescent and adult circumcision

2.8. Summary

SECTION 3. Methods of the review

3.1. Search strategies

3.2. Data abstraction

3.3. Results of search

3.4. Additional surveys

3.5. Key papers

3.5.1. Selected studies from the Middle East and Africa

3.5.2. Selected studies from the United States of America

3.6. Summary

SECTION 4. Neonatal and infant circumcision

4.1. Introduction

4.2. Providers

4.3. Methods used

4.3.1. Circumcision by medically trained providers

4.3.2. Circumcision by non-medically trained providers

4.4. Knowledge of circumcision practices

4.5. Summary

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SECTION 5. Child circumcision

5.1. Introduction

5.2. Age at circumcision

5.3. Providers

5.3.1. Factors determining choice of provider

5.4. Methods used

5.4.1. Circumcision by medically trained providers

5.4.2. Circumcision by non-medically trained providers

5.5. Partial circumcision

5.6. Summary

SECTION 6. Complications following circumcision

6.1. Introduction

6.2. Complications following neonatal or infant circumcision

6.3. Complications following child circumcision by medically trained providers

6.4. Complications following circumcision by non-medically trained personnel

6.5. Summary

SECTION 7. Public health considerations

7.1. Introduction

7.2. Cost and cost-effectiveness

7.3. Legislation

7.4. Cultural acceptability of neonatal male circumcision

7.5. Health consequences of male circumcision

7.5.1. Circumcision and urinary tract infections in male infants

7.5.2. Circumcision and HIV infection

7.5.3. Circumcision and the risk of other sexually transmitted infections

7.6. Summary

SECTION 8. Conclusions and recommendations

REFERENCES

APPENDIX. Survey on knowledge of circumcision practices

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Acknowledgements

Helen Weiss led a team composed of Natasha Larke, Daniel Halperin and Inon Schenker in

researching, drafting and ﬁnalising this report.

This report was commissioned and funded by the Bill and Melinda Gates Foundation. HW

was funded by the UK Medical Research Council. We thank Amy Adelberger, Chris Eley,

Catherine Hankins, Renee Ridzon, David Tomlinson for their detailed comments on the

manuscript and Tim Farley, Kim Dickson and Richard Hayes for advice. We also thank

Precious Lunga and Lon Rahn for layout and production of the report.

Photos used in this document are courtesy of David Tomlinson MD, Brown University (front

page, Figures 2, 3, 4, 7), Helen Weiss PhD, LSHTM (Figures 6, 8, 9, 10), and Inon Schenker PhD

MPH, The Jerusalem AIDS Project (Figure 11).

Tables

Table 1.

Table 2.

Table 3.

Table 4.

Table 5.

Table 6.

Table 7.

Table 8.

Table 9.

Table 10.

Advantages and disadvantages of common methods of pediatric circumcision

Summary of new disposable male circumcision devices

Number of papers on different circumcision topics identiﬁed in the

literature search

Typical age at circumcision by country and adult male circumcision prevalence

Summary of frequency of complications in prospective studies of neonatal

and infant circumcision

Summary of frequency of complications in retrospective studies of neonatal

and infant circumcision

Summary of frequency of complications in prospective studies of child

circumcision undertaken by medical providers

Summary of frequency of complications in retrospective studies of child

circumcision undertaken by medical providers

Summary of frequency of complications in retrospective studies of child circumcision

undertaken by non-medical providers

Frequency of complications in studies of adolescent and adult circumcision

Figures

Global map of male circumcision prevalence at the country level,

as of December 2006.

Figure 2: An uncircumcised infant penis (left) and the same penis two weeks after

male circumcision.

Figure 3: Injection of local anaesthetic for a dorsal penile nerve block at the 10 o’clock position

at the base of the penis.

Figure 4: Foreskin being retracted to expose the glans.

Figure 5: Three different non-disposable male circumcision devices:

Gomco, Mogen and Plastibell.

Figure 6: Ali’s Klamp being used to circumcised a young boy.

Figure 7: Plain gauze impregnated with petroleum jelly (Vaseline).

Figure 8: Traditional circumcision provider (Wanzam) with basic kit provided

following training by the Ghana Health Service in Greater Accra.

Figure 9: Infant male circumcision in Korle-Bu Teaching Hospital, Accra, Ghana.

Figure 10: Operation Abraham Collaborative trainers introducing the clamp method in

Swaziland.

Figure 11. Acceptability of safe, low-cost male circumcision in southern and eastern African

countries.

Figure 1.

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SECTION 1. Summary

1.1. Background

Male circumcision, which is practised for social, cultural and medical reasons, is one of the oldest

and most common surgical procedures performed globally. It is estimated that one in three males

worldwide are circumcised, with almost universal coverage in some settings. There is currently

increased interest in male circumcision services, since three randomized controlled trials have

confirmed that circumcision reduces the risk of acquiring HIV infection in males.

Several countries with a high prevalence of HIV are now expanding access to safe male

circumcision.The immediate focus of circumcision for HIV prevention is on adolescents and adult

men, but a longer-term HIV prevention strategy is likely to include the provision of neonatal and

child circumcision. Information on paediatric male circumcision practices is therefore needed, not

only to guide further expansion of male circumcision services for long-term HIV prevention, but

also to ensure that the procedure is conducted as safely as possible where it is routinely undertaken

for religious or cultural reasons.

1.2. Scope of the review

The aim of this report is to review global practices of male circumcision among neonates and

children, including prevalence, age at circumcision, type and training of provider, common

circumcision methods, frequency of complications and cost. Data were collected through a

systematic review of the published literature.

1.3. Findings

Male circumcision is almost universal in much of the Middle East, North and West Africa and

Central Asia and is common in other countries, including Australia, Bangladesh, Canada, Indonesia,

Pakistan, the Philippines, the Republic of Korea, Turkey and the United States of America (USA).

It is also prevalent among certain ethnic groups in central, eastern and southern Africa.

In some settings, such as North Africa, Pakistan, Indonesia, Israel and rural Turkey, the majority

of providers are not medically trained. In contrast, circumcision is provided almost exclusively by

medically trained personnel in Saudi Arabia and other Gulf States, and in Egypt, the Republic of

Korea and the USA.

Circumcision tends to be practised shortly after birth in parts of West Africa, Israel, the Gulf States

and the USA. In contrast, in North Africa, the Middle East and parts of Asia males are circumcised

as young boys, and in some regions of east and southern Africa as adolescents or young adults.

The most common complications of circumcision are bleeding and wound infection. We

identified 16 prospective studies documenting complications following neonatal and infant

circumcision, in which the median frequency of any complication was 1.5% (range 0–16%). Most

studies reported no severe adverse events, but two studies reported a frequency of 2%. Among

studies of boys circumcised aged over one year by medical providers, the median frequency of

any adverse event was 6% (range 2–14%); serious adverse events were rare (median frequency 0%,

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range 0–3%). This is a similar proportion as among adult males in the three randomized controlled

trials of circumcision for HIV prevention. Traditional circumcision is associated with greater risks,

more severe complications and slower healing than medical circumcision. However, definitions

of complications vary, as do methods of ascertainment, and prospective studies with standardized

definitions and reporting methods of adverse events are needed.

Serious complications among neonates or young boys are rare when the procedure is carried

out by experienced providers. Several studies stressed the need for comprehensive training of

circumcision providers, as complications were more common when the procedure was undertaken

by inexperienced or poorly trained providers, or by those with inadequate equipment or supplies.

Cost is often a factor influencing the choice of provider, and the costs of neonatal and young boy

circumcision vary widely depending on the setting. There is relatively little data in the published

literature on the cost of male circumcision. In general, circumcision provided by non-medically

trained providers is cheaper than that provided by medical providers. Recent cost-effectiveness

studies indicate that both neonatal and adult circumcision are relatively low cost and have multiple

health benefits, including lower risks of urinary tract infections and of invasive penile cancer.

1.4. Conclusions

Circumcision occurs at a wide range of ages, and neonatal and child male circumcision is routinely

practised in many countries for religious and cultural reasons. There are several advantages of

circumcising males at a younger versus older age, including a lower risk of complications, faster

healing and a lower cost. However, some parents may wish to wait for an older age for religious

or cultural reasons, or have a preference to wait until the child can give consent for the procedure.

The procedure is undertaken by a range of providers, with the choice of provider depending on

family or religious tradition, cost, availability and the perception of service quality. As an engrained

religious and cultural practice, paediatric circumcision is likely to continue to be highly prevalent

around the world, and is now being considered as a long-term HIV prevention strategy.

This review shows that circumcision complications are rare when conducted by trained and

experienced providers with adequate supplies and in hygienic conditions. However, there is a

clear need for comprehensive, ongoing training programmes for both medically trained and

non-medically trained providers, which should cover all aspects of the procedure and after-care in

order to avoid the current unnecessary morbidity associated with the procedure in many settings.

There is currently relatively little data comparing risks by different methods, types of provider

or age at circumcision, and further prospective studies are needed. A number of new disposable

devices for circumcision are available, and further work is needed to evaluate the potential for

these to be used in different settings.

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SECTION 2. Background

2.1. Introduction

Approximately one in three males worldwide are circumcised, with almost universal coverage

in some settings.

However, the practices and procedures of male circumcision (hereafter called

circumcision), and risks of complications, are not well documented.

Randomized controlled trials have shown that adult circumcision reduces the risk of acquiring HIV

infection in heterosexual males by 50–60%,

2–4

and several African countries with a high prevalence

of HIV are now expanding access to safe circumcision. The immediate focus of circumcision for

HIV prevention is on adolescents and adult men, but a longer-term HIV prevention strategy is

likely to include the provision of neonatal and child circumcision.

In this report, we review the current global practices of circumcision among neonates (age

less than one month), infants (1 to 11 months) and children (age 1 to 12 years), including

age at circumcision, type and training of provider, circumcision methods used, frequency and

management of complications, cost and legislation.

In this section we provide a background to the review by summarizing the global prevalence and

determinants of circumcision, the physiology of the foreskin and the common surgical methods

for paediatric circumcision.

2.2. Determinants of male circumcision

Male circumcision is one of the oldest surgical procedures known, traditionally undertaken

as a mark of cultural identity or religious importance or for perceived health benefits such as

improved penile hygiene or reduced risk of infection. Muslims are the largest religious group to

practise circumcision, and an estimated 68% of circumcised men are Muslim.

Circumcision is

known in Arabic as al-Tohour and is practised as a confirmation of the relationship with God;

the practice is also known as ‘tahera’, meaning ‘purification’, but there is no specific mention of

circumcision in the Koran. The Prophet Muhammad was ordered to follow the faith of Abraham

(Koran 16:123), including the act of circumcision. In other writings circumcision is ordered as

one of five behaviours that men should follow to attain a high degree of respectability and dignity.

Circumcision is also almost universally practised among Jewish people. The religious justification

for Jews comes from Genesis 17, which states that circumcision is a covenant with God and that all

boys should be circumcised on the eighth day of life. Most other religions, including Christianity,

Hinduism and Buddhism, tend to have a neutral stance towards circumcision.

Circumcision has been widely practised for non-religious reasons for many centuries in West

Africa and in parts of central, east and southern Africa, as well as among aboriginal Australasians

5,6

and the Aztecs and Mayas in the Americas,

7–9

in the Philippines and eastern Indonesia

and on

various Pacific islands, including Fiji

and the Polynesian islands.

More recently, circumcision has

become common in other settings, including the USA and the Republic of Korea.

13,14

In some

cultures, circumcision is an integral part of a rite of passage to manhood

and is associated with

factors such as masculinity, self-identity and spirituality.

For example, circumcision in Turkey is

seen as part of becoming a man and a member of society,

and it can be seen as unacceptable to

remain uncircumcised.

In other settings, circumcision is most commonly carried out neonatally

or in childhood, with the primary reason being perceived improved penile hygiene, or to fit with

the social norm.

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2.3. Global prevalence of male circumcision

Estimated country-level prevalences of circumcision are shown in Figure 1. Due to the almost

universal coverage of circumcision among Muslim and Jewish men, prevalence in the Middle East

and North Africa is high, with published data from Egypt, the Islamic Republic of Iran, Morocco

and Turkey suggesting that over 95% of males are circumcised in those countries.

18–26

Figure 1. Global map of male circumcision prevalence at the country level, as of

December 2006.

In West Africa, where circumcision is common among both non-Muslim and Muslim men,

demographic and health surveys (DHS) show a very high prevalence overall (97% in Benin, 96%

in Côte d’Ivoire, 95% in Ghana and 90% in Burkina Faso).

There are some variations within the

region; for example, circumcision is less common in the Upper West region in Ghana (68%) and

among the Lobi in south-west Burkina Faso (28%). Published sources indicate the prevalence of

circumcision to be greater than 80% in most West African countries (Gambia, Guinea, Guinea-

Bissau, Liberia, Mali, Mauritania, the Niger, Nigeria, Senegal, Sierra Leone and Togo

28–30

In other parts of sub-Saharan Africa, ethnicity is a major determinant of circumcision. Overall

prevalence is low in Rwanda (9%), Burundi (<20%) and Uganda (25%), and higher in other

countries (70% in the United Republic of Tanzania, 84% in Kenya, 92.5% in Ethiopia, 93% in

Cameroon and greater than 80% in Chad, the Democratic Republic of the Congo, Djibouti,

Eritrea and Somalia

27,28,31,32

). In contrast, circumcision is less common in southern African

countries, with prevalence estimates of around 15% in Botswana and Swaziland, 10% in Zimbabwe,

17% in Zambia, 21% in Malawi and Namibia and 35% in South Africa; the prevalence estimates

are higher in Mozambique (60%), Angola (>80%) and Madagascar (98%).

27,28,33,34

Circumcision is

highly prevalent in Muslim Asian countries (Bangladesh, Malaysia, Indonesia, Pakistan) and also

in the Republic of Korea and the Philippines.

10,28,35,36

It is uncommon in other parts of South-

East Asia, including the Hong Kong Special Administrative Region,

Thailand,

38,39

Viet Nam, the

Lao People’s Democratic Republic, Cambodia, Myanmar, China, Japan and Taiwan, China.

10,40

Only 3% of Chinese boys attending a clinic in the Hong Kong Special Administrative Region

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were circumcised.

These circumcisions were performed either for medical reasons, because the

doctor recommended it as routine, for familial preference or for the perceived health benefits.

The prevalence among a sample of 1145 Taiwanese boys aged 7 to 13 years was 8%.

A recent

study of mothers of infant boys in Mysore, southern India, found that, as expected, prevalence

was associated with religion, with 57% of Muslim boys circumcised compared with 2.5% of

non-Muslim boys.

The relatively low prevalence of circumcision among the Muslim boys in

this study is likely due to the young age of the boys at time of the interview (90% of the Muslim

mothers reported that they would typically circumcise their sons at age greater than one year).

Neonatal circumcision became common in English-speaking industrialized countries in the

mid-19th century, but is currently widely practised only in the USA, where currently between

60% and 90% of newborn males are circumcised, depending on the region.

43–51

Nationally

representative studies have shown that the overall prevalence of circumcision among adult men

is around 79% in the USA

, 59% in Australia

and 16% in the United Kingdom.

There is little

representative data from other European countries, except for Denmark (1.5%)

and Slovenia

(4.5%),

with circumcised men in the latter survey being almost exclusively Muslim or of

non-Slovenian origin.

2.4. Physiology of the foreskin in neonates and boys

Circumcision removes some, or all, of the foreskin from the penis (Figure 2). The foreskin is

a continuation of skin from the shaft of the penis that covers the glans penis and the urethral

meatus. There is debate about the role of the foreskin, with possible functions including keeping

the glans moist

and protecting the developing penis in utero.

The foreskin develops during the third month of intra-uterine development (about 65 mm

stage), when a fold of skin develops at the base of the glans penis and beings to grow distally.

This free fold of skin will become the prepuce. The dorsal aspect grows more rapidly than the

ventral, so that initially only the dorsum is covered. As the glanular urethra closes, so does the

ventral prepuce, and the resultant fusion is marked by the frenulum. This process is completed by

the fifth month,

and fusion then occurs between the inner epithelium of the prepuce and the

epithelium of the glans penis, both of which are made of stratified squamous cells. The squamous

cells arrange themselves in whorls as they keratinize and then degenerate so that clefts appear.

These clefts increase in size and fuse with each other so that eventually the inner preputial

epithelium and epithelium of the glans are separated from each other. This separation is usually

incomplete at birth, and consequently, the foreskin is not usually retractable in newborn males.

The phenomenon of incomplete separation is commonly referred to as ‘adhesions’, which need

to be broken with a blunt probe during paediatric circumcision. By the age of three years, about

10% of males still have an unretractable foreskin, and by the age of 17, the foreskin is completely

retractable in almost all males.

2.5. Medical indications for circumcision

The most frequent medical reason for circumcision is phimosis (a stricture of the foreskin that

narrows the opening and prevents it from being retracted to uncover the glans) or otherwise

untreatable paraphimosis (in which the foreskin is trapped behind the corona and forms a tight

band of constricting tissue, causing swelling of the glans and foreskin). Less common medical

indications for circumcision are balanoposthitis (inflammation of the foreskin and glans) and

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balanitis xerotica obliterans (a chronic sclerosis and atrophic process of the glans penis and

foreskin—a risk factor for penile cancer). In addition, preputial neoplasms, excessive skin and tears

in the frenulum are also rare medical indications for adult circumcision.

59,60

Contraindications for

newborn circumcision include some haematological disorders, jaundice and any abnormality of

the penis, including hypospadias and epispadias.

2.6. Paediatric circumcision by medically trained providers

The goal of circumcision is to remove enough shaft skin and inner foreskin to uncover the

glans.

As with any surgical procedure, there are risks associated with circumcision, and the

principles common to all methods of circumcision to reduce risks are: asepsis; adequate but not

excessive excision of the outer and inner foreskin; haemostasis (stopping bleeding); and cosmetic

appearance.

Figure 2: An uncircumcised infant penis (left) and the same penis two weeks after male

circumcision (right).

2.6.1. Screening and consent for circumcision

The first procedure prior to circumcision is screening to ensure that the child is suitable for surgery.

For neonates, this means that the baby should be a normal full-term delivery with no significant

medical problems after birth. Guidelines for informed consent for the circumcision of minors

have been published by UNAIDS.

The guiding principle is that all decisions must be based

on the best interests of the child. For infants, informed consent must be obtained from parents,

legal guardians or, in the absence of both, the primary caregiver. This person should be provided

with clear and understandable information on the benefits and risks of circumcision in infancy

compared with older ages, including when the child is mature enough to decide for himself. In the

case of children who have some capacity to appreciate the risks and benefits associated with the

procedure, the child’s assent should also be sought, and they should be counselled about the risks

and benefits in language that they can understand, describing how the procedure will be done,

what type of anaesthetic will be used, what possible complications there may be and what type of

postoperative care should be provided. After receiving the information about circumcision, parents

should be given time to consider the issues before they are asked to sign a consent document.

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2.6.2. Anaesthesia in paediatric circumcision

Local anaesthesia is recommended by the World Health Organization (WHO), and is easiest for

neonates and infants who can be held still and for boys aged around four to five years upwards,

who are able to remain still enough to cooperate with the procedure.

For young boys, however,

use of local anaesthetic is more problematic, as they are unlikely to be able to remain still during

the procedure. General anaesthesia can be used, but has greater associated risks, so it may be

preferable to postpone the circumcision until the boy is older and able to cooperate under local

anaesthesia. Most circumcisions performed by traditional circumcisers are carried out with no

anaesthesia.

A systematic review of randomized controlled trials of pain relief for neonatal circumcision

found that a dorsal penile nerve block (DPNB), which blocks the twin dorsal penile nerves

and branches, is the most effective method of local anaesthesia

and has an excellent safety

Figure 3: Injection of local anaesthetic for a dorsal penile nerve block at the 10

o’clock position at the base of the penis.

record.

A second systematic review also showed that due to temporary leg weakness that may be

experienced after caudal block, a penile block may be preferred.

Compared with a placebo, the

topically applied eutectic mixture of analgesics (EMLA

) cream is also effective, but less so than the

DPNB. Reviews have found that the administration of oral sucrose was superior to no analgesia

in neonatal circumcision, but not as effective as DPNB.

68,69

Other methods, such as swaddling,

dimmed lighting and repeated doses of oral acetaminophen, can also reduce behavioural distress

in neonates.

A common practice in Muslim neonatal circumcision in Israel is to breastfeed the

baby 30 minutes before the operation (Dr Jamal Garah, personal communication, 29 June 2008).

EMLA 5% cream (containing 2.5% lidocaine and 2.5% prilocaine) has been extensively used for

Plastibell circumcision in children of all ages. However, it must be applied with care in neonates

because of the potential risk of the development of methaemoglobinaemia with its use. Possible

minor adverse events from EMLA cream include transient local skin reactions, such as blanching

and redness.

Eutectic mixture: separately, lidocaine and prilocaine are solid bases. When mixed together in equal quanitites by

weight, however, they form a eutectic mixture—that is, the melting point of the mixture is lower than the melting

points of the individual components. The lidocaine/prilocaine eutectic mixture is an oil with a melting point of 16°C,

thus can be formulated into preparations without the use of a non-aqueous solvent. This allows higher concentrations

of anaesthetic to be formulated into the preparation and maintained during application.

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2.6.3. Surgical methods for paediatric circumcision

Details of commonly used methods for paediatric and adult circumcision are published in the

WHO, UNAIDS and JHPIEGO

Manual on male circumcision under local anaesthesia.

The main

methods use a shield or device to protect the glans and to achieve haemostasis by crushing or

clamping the foreskin (or by ligature for the Plastibell method).

The goals of any surgical circumcision device are shown in Box 1.

Box 1. Important functions of a circumcision device

Protect glans

Position foreskin for tissue removal

Provide a guide for tissue removal

Control the amount of tissue removed

Minimal blood loss (haemostasis)

Ease of training and easy to use

Low adverse event rate

Acceptable cosmetic result

Low cost

Sterile

In paediatric circumcision, the foreskin may be fused to the glans penis, especially in infancy, and

it is then necessary to separate these prior to circumcision by gently stretching the opening of the

foreskin with artery forceps. Once the foreskin has been dilated, the foreskin is slowly retracted

and separated from the glans penis by gently running a blunt probe around the glans until the

corona is exposed and the circumcision procedure can be carried out (Figure 4).

Figure 4: Foreskin being retracted to expose the glans.

Circumcision devices have a shield to protect the glans and may be disposable (e.g. the Plastibell)

or reusable (e.g. the Mogen and Gomco clamps). A summary of the advantages and disadvantages

of the most common methods is shown in Table 1.

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The Plastibell is commonly used in many settings around the world, including by nurses or

midwives without surgical training. With the Plastibell, bleeding is controlled by using a ligature

which acts as a tourniquet, interrupting the blood supply to the foreskin causing it to separate

over time. Wound healing is usually complete within a week. A disadvantage of the Plastibell is

that the ring and ligature must stay in place for several days before the skin separates. During

this time complications can occur related to the retained ring.

Some newer disposable devices are now available for use in both paediatric and adult

circumcision (Table 2).

Table 1. Advantages and disadvantages of common methods of paediatric circumcision

Method

Dorsal slit

Advantages

Can be performed in

any hospital or clinic

equipped with standard

surgical instruments

Simple technique

Can be performed using

EMLA cream anaesthesia

Disadvantages

Requires more surgical skill

than other methods

Comments

Can be undertaken by

skilled surgeons who do

not regularly perform

circumcision

Suitable for clinics

dealing with large

numbers of babies

Plastibell

Requires a stock of

different sizes of device

Plastibell stays attached for

3–4 days until it drops off

May require second clinic

attendance to have the

bell removed

Mogen

clamp

Technique using one-

piece instrument, which

is simple to use; simple

to teach

Produces a crushed

welded edge, which

does not need suturing

Risk of partial amputation

of glans if device is not

applied carefully

Risk of glans being buried

by cross-adhesions

Although suturing is not

usually needed, it may

be on occasion, thus

surgical skills must be

available in clinics where

these devices are used

Although suturing is not

usually needed, it may

be on occasion, thus

surgical skills must be

available in clinics where

these devices are used

Gomco

clamp

Simple technique; can

be performed with

EMLA anaesthesia

Produces a circular

crushed welded edge

that does not need

suturing

Clinic needs to have a set

of Gomco clamps with

different bell sizes

Multipart device, with risk

that parts will be lost or

damaged

Parts not readily

interchangeable between

different clamp sets

Risk of partial amputation

of glans, if circumciser is

not careful

Metal

shield

Simple technique using

one-piece instrument

(the shield that protects

the glands), which is

simple to use; simple to

teach even to laypeople

Can be performed

anywhere and with any

amount of (neonatal)

foreskin

Used by mohels and

could be found in

several formats: one-

time use or multi-use

with sterilization

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Gomco (Yellen) clamp

Mogen (Bronstein) clamp

Plastibell (Ross style)

tourniquet device

Figure 5: Three different male circumcision devices: Gomco and Mogen (non-disposable)

and Plastibell (disposable).

With these new devices, the glans is protected by a shield, the clamp is applied and the foreskin

removed with a scalpel. There is generally little bleeding and the device is left on the patient for

several days (Figure 6). To our knowledge, there are published data on only two of these clamps—

the Tara Klamp

and the Shenghuan device (also known as the Shang Ring).

Laser circumcision

has been used in Singapore and has shown low morbidity rates.

In traditional (neonatal) Jewish

circumcision, a metal shield is used to protect the glans when cutting off the foreskin and

haemostasis is achieved through pressing bandages on the circumcised penis.

Table 2. Summary of new disposable male circumcision devices

Device

Country of

origin

Ages

Duration of

clamp for

haemostasis

—

Several days

Published

reference

Web site

Accu-circ

Alisklamp

USA

Turkey

Infant

Infant to

adult

Infant to

adult

Infant to

young

adult

Five

years to

adult

www.accucirc.com

www.alisklamp.com

Ismail clamp

Malaysia

5 to 10 days

www.ismailclamp.com

Kirve Klamp

Turkey

3 to 5 days

www.kirveklamp.com

Shenghuan

Disposable

Minimally

Invasive

Circumcision

Anastomosis

Device

SmartKlamp

China

7 days

Netherlands

Infant to

adult

Infant to

adult

Infant to

adult

5 days

www.smartklamp.com

Sunathrone

Malaysia

8 to 12 days

www.sunathrone.com

Tara Klamp

South Africa

5 days

www.taraklampsa.co.za

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Of the re-usable clamps, the Mogen clamp has the

advantage of consisting of only one part, unlike the

Gomco, which has four parts. Both devices crush

the foreskin, and bleeding in neonatal or infant

circumcision is rare as the clamp crushes the edge

of the foreskin.

In infants, the foreskin is long in relation to the

penis, and there is less chance of strong penile

erection. This has two important consequences

compared with adolescent or adult circumcision.

First, the longer foreskin may make the procedure

less complicated in neonates than in older boys.

Second, clamping devices that remain on the penis

for a few days are more feasible for children than

adults, because there is less chance of the device

being pushed off by an erection.

Following circumcision by any of these methods,

a piece of gauze impregnated with petroleum jelly

should be applied to the wound after removal of the

device (Figure 7). No additional dressing is usually

required, and the child can be looked after in the

normal way. In some settings it is common practice

to require infants to remain in hospital until they

have been observed passing urine, but this policy has

been criticized as unnecessary.

Healing is usually

complete after about one week.

Figure 6: Ali’s Klamp being used

to circumcised a young boy.

Figure 7: Plain gauze

impregnated with petroleum jelly

(Vaseline).

2.7. Adolescent and adult circumcision

Adolescent and adult circumcision is more complex than in neonates or children. For example,

the recent randomized controlled trials of adult circumcision for HIV prevention used the forceps

guided and sleeve methods. Details are given in the WHO, UNAIDS and JHPIEGO

Manual on

male circumcision under local anaesthesia.

Adult circumcision requires suturing and dressing, and

once bleeding has ceased the wound is dressed and the dressing is left in place for 24–48 hours.

A follow-up visit is needed within a week to assess the progress of healing and to look for signs

of infection.

2.8. Summary

Circumcision, a common surgical procedure in infants and young boys in many regions of the

world, is conducted for religious, social or medical reasons. Local anaesthesia is recommended for

paediatric circumcision, especially in neonates, infants and boys old enough to remain still during

the procedure. There are several widely used methods of paediatric circumcision, and several new

devices for circumcision are available. Comparative studies are needed to evaluate the relative cost,

training needed, performance and complication risks of each device, as well as the potential for

use in new settings if circumcision services are expanded.

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SECTION 3. Methods of the review

3.1. Search strategies

Since expansion of circumcision for HIV prevention is recommended in regions with high rates

of heterosexual transmission (in practice, much of southern Africa and parts of eastern Africa),

we focused our searches on non-Western regions of the world. Searches were conducted on 6

November 2007 and were updated on 28 July 2009. Additional searches of the Arabic literature

were conducted on 29 June, 18 July and 20 July 2008, with follow-up searches on 18 August and

22 August 2008. There was no language restriction.

We searched PubMed with the following search terms: “Circumcision, Male”[Mesh] AND “Infant,

Newborn”[Mesh] AND (“Africa”[Mesh] OR “Asia”[Mesh]); “complications “[Subheading]

OR “Intraoperative Complications”[Mesh] OR “Postoperative Complications”[Mesh]) AND

“Circumcision, Male”[Mesh] AND (“Africa”[Mesh] OR “Asia”[Mesh]); (“Child”[Mesh]

AND “Circumcision, Male”[Mesh]) AND (“Africa”[Mesh] OR “Asia”[Mesh]); (“Infant,

Newborn”[Mesh] OR “Child”[Mesh]) AND (“Circumcision, Male”[Mesh] OR (“Circumcision,

Male/adverse effects”[Mesh] OR “Circumcision, Male/complications”[Mesh] OR “Circumcision,

Male/contraindications”[Mesh] OR “Circumcision, Male/mortality”[Mesh])); “Circumcision,

Male “[Mesh] AND “Arabic”.

In addition, we searched the reference lists of relevant papers, including the previous systematic

review of complications of circumcision in Anglophone Africa,

and books on circumcision in 10

key academic centres on Middle Eastern studies in the USA, Australia and Israel.

We also searched African Healthline with the following search terms: (CIRCUMCISE OR

CIRCUMCISING OR CIRCUMCISIO OR CIRCUMCISION OR CIRCUMCISION-

ASSOCIATED OR CIRCUMCISION-INDICATION OR CIRCUMCISION-RELATED

OR CIRCUMCISIONS) AND (NEONATAL OR PEDIATRIC OR PEDIATRIC OR

PAEDIATRIC OR CHILD); and Medicus for WHO Eastern Mediterranean, IMEMR current

contents, the Arabic Medical Library, Iran Medex and ALEF with the following search terms:

(CIRCUMCISION OR CIRCUMCISING OR CIRCUMCISION-ASSOCIATED).

Further searches of the LILACS database and the School of Oriental and African Studies library

produced 18 further papers and searches of Hebrew University libraries produced Master and PhD

research theses focused on the circumcision of males.

A total of 1382 papers were identified through the non-Arabic literature searches. The abstracts

of these papers were read and 364 were deemed potentially relevant. Full copies of these papers

were obtained from the London School of Hygiene & Tropical Medicine (LSHTM), the British

Library or other university libraries in the London area. The Arabic literature searches identified a

total of 45 relevant books, monographs, theses and papers.

We also used information from the demographic and health surveys,

which collected information

on circumcision status (Burkina Faso, Cameroon, Côte d’Ivoire, Ethiopia, Ghana, Kenya, Lesotho,

Malawi, Namibia, the Niger, Rwanda, Uganda, the United Republic of Tanzania and Zimbabwe),

as appropriate.

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We used limited information from the Internet. We used Google to search for the Arabic terms

for ‘circumcision’ and ‘male circumcision’ and only included sites that contained information

by named authors who deemed reliable (medical doctors or organizations dealing with family

planning, reproductive health, etc.). After careful review of 521 sites, only 28 qualified for inclusion.

Finally, we used reports from two workshops on neonatal and child circumcision organized by

WHO in Abuja (26 to 27 March 2008)

and Accra (23 April 2008).

3.2. Data abstraction

Each paper was abstracted using an Access database form and information on each of the following

areas was summarized:

Prevalence of circumcision;

Ages at which circumcision is performed;

Types and training of circumcision providers;

Circumcision methods used;

Systems for recording and managing complications;

Incidence of adverse events;

Attitudes towards medical and traditional circumcision;

Parent’s attitudes;

Related legislation.

3.3. Results of search

Of 364 published papers thought suitable for data extraction, 293 contained pertinent data and

are included in the literature review. Of these, 60 were general review papers and 233 came from

specific countries. Despite our focus on the literature from outside the USA, one third of these

papers came from North America. The breakdown by region and country is as follows:

Seventy-ﬁve (33%) were from North America (71 from the USA, four from Canada).

Fifty-six (25%) were from the Middle East and North Africa (including 20 from Turkey

and 13 from Israel).

Forty (17%) were from sub-Saharan Africa (including 16 from Nigeria and nine from

South Africa).

Thirty-ﬁve (14%) were from Europe (including 13 from the UK and ﬁve from Den-

mark).

Thirteen (5%) were from Asia (including four from the Republic of Korea, three from

the Hong Kong Special Administrative Region and two from the Philippines).

Eleven (5%) were from the Paciﬁc region (including seven from Australia).

Three (1%) were from the Caribbean and Latin America (from Jamaica, Mexico and

Trinidad and Tobago).

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Table 3 summarizes the type of information included in the papers identified in the literature search.

Table 3. Number of papers on different circumcision topics identified in the

literature search

Topic

Prevalence of circumcision

Age at circumcision

Provider information

Method of circumcision

Method of recording complications

Complications (including case reports)

Attitudes of population

Attitudes of parents

Legislation

Cost

Number of papers

196

223

The most common type of data (n = 223) were on complications of circumcision—these were

mostly case reports. Papers detailing methods of circumcision (n = 196), provider information

(n = 70) and age at circumcision (n = 77) were also common. There were few papers on the cost of

circumcision (n = 10) or legislation of the procedure (n = 10).

In addition, 45 books, monographs, theses and papers and 28 web sites were included from the

Arabic literature search. The articles included studies in Egypt, India, the Islamic Republic of Iran,

Israel, Saudi Arabia, Turkey, Oman and Pakistan.

3.4. Additional surveys

In addition to searches of the published literature, we conducted two surveys to gather further

information on circumcision practices. The first (the ‘LSHTM survey’) comprised a detailed

questionnaire sent to authors of the published literature and their contacts, participants at the

WHO workshops on neonatal circumcision in Ghana and Nigeria and members of the Royal

College of Obstetricians and Gynaecologists. Completed questionnaires were received from 124

individuals from 23 different countries. Full details of the survey are reported in the Appendix.

A further survey was conducted by colleagues at Bethlehem University among 20 nurses and 10

doctors in three Palestinian hospitals. Data were collected by nursing students through face-to-face

semi-open interviews.

3.5. Key papers

Several papers were of particular relevance to our review because they were large studies

documenting circumcision complications. For ease of reference, the designs of these key studies

are briefly summarized below. The results are discussed in Sections 4–6.

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3.5.1. Selected studies from the Middle East and Africa

al-Samarrai AY et al. (1988). A review of a Plastibell device in neonatal circumcision in

2,000 instances. Surgery, Gynecology & Obstetrics, 167(4):341–343.

This prospective study followed 2000 male neonates in Riyadh, Saudi Arabia, circumcised with

the Plastibell device on the second to third day of life. The infants were followed up at well baby

and immunization clinics.

Amir M, Raja MH, Niaz WA (2000). Neonatal circumcision with Gomco clamp—a

hospital-based retrospective study of 1000 cases. Journal of the Pakistan Medical Association,

50(7):224–227.

This prospective study from Saudi Arabia documented complications in 1000 neonates circumcised

with the Gomco clamp under local anaesthetic. The mean follow-up time was two years.

Atikeler MK et al. (2005). Complications of circumcision performed within and outside the

hospital. International Urology and Nephrology, 37(1):97–99.79

This Turkish study compared complications among two groups of patients—407 boys circumcised

by traditional unlicensed providers outside hospital and 782 boys circumcised by surgeons within

hospital.

Bailey RC, Egesah O, Rosenberg S (2008). Male circumcision for HIV prevention: a

prospective study of complications in clinical and traditional settings in Bungoma, Kenya.

Bulletin of the World Health Organization, 86:669–677.80

This prospective study was carried out in Bungoma district in western Kenya, where male

circumcision is almost universal. During the July to August 2004 circumcision season, 1007 males

were interviewed 30 to 89 days post-circumcision.Twenty-four men were directly observed during

and up to three months post-circumcision. Twenty-one traditional and 20 clinical practitioners

were interviewed to assess their experience and training. Approximately 44% of the participants

were circumcised traditionally, with the remainder circumcised in a clinical setting.

Ben Chaim J et al. (2005). Complications of circumcision in Israel: a one-year multicenter

survey. The Israel Medical Association Journal, 7(6):368–370.81

This study followed 19 478 males born in four major tertiary care medical centres in Israel. All

the children were circumcised in non-medical settings within the community. The patients were

medically evaluated either urgently due to immediate complications or electively in outpatient

clinics. Upon the initial assessment a detailed questionnaire was filled to obtain data regarding the

procedure, the performer and the subsequent complications.

Magoha GA (1999). Circumcision in various Nigerian and Kenyan hospitals. East African

Medical Journal, 76(10):583–586.82

This prospective study reports complications among 249 boys circumcised under local anaesthesia

in Nigeria and Kenya. This paper also documents 50 patients with previous circumcisions who

were referred for treatment of complications; 80% of these had been circumcised traditionally by

medically untrained providers, under non-sterile conditions.

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Mousavi SA, Salehifar E (2008). Circumcision complications associated with the Plastibell

device and conventional dissection surgery: a trial of 586 infants of ages up to 12 months.

Advances in Urology, 606123.

Complications were compared between 586 boys circumcised with the Plastibell device and

conventional dissection surgery in a prospective study in the Islamic Republic of Iran conducted

from 2002 to 2008.

Okeke LI, Asinobi AA, Ikuerowo OS (2006). Epidemiology of complications of male

circumcision in Ibadan, Nigeria. BMC Urology, 6:21.29

The authors studied circumcision practices and complications among boys attending an infant

welfare clinic for immunization. Of the 370 boys examined, 87% were circumcised, of whom 82%

had been circumcised within the first month of life, mostly (80%) in hospital.

Ozdemir E (1997). Significantly increased complication risks with mass circumcisions.

British Journal of Urology, 80:136–139.20

This paper describes a number of studies undertaken in Turkey to describe complications

associated with mass and individual circumcision. One study documented complications among

700 boys circumcised as part of a mass circumcision ceremony at a hospital over a five-day period.

A complimentary study was carried out among 600 boys circumcised individually in hospital,

mainly for medical reasons.

Yegane RA et al. (2006). Late complications of circumcision in Iran. Pediatric Surgery

International, 22(5):442–445.24

This rare study of complications in older boys rather than neonates or infants is a cross-sectional

study of 3205 boys aged 6 to 12 in Lorestan Province, Islamic Republic of Iran, of whom 97.5%

were circumcised. Of these, 71% had been circumcised after two years of age and 44% had been

circumcised by traditional providers.

3.5.2. Selected studies from the United States of America

Christakis DA et al. (2000).A trade-off analysis of routine newborn circumcision. Pediatrics, 105

(1 Pt 3):246–249.83

A retrospective review of male infants born in Washington State from 1987 to 1996. Of the 354

297 male infants born during the study period, 130 475 (37%) were circumcised during their

newborn stay.

Gee WF, Ansell JS (1976). Neonatal circumcision: a ten-year overview: with comparison of

the Gomco clamp and the Plastibell device. Pediatrics, 58(6):824–827.43

This study reviewed records of 5882 boys born at the University of Washington hospital from

1963 to 1972. Of these, 5521 (94%) were circumcised before discharge from the newborn nursery.

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Approximately half the circumcisions were performed with the Gomco clamp and half with the

Plastibell device.

Metcalf TJ, Osborn LM, Mariani EM (1983). Circumcision. A study of current practices.

Clinical Pediatrics, 22(8):575–579.84

This paper reports four surveys on neonatal circumcision practices and complications in Utah

in the late 1970s. Of 15 905 males born in 16 Utah hospitals, 85% were circumcised, mainly for

perceived hygiene benefits or because it was socially the norm. The majority of circumcisions

were performed by obstetricians in a hospital.

Stang HJ, Snellman LW (1998). Circumcision practice patterns in the United States.

Pediatrics, 101:e5.85

This postal survey was conducted in 1996 by randomly selecting physicians delivering or caring

for infants. Of the 3500 physicians selected, 1778 (58%) completed and returned the survey.

Just over half (54%) of respondents performed at least one circumcision a month, and 45% used

anaesthesia (mainly DPNB).

Wiswell TE et al. (1993). Circumcision in children beyond the neonatal period. Pediatrics,

92(6):791–793.45

This study extends a previous one by reviewing post-neonatal circumcision frequency and

complications in the first year of life for all 138 597 boys born in US Army facilities from 1985 to

1992. In addition, individual records were reviewed for 476 boys who were circumcised after the

newborn period; 77% of boys were circumcised neonatally. Of the boys circumcised in the post-

neonatal period, most were circumcised after their first birthday (mean age 2.9 years). The most

common method was the sleeve or freehand resection, and 91% were performed under general

anaesthesia.

3.6. Summary

This is the first systematic global review of published papers on neonatal and child circumcision

practices and complications. We identified 293 relevant papers from 22 countries. Although we

did not limit the language of publication, our search methods may have biased our search towards

English, Hebrew and Arabic speaking countries.

The most common type of paper were case reports of complications following circumcision, but

there were relatively few papers enabling a risk of circumcision complication to be calculated. The

largest studies (of hundreds of thousands of circumcisions) come from the USA and Israel, but

there are also several large prospective studies from developing countries, including Saudi Arabia,

Nigeria and Kenya.

In the following sections we report the results of the review, including descriptions of circumcision

methods, providers, complications, costs and legislation.

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UNAIDS

SECTION 4. Neonatal and infant circumcision

4.1. Introduction

Neonatal circumcision is routinely practised in most countries in the Middle East (including

Egypt, the Islamic Republic of Iran, Jordan, Lebanon, the Syrian Arab Republic, Turkey and

Yemen), the Gulf States, Israel, the USA and some West African countries, including Senegal,

Ghana and parts of Nigeria.

29,30,50,86–88

The event is often, but not always, associated with

ceremony. For example, many Nigerian boys are circumcised around the seventh day of

life to coincide with the naming ceremony,

82,89–91

Jewish boys are typically circumcised in a

religious ceremony on the eighth day after birth (the Bris),

78,81

and in the Comoros Islands

infant circumcision occurs during festivities to commemorate the birthday of the prophet

Mohammed.

In contrast, in Ghana and the USA, neonatal circumcision is typically not

associated with ceremony.

4.2. Providers

Neonatal and infant circumcision does not normally require sutures and in many settings is

undertaken by non-medically trained personnel. For example, in Israel circumcision is usually

conducted by non-medical religious traditional circumcisers (mohel in Hebrew), who are

trained and supervised by the Ministry of Religion and the Ministry of Health.

There is,

however, an increasing tendency among the educated secular population to prefer a medical

procedure performed by a physician using a local anaesthetic.

These medical circumcisions

are often performed by obstetricians, neonatologists, paediatricians, general practitioners and

general surgeons, with paediatric urologists generally serving as referral physicians in all cases of

circumcision-related complications.

Traditional circumcision is also common in some countries in the Middle East, and account for

90–95% of procedures in Pakistan and 85% of procedures in Turkey.

In many Arab countries

traditional circumcision is more common in rural areas where no health facility is nearby or

among poorer communities. Traditional circumcisers are termed motaher in Arabic and are

known as sunnatji in Turkey and dallak in the Islamic Republic of Iran.

26,93,94

Motahers are

commonly barbers in Egypt

, the Islamic Republic of Iran

and Pakistan

and run family

businesses in which the circumcision skills are handed down through the generations.

In contrast, in the USA and the Gulf States neonatal circumcision is routinely undertaken by

medically trained staff. For example, a US hospital-based study from 1983 found that 88% of

circumcisions were performed by obstetricians.

A postal survey sent to 3500 obstetricians,

family practitioners and paediatricians in the USA found that of the 1778 respondents, 54%

performed at least one circumcision a month.

In the Gulf States, circumcision is also mainly

provided in hospitals,

21,78,97,98

with the vast majority of providers being surgically qualified.

Further, in Saudi Arabia, circumcision by non-qualified people is prohibited.

78,97

A survey of

physicians at three hospitals by the Palestinian National Authority found that the vast majority

of circumcisions were performed by trained medical personnel at a hospital or health clinic,

usually at the age of two weeks old, and almost always before the age of 40 days old.

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In the UK, the National Health Service provides circumcision if it is clinically indicated, but in

general does not provide non-therapeutic circumcision. The demand for religious circumcision

is mostly met by general practitioners and is paid for directly by parents. However, it was

recently announced that religious circumcision of

children will now be provided under the National

Health Service in Scotland.

A not-for-profit, nurse-

delivered service has been pioneered in the UK city

of Bradford and has proved popular.

100

In many parts of West Africa, neonatal circumcision is

routinely available both clinically (by nurses, midwives

or physicians) and through traditional providers

101,102

and there is some evidence of changing patterns

away from traditional circumcision. For example, in

south-west Nigeria one study found that almost all

adult males had been circumcised traditionally, but

fewer (68%) chose a traditional provider for their

sons.

The remainder preferred a nurse/midwife

(25%) or physician (4%). A 2006 study noted that in

Ibadan, Nigeria, 81% of circumcised infants had been

circumcised in hospital, and the remainder at home.

Figure 8: Traditional circumcision provider

The most common provider was a nurse (56%),

(Wanzam) with basic kit provided follow-

followed by doctors (35%), and only 9% had been

ing training by the Ghana Health Service in

circumcised by a traditional provider. The choice

Greater Accra.

of provider is likely to reflect familial or religious

tradition, cost, perception of quality and word-of-mouth recommendation. For example, in

northern Nigeria, the numbers of circumcisions performed at a teaching hospital decreased

sharply in the 1980s, likely due to the introduction of hospital fees.

103

By 1999, the cost of

medical circumcision was about 10 times that charged by the cheapest untrained practitioner

for traditional circumcision without anaesthesia.

4.3. Methods used

4.3.1. Circumcision by medically

trained providers

The published literature suggests that the Gomco

clamp and the Plastibell device are the most

widely used devices. A review of 5521 neonatal

circumcisions in the USA from 1963 to 1972

reported similar proportions using the Gomco clamp

Figure 9:

Infant male circumcision in Korle-

and the Plastibell (52% versus 48%),

but a more

Bu Teaching Hospital, Accra, Ghana.

recent nationwide survey (1996) found that the

Gomco clamp was preferred by 67% of physicians,

with the Plastibell used by 19% and the Mogen clamp by 10%.

No reasons for preference

are given in the paper. The Plastibell is commonly used in many Muslim countries, including

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Oman

88,104

and Pakistan.

88,105

For example, a recent survey in Shifa International Hospital

in Islamabad revealed that 72% of circumcisions were performed using the Plastibell.

106

Saudi Arabia, the Plastibell and the Gomco clamp are both commonly used.

62,78

One study

suggests that the Gomco clamp has never gained popularity in the Islamic world because

of the financial cost and apprehension about using the device to both the circumciser and

the patient.

107

The dorsal slit method under local anaesthesia was used in a series of 3824

circumcisions carried out during a planned campaign in the Comoros Islands by surgical

teams.

The Plastibell is also reported to have been very popular in the Cape Peninsula in

South Africa in the 1980s

108

and in a Nigerian study that reported 102 circumcisions using

the Plastibell immediately postpartum, rather than on the eighth day, as is traditional.

109

The

study found that this immediate postpartum circumcision was acceptable to parents and was

practical and safe (no complications were seen among the 102 circumcisions carried out).

In Israel, a physician performing a (Jewish) religious circumcision will follow the excision

technique similar to that of the mohel, using a shield to protect the glands but adding

DPNB for anaesthesia.

110

In the Palestinian Territories, physicians most commonly use the

Mogen clamp, with bandages applied for homeostasis. Respondents of the LSHTM survey

from the Syrian Arab Republic indicated that the dorsal slit and forceps guided methods are

commonly used, with no anaesthetic in neonates and general anaesthetic in infants.

Although local anaesthesia is recommended by WHO for infant circumcision, it is not

universally used, even for circumcision by medically trained providers. For example, a study

in the United Republic of Tanzania documented the use of the Plastibell without anaesthesia

for routine neonatal circumcision and stated that there was a preference not to use local

anaesthesia on infants up to the age of two months, in order to avoid the additional cost

and potential risks involved.

111

The authors report that many other hospitals throughout the

United Republic of Tanzania use no anaesthesia, even in older children. One author argues

that anaesthesia is not necessary when circumcision is performed in many Islamic countries

because practitioners have a lot of experience and are able to perform the procedure

quickly.

107

In contrast, general anaesthesia is used in children older than one month in New York

and in

the US Army.

The 1996 US postal survey found that only 45% of providers used anaesthesia

(most commonly DPNB).

Recently trained paediatricians and family practitioners were

most likely to use anaesthesia. The respondents who did not use anaesthesia cited concern

over adverse drug effects and commented that the procedure does not warrant it.

These

results suggest that continuing education of practitioners is needed to increase the use of

anaesthesia in circumcision.

4.3.2. Circumcision by non-medically trained providers

Traditional neonatal and infant circumcision by non-medically trained providers typically

occurs without the use of anaesthesia or sutures—manual pressure is used to stop bleeding.

A variety of devices are used. For example, in Bendel State, southern Nigeria, locally made

iron knives or glass fragments are sometimes used, and bleeding is stopped by pressure with

a cloth, sometimes soaked in antiseptic solution, especially if the provider is a nurse or

midwife.

After-care consists of daily application of native soap (made from plantain skin

ash and palm oil), palm oil kerosene, petroleum jelly or engine oil. In Pakistan, barbers

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commonly perform the procedure and instruments are frequently reused without adequate

sterilization.

In Accra, there are good links between the traditional providers (wanzams)

and the formal sector, and traditional providers are given training in basic hygiene and

are supplied with disposable gloves and blades.

However, the procedure still occurs in

non-aseptic conditions.

In Israel, the traditional procedure typically occurs in a celebration hall, a synagogue or the

home of the newborn’s parents. The mohel (Jewish traditional circumciser) will typically

lay the newborn on the knees of a grandfather, who will hold the baby’s legs spread open.

Sweet wine sucked by the baby minutes before the procedure is used for calming the baby.

The penis is disinfected, and using sterile (autoclaved) instruments the mohel will insert the

foreskin into a metal shield protecting the glans.

81,110

A scalpel is run across the face of the

shield, removing the foreskin. The remaining inner foreskin is subsequently pulled back away

from the glans and excised with small scissors, and the wound is bandaged without the use

of stitches. The frenulum is not excised in this method, and hence bleeding is minimized.

Haemostasis is achieved by tightly wrapping the shaft of the penis with a strip of dry sterile

gauze for several hours, usually overnight. The mohel is the only one who unwraps the

dressing on his obligatory follow-up visit 24 hours after the circumcision.

Among orthodox Jews, the ancient practice of metitsah, during which the mohel orally

suctions small drops of blood after the foreskin is cut, may still occur. This practice is rare,

and following the arrival of the HIV pandemic has been replaced with a suction of the blood

droplets through a glass tube, also to minimize the few reported transmission cases of herpes

simplex virus (HSV) infection from a mohel to a newborn during circumcision.

112–115

Although most circumcisions in the Palestinian Territories are performed by physicians,

when they are performed by traditional motaher they are normally done at home, following

methods developed within families using a simple blade and not always under aseptic

conditions.

4.4. Knowledge of circumcision practices

The LSHTM survey was completed by 124 respondents, of whom the majority (88%) stated

they had direct experience in circumcision practice, training or delivery. However, even

among this group of professionals, there were inconsistencies between reported practices

and those in the literature. Further, there was considerable variation in responses from

practitioners from the same country, indicating that in many settings there may not be

accurate knowledge of country-level circumcision practices. For example, the published

literature indicates a high prevalence of neonatal circumcision in Ghana, yet 17 out of 57

respondents (30%) reported a country-level prevalence of 50% or less. Similarly, 3 out of

19 respondents from Nigeria reported that circumcision was not commonly performed in

children (age 1 to 7 years) or pre-pubescents (age 8 to 11 years). Of those who thought

that child circumcision was practised in Nigeria, the reported prevalence varied from less

than 5% (two respondents) to over 95% (five respondents). Respondents also had differing

perceptions regarding the proportion of procedures delivered in a medical setting and

complication rates. Full details of the findings are given in the Appendix.

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4.5. Summary

Neonatal and infant circumcision is a relatively simple procedure compared with the circumcision

of older children or adults. The type of provider varies by setting, being mainly medically or

surgically qualified in the USA and the Gulf States, but not so in other settings, such as West

Africa, where nurses, midwives, or traditional providers commonly carry out the procedure. The

traditional providers provide a popular service, being cheaper and more accessible than hospitals,

but hygiene training may be minimal. In Accra, good links have been established between the

Public Health Service and traditional circumcisers in order to provide regular training in safe

infant circumcision. Similar models should be explored in other settings

Use of anaesthesia also varies widely, with general anaesthesia common in infant circumcision in

the USA and no anaesthesia used in many other settings, especially for traditional circumcision.

Local anaesthesia for neonatal and infant circumcision is recommended by WHO, and there

is a need to improve the training of circumcision providers in order to increase the use of

anaesthesia for neonatal and infant circumcision.

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SECTION 5. Child circumcision

5.1. Introduction

In this section we describe patterns of male child circumcision (aged 1 to 11 years) in different

settings, including the typical age at circumcision, the types of provider and the methods used.

5.2. Age at circumcision

The typical age at circumcision varies widely by region (Table 4). Boys in many Muslim countries

are circumcised after one year of age.

For example, in Turkey circumcision normally occurs

between the ages of 3 and 13 years old,

18,116,117

in Morocco at ages five to seven years,

25,118

and

among the Bedouin tribes of the Negev between the ages of 2 and 12 years old.

119

In the Islamic

Republic of Iran, the age at circumcision varies from a few days after birth to 13 years.

In Iranian

cities the operation tends to be carried out in the hospital where the boy is born two or three days

after birth, but in villages and rural areas there is a greater variation in the time of the operation.

Similarly, in Pakistan circumcision can take place in hospital in the neonatal period,

106,120

but if

boys are not circumcised before hospital discharge the typical age is age three to seven years, or

age five to seven years in rural areas.

Circumcision in Asian countries typically occurs at a slightly older age. For example, in Malaysia

the median age of circumcision is around 10 years (range 7 to 12 years),

and 10 to 15 years in

the Republic of Korea,

121–123

with few boys being circumcised neonatally despite the fact that

circumcision was introduced to the country through the influence of the USA, where neonatal

circumcision is the norm.

123

In the Philippines, where about 80–90% of men are circumcised,

28,35

the majority of boys undergo the procedure between the ages of five to nine years (42%) or 10

to 14 years (52%), with the remainder being circumcised at 15 to 18 years old.

35,124

The Maluku

group in eastern Indonesia also commonly practise circumcision, although there is a wide range

in age at circumcision: most are circumcised between 5 and 18 years old, but circumcision

among Christians in this region is normally performed in neonates.

Child circumcision is also

common in West Africa. For example, a hospital-based study in Zaria, Nigeria, found that the

age at circumcision is around four years old

103

and depends on religion, being typically older for

Muslim boys (age four to seven years) than Christians (more likely to be infants).

103

Circumcision

among the Etsako and Esan ethnic groups in Nigeria tends to occur either before three months or

between 6 and 10 years.

Data from the LSHTM survey indicate that circumcision in the Central

African Republic and the Sudan is most common in childhood (age one to four years and five to

seven years, respectively; see the Appendix). There is a trend towards a younger age at circumcision

in West Africa, sometimes because parents want the circumcision to occur before primary school,

so that children do not miss lessons.

For example, the Bariba ethnic group in north Benin used to

circumcise boys in groups at ages 9 to 11 years, but more recently circumcise as infants in private

family ceremonies,

125

and the age at circumcision among Muslim boys in northern Nigeria was

previously reported as six to seven years, but more recently as three to four years.

Similarly, the

Mandinga, Wolof and Sérer ethnic groups in Senegal are now circumcised at age 6 to 13 years,

whereas previously this was done as adults. In the larger cities of Senegal, circumcision is now

more commonly practised in private family ceremonies and in medical centres rather than at

community circumcision ceremonies, but the traditional system is still strong in rural areas.

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Table 4. Typical age at circumcision by country and adult male circumcision prevalence

Adult male circumcision prevalence

Most common

age

Neonatal/infant

(<1 year)

Low (<20%)

Jamaica, New Zealand,

Medium (20–80%)

Australia, Canada

High (>80%)

Ghana, Israel, Kuwait,

Nigeria (Christian),

Oman, Qatar, Saudi

Arabia, United Arab

Emirates, USA

Benin, Burkina Faso,

Comoros Islands, Côte

d’Ivoire, Indonesia,

Islamic Republic of Iran,

Morocco, Niger, Nigeria

(Muslim), Pakistan,

Philippines, Senegal,

Gambia, Turkey

Kenya, Vanuatu

Child (1 to 11

years)

Netherlands, Norway,

Sweden, Zambia

Namibia, Malaysia,

Republic of Korea

Adolescent (12

to 20 years)

Swaziland

South Africa, United

Republic of Tanzania,

Uganda

In eastern, central and southern Africa, the age at circumcision is strongly influenced by cultural

and religious practices. For example, in Kenya, where circumcision is highly prevalent in most

ethnic groups, except among the Luo (circumcision prevalence 17%), Turkana (40%) and

Maasai (77%),

the age at circumcision is typically younger (2 to 12 years) in coastal regions

and older (14 to 20 years) in the Rift Valley and Nyanza provinces and southern regions.

126

A study in Lagos, Nigeria, and Nairobi found that of 249 consecutive patients presenting at

hospital for circumcision or for complications following circumcision, 62% were aged 13 to

24 years, with the remainder being mainly neonates.

In the United Republic of Tanzania

circumcision prevalence also varies with ethnicity, and most commonly occurs in adolescence,

although a younger age at circumcision (2 to 15 years) is reported in the Eastern Province

and around Tanga.

111,126

The Sukuma tribe in the north-west of the country is traditionally

non-circumcising, although about 20% are currently circumcised, which typically occurs in the

late teens or early twenties.

127

In Uganda, where circumcision is most common in the eastern

region (prevalence 55%) and is rare (<10%) in the north and south-west,

age at circumcision

is typically during early adolescence.

126

For example, in rural Rakai, south-west Uganda, 80%

of circumcised boys had been circumcised at age 12 or younger.

128

In southern Africa, child circumcision tends to be less common, and when it occurs the

procedure is typically carried out in adolescence or early adulthood as an initiation to manhood.

For example, in South Africa the Xhosa commonly practise circumcision—this is usually

performed in adolescence or adulthood between the ages of 12 and 20 years as a rite of passage

to adulthood.

129,130

However, a report from Zambia states that boys are generally circumcised

slightly younger, at 7 to 10 years old,

131

and the 2006 demographic and health survey in Namibia

found that 84% of those circumcised had the procedure at age 12 or younger.

Circumcision in Europe is largely confined to Muslim and Jewish boys, or those with a

medical indication for the procedure, such as phimosis. Muslim boys are typically circumcised

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in childhood. For example, in Norway and Sweden approximately 59% of Muslim boys were

reported circumcised younger than the age of 10, and 21% circumcised at age 10 or older.

132

Similarly, studies from Demark indicate that circumcision is commonly performed between four

and six years old (range 0–14 years);

133–135

other European studies indicate that circumcision is

performed at ages up to seven years in France,

136

one to six years in Poland

137

and three years

among Muslim boys in the Netherlands.

138

One study in the Netherlands found that the age

at circumcision was younger among Moroccan Muslims (two to three years old) than Turkish

Muslims (four to nine years old).

138

5.3. Providers

As with neonatal and infant circumcision, both medical and traditional providers perform

child circumcision in many settings. The choice may depend on the culture, cost, location and

socioeconomic status of the parents. In some settings, including Indonesia and rural areas of

Turkey and Egypt, child circumcision is most commonly carried out by informal health-care

providers who have no formal training and who learn by observation and experience.

10,20,22,97

For example, in Indonesia the procedure tends to be regarded as too simple for surgeons and

urologists, and most providers are not medically trained or professionally qualified.

However,

Muslim community groups in Indonesia can arrange for mass circumcisions for the children of

poor families, and the practitioners then tend to be medical students, male nurses and young

general practitioners.

Most medical practitioners interviewed in one study said they learned

Figure 10: Operation Abraham Collaborative trainers introducing the clamp method in

Swaziland. (©

Inon Schenker)

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the technique through participation in a mass circumcision event. In the Sudan, circumcision

is reportedly commonly performed by medical personnel in a health facility or in the home

(Appendix), with respondents from our survey stating that local or general anaesthetic was

commonly used for boys aged one to seven years and topical or local anaesthetic for boys aged

8 to 11 years. In the 2006 Namibian demographic and health survey, 70% of circumcised males

reported having had the operation performed by a health professional.

In the Republic of Korea and Malaysia, child circumcision is carried out exclusively by

medically qualified providers.

36,70,123

A survey of 4225 parents in Busan, Republic of Korea,

found that 86% thought urologists were the most suitable surgeons for circumcision, while the

remainder chose a general surgeon, obstetrician/gynaecologist or paediatrician.

123

Similarly,

in Malaysia most circumcisions are performed under local anaesthesia either in hospital by

surgeons or outside hospitals by general practitioners,

and the government organizes group

circumcisions by general practitioners in the capital city. In the Philippines, the dorsal slit

procedure is carried out by medical professionals with specialized medical facilities, equipment

and anaesthesia in clinics and in semi-private premises such as town and community halls during

mass circumcision missions organized by medical mission teams or politicians.

However, the

proportion of Filipino males circumcised traditionally versus medically is not known—one

study of 114 circumcised males in urban and semi-rural settings found that about two thirds

had been circumcised by non-medical providers.

124

5.3.1. Factors determining the choice of provider

There is relatively little data on the reasons for choosing certain providers. The 2008 WHO

workshop on male circumcision in Nigeria reported that, among Muslims in northern Nigeria,

about 70% of parents prefer to take their sons to a traditional practitioner, because they trusted

these providers and found them more accessible than hospitals.

There is some evidence that

the proportion of circumcisions performed medically is increasing in some countries, especially

among those of higher socioeconomic status. For example, among 3125 boys aged 6 to 12 years

in the west of the Islamic Republic of Iran in 2002, parents with lower levels of education were

much more likely to choose traditional providers (72% of illiterate parents chose traditional

circumcision, compared with 18% of university graduates).

In Turkey, traditional circumcisions

appear to be becoming less common in urban areas and those with higher levels of education, as

more parents opt to have the children circumcised in hospitals by surgeons or as an outpatient

procedure by general practitioners.

18,79,139

For example, a study in Ankara found that 13% of

circumcised boys had been circumcised by a traditional provider and the rest by paediatric

surgeons or urologists,

and only 5% of parents were intending to use a traditional provider

for any future sons.

Similarly, a study in rural upper Egypt found that the proportion of men

circumcised by an informal health-care provider increased with age from 60% of those aged

under 30 to 91% of those aged over 30 years,

suggesting a change in practice over time. The

proportion being circumcised medically is also reported to be increasing in the Philippines

and

among the Babusu in western Kenya.

140

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5.4. Methods used

5.4.1. Circumcision by medically trained providers

As outlined in Section 2.6.3, the most common methods for paediatric circumcision are the dorsal

slit, Gomco clamp, Mogen clamp and Plastibell.

If the child is old enough to keep still, local

anaesthesia is recommended.

However, as with neonatal and infant circumcision, anaesthesia

practices vary for child circumcision. For example in Java, Sumatra and eastern Indonesia, no

anaesthesia is used.

In contrast, general anaesthesia was reported in 91% of circumcisions of boys

older than one year born in US army facilities in 1985–1992,

and is also used for children aged

over one year in Saudi Arabia.

The most common method used in the US study was the sleeve

(freehand) technique, which involves making two circular incisions on the foreskin and removing

the strip of foreskin between them. This can be virtually bloodless, but requires a higher degree of

surgical skill than the other methods.

The LSHTM survey also revealed marked variations in the

use of anaesthesia between countries (Appendix) and suggested that in many cases circumcision is

performed in older children without anaesthesia. For example, 23 out of 55 respondents from Ghana

stated that circumcision may be performed in children aged 8 to 11 years old without anaesthetic.

The sleeve technique has been reported for child circumcision in Turkey

and Jordan,

141

where

it is used to revise circumcisions in patients with redundant penile skin or a concealed penis. The

Turkish study compared the routine standardized clamp technique with the sleeve technique

and found that the sleeve technique provided better cosmetic results, despite the disadvantage of

taking longer to perform.

The sleeve technique was compared with a new disposable clamp, the

SmartKlamp Circumcision Device,

139

in a non-randomized study in Turkey. This study compared

130 circumcisions with the SmartKlamp with 70 sleeve-technique circumcisions on boys with a

mean age of 4.7 (two to nine years) and 3.9 (two to seven years), respectively. Using the SmartKlamp

was faster than the sleeve technique, and postoperative pain and complication rates were fairly similar,

although the numbers were small (overall complication rate 4%). The authors concluded that the

advantages of the SmartKlamp were the speed and reliable haemostasis directly after the procedure.

Disadvantages were that nocturnal pain was more frequent among boys circumcised with this device

and that analgesics were required for longer. In the LSHTM survey, respondents from the Sudan

indicated that the Mogen clamp was frequently used for child circumcision.

To date there is little published literature on the other new disposable methods (Table 2).

Complications associated with child circumcision are detailed in Section 6.3.

5.4.2. Circumcision by non-medically trained providers

As with neonatal and infant circumcision, traditional circumcision among children often takes

place in the community under non-aseptic conditions, with no use of sedation or sutures.

24,81

For example, a study from Zaria, Nigeria (mean age of circumcision four years old), notes that

traditional providers in the area lacked even rudimentary knowledge of operative procedures.

103

In some cultures, boys cannot be considered to be men unless circumcised,

and the circumcision

ceremony itself may mark the passage to manhood and occur during adolescence. A description of

traditional circumcision among the Babukusu ethnic group in Kenya, who traditionally circumcise

at ages 12 to 20 years, is given in Box 2.

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Box 2. The Bukusu traditional model of circumcision

140

Prior to the circumcision, initiates are traditionally secluded for up to six months. At one

point during their sequestration, the young males are spiritually ‘put to death and reborn’

in a circumcision grove by the ritual circumcision chief. Only those already initiated or

awaiting circumcision may enter the sacred grove. When the family determines that it

is a boy’s year to be circumcised, the boy must visit his mother’s brother to inform the

uncle that this will be his year to become a man. If the uncle agrees, he must provide a

bull to be slaughtered, and other relatives should help to prepare food and brew for the

circumcision day. The day prior to the ceremony, the boy arrives at the uncle’s residence

for the slaughtering of the bull. The boy then must carry a large portion of the meat on

his head back to his father’s compound. Early the next morning, before sunrise, the boy

and his male relatives go to a stream and, as the boy bathes in the cold water, ritual

songs are sung. When they return to the compound, the boy is circumcised in front of

his many male relatives by an elder and his assistant, who is likely later to become a

circumciser himself. The initiate must stand rigid without moving, and if his feet move or

his facial expression changes, his family is disgraced. If he is especially brave, he jumps

up and down after the cut, blood splashing over the observers. The initiate sometimes

holds a small rooted tree above his head, which is to give him strength throughout the

procedure. The circumciser’s assistant sprinkles dried and pounded clay on the initiate’s

penis to prevent the prepuce from sliding forward again. To prevent the wound from

becoming infected a ﬁbre ring is wrapped around the penis until it heals and the boy

carries medicine with him to care for his wounds. A cohort of initiates is secluded for

three months together in a hut. If they leave, they are required to hide themselves

under a grass hood. Girls are not supposed to come within sight of them. When the

seclusion period is over, the initiates bathe in a river and are told how to behave as

men, what their responsibilities are as protectors of the village, as owners of cattle, as

husbands of women and as fathers of children. They are presented with a shield and

spear and told to be warriors and guardians of the village. They are then eligible as men

to build a separate hut in their father’s compound, to have their own garden, to have

rights to land, to herd their own cattle and to acquire their ﬁrst wife.

Bailey RC, Egesah O (2006). Assessment of clinical and traditional male circumcision services in Bungoma

District, Kenya: Complication rates and operational needs, Washington DC, USAID.

In Turkey, circumcision is an important social event for the family

and the traditional technique

uses a self-made device similar to the Mogen clamp that involves pulling the foreskin in front of

the glans, placing a shield to protect the glans and excising the skin

. This is usually performed

without anaesthesia

117

or with a mild topical analgesia

. In Punjab Province, Pakistan, relatives

and guests are invited to celebrate the event. The boy is held in a seated position with both legs

apart and a probe, a cutter made from wood and a razor are used to excise the foreskin.

The

operation is performed with no anaesthesia, no sutures and with unsterilized instruments. Ash is

used to establish haemostasis, and other substances, including ghee, dung and urine, may also be

applied.

120,142

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In Indonesia, the traditional procedure of circumcision is called sunatan, and in some parts of

eastern Indonesia traditional providers carry out the ceremony in the mountains at the site of cold

mountain springs, where the cold water acts as a partial anaesthetic.

. Bamboo clamps are used to

fix the four sides of the foreskin and a sharp knife or razor is used to cut off the foreskin. Another

traditional method also uses a bamboo clamp that is fixed to the foreskin to cut off the blood flow

to the superfluous skin. The clamp is released for urination and then replaced. After a few weeks,

the foreskin shrivels and is cut away without bleeding.

Similarly, in the Philippines the traditional

procedure is community-based and is often performed without anaesthesia by laymen in public

places using ordinary implements such as a household knife or razor and a piece of wood that is

inserted under the foreskin.

Group circumcisions also occur in rural Egypt, Turkey, Morocco, the Philippines and parts of

rural eastern and southern Africa.

15,20,22,102,143

In these ceremonies, the same tools may be used for

consecutive circumcisions without adequate cleaning between each one.

5.5. Partial circumcision

The amount of foreskin removed by different (mainly traditional) circumcision methods can vary.

For example, among the Meru in central Kenya, a freehand method is used in which a smaller

part of the foreskin is removed and part of the outer layer of the foreskin is retained. This is

sometimes termed partial circumcision.

144

In some forms of partial circumcision in eastern Africa,

the remaining outer layer of the foreskin remains suspended from the penis. In Lesotho, the self-

reported prevalence of circumcision is 48%,

but this figure is thought to be an overestimate as

there is wide prevalence of incomplete circumcision, some of which are only an incision without

removal of any foreskin.

A recent study from Mwanza, United Republic of Tanzania, found

relatively high rates of misclassification of both self-reported and clinically assessed circumcision

status among adolescent boys, which may be partly due to partial circumcisions.

145

The study of

traditional circumcision among the Babukusu in Kenya also found that circumcisions were highly

variable, with some resulting in insufficient skin removal and others with excessive skin removed,

including non-foreskin tissue from the penile shaft.

Similarly, adult and adolescent Ethiopian

Jews immigrating into Israel undergo ‘correctional’ circumcision to further remove (small or large)

foreskin portions not cut by the traditional circumcisers in their home villages. This is required

as the Jewish definition of circumcision is the complete removal of the foreskin.

146

There are also

different definitions of circumcision by Muslim scholars. For example, according to Abu’I-Barakat

Kitab al-Ghaya,

either the whole or the majority of the foreskin should be removed. Others

state that partial removal of the foreskin is sufficient providing the cut goes all around the tip.

147

Partial circumcision is also practised in Indonesia, where circumcision does not always involve

the foreskin being cut.

For example, in Sumatra, Indonesia, the retained skin may be tied in a

bundle or left as a flap with a hole through which horsehair or other stimulants can occasionally

be attached prior to intercourse.

This form of circumcision is thought to originate from the

introduction of Islam to the region centuries ago, as adult men had died of traditional circumcision,

so the Islamic leaders changed the nature of the ceremony to overcome the communities’ fears.

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5.6. Summary

Age at circumcision depends on the setting and culture. In general, child circumcision (i.e. between

the ages of 1 and 11 years) commonly occurs among Muslim boys in many countries, as well as

in the Republic of Korea, the Philippines and among certain ethnic groups in eastern, central and

southern Africa. Other ethnic groups, especially in eastern and southern Africa, tend to circumcise

in adolescence as a rite of passage to manhood. As with neonatal circumcision, providers may be

clinically or non-medically trained, and the methods used depend on the training. In general,

traditional circumcision is more common in rural areas and among less-educated parents, and

there is a trend towards the provision of circumcision by medically trained providers in some

settings.

A variety of devices are available for the circumcision of boys, with the most common being the

Gomco clamp and the Plastibell. However, compared with neonates and infants, the circumcision

of boys is more complex and the use of local anaesthesia is problematic, since it is more difficult

for the boy to remain still during the procedure. It may be preferable to wait until the boy is old

enough to keep still during the procedure, or to use general anaesthesia. Circumcision of boys

by non-medically trained providers often takes place under non-aseptic conditions and with no

anaesthesia. Ongoing training of providers is needed to educate them on appropriate methods of

anaesthesia and hygiene practices.

Validity of self-reported circumcision can vary, especially in settings where partial circumcisions

occur. Further research is needed to ascertain methods of improving the accuracy of self-reported

circumcision status, for example by using visual aids.

A number of new devices are now available that are suitable for the circumcision of males of all

ages, from infancy to adulthood. To date, there is little published data on the performance of these

devices, and a detailed review and comparative studies of safety, cost and client satisfaction are

needed.

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SECTION 6. Complications following circumcision

6.1. Introduction

As with any surgical procedure, circumcision can result in complications.

61,148,149

The most common

early (intra-operative) complications tend to be minor and treatable: pain, bleeding, swelling or

inadequate skin removal. However, serious complications can occur during the procedure, including

death from excess bleeding and amputation of the glans penis if the glans is not shielded during the

procedure.

29,81,103,150–152

Late (postoperative) complications include the formation of a skin bridge

between the penile shaft and the glans, infection, urinary retention, meatal ulcer, impetigo,

153

fistulas

loss of penile sensitivity, sexual dysfunction and oedema of the glans penis.

Our literature search found many case reports and case series of circumcision-related

complications, but relatively few studies that reported the proportion of circumcised males with

a complication. For an accurate estimate of risks, active follow-up of circumcised boys is needed.

Hospital-based studies of circumcision-related complications are usually retrospective and record-

based.

45,49,81

Complications in these studies are commonly recorded from discharge sheets, so tend

to underestimate the true frequency of complications because events occurring after discharge

are not captured. Furthermore, not all postoperative complications will be seen again at the same

hospital. We therefore present results separately for prospective and retrospective studies. Age at

circumcision and type of provider (medical or non-medical) were also thought a priori to be

associated with frequency of complications, and we present results stratified by these factors. We

define neonatal as age up to 28 days, infant as 28 days to 11 months, and child as 12 months to

12 years. Many studies included boys circumcised at a range of ages. We included studies in which

the mean or median age at circumcision was age 12 years or younger.

An additional problem in estimating complication risks is that precise definitions are not often

given. For example, ‘bleeding’ may mean oozing, which is readily stopped by compression, or more

severe bleeding requiring a blood transfusion. Therefore, to report complications as consistently as

possible between studies, we excluded all cases of oozing or minor bleeding as well as some other

minor complications (noted under the individual studies). Cases of excess residual foreskin or

inadequate circumcision are also excluded—these are adverse outcomes of circumcision and may

involve further surgery, but are not medical complications per se. We have also reported serious

adverse events separately—these include complications defined as ‘severe’ or ‘serious’ by authors,

or with long-term or life-threatening sequelae.

In this section we describe the proportion of neonates, infants and children with adverse events

following circumcision, focusing on larger prospective studies of consecutive patients rather than

individual case reports.

6.2. Complications following neonatal or infant

circumcision

We identified 16 prospective studies, from 12 countries, of complications following neonatal

and infant circumcision (Table 5).

29,44,62,74,78,81,100,104,109,111,154–159

Of these, most used the Plastibell,

62,100,104,109,111,154,155

with others using the Gomco clamp,

44,74,78,158

freehand circumcision

81,157

or a

combination of methods.

155,156,159

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The median frequency of any adverse event was 1.5% (range 0–16%) and the median frequency

of any serious adverse event was 0% (range 0–2%). Three studies reported that 1–2% of boys

had a serious complication.

29,155,156

One study, a Canadian study of 100 neonates circumcised

in 1961–1962 using the Gomco clamp or the Plastibell reported one severe infection requiring

antibiotics and one severe meatal ulcer

.156

Less severe complications were reported in a further

13 boys in this study. The other two studies with serious complications were from Nigeria. In

one, among 141 boys circumcised in three hospitals in south-east Nigeria, complications were

assessed at a six-week postoperative visit or if they presented earlier with any complication.

155

Three boys (2.1%) had a urethral laceration. The most common complications in this study were

minor, including bleeding (9%) and meatal stenosis (3.5%). Complications were substantially

more common when circumcision had been performed freehand (27%, excluding incomplete

circumcision) rather than using the Plastibell (8%), and when performed by midwives (19%) rather

than by doctors (7%). Moreover, among the doctors, the reported frequency of complications at

the public university teaching hospital was 1.6%, compared with 20% at private hospitals, where

the level of training and supervision was lower. A much higher frequency (90%) was seen at the

mission hospital, which acts as a referral centre for complicated circumcisions.Three circumcisions

had been performed by a traditional birth attendant, and all three had resultant complications (one

bleeding, one incomplete circumcision and one urethral fistula). The other study was among 322

infants attending a welfare clinic in Ibadan,

in which there were two cases of amputation of the

glans penis and one buried (trapped) penis. Overall in this study, complications were reported in

9.3% of boys, with a further 11% having excess residual foreskin. The most common complication

was excessive loss of foreskin (n = 16; 5%). Unusually, no cases of bleeding, wound infection or

haematoma were reported in this study. The method used was not reported for the majority of

infants, and complications were most frequent when the procedure was performed by nurses

rather than by doctors or traditional circumcisers (data not given).

Of the remaining 13 studies, five reported adverse events in 0.3% or fewer boys,

74,81,104,109,158

four

in around 2%,

62,78,111,154

and the remaining four studies reported adverse events in up to 16% of

boys.

44,100,157,159

The studies with the highest frequency of complications were in Pakistan and

the UK. The study in Pakistan reported on 200 infants circumcised under local anaesthesia at a

military hospital using either the freehand or bone-cutter method (a forceps-guided method that

does not shield the glans).

157

Bleeding (defined as requiring more than an application of a pressure

bandage) was reported in 9% of boys, and 7% had a local infection of the skin and mucosa. In the

UK study, 1129 infants were circumcised by nurses using the Plastibell under local anaesthesia,

100

and overall 125 (11.1%) of infants required some degree of follow-up, with complications seen

in 5.5%. The most common complication involved the Plastibell ring device itself (3.6%), which

is left on after the procedure and normally takes 7 to 10 days to fall off. The problems included

delayed separation of the ring, incomplete separation of the ring, or the ring becoming stuck on

the penile shaft. In all cases, the ring was removed without the need of anaesthesia and the authors

report that this removal was quick, simple and atraumatic.

Three studies reported substantial variation in complication frequencies by age or circumcision

method. For example, a US study of circumcision by the Gomco clamp stratified by age at

circumcision found no complications in 98 boys circumcised neonatally, but that 12/32 (30%)

of infants aged 3 to 8.5 months had postoperative bleeding requiring suture repair.

These 32

boys were circumcised under general anaesthesia, and no complications from the anaesthesia were

reported. In another study, complications were seen more frequently using the Plastibell technique

(12/381; 3.1%) than the sleeve technique (4/205; 1.95%).

159

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A further 10 studies on neonatal/infant circumcision were retrospective hospital-record based

studies (Table 6). Five of these were from the USA, two from Pakistan and one each from Israel,

Oman and Turkey. The reported frequencies of complications were slightly lower than for the

prospective studies, with five studies finding very low frequencies (≤0.6%)

49,83,98,160,161

and four in

the range 2–4%.

43,105,162,163

The study reporting the highest proportion (4% in neonates, 10% in

infants) included late complications (most commonly foreskin adhesions (7.8%)), with three cases

(1.3%) of meatitis and three requiring revision of the circumcision (1.3%). As with prospective

studies in neonates and infants, few serious adverse events were reported (<0.2% in all studies

except among infants in one US study, where 3/230 (1.3%) of infants required circumcision

revisions

In addition to the published studies, participants at the WHO-sponsored workshop in Ghana,

where neonatal circumcision is almost universal, reported that few complications are seen. For

example, only 16 circumcision-related complications were seen at the main teaching hospital in

Accra in 2007 out of the many thousands of circumcisions that were performed in the city.

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Table 5. Summary of frequency of complications in prospective studies of neonatal and infant circumcision

Author

al Samarrai

et al.

Amir et al.

d 78

Banieghbal

158

Ben Chaim

et al.

Bhat et al.

104

Duncan et al.

154

Horowitz &

Gershbein

Year of Setting

study

Saudi Arabia 1980s Hospital

Country

Number

Age

of patients

2000

2 to 3 days

Type of provider

Method used

Member of junior

Plastibell

staff with supervision

Surgeon

Gomco clamp

83% mohel

17% physician

Paediatrician

Surgeon

Freehand

Plastibell

Gomco clamp

Saudi Arabia 1996–

1998

South Africa 2005–

2008

Israel

2001

Oman

Jamaica

USA

1999

2000–

2003

1996–

1998

Hospital

1000

583

Mean 9 days

Neonatal

Mean 8 days

Neonatal

(min. 1 day old)

Neonatal

Anaesthesia Follow-up

used

period

None

6 weeks plus

immunization

clinic visits

Local

1 year

Local

None

Local

(neonates)

General

(infants)

None

1 month

—

1 week

3 days

Frequency of

adverse events

1.4%

Frequency of serious

adverse events

UNAIDS

1.6%

0.3%

0.1%

1.5%

Overall: 7.4%

Neonatal: 0%

Infants: 30%

2.8%

0.1%

Community 19 478

Hospital

250

205

130

Manji

111

Mousavi &

Salehifer

159

Okafor et al.

109

Okeke et al.

g 29

United

Republic of

Tanzania

Islamic

Republic of

Iran

Nigeria

1992–

1998

2002–

2008

2002

2005

Hospital

368

98 neonatal

Paediatric urologist

(age 4 to 30 days)

32 infants (age

3 to 8.5 months)

7 days to 9

Paediatrician

months

<12 months

Surgeon

Plastibell

—

Hospital

586

50% sleeve

50% Plastibell

Plastibell

—

Local

—

Sleeve: 1.95%

Plastibell: 3.1%

9.3%

Sleeve: 0%

Plastibell 2.1%

1.0%

Hospital

81%

hospital

19% home

Hospital

102

322

Immediate

postpartum

8 days to

13 months

7 to 9 days

Osuigwe et al.

155

Nigeria

2001

141

Palit et al.

100

1996–

2005

1961–

1962

1992–

1993

2003–

2004

Hospital

1129

Mean age

11 weeks

3 to 5 days old

Patel

156

Canada

Hospital

100

Perlmutter et al.

USA

Hospital

Neonatal

Rehman et al.

157

Pakistan

Hospital

200

Infant

Experienced

surgeon

55% nurses 35%

doctors

9% traditional

54% doctors

44% midwives

2% traditional birth

attendants

Trained nurses

under supervision of

consultant urologist

98% medical doctors

2% traditional

providers

Obstetric resident

or attending

obstetrician

Surgeon

None

1 year

3 months

68% Plastibell

31% freehand

None

6 weeks

13.5%

2.1%

Plastibell: 8%

Freehand: 27.3%

5.5%

0.1%

Plastibell

Local

3 months

51% Gomco

47% Plastibell

2% ritual

Gomco

Not stated

—

15%

None

Up to 2 hours 0%

50% freehand

Local

50% bone cutter

1 week

16%

0.5%

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Cases of minor bleeding stopped with simple pressure or ‘conservative management’ and excessive foreskin/inadequate circumcision are not included.

Includes complications deﬁned as ‘serious’ or ‘severe’ by authors or with long-term or life-threatening sequalae (partial amputation of glans, urethral laceration, need for re-surgery or plastic

surgery).

Eighteen patients with yellowish patches of sloughed tissue and erythema who did not have an infection conﬁrmed through cultures, four patients with irregular skin margin and four patients

with inadequate skin excision were excluded.

In these studies patients who had undergone circumcision were identiﬁed retrospectively, but wherever possible patients were actively followed-up to obtain accurate complication risks.

Risks by age at circumcision: 7–14 days: 0.9%; 15 days–2 months: 4.7%; 2–9 months: 11.5%.

Excludes ‘excess mucosa’ and ‘delayed Plastibell falling off’.

Patients were identiﬁed through an immunization clinic and a physical examination was conducted to conﬁrm circumcision status and the presence and type of complications. Uncircumcised

boys were followed up to identify boys circumcised at a later age and any complications.

Thirty-one cases of mild oozing, seven cases of mild infection with no antibiotic treatment were excluded.

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Table 6. Summary of frequency of complications in retrospective studies of neonatal and infant circumcision

Author

Country

Year of Setting

study

1997–

2000

1987–

1996

2001–

2002

1963–

1972

Hospital

Number

Age

of patients

171

130 475

214

5521

Neonatal

Type of

provider

Surgeon

—

Surgeon

Supervised

medical

student,

resident, or

physician

Paediatric

surgeon

—

Method used

Plastibell

—

Gomco clamp

Anaesthesia

used

Local

Not stated

Local

Follow-up

period

As parents want

—

Frequency of

adverse events

1.2%

0.2%

2.3%

Frequency of serious

adverse events

(2 needed sutures)

0.2%

(1 needed suture)

0.2%

Al-Marhoon & Oman

Jaboub

Christakis et

al.

USA

Eroglu et al.

163

Turkey

Gee & Ansell

USA

52% Gomco clamp Not stated

48% Plastibell

Prior to discharge 1.7% Gomco clamp

2.3% Plastibell

Iftikhar

160

Pakistan

1998–

2001

1974–

1979

1985–

1986

Hospital

316

0–12 yrs (72%

within 1 week

of birth)

61% neonatal

39% post-

neonatal

Neonatal

Plastibell (<2 yrs old) Local (children

Open technique

<2 yrs old)

(≥2 yrs)

General (≥2 yrs)

—

Not stated

—

0.6%

Metcalf et

al.

O’Brien et

al.

162

USA

Hospital

591

—

4% neonatal

10% infantse

3.1% overall

0.3% neonatal

1.3% infants

USA

Hospital

1951

—

43% Gomco

9.5% Plastibell

14.5%

electrocautary

33.1% not

speciﬁed

Plastibell

—

Not stated

—

Raﬁq

105

Shulman et

al.

161

Wiswell &

Geschke

Pakistan

Israel

USA

2000

1955–

1963

1980–

1985

Hospital

100

8000

100 157

Neonatal

Surgeon

Mohel

Surgeons

None

Not stated

—

0.3%

0.2% ‘serious’

0.1%

0.2%

Cases of minor bleeding stopped with simple pressure or ‘conservative management’ and excessive foreskin/inadequate circumcision are not included.

Excludes one patient unable to pass urine for 24 hours.

The authors note that 14 patients (0.2%) had ‘really signiﬁcant’ complications—one life-threatening haemorrhage, four systemic infections, eight circumcisions of infants with hypospaidas and one

complete denudation of the penile shaft.

Six patients with hygiene concerns were excluded.

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6.3. Complications following child circumcision

by medically trained providers

We identified 10 prospective studies of complications in children aged one year old or older

following circumcision by medically trained providers (Table 7).

20,70,92,135,138,139,164–167

The median

frequency of any adverse event was 6% (range 2–14%), and the median frequency of any

serious adverse event was 0% (range 0–3%). Adverse events were seen most commonly among

boys circumcised mainly for medical, rather than religious or cultural, reasons, possibly because

the underlying medical condition results in a more complicated procedure. In one of these

studies, among boys circumcised in the UK mainly for phimosis, 4/140 boys (2.8%) required

acute re-admission to hospital,

167

and the frequency of adverse events was 6.4%. In the other, a

Danish study of boys circumcised mainly for balanitis or phimosis, 1/43 (2.3%) boys required

re-operation following Plastibell circumcision.

135

Of the other studies, in which boys were

circumcised mainly for non-medical reasons, two studies reported an adverse event in about 2%

of boys,

70,92

three reported adverse events in 2–5%,

139,166,167

and higher frequencies (7–14%) were

seen in studies from the Netherlands,

138

India,

164

the Islamic Republic of Iran

165

and Turkey.

Complications included bleeding, infection, meatal stenosis and problems with the Plastibell

device. The study from the Netherlands reported on complications among 94 Muslim boys

circumcised under local anaesthesia outside the hospital. Of these, 13 were seen again because

of bleeding (n = 4), infection (n = 2) or swelling (n = 7);

138

excluding the two cases of mild

bleeding, the frequency of complications was 12%. The Indian study was also small (n = 15)

and reported two cases of minor wound separation, which did not require further surgical

intervention.

164

The study in the Islamic Republic of Iran was a randomized controlled trial

comparing petroleum jelly to no topical medication after circumcision in 394 boys, in which a

total of 13 (3.3%) boys developed meatal stenosis, 26 (6.6%) had infections at the circumcision

site and 43 (10.9%) had post-circumcision bleeding. Complications were significantly less

frequent among boys who parents were randomized to use a lubricant (petroleum jelly) on the

circumcision site compared with no topical medication.

165

Finally, the Turkish study reports

complications following a hospital-based mass circumcision exercise, in which 700 boys were

circumcised over five days. Excluding the cases of bleeding stopped by simple compression, 8%

of boys had a complication, most commonly infection (2.7%) and inadequate foreskin removal

accompanied by secondary phimosis (2.1%).

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Table 7. Summary of frequency of complications in prospective studies of child circumcision undertaken by medical providers

Author

Country

Years

Setting

Age

Type of provider Method used

Anaesthesia

used

Indication

Follow-up Frequency of

period

adverse events

Ahmed

168

Comoros

Islands

Turkey

1997– Home

1998

2006

Hospital

3824 2 to 8 years

Aldemir et al.

139

200

2 to 9 years

Trained surgical

aids, nurses and

midwives

Urologist

Dorsal slit

Local

Routine

11 days

2.3%

Frequency

of severe

adverse

events

0.5%

UNAIDS

65% SmartKlamp

Local

35% conventional

dissection technique

Sleeve method

Not mentioned

Routine

6 weeks

5% (4.6% Smart

clamp, 5.7% conven-

tional technique)

Bazmamoun et

al.

165

Grifﬁths et al.

167

Islamic

Republic of

Iran

2006– Hospital

2007

1985

Hospital

394

Mean 9mths Surgeon

(range 9

days–23 mths)

Mean 4.3

—

years (range

3 months–

14 years)

8 days to

puberty

Median 3

years (range

2–24 years)

—

Routine

6 months 7–10%

Dissection

circumcision

Caudal epidural

in boys aged

over 12 months

Ozdemir

Turkey

1990s

Schmitz et al.

138

Netherlands

1997

Mass

circumcision

in hospital

Health

centre

700

Forceps guided

Local

85% medical 3 to 5

(phimosis/

weeks

balanitis)

11% religious

4% other

Routine

—

6.4%

2.8%

Schmitz et al

.70

Malaysia

2001

Community

Sharma

164

Sorensen &

Sorensen

135

India

Denmark

2003

Hospital

Residents of

general practice

under the

supervision of a

surgeon

Median 10

Medical

years (range assistants

7–12 years) supervised by

medical doctors

2 to 25 years Surgeons

Freehand

Local

Religious (all

Muslim boys)

1 week

12%

Tara Klamp

Local

Routine

6 weeks

1.6%

Dorsal slit

Local, or general

in younger boys

Not stated

Medical or

religious

Medical

90 days

Mean 29

months

13.3%

Immediate

postoperative

(reported) 9.3%g

Late complications

(reported) 0%h

4.6%

1981– Hospital

1983

Mean 6.5

years (range

1–13 years)

Surgeon (early

Plastibell

stage of training)

Subramaniam &

Jacobsen

166

Singapore

—

Hospital

152

Mean 7

years

Surgeon

CO2 laser

Not stated

Not given

—

0.7%

Cases of minor bleeding stopped with simple pressure or ‘conservative management’ and excessive foreskin/inadequate circumcision are not included.

Thirteen boys had meatal stenosis and 26 had infection. It is not clear whether there is an overlap between these two groups.

Deﬁned by the authors as any admission to hospital or further surgery.

Acute re-admissions to hospital.

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Table 8. Summary of frequency of complications in retrospective studies of child circumcision undertaken by medical providers

Author

Country

Years

Setting

Age

Type of provider

Method

used

—

Anaesthesia

used

Not stated

Indication

Frequency of adverse

events

0.3%

2.6%

Frequency of

severe adverse

events

—

Ahmed et al.

103

Atikeler et al.

Nigeria

Turkey

1981–

1995

1999–

2002

Hospital

1563

782

Mean 4 years

Mean 6 years

Medical

Surgeon

Routine

Medical

indication

or religious

reasons

98% medical

Medical or

religious

71% medical

29% cultural

19 revisions

Routine

Mainly

medical

Cathcart et al.

169

Lazarus et al.

170

Leitch

171

Millar &

Roberts

108

Ozdemir

Peng et al.

South Africa

Australia

South Africa

Turkey

China

1997–

2004

1999–

2005

1960s

1985–

1987

1990s

2005–

2007

Hospital

66 519

200

129

600

160

0 to 15 years

‘Boys’

Mean 2 years

3 months to 10

years

8 days to

puberty

5 to 12 years

Surgeon

—

Surgeon

—

Plastibell

Forceps

guided?

Shenghuan

disposable

device

Not stated

Local

1.2%

5.1%

11%

12%

1.7%

Complications while

wearing device:

17.5%

Complications

after removal of

device: 0.6%

1.6%

2.5%

—

0.6%

N E O N ATA L A N D C H I L D M A L E C I R C U M C I S I O N : A G L O B A L R E V I E W

Rizvi et al.

Wiswell et al.

Yegane et al.

Pakistan

USA

Islamic

Republic of

Iran

1981–

1991

1985–

1992

2002

Hospital

Community

3096

‘Children’

Mean 3 years

Medical

78% urologists

Surgeons,

urologists,

general

practitioners,

paediatricians,

and paramedics

—

Not stated

—

0.2%

476

1766

71% after 2

years of age

Freehand or 91% general

sleeve

—

Not stated

Cultural (67%) 1.7%

Medical (33%)

—

4.6% overall (late

complications)

2.8% urologists/

surgeons

6.1% general

practitioners/

paediatricians

9.1% paramedics

Cases of minor bleeding stopped with simple pressure or ‘conservative management’ and excessive foreskin/inadequate circumcision are not included.

Seventy cases of swelling pain from nocturnal erection excluded.

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UNAIDS

Adverse events in 11 retrospective studies tended to be less frequent than for the prospective

studies, probably due to under-ascertainment of complications. Most studies reported no serious

adverse events (Table 8), but one

170

reported that 2/79 (2.5%) boys required circumcision revisions

following circumcision by the Plastibell device. Frequencies of any adverse event varied from

0.3% in a study from Nigeria (five minor complications reported out of 1563 circumcisions in a

hospital over a 15-year period

103

) to 12% (15/129) in South Africa (mostly bleeding, haematoma

and infection) and 17.5% (28/160) among boys circumcised with a new disposable device (the

Shenghuan Disposable Minimally Invasive Circumcision Anastomosis Device) in China (mainly

mild oedema (10%), but also moderate oedema and two cases of infection).

6.4. Complications following circumcision by non-

medically trained personnel

Table 9 summarizes the five studies of complications following circumcision by non-medically

trained providers. In these studies, frequencies of adverse events are generally higher, and

complications more serious, even including penile amputation.

103

A high frequency of complications

was seen in a retrospective study from Turkey of 407 boys circumcised at two traditional mass

circumcision events.

The mean age of the boys at the time of circumcision was seven years

(range 1–14 years) and the procedure had taken place in non-sterile conditions by unlicensed

providers. Overall, complications were seen in 73% of boys, with the most common complications

being wound infection (14%), subcutaneous cysts (14%), bleeding that needed suturing (12%) and

haematoma (6%). Five boys (1.3%) developed a urinary infection requiring hospitalization and

intravenous antibiotics. A further 12% of boys were deemed to have incomplete circumcision. In

addition, three patients with hypospadias had been circumcised, indicating inadequate screening

of the boys, as the procedure is contraindicated if hypospadias is present.

The retrospective study from the Philippines interviewed 114 males aged 13 to 51 (mean age 25.9

years), of whom 94% reported having been circumcised below the age of 14 years. Most (68%)

had been circumcised by non-medical personnel, 60% reported post-circumcision complications

(inflammation and swelling) to their circumciser and four (3.5%) reported profuse bleeding.

In contrast, in a household-based study in south-west Nigeria, respondents reported very few

complications (2.8%) following circumcision, mainly by traditional providers.

Among 750 child

circumcisions, there were 12 cases reported of excessive bleeding, six infections, two cases of tetanus

and one death. The authors report that although they include the death there was insufficient

information to be certain that it was caused by circumcision. A study from the Islamic Republic

of Iran reported a late-phase complication frequency of 2.7% following traditional circumcision

and a further 5% had excessive residual foreskin. This was similar to circumcisions performed by

urologists or surgeons (2.8%), but lower than for general practitioners/paediatricians (6.1%) or

paramedical personnel (9.1%). The authors argue that this is because traditional circumcisers in

the Islamic Republic of Iran are experienced and paramedical personnel do not receive effective

training.

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Table 9. Summary of frequency of complications in retrospective studies of child circumcision undertaken by non-medical providers

Author

Ahmed et al.

103

Atikeler et al.

Lee

Country

Nigeria

Turkey

Phillipines

Years

1981–1995

1999–2002

2002

Setting

Community

Number of males

1360 (approx.)

407

114

Age at circumcision

Mean 4 years

Mean 7 years

42% 5 to 9 years

52% 10 to 14 years

5% 15 to 18 years

Infant/child

Type of provider

Traditional

32% medical

68% traditional

25% nurse/midwife

4% medical doctor

Traditional

circumcisers

Frequency of

adverse events

3.4%

73%

63%

Frequency of serious

adverse events

—

3.5%

Myers et al.

Nigeria

—

Community

750

2.8%

—

N E O N ATA L A N D C H I L D M A L E C I R C U M C I S I O N : A G L O B A L R E V I E W

Yegane et al.

Islamic Republic

of Iran

2002

Community

1359

71% after 2 years

of age

2.7% (late

complications)

Cases of minor bleeding stopped with simple pressure or ‘conservative management’ and excessive foreskin/inadequate circumcision are not included.

This very high rate of complications consisted of bleeding (24%), infection (14%), incomplete circumcision (12%), subcutaneous cysts (15%), haematoma (6%), ischaemia (3%), penile adhesion (3%) and

other conditions. Of the 97 cases of bleeding, 48 could not be stopped by haemostatic bandage and were sutured. Infections were treated with parenteral or oral antibiotics.

Of these, 94% were reported swollen or inﬂamed penises. Four respondents (3.5% of those circumcised) reported profuse bleeding.

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UNAIDS

6.5. Summary

Circumcision is a common surgical procedure, but few epidemiological studies have reported on

the frequency of adverse events, which are most commonly bleeding and infection. Our review

shows that serious adverse events are rare, but there is a wide variation in reported frequencies of

adverse events following circumcision. This is likely to be due to several factors directly associated

with complications, such as age at circumcision, the training and expertise of the provider, the

sterility of the conditions under which the procedure is undertaken and the indication (medical/

cultural) for circumcision. In addition, there is variation due to methodological issues such as

duration of follow-up, epidemiological study design and definition of complications.

In general, complications occur less frequently among neonates and infants than among older boys,

with the majority of prospective studies in neonates and infants finding no serious complications

and relatively few other adverse events, which were minor and treatable.The prospective studies in

older boys also found virtually no serious adverse events, but a higher frequency of complications

(up to 14%), even when conducted by trained providers in sterile settings.

166

The lower frequency

of complications among neonates and infants is likely to be attributable to the simpler nature

of the procedure in this age group and to the healing capability of the newborn. Further, a

major advantage of neonatal circumcision is that suturing is not usually necessary, whereas it is

commonly needed for circumcisions in the post-neonatal period. This advantage is illustrated by

the US study in which no complications were seen among 98 boys circumcised in the first month

of life, but 30% of boys aged 3 to 8.5 months had significant postoperative bleeding.

There are

alternatives to suturing, either with disposable clamps or with alternatives such as cyanoacrylate

glue

164

and further research in this area is needed.

Several studies stress the importance of careful training, the experience of the provider and the

sterility of the setting.This was most clearly noted in a Nigerian study

155

in which 24% of the boys

reported complications (including retention of excess residual foreskin), but only 1.6% of those

circumcised at a public university teaching hospital by medical doctors reported complications. A

further example is the study from the Comoros Islands, which reported the results of an exercise

in which specific training had been given to surgical aids and nurses to perform circumcisions.The

proportion of boys with complications (2.3%) was reported to be a great improvement on that by

traditional non-medically trained providers.

92,168

The high frequency of adverse events following

circumcision by untrained providers in non-sterile settings is striking in two studies of traditional

circumcision, which found an alarmingly high prevalence of around 80%.

79,80

Notably, in one of

these the self-reported frequency was much lower, illustrating the under-ascertainment that can

occur in retrospective studies. Mass circumcisions are particularly risky, even when undertaken

in a hospital. For example, a Turkish study of 700 children circumcised during a five-day period

recorded a complication frequency of 8%, likely due to the difficulty in providing sufficient sterile

equipment and conditions.

The reason for surgery can also influence the risk of adverse events,

as seen in the studies of child circumcision, where more complications were generally seen if

circumcision was conducted for medical rather than religious reasons.

Our systematic review was restricted to circumcision complications among boys aged 12 years or

under. However, there are several published studies of circumcision complications among adolescent

and adult men (Table 10) that indicate a generally higher frequency of complications than seen in

neonates, infants and children. In the three randomized controlled trials of circumcision in adult

men, complications were observed in 2–7% of HIV uninfected men

4,172,173

and in 6–8% of HIV

infected men.

4,173

The most detailed observational study was conducted among the Babukusu

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Table 10. Frequency of complications in studies of adolescent and adult circumcision

Author

Country

Years

Setting

Age

Type of

provider

Experienced

general

practitioners

Experienced

general

practitioners

Traditional

Method

used

Forceps

guided

Forceps

guided

—

Anaesthesia

used

Local

Indication for

circumcision

Follow-up

period

Auvert et al.

South Africa

2002–

2004

2002–

2004

Auvert et al.

South Africa

Bailey et al.

Kenya

Bailey et al.

Kenya

Bailey et al.

Kenya

General

practitioner

ofﬁces

General

practitioner

ofﬁces

Home or

community

Home or

community

Hospital, health

centre or private

ofﬁce

1495

18 to 24 yrs

HIV-

negative

73 HIV- 18 to 24 yrs

positive

445

562

90% aged

below 15 yrs

66% aged

below 15 yrs

Enrolled in trial 1 month

Frequency

of adverse

events

3.6%

Frequency of

severe adverse

events

—

Local

Enrolled in trial 1 month

8.2%

—

None

Local or

rarely,

general

Local (83%)

General

(17%)

Local

Cultural

30 to 89

35%

days

~3 months 83%

30 to 89

days

18%

24%

33%

19%

Clinician

N E O N ATA L A N D C H I L D M A L E C I R C U M C I S I O N : A G L O B A L R E V I E W

Bailey et al.

Kenya

2004

Hospital, health 12

centre or private

ofﬁce

Urology

outpatient clinic

Trial operating

theatre

Trial operating

theatre

Trial clinic

Hospital

900

—

Clinician

—

Cultural

~3 months

92%

25%

Bowa &

Zambia

Lukobo

179

Kigozi et al.

173

Uganda

2004–

2006

2003–

2005

2003–

2006

2002–

2005

1981–

1998

Kigozi et al.

173

Uganda

Krieger et

al.

172

Magoha

Kenya

Nigeria and

Kenya

2326

HIV-

negative

420 HIV- 15 to 49 yrs

positive

1475

18 to 24 yrs

249

5 months to

96 yrs

15 to 49 yrs

Trained clinical

ofﬁcer

Trained

physician

Trained

physician

Medical and

clinical ofﬁcers

Surgeon

Dorsal slit

method

Sleeve

method

Sleeve

method

Forceps

guided

Forceps

guided

Cultural

8 weeks

3.0%

7.4%

0.06% at 8 weeks

0.2% severe

(3.3% moderate)

0% severe

(3.1% moderate)

0% severe

(0.7% moderate)

2.8% severe

Enrolled in trial 6 weeks

Local

Enrolled in trial 6 weeks

Enrolled in trial 90 days

72% cultural/

—

religious

12% parental

request

16% medical

Cultural (Xhosa —

initiates)

6.0%

1.8%

11%

Peltzer &

Kanta

180

South Africa

32% neonates

6% children

61%

adolescent/

adult

Median age

19 yrs

(range 16–25)

Doctors and

nurses following

1 day of training

Local

3.8%

Cases of minor bleeding stopped with simple pressure or ‘conservative management’ and excessive foreskin/inadequate circumcision are not included.

Wound not healed at 60 days after surgery.

Permanent adverse sequale.

Anyone considered by the participant to be a clinician.

Including an unknown number with residual foreskin.

Includes severe haemorrhage (

= 3), scrotal laceration (

= 2), penile shaft denudation (

= 1) and glandular injury (n = 1).

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UNAIDS

ethnic group in western Kenya. Of 562 adolescents circumcised by a medical provider (or reported

as such), 18% had a complication, as did 35% of boys circumcised traditionally.

A substudy in

the same population directly observed 24 boys undergoing medical and traditional circumcision

and found that of those circumcised medically only one boy had no adverse events, and three

permanent adverse sequelae were reported, including one very serious life-threatening case caused

by a ‘medical practitioner’ who was later found to have no documented medical qualifications.

Among the 12 directly observed traditional circumcisions, complications were seen in 10 boys

(83%), and four (33%) were judged to have permanent adverse sequelae. None had fully healed

by 30 days postoperation. Detailed examination showed that traditional circumcision was also

associated with slower healing, more swelling, laceration and keloid scarring.

These results show

that under non-sterile conditions, adolescent and adult circumcision can frequently be associated

with severe complications. Other case series of circumcision complications among adolescents and

young men also report severe morbidity and mortality.

10,97,101,130,174,175

Reported complications tend

to be more common in this age group than for neonates and infants, even when circumcision is

conducted under ‘gold standard’ conditions such as in randomized controlled trials.

A major challenge in our review was to standardize the definition of complications. For example,

Okeke et al.

reported complications in 20% of boys, of which half were excessive residual

foreskin—an adverse event, but arguably not a medical risk. These cases were excluded where

possible. Similarly, the paper by Gee et al.

cites a total of 110 complications out of 5521 (2.0%),

but states that only 14 complications (0.2%) were considered ‘really significant’ (one life-threatening

haemorrhage, four systemic infections, eight circumcisions of infants with hypospadias and one

complete denudation of the penile shaft). The other complications included bleeding, infection,

circumcision of hypospadiasis and a Plastibell ring that was too tight. The problem of defining

complications is also highlighted in the early (1961–1962) study in Canada in which moderate

or severe complications (bleeding, infection, meatal ulcer, meatal stenosis and phimosis) were seen

in 15 infants (15%) and a further 68 infants had mild bleeding, meatal ulcers or infections.

156

Complication risks in this study have previously been reported as 55%,

149

which includes

any bleeding, including oozing. A further example is the Australian study,

171

which reported

complications in 8% of boys, which included several cases of mild bleeding that either ceased

spontaneously or with simple management such as digital pressure. We have attempted to report

‘severe’ or ‘serious’ adverse events as a separate outcome, but data on this are often limited and it

would be useful to produce a standard classification of mild, moderate and severe complications

following circumcision so that in the future studies may be more easily comparable. Other

limitations are related to the design of the epidemiological studies. The length of follow-up varies

between, and within, studies, and may affect the estimated frequency of complications. For this

reason we tend not to term the frequency as a ‘risk’. It is also possible that the lower frequencies of

complications in prospective studies are due to improved procedures by practitioners or improved

hygiene by patients as a result of participating in the study. Finally, a number of studies are small

and the estimates of the frequency of complications will be correspondingly imprecise.

One study of circumcision among patients with inherited bleeding disorders

was excluded, as

this report focuses on complications in general populations. In this study, of 71 patients diagnosed

from 1961 to 1996, 52% had a record of post-circumcision bleeding. In many settings boys are

not asked about a family history of bleeding disorders, and this can potentially lead to severe

circumcision-related complications.

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Circumcision is commonly practised and will continue to occur for religious, cultural and medical

reasons. In general, complications are minor and treatable, especially at young ages, but a high

frequency of complications, and severe complications, is seen when the procedure is undertaken

by inexperienced providers, in non-sterile settings or with inadequate equipment and supplies.

Further prospective studies with monitoring of risks following circumcision are needed to

document complications using standardized definitions and to compare the risks associated with

different methods and age at circumcision and to evaluate the impact of specific and ongoing

training of providers. Such studies are under way in some settings where circumcision services are

being expanded for HIV prevention. A set of guidelines on expansion of circumcision services

produced by WHO and UNAIDS includes operational guidance for scaling up circumcision for

HIV prevention, a surgical manual for circumcision under local anaesthesia, guidance for decision-

makers on human rights and ethical and legal considerations for protocols for monitoring and

evaluation.

176

There is a clear need to improve the safety of circumcision at all ages through improved training

or retraining for both traditional and medically trained providers and to ensure that providers have

adequate supplies of the necessary equipment and instruments for safe circumcision. Strategies for

training and quality assurance are needed and will be context-specific. In Swaziland, Operation

AB demonstrated a comprehensive model of training teams of medical providers in safe and swift

adolescent and adult circumcisions, with improved sterilization equipment and client education, at

community-level clinics.

177

In Ghana, where neonatal circumcision is almost universal, the formal

health service provides training to traditional providers in Accra, with training on basic hygiene

and the provision of necessary equipment, such as sterile gloves and dressings.

102

In South Africa

it has been suggested that community health nurses create opportunities to educate traditional

circumcisers of adolescents and adults on the basic hygiene requirements to be met before, during

and after circumcision.

102

USAID, the Program for Appropriate Technology in Health (PATH)

and Management Sciences for Health (MSH) have designed a training programme in the Eastern

Cape for training traditional providers about safe circumcision practices.

178

Links between the

formal and informal health sectors should be explored elsewhere to institute quality standard

practices for both traditional and medical circumcisers, for example wearing sterile gloves, using

sterile instruments and appropriate after-care, and for creating a formal structure through which to

monitor and regulate the conduct of circumcision. Through these steps, it is likely that the safety

of this common procedure can be substantially improved.

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UNAIDS

SECTION 7. Public health considerations

7.1. Introduction

Aside from the major public health issue of the safety of circumcision provision, other

considerations include costs, legal issues, the health consequences of the procedure and cultural

acceptability. In this section we review the findings on costs, legal issues and cultural acceptability

from the literature review and give a brief summary of the health consequences, which have been

extensively reviewed elsewhere.

1,51,181,182

7.2. Cost and cost-effectiveness

We found relatively little information on the cost of circumcision in developing countries in the

published literature. In the United Republic of Tanzania the user fee for the Plastibell was about

US$15–20 between 1992 and 1998. This included sterilization, sterile dressing and sheets, gloves

and the Plastibell ring.

111

In the Comoros Islands the average cost was about US$10.

At the

WHO workshop in Ghana in 2008 it was reported that traditional providers charge about US$ 15

for circumcision and hospital providers charge US$45,

and in northern Nigeria circumcision by

a traditional provider was in the range US$0–34,

and was US$13 in hospital settings under local

anaesthesia, up to US$50 if general anaesthesia was used. A study from Anambra State, south-east

Nigeria, in 2004 reported a cost of US$3 for hospital circumcision using a traditional method and

US$4 for Plastibell circumcision.

155

In Bungoma, Kenya, in 2004 the cost charged by a traditional

provider was around US$5, compared with US$8 (range US$5–30) for circumcision by a medical

provider.

In a community-based study in the Philippines, respondents paid for their circumcision in cash

(52%) or in-kind (6%). About one third (36%) said that they used the services at no cost but

by courtesy of the community.

124

In another Filipino study men reported paying up to US$ 1

for traditional providers and US$2–4 for medical circumcision.

In Israel, most traditional

circumcisers consider circumcision as a religious command to be performed for free, and parents

provide a gift (cash and in-kind). The Ministry of Religious Affairs recently published a fee

range of US$200–290 for neonatal circumcision, to guide parents as to an acceptable fee should

it be charged.

The cost of neonatal circumcision by medical practitioners in other settings is estimated to be

US$ 35 in Canada (in 1984),

183

US$40–53 in the Palestinian Territories, US$120 in a nurse-led

service in the United Kingdom,

184

US$165 in the USA (in 1996),

185

US$715 in Israel and

US$ 500 under the UK National Health Service.

186

Cost-effectiveness studies of adult circumcision for preventing HIV infection have been conducted

in sub-Saharan Africa following randomized controlled trials. The cost per adult circumcision was

between US$30 and US$60, depending on the programme, and the estimated cost per HIV

infection averted was between US$100 and US$350 in high-prevalence settings, decreasing with

increasing HIV incidence.

187

In contrast, discounted lifetime HIV treatment costs have been

estimated for various settings and typically exceed US$7000 per HIV infection if only first-line

treatment is provided, and twice as much if second-line treatment is available. The Expert Group

on Modelling the Impact and Cost of Male Circumcision for HIV Risk Reduction concluded

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that circumcising any adult age group was likely to be cost-saving in the short term compared

with the lifetime HIV treatment costs.

187

There have been several cost–benefit analyses of the impact of neonatal circumcision, all from

the USA. The results vary depending on the assumptions of the risks and benefits of neonatal

circumcision, and most were conducted prior to the results of the adult circumcision trials

showing partial protection against HIV infection.

183,185,188–192

The most recent analysis,

185

which

included a protective effect against HIV as well as a range of conditions, including urinary

tract infection, phimosis, balanoposthitis, penile cancer and HIV infection, found that neonatal

circumcision saved an average of US$183 (range US$93 to US$303 in 95% of simulations),

assuming a cost per neonatal circumcision of US$200, which is substantially higher than the

estimates for most countries.

7.3. Legislation

In many countries there appears to be little or no legislation around the provision of neonatal

and child circumcision. Any future expansion of circumcision services must ensure that the

procedure is carried out safely, under conditions of informed consent, without discrimination

and within a legal, regulatory and policy framework that ensures accessibility, acceptability and

quality of service provision. A national legal and regulatory self-assessment has been developed

by UNAIDS and is now available.

In South Africa, traditional surgeons are now required by law to be officially recognized and

registered with the provincial Department of Health,

175

and the Children’s Act 2007 makes the

circumcision of males under 16 unlawful except for religious or medical reasons. Most other

countries do not currently have laws dealing specifically with circumcision. Exceptions are Israel

and Saudi Arabia. Israeli legislation is very specific about circumcision. Up to six months of age,

the procedure is considered a religious ritual act and can be performed by medical or traditional

circumcisers. A voluntary medico-religious committee supervises the training and performance

of traditional and medical circumcisers. Above the age of six months, circumcision is considered

to be a surgical procedure that should only be carried out by qualified and licensed surgeons

and in an approved surgical theatre.

146

Similarly, in Saudi Arabia circumcision by non-qualified

people is prohibited.

78,97

One Iranian paper states that circumcisions should be performed by

trained surgeons and urologists and should be legally prohibited by unqualified providers,

and

there was a strong recommendation from a Palestinian survey of circumcision providers that

traditional motaher should undergo formal training and be legally and medically authorized to

perform circumcisions.

In the UK, circumcision is also not grounded in statute, but judicial review assumes that,

provided both parents consent, non-therapeutic neonatal circumcision is lawful

193

provided that

it is performed competently and is believed to be in the best interests of the child. Further, if

the child is old enough to express a view, he should be involved in decisions about whether

he should be circumcised. However, in a recent retrospective review of 62 non-therapeutic

circumcisions undertaken in the UK, both parents consented to the procedure in only four cases

(6.2%), and in no case was the patient’s consent obtained.

194

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7.4. Cultural acceptability of neonatal male circumcision

One concern around the potential for circumcision as an HIV prevention measure is that

it may not be acceptable in communities that do not traditionally circumcise. A recent

comprehensive review

182

addresses this issue by summarizing eight quantitative and five

qualitative studies assessing the acceptability of offering circumcision services among

traditionally non-circumcising groups in eastern and southern Africa. The studies were

carried out between 1991 and 2003 in Botswana, Kenya, Malawi, South Africa, Swaziland,

Uganda, the United Republic of Tanzania, Zambia and Zimbabwe. Women as well as men

were included in 10 of the studies, which enabled an assessment of female perspectives on

the acceptability of male circumcision. Overall, 71% (50–74%) of men and 81% (62–89%)

of women were willing to have their sons circumcised (Figure 11). The response varied

with how the questions were posed and the context of the study. For example, one of the

highest acceptability levels was recorded in Botswana after an informational session in which

participants were told about the health benefits and risks associated with the procedure.

195

Significantly, these studies were conducted prior to the publication of the results of the

randomized controlled trials that confirmed the benefit of circumcision against HIV infection.

Uganda 1997

Kenya 1999

S Africa 1999-2000

Zimbabwe 2000

S Africa 2001

S Africa 2002

Botswana 2003

Swaziland 2006

% of uncircumcised men willing

to be circumcised

% of men willing to circumcise

their sons

% of women favouring circumcision

of their partners

% of women willing to circumcise

their sons

Figure 11. Acceptability of safe, low-cost male circumcision in southern and eastern

African countries.

182

In these studies the main barriers to the acceptability of circumcision were fear of pain, concerns

for safety and the cost of the procedure. In areas where traditional circumcision is uncommon, the

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preference was overwhelmingly for a medical practitioner to be the provider, as this was perceived

to be safer. All studies reported fear of infection, bleeding, excessive pain and possible mutilation

at the hands of traditional circumcisers.

There have also been studies of the acceptability of child circumcision outside sub-Saharan

Africa. In two Korean studies, where about 60% of males are circumcised,

over 90% of

parents thought their son should be circumcised, the main reason overwhelmingly being for

improved penile hygiene (89%).

40,196

The primary barriers were lack of medical evidence of

the benefits and fear of pain, complications or a poor cosmetic result. Circumcision was more

popular among better educated parents and those with a higher socioeconomic status. A

recent study in Mysore, India, found that 82% of non-Muslim mothers of uncircumcised boys

would definitely circumcise their sons if the procedure was offered in a safe hospital setting

free of charge.

Only 18% of non-Muslim mothers stated that the procedure was culturally

unacceptable.

One study in Turkey assessed attitudes towards circumcision among haemophiliacs and their

parents.

Circumcision is potentially risky among haemophiliacs, although possible with the

use of fibrin glue, which aids local haemostasis and tissue sealing.

197

Of the 39 boys in this

study,

(74%) were circumcised. Almost all boys and parents knew that circumcision was

risky in haemophiliacs, but 87% thought that a haemophiliac patient must be circumcised.

Sixty per cent of the boys and 85% of the families of uncircumcised boys were anxious

about circumcision—the primary concern was risk of haemorrhage. Twenty-five per cent of

individuals said being circumcised was only an obligation, 51% said it was an important event

and 19% stated that it was the most important thing in life.

Several studies have examined the parental decision-making role for child circumcision.

A study in Bendel State, south-west Nigeria, asked about the primary decision-makers for

the children’s circumcision operations. The father was the primary decision-maker in 75%

of cases and the father’s parents in 13% of cases. Mothers made the decisions in 11% of

cases.

In the Republic of Korea, where circumcision happens at an older age, the decision

of whether or not to circumcise was most often made by the father (35%), followed by the

mother (32%), the boy himself (28%) and a health-care provider (5%). The main reason given

for circumcision in this study was to improve penile hygiene (89%).

123

One study conducted

in Israel in a very small non-circumcising community found that the primary reason for

parents choosing not to circumcise their babies, of whom 83% were Jewish, was based on

child rights.

198

The main fears of these parents regarding their decision not to circumcise were

almost universally around the social consequences of the child being anatomically different

(with an uncircumcised penis) than most of his peers.

7.5. Health consequences of male circumcision

Circumcision is associated with a reduced risk of several infections, including urinary tract

infection in infants, HIV and some other sexually transmitted infections.

1,51,181

There are

several likely biological mechanisms for this. The area under the foreskin is a warm, moist

environment that may enable some pathogens to persist and replicate, especially when

penile hygiene is poor.

199

In addition, the inner mucosal surface of the foreskin is only

thinly keratinized,

200

unlike the heavily keratinized penile shaft and the outer surface of the

foreskin,

201

and may be more susceptible to minor trauma and abrasions that facilitate the

entry of pathogens.

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UNAIDS

7.5.1. Circumcision and urinary tract infections in male infants

Uncircumcised infants are more likely to harbour a reservoir of uropathogenic organisms (e.g.

Escherichia coli)

in the urethral meatus and periurethral area;

202

these uropathogenic bacteria

adhere especially well to the inner mucosal surface of the foreskin, compared with the keratinized

surface.

203

These very adherent, more abundant uropathogenic organisms may then ascend to the

bladder and kidneys, causing urinary tract infections and pyelonephritis.

204

There is strong epidemiological evidence that circumcision reduces the risk of urinary tract

infections several-fold, with a systematic review and meta-analysis of 12 studies finding a summary

odds ratio of 0.13 (95% confidence interval 0.08–0.20).

205

Assuming a complication rate of

2%, the authors found that the benefit of circumcision on urinary tract infections outweighed

the risk only in boys at high risk of urinary tract infection (e.g. those who previously had a

urinary tract infection). Another risk–benefit analysis found a complication rate of 0.2% (as a

discharge diagnosis) and estimated that six urinary tract infections could be prevented for every

complication.

In addition to the English language review, the search of the Arabic literature

revealed unpublished data from Israel that provided some evidence that urinary tract infections

were more likely to result from circumcisions performed by traditional mohels compared with

those performed by physicians.

206

7.5.2. Circumcision and HIV infection

As mentioned above, randomized controlled trials have shown that circumcision reduces the risk

of heterosexually acquired HIV infection in men by 50–60%.

2–4

Observational studies suggest that

the protective effect is similar if circumcision occurs neonatally.

207

There are several mechanisms

by which the foreskin may specifically increase the risk of HIV acquisition. Firstly, there is an

increased risk of genital ulcer diseases in uncircumcised men,

208

which in turn increases the risk

of HIV, as the disrupted mucosal surface of the ulcer increases the risk of HIV acquisition.

209

Secondly, the foreskin may increase the risk of HIV infection directly as tissue from the inner

surface of the foreskin mucosa contains accessible HIV-1 target cells (CD4 + T cells, macrophages

and Langerhans cells).

210

The density of these HIV-1 target cells in the outer foreskin is similar to

that in the glans penis, but those in the inner foreskin are closer to the epithelial surface than those

situated elsewhere in the penis, due to the relative lack of keratin.

200

Within the inner foreskin

Langerhans cells are more likely to be found near the epithelial surface than other cells, and are

likely to be the first to be infected by HIV-1.

211

More direct evidence of the susceptibility of the

foreskin to HIV-1 infection comes from Patterson et al.,

210

who found that infectivity of the inner

mucosal surface (assessed by quantity of HIV-1 DNA one day after ex vivo infection with explant

culture) was greater than that of cervical tissue, a primary site of HIV-1 acquisition in womenIn

an uncircumcised man, the cells in the inner foreskin are directly exposed to vaginal secretions

during heterosexual intercourse, and the superficial location of the HIV-1 target cells presumably

increases the risk of infection. In contrast, in a circumcised man the penile shaft is covered with a

thickly keratinized epithelium that provides some protection from infection.

200

7.5.3. Circumcision and the risk of other sexually transmitted

infections

There is increasing evidence from randomized controlled trials and from observational studies

that circumcised males have a lower risk of several reproductive tract infections, including human

papillomavirus,

212–214

which causes penile cancer,

Chlamydia trachomatis,

215

Trichomonas vaginalis

215

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and possibly herpes simplex virus type-2 infection.

208,216

In addition, some studies indicate that

the female partners of circumcised men have a lower risk of cervical cancer, which is caused by

human papillomavirus.

28,217

Recent evidence also suggests that the female partners of circumcised

men have reduced risks of some vaginal infections.

216

7.6. Summary

There is relatively little published documentation on the cost of circumcision or on legal issues

around the provision of circumcision. Data suggest that the cost varies widely, being generally lower

among traditional providers. The maximum cost of child circumcision reported in developing

countries was US$ 50 for circumcision under general anaesthesia in Nigeria. More typically,

reported user fees were around US$ 10, but there is little published data on this and further studies

are needed. As a comparison, the cost of adult circumcision in randomized controlled trials was

around US$ 30–60. Further work is needed to document the current costs of neonatal, child and

adult circumcision, and to update cost–benefit analyses in light of the protective effect against HIV,

as well as against diseases such as cervical cancer.

Neonatal and child circumcision is predominantly conducted for religious and cultural reasons and

will continue to be a very common procedure where it is currently practised for these reasons. In

addition, studies show that circumcision is highly acceptable in settings where it is not currently

practised. All services, either existing or newly initiated, must clearly be provided as safely as

possible and under conditions of informed consent, following the legal and regulatory framework

set out by UNAIDS.

SECTION 8. Conclusions and recommendations

Our review of the published literature shows that there is relatively little literature on

this very common surgical procedure, but that neonatal, infant and child circumcision is

generally a safe procedure when conducted by trained and experienced providers in hygienic

conditions. There is a lack of a standardized operating practice for circumcision, including the

management and reporting of adverse events. Further prospective studies of circumcision risks

are needed, with rigorous documentation using standardized definitions, and to compare the

relative risks of different methods, the optimal age for circumcision and the impact of specific

and ongoing training of providers.

Unacceptable levels of risk have been recorded in some prospective studies of child

circumcision by medical providers, and there is an urgent need to improve the safety of the

procedure through renewed training where necessary. Setting-specific strategies for such

training are needed, including guidelines for safe neonatal and child circumcision, both in

settings where it is conducted already and where it may be introduced for HIV prevention.

The risks following the traditional circumcision of older boys tend to be even higher and

are a cause of unnecessary morbidity. Methods to improve training and practices are urgently

needed in order to avoid unnecessary morbidity and could follow the examples of the good

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links between the formal and informal health-care services for the provision of traditional

neonatal circumcision in Israel and Ghana.

The use of anaesthesia for circumcision varies widely, with general anaesthesia common in

infant circumcision in the USA, local anaesthesia used in other settings and no anaesthesia

used in most other places, especially for traditional circumcision. Local anaesthesia for

neonatal and infant circumcision is recommended by WHO and there is a need to improve

the training of circumcision providers in order to educate them on appropriate methods of

anaesthesia and on hygiene practices.

A number of new devices are now available that are suitable for the circumcision of males of

all ages, from infancy to adulthood. To date, there is little published data on the performance

of these devices, and detailed reviews and comparisons of safety, cost and client satisfaction

are needed.

Neonatal and child circumcision is routinely practised in many countries for religious,

cultural or medical reasons. The procedure is undertaken by a range of providers, with the

choice of provider depending on family or religious tradition, cost, availability and perception

of service quality. As a traditional religious and cultural practice, circumcision is likely to

continue to be highly prevalent around the world, and, in addition, is now being considered

for HIV prevention. Every effort must be made to ensure that the procedure is undertaken as

safely as possible, by trained and experienced providers with adequate supplies and in hygienic

conditions.

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and Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis: observations in

the aftermath of a randomised controlled trial for HIV prevention.

Sex Transm Infect

2008.

216.Tobian A.Trial of male circumcision: prevention of HSV-2 in men and vaginal infections in female

partners, Rakai, Uganda. Abstract 28LB. 15th Conference on Retroviruses and Opportunistic

Infections 2008, Boston, USA.

217. Castellsague X, Bosch FX, Munoz N, Meijer CJ, Shah KV, de Sanjose S, Eluf-Neto J, Ngelangel

CA, Chichareon S, Smith JS, Herrero R, Moreno V, Franceschi S. Male circumcision, penile

human papillomavirus infection, and cervical cancer in female partners.

N Engl J Med

2002;346(15):1105-12.

215.

Sobngwi-Tambekou J et al. (2009). Male circumcision and

Neisseria gonorrhoeae, Chlamydia

trachomatis,

and

Trichomonas vaginalis:

observations in the aftermath of a randomised controlled trial

for HIV prevention.

Sexually Transmitted Infections,

85:116–120.

Tobian A.Trial of male circumcision: prevention of HSV-2 in men and vaginal infections in female

partners, Rakai, Uganda. Abstract 28LB. 15th Conference on Retroviruses and Opportunistic

Infections 2008. Boston, USA.

Castellsague X et al. Male circumcision, penile human papillomavirus infection, and cervical

cancer in female partners.

New England Journal of Medicine,

346(15):1105–1112.

216.

217.

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APPENDIX. Survey on knowledge of

circumcision practices

Introduction

To collect data from countries poorly represented in the published literature, we e-mailed a

questionnaire on circumcision practices to the authors of the articles identified through the

literature search, known researchers working on circumcision, the participants at two WHO

workshops in Nigeria and Ghana and members of the Royal College of Obstetricians and

Gynaecologists based in the Middle East, Africa and Asia. Completed questionnaires were received

from 124 individuals from 23 different countries (Table A1). The majority were from Ghana

and Nigeria, where the questionnaire was distributed to the participants at WHO workshops

on neonatal and young boy circumcision practices. For most countries the collected data are

in addition to information gathered from the published literature, but survey responses from

individuals in the Central African Republic, the Sudan and the Syrian Arab Republic represent

the sole source of information on circumcision in those countries.

All but four respondents stated that circumcision was widely practised in their country.Those who

stated that circumcision was not widely practised came from South Africa, the Hong Kong Special

Administrative Region and Singapore. The majority of respondents had experience in service

delivery (Table A1) and in circumcision training. Fifteen respondents (12.1%) stated they had no

direct experience in circumcision practice, training or delivery.

Prevalence of circumcision

Reported circumcision prevalence was highest in the Middle East and North Africa, with the

majority of respondents from this region reporting a prevalence of at least 75%. However, one

respondent (out of three) from the United Arab Emirates stated that the prevalence of circumcision

was 25–50% (Table A2). A prevalence of greater than 95% was commonly stated by respondents

from Egypt, Qatar, Saudi Arabia, the Syrian Arab Republic and Turkey, which is consistent with

the published literature.

The reported prevalences in countries from sub-Saharan Africa and Asia were considerably more

variable. In sub-Saharan Africa the majority of respondents from Nigeria cited a high prevalence

(75% or above), although 3/19 (16%) of respondents stated that the country-level prevalence was

50–75%. A high prevalence was also cited by the respondents from Ghana, where the majority

(35/57; 61.4%) cited a prevalence greater than 75%. In both Ghana and Nigeria the published

literature revealed a high prevalence (>80% and 95%, respectively). Respondents from South

Africa and Zimbabwe cited a low or intermediate prevalence (<50%), again consistent with the

published literature.

In Asia, reports were also generally consistent with the published literature. Respondents from

Bangladesh and the Philippines cited a high prevalence (>75%), respondents from India cited a

low/intermediate prevalence and respondents from the Hong Kong Special Administrative Region

cited a low prevalence. In contrast, the three respondents from Malaysia reported prevalences of

either 25–50% or 50–75%, yet the published literature indicates that the country-level prevalence

is greater than 80%.

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Table A1. Country of residence of respondents and experience with circumcision

Professional experience of respondents with circumcision

Country

Middle East and North Africa

Egypt

Morocco

Oman

Pakistan

Qatar

Saudi Arabia

Sudan

Syrian Arab Republic

Turkey

United Arab Emirates

Sub-Saharan Africa

Central African Republic

Ghana

Mauritius

Nigeria

South Africa

United Republic of Tanzania

Zimbabwe

Asia

Bangladesh

Hong Kong SAR

India

Malaysia

Philippines

Singapore

Limited experience during training (1)

Experience of religious circumcisions (1)

Family trade (2), as an anaesthetist (1), a gift from god (1)

Experience of religious circumcisions (1)

Trained during housemanship (1)

As a urologist (1)

As head of gynaecology and obstetrics (1)

Number of

respondents

experience

Service

delivery

Health

policy

Circumcision

training

Research

Other

UNAIDS

Total

124

Respondents could provide more than one answer

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Table A2. Overall prevalence of male circumcision by region and country

<25%

Middle East and North Africa

Egypt (6)

Morocco (1)

Oman (1)

Pakistan (5)

Qatar (1)

Saudi Arabia (6)

Sudan (3)

Syrian Arab Republic (1)

Turkey (2)

United Arab Emirates (4)

Sub-Saharan Africa

Central African Republic (1)

Ghana (57)

Mauritius (1)

Nigeria (19)

South Africa (4)

United Republic of Tanzania (1)

Zimbabwe (1)

Asia

Bangladesh (1)

Hong Kong SAR (2)

India (2)

Malaysia (3)

Philippines (1)

Singapore (1)

25–50%

50–75%

75–95%

>95%

Numbers in brackets represent the total number of respondents; numbers relate to the number of

respondents who gave that answer. Note: not all respondents answered this question.

Age at circumcision

Respondents from the Middle East cited the neonatal period as the most common age at

circumcision (Table A3). Circumcision during infancy and childhood was also reported in some

countries of this region (Egypt, Oman, Pakistan, Saudi Arabia and the United Arab Emirates).

Childhood (one to seven years) was cited as the most common age at circumcision by respondents

from the Sudan and Turkey. This is broadly in line with the published data. No respondents from

this region cited the most common age at circumcision as greater than seven years of age.

Respondents from parts of sub-Saharan Africa, including Nigeria, South Africa and Ghana,

reported that neonatal circumcision occurred commonly, and circumcision during the infant

and childhood periods was cited by respondents from the Central African Republic, Ghana,

Nigeria and the United Republic of Tanzania. Circumcision at older ages was cited in South

Africa (adolescents) and Zimbabwe (adults). There were few respondents from Asia, but the most

common age at circumcision in Asia appeared to vary considerably by country (Table A3).

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UNAIDS

Table A3. Most common age at circumcision

Neonatal Infants

(birth to

(one

one month) month to

one year)

Middle East and North Africa

Egypt (6)

Morocco (1)

Oman (1)

Pakistan (5)

Qatar (1)

Saudi Arabia (6)

Sudan (3)

Syrian Arab Republic (1)

Turkey (2)

United Arab Emirates (4)

Sub-Saharan Africa

Central African Republic (1)

Ghana (57)

Mauritius (1)

Nigeria (19)

South Africa (4)

Zimbabwe (1)

Asia

Bangladesh (1)

Hong Kong SAR (2)

India (2)

Malaysia (3)

Philippines (1)

Singapore (1)

Children

(one to

seven

years)

Pre-

pubertal

(8 to 11

years)

Adolescents Adults

(12 to 17

(18+

years)

United Republic of Tanzania (1) 0

Numbers in brackets represent the total number of respondents; numbers relate to the number of

respondents who gave that answer. Note: not all respondents answered this question.

Neonatal and infant circumcision

Of the 124 completed questionnaires, 115 stated that neonatal circumcision was performed in

their country. Four respondents did not answer this question. The other five respondents, from the

Central African Republic, the Hong Kong Special Administrative Region, Malaysia, Morocco and

the Sudan, stated that neonatal/infant circumcision was not performed routinely in their country

or territory.

Prevalence

The reported prevalence of neonatal and infant circumcision in countries in the Middle East and

North Africa was high in most countries (Table A4). The majority of respondents from Egypt

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(4/6), Oman (1/1), Qatar (1/1) and Saudi Arabia (3/5) cited prevalence as above 95%. A high

prevalence (75–95%) was also cited by the majority of respondents from the United Arab Emirates

(2/3). An intermediate to high prevalence (50% or above) was cited by the five respondents from

Pakistan. Interestingly, one respondent from Saudi Arabia and one respondent from the United

Arab Emirates cited a prevalence of 5–25%, which is inconsistent with the published literature.

The prevalence of neonatal and infant circumcision was reportedly low in the Sudan, the Syrian

Arab Republic and Turkey (<25%). However, the respondent from the Syrian Arab Republic had

previously noted that circumcision was highly prevalent in that country and was most commonly

conducted neonatally.

The prevalence of neonatal/infant circumcision in sub-Saharan Africa varied considerably

between countries (Table A4). A higher prevalence (>50%) was commonly cited by respondents

from Ghana and Nigeria, while a lower prevalence was reported by the few respondents from

South Africa, the United Republic of Tanzania and Zimbabwe. These overall observations are

consistent with the published literature. However, there was considerable variation in the reported

country-level prevalences. For example, while the majority of respondents from Nigeria (16/19)

and Ghana (38/57) cited prevalence as 50% or higher, one respondent from each country cited

prevalence as 5–25%. A lower prevalence was consistently reported by respondents from Asia; the

highest cited prevalence was 25–50%, in Malaysia (Table A4).

Age at circumcision

The most common age that circumcision is performed among neonates and infants in the Middle

East and North Africa varied considerably between respondents from the same country (Table

A4). For example, one respondent from Egypt cited one to two days as the most common age,

three respondents cited less than three months and one respondent cited 4 to 12 months as the

most common age. Responses from sub-Saharan Africa were a little more consistent, with 18/19

respondents from Nigeria citing less than three months as the most common age at circumcision,

probably reflecting the fact that many Nigerian boys are circumcised on the eighth day of life

(Table A4).

Providers

Medical staff such as general practitioners, clinical officers, obstetricians and urologists/surgeons

were commonly cited as the most common provider of neonatal/infant circumcision in many

countries in the Middle East, North Africa and Asia (Table A4). While many respondents cited

medical personnel as the main providers in African countries, traditional providers were also very

commonly named. Traditional providers also commonly perform the procedure in Pakistan, the

Sudan and the Syrian Arab Republic.

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UNAIDS

Table A4. Age, prevalence, provider and location of circumcision procedure

among neonates and infants

Country

prevalence

Most common

age at

circumcision

Most common

Percentage

of procedures provider

delivered in a

medical setting

21–40% (1)

41–60% (2)

61–80% (2)

81–100% (1)

21–40% (4)

Clinical ofﬁcer (1)

General practitioner (1)

Obstetrician (1)

Traditional provider (1)

Urologist/surgeon (2)

Clinical ofﬁcer (1)

General practitioner (1)

Traditional provider (2)

Technician (1)

Obstetrician (1)

Urologist/surgeon (5)

Locations in which the

procedure commonly

takes place

Middle East and North Africa

Egypt (6)

50–75% (1)

75–95% (1)

>95% (4)

1 to 2 days (1)

<3 months (4)

4 to 12 months (1)

Medical facility

(6)

Home (3)

Religious building

(1)

Oman (1)

Pakistan (5)

Qatar (1)

Saudi Arabia (5)

Sudan (1)

Syrian Arab

Republic (1)

Turkey (2)

United Arab

Emirates (3)

Sub-Saharan Africa

Ghana (57)

>95% (1)

50–75% (2)

75–95% (1)

>95% (1)

5–25% (1)

75–95% (1)

>95% (3)

<5% (1)

5–25% (1)

75–95% (2)

5–25% (1)

25–50% (16)

50–75% (1)

75–95% (30)

>95% (7)

5–25% (1)

25–50% (1)

50–75% (6)

75–95% (2)

>95% (8)

<5% (2)

5–25% (1)

25–50% (1)

<5% (1)

5–25% (1)

<5% (1)

5–25% (1)

<5% (1)

25–50% (1)

No data

<5% (1)

4 to 12 months (1)

<3 months (3)

4 to 12 months (1)

1 to 2 days (1)

<3 months (3)

4 to 12 months (1)

1 to 2 days (1)

4 to 12 months (2)

<3 months (3)

Medical facility

(1)

Medical facility

(5)

Home (5)

Medical facility

(1)

Medical facility

(5)

Home (1)

Medical facility

(1)

Home (1)

Medical facility

(1)

Medical facility

(2)

Medical facility

(3)

81–100% (1)

61–80% (2)

81–100% (3)

61–80% (1)

21–40% (1)

41–60% (2)

81–100% (3)

Traditional provider (1)

Clinical ofﬁcer (1)

General practitioner (1)

Urologist/surgeon (2)

Traditional provider (1)

<3 months (1)

41–60% (1)

Nigeria (19)

1 to 2 days (1)

<3 months (18)

<20% (1)

21–40% (7)

41–60% (5)

61–80% (1)

<20% (1)

61–80% (2)

81–100% (1)

41–60% (1)

<20% (1)

81–100% (1)

21–40% (1)

41–60% (1)

<20% (1)

81–100% (1)

No data

81–100% (1)

General practitioner (4)

Midwife (4)

Nurse (4)

Traditional provider (7)

Obstetrician (3)

Religious provider (1)

General practitioner (1)

Urologist/surgeon (1)

Urologist/surgeon (2)

Medical facility

(39)

Home (54)

Religious building

(1)

Circumcision house (2)

Private facility (1)

Scan centre (1)

Medical facility

(18)

Home (18)

Religious building

(5)

South Africa (4)

1 to 2 days (2)

<3 months (2)

4 to 12 months (1)

<3 months (1)

No data

1 to 2 days (1)

<3 months (1)

4 to 12 months (1)

1 to 2 days (1)

<3 months (1)

No data

1 to 2 days (1)

United Republic of

Tanzania (1)

Zimbabwe (1)

Asia

Bangladesh (1)

Hong Kong SAR (1)

India (1)

Malaysia (2)

Philippines (1)

Singapore (1)

Medical facility

(2)

Home (1)

Religious building

(1)

Medical facility

(1)

Medical facility

(1)

Medical facility

(1)

Medical facility

(1)

Medical facility

(2)

Home (1)

General practitioner (1) Medical facility

(2)

Obstetrician (1)

Home (1)

General practitioner (1) Medical facility

(1)

Urologist/surgeon (1)

Medical facility

(1)

Numbers in brackets represent the number of respondents.

Respondents could give more than one

answer.

Medical facilities include hospitals, health centres and dispensaries.

Religious buildings included

churches, mosques and synagogues.

Data missing from 56 Ghanaian attendees at a WHO workshop.

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Location

There was a considerable variation within many countries in the reported proportion of

procedures performed in a medical setting (Table A4), which possibly reflects the fact that

common neonatal circumcision practices are poorly known in many countries. Medical facilities

(hospitals, health centres and dispensaries) were commonly cited as the main location in which

the procedure was performed. Home was also cited as a common location for circumcision, and

in particular this location was common in Ghana, Nigeria and Pakistan. The observations that

circumcision is commonly practised in a medical setting by medical personnel may reflect the fact

that many respondents (except for those in Ghana) were medically trained. This may also reflect

an observation in the published literature that there is a trend away from traditional circumcision.

Anaesthesia, surgical management and circumcision procedures

used

The published literature indicates that the Gomco clamp and the Plastibell are the most commonly

used techniques. Respondents from the electronic survey indicated that a wide range of methods

were employed for neonatal and infant circumcision (Table A5). In Nigeria and Ghana there was

some suggestion that the forceps guided method was a more commonly used technique. In Saudi

Arabia there was some evidence that the Plastibell and the Gomco clamp were more popular,

consistent with published data. While the Plastibell was popular in some regions of South Africa

during the 1980s, the results of the electronic survey indicate that the Gomco clamp is more

commonly used now.

The reported type of anaesthesia used for neonatal and infant circumcision varied considerably

between different respondents within countries (Table A5). Respondents frequently cited that no

anaesthesia was used for neonates, but there was evidence in some countries that anaesthesia was

more commonly used for infants. The reported lack of anaesthesia used for infant circumcision

is consistent with the published literature for these regions and supports the call for improved

training of circumcision providers in the use of anaesthesia.

Respondents commonly stated that neonates and infants were routinely followed up post-surgery

(Table A5), although this may reflect the fact that many of the respondents were medical personnel.

Medication was reportedly given routinely to patients in many Middle Eastern, North African and

Asian countries. There was some evidence that medication was given more commonly only as a

treatment in some sub-Saharan countries (South Africa and Zimbabwe).

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Table A5. Anaesthesia, surgical management and circumcision procedure among neonates and infants

Neonates

Country

Egypt (6)

Anaesthesia

None (6)

Topical (1)

Local (1)

General (1)

None (1)

Topical (1)

None (3)

Topical (2)

Local (3)

General (1)

Procedure

Plastibell (2)

Mogen clamp (2)

Gomco clamp (2)

Forceps guided (3)

Plastibell (1)

Dorsal slit (2)

Plastibell (3)

Mogen clamp (1)

Gomco clamp (1)

Forceps guided (2)

Tools made by traditional provider (1)

Gomco clamp (1)

Dorsal slit (1)

Plastibell (2)

Gomco clamp (4)

Forceps guided (1)

Bone cutting (1)

No data

Dorsal slit (1)

Forceps guided (1)

Dorsal slit (2)

Alisklamp (1)

Dorsal slit (1)

Forceps guided (1)

Post-surgical management

Follow-up visit (5)

Written instructions (2)

Routine medication (3)

Medication as treatment (4)

No data

Follow-up visit (4)

Written instructions (1)

Routine medication (1)

Medication as treatment (3)

Anaesthesia

None (4)

Topical (2)

Local (1)

General (4)

Local (1)

General (1)

None (2)

Topical (2)

Local (3)

General (3)

Procedure

Dorsal slit (1)

Plastibell (1)

Mogen clamp (3)

Gomco clamp (1)

Forceps guided (3)

Forceps guided (1)

Dorsal slit (2)

Plastibell (3)

Mogen clamp (1)

Gomco clamp (1)

Forceps guided (2)

No data

Dorsal slit (1)

Plastibell (1)

Gomco clamp (3)

Forceps guided (3)

Infants

Post-surgical management

Follow-up visit (5)

Written instructions (2)

Routine medication (4)

Medication as treatment (3)

Follow-up visit (1)

Routine medication (1)

Follow-up visit (3)

Routine medication (3)

Medication as treatment (2)

UNAIDS

Middle East and North Africa

Oman (1)

Pakistan (5)

Qatar (1)

Saudi Arabia (5)

Topical (1)

None (3)

Topical (2)

Local (1)

General (1)

Local (1)

General (1)

None (1)

Local (2)

General (1)

Routine medication (1)

Medication as treatment (1)

Follow-up visit (5)

Routine medication (3)

Medication as treatment (1)

No data

Topical (1)

Local (2)

General (4)

No data

Follow-up visit (4)

Routine medication (2)

Medication as treatment (1)

Sudan (1)

Syrian Arab Republic (1)

Turkey (2)

Routine medication (1)

Follow-up visit (1)

Medication as treatment (1)

Follow-up visit (1)

Written instructions (1)

Routine medication (1)

Follow-up visit (2)

Routine medication (1)

Medication as treatment (1)

Local (1)

General (1)

Local (1)

General (2)

Local (2)

General (2)

Routine medication (1)

Dorsal slit (1)

Forceps guided (1)

Dorsal slit (2)

Alisklamp (1)

Dorsal slit (1)

Forceps guided (1)

Follow-up visit (1)

Medication as treatment (1)

Follow-up visit (1)

Written instructions (1)

Routine medication (1)

Follow-up visit (2)

Routine medication (2)

Medication as treatment (1)

United Arab Emirates (3) None (1)

Local (1)

General (1)

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Sub-Saharan Africa

Ghana (1)

None (51)

Topical (2)

Local (17)

General (6)

Dorsal slit (12)

Plastibell (10)

Mogen clamp (2)

Gomco clamp (8)

Forceps guided (45)

Dorsal slit (9)

Plastibell (11)

Gomco clamp (1)

Forceps guided (12)

Surgical excision methods (1)

Plastibell (1)

Mogen clamp (1)

Gomco clamp (3)

Forceps guided (1)

Plastibell (1)

Conventional (1)

Mogen clamp (1)

Gomco clamp (1)

Follow-up visit (50)

Written instructions (18)

Routine medication (22)

Medication as treatment (26)

None (36)

Topical (2)

Local (22)

General (9)

Dorsal slit (13)

Plastibell (10)

Mogen clamp (2)

Gomco clamp (10)

Forceps guided (41)

Dorsal slit (6)

Plastibell (9)

Gomco clamp (1)

Forceps guided (10)

Surgical excision

methods (1)

Plastibell (1)

Mogen clamp (1)

Gomco clamp (2)

Forceps guided (1)

Plastibell (1)

Conventional (1)

Mogen clamp (1)

Gomco clamp (1)

Routine medication (1)

Nigeria (19)

None (18)

Topical (6)

Local (7)

General (1)

Follow-up visit (12)

Written instructions (1)

Routine medication (4)

Medication as treatment (5)

None (11)

Topical (6)

Local (8)

General (6)

Follow-up visit (9)

Written instructions (2)

Routine medication (4)

Medication as treatment (3)

South Africa (4)

Local (2)

Follow-up visit (1)

Medication as treatment (2)

General (1)

Follow-up visit (1)

Medication as treatment (1)

N E O N ATA L A N D C H I L D M A L E C I R C U M C I S I O N : A G L O B A L R E V I E W

United Republic of

Tanzania (1)

Zimbabwe (1)

None (1)

Local (1)

General (1)

Follow-up visit (1)

Written instructions (1)

Medication as treatment (1)

Written instructions (1)

Routine medication (1)

Follow-up visit (2)

Routine medication (1)

Follow-up visit (2)

Written instructions (1)

Routine medication (1)

No data

None (1)

Local (1)

General (1)

Follow-up visit (1)

Written instructions (1)

Medication as treatment (1)

Written instructions (1)

Routine medication (1)

No data

Follow-up visit (2)

Routine medication (1)

Follow-up visit (2)

Asia

Bangladesh (1)

Hong Kong SAR (1)

India (2)

Malaysia (2)

General (1)

Local (1)

General (2)

Topical (1)

Local (1)

General (1)

No data

Plastibell (1)

Dorsal slit (2)

Forceps guided (1)

Dorsal slit (1)

Plastibell (1)

Dorsal slit (1)

Plastibell (1)

General (1)

Local (1)

General (2)

Topical (1)

Local (1)

General (1)

No data

Dorsal slit (1)

Plastibell (1)

Dorsal slit (1)

No data

Philippines (1)

Singapore (1)

No data

Numbers in brackets represent the number of respondents.

Respondents could give more than one answer .

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UNAIDS

Child circumcision

Of the 124 completed questionnaires, 98 stated that neonatal circumcision was performed in their

country. Sixteen respondents did not answer this question. The other 10 respondents, from Egypt

(1), Ghana (1), Nigeria (3), Qatar (1), Saudi Arabia (3) and the Syrian Arab Republic (1), stated

that child circumcision was not performed routinely in their country.

Prevalence

The reported prevalence of child circumcision was generally high among countries in the Middle

East and North Africa (Table A6). For example, the cited prevalence was greater than 75% in Egypt

(4/4), Oman (1/1), Pakistan (3/5), Saudi Arabia (1/2), Turkey (2/2) and the United Arab Emirates

(1/1). The reported prevalence of circumcision varied markedly both between and within

countries in sub-Saharan Africa. A large proportion of respondents from Ghana (47%) and Nigeria

(64%) stated that the prevalence of circumcision was 75% or greater, but some respondents also

stated that prevalence was 25% or less. The reported prevalence of child circumcision was lower

in South Africa (25–50%) and the United Republic of Tanzania (5–25%). In Asia, the reported

prevalence was highest in Muslim countries (Bangladesh, Malaysia) and the Philippines, which is

consistent with published data.

Age at circumcision

Childhood (1 to 11 years) was reported to be the most common age for circumcision in many

Asian countries (Table A3). For most Asian countries the procedure was performed later than in

Middle Eastern and North African countries, with many respondents stating that the most common

age for the procedure was during mid-childhood (five to seven years) or late childhood (8 to 11

years) (Table A6). This is consistent with published data, which show that typically boys from Asia

are circumcised between 10 and 15 years (Section 5.2). The most common age for circumcision

during childhood varied considerably between different countries in sub-Saharan Africa: early

childhood (one to four years) was commonly cited by respondents from the Central African

Republic, Ghana and the United Republic of Tanzania, whereas the majority of respondents from

Nigeria stated that mid-childhood (five to seven years) was the most common age.

Providers

As with the neonatal/infant procedure, most respondents from the Middle East and North

Africa stated that medical staff such as general practitioners and urologists/surgeons were the

most common providers of child circumcision (Table A6). This contrasts with the published

literature, which indicates that, particularly in rural areas of Turkey and Egypt, circumcision was

performed by informal providers with no official training (Section 5.3). The only respondents

from this region who claimed that traditional providers were the most common providers were

from Pakistan. Traditional providers were more frequently named as the most common provider

by respondents from sub-Saharan Africa; for example, 55% of Nigerian respondents thought that

most circumcisions were undertaken by traditional providers. In many Asian countries traditional

providers were also identified as the most common circumcision provider—this is in contrast

to the provision of neonatal/infant circumcision, where most respondents from Asian countries

named medical personnel.

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N E O N ATA L A N D C H I L D M A L E C I R C U M C I S I O N : A G L O B A L R E V I E W

Location

In most countries medical facilities were common locations for child circumcision. The home

was the second most frequently named location for the procedure to be performed. Religious

buildings, circumcision houses and villages/towns were also cited as common places for the

procedure to be performed.

Anaesthesia, surgical management and circumcision procedures

used

Anaesthesia is used more frequently when circumcision is performed on children than on

neonates/infants (Tables A5 and A7). For example, in Egypt all six respondents stated that

circumcision may be performed on neonates without any anaesthesia, whereas only one (out of

four) respondents indicated that this would happen for children. In some countries there were

reports that anaesthesia was more likely to be used for older children. For example, in Ghana 31

(56%) respondents thought that the procedure may be performed on young children (aged one

to seven years) without anaesthesia, whereas 42% stated the same would occur when circumcision

was performed on older boys (8 to 11 years). Notably, many respondents, from several countries,

stated that no anaesthesia is used for children. As expected, respondents were more likely to state

that no anaesthesia was used for children if they came from a country where traditional providers

were the main provider of circumcision.

A wide range of procedures, both within and between countries, was named by the respondents.

Consistent with the published literature (Section 5.4.1), the sleeve resection technique was named

as a commonly used method for children by one respondent from Turkey. As with neonates/infants,

the forceps guided method appeared to be commonly used for the circumcision of children.

Respondents commonly stated that patients were examined at a follow-up visit after the procedure

and there was some suggestion that this was more likely in younger children in some countries

(Egypt, Nigeria, Hong Kong Special Administrative Region). Routine medication is provided to

children in many countries, but medication as a treatment only was less commonly named by

respondents. Exceptions to this include South Africa and the United Republic of Tanzania, where

respondents stated that medication was provided as a treatment only and was not given routinely.

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UNAIDS

Table A6. Age, prevalence, provider and location of circumcision procedure

among childre

Country

prevalence

Most common

age at circumcision

Most common provider

Locations in which the

procedure commonly takes

place

Medical facility

(4)

Home (1)

Medical facility

(1)

Home (1)

Barbers’ (1)

Medical facility

(1)

Medical facility

(5)

Home (2)

Medical facility

(2)

Medical facility

(1)

Home (2)

Medical facility

(2)

Home (1)

Medical facility

(1)

Private clinics (1)

Medical facility

(1)

Home (1)

Medical facility

(38)

Home (47)

Religious building

(1)

Circumcision house (3)

Scan centre (1)

Medical facility

(11)

Home (9)

Religious building

(4)

Town/village (1)

Traditional provider’s place

(1)

Medical facility

(1)

Medical facility

(1)

Middle East and North Africa

Egypt (4)

>95% (4)

Morocco (1)

No data

1 to 4 years (2)

5 to 7 years (1)

No data

General practitioner (2)

Urologist/surgeon (2)

No data

Oman (1)

Pakistan (5)

Saudi Arabia (2)

Sudan (2)

Turkey (2)

United Arab Emirates (1)

>95% (1)

<5% (1)

75–95% (1)

>95% (2)

5–25% (1)

>95% (1)

<5% (1)

>95% (1)

75–95% (1)

>95% (1)

1 to 4 years (1)

1 to 4 years (3)

General practitioner (1)

Urologist/surgeon (1)

Traditional provider (3)

Urologist/surgeon (2)

Urologist/surgeon (1)

Nurse (1)

Clinical ofﬁcer (1)

General practitioner (1)

5 to 7 years (2)

1 to 4 years (1)

5 to 7 years (1)

1 to 4 years (1)

Sub-Saharan Africa

Central African Republic (1) >95% (1)

Ghana (55)

<5% (2)

5–25% (3)

25–50% (2)

50–75% (13)

75–95% (18)

>95% (8)

<5% (2)

5–25% (1)

50–75% (1)

75–95% (2)

>95% (5)

25–50% (1)

1 to 4 years (1)

1 to 4 years (23)

5 to 7 years (8)

8 to 11 years (6)

Nurse (1)

Nigeria (11)

1 to 4 years (2)

5 to 7 years (4)

3 to 5 years (1)

General practitioner (3)

Midwife (1)

Traditional provider (6)

South Africa (2)

No data

1 to 4 years (1)

Urologist/surgeon (1)

Clinical ofﬁcer (1)

United Republic of Tanzania 5–25% (1)

(1)

Asia

Bangladesh (1)

75–95% (1)

Hong Kong SAR (2)

India (2)

Malaysia (3)

Philippines (1)

5–25% (1)

<5% (1)

5–25% (1)

25–50% (1)

50–75% (2)

50–75% (1)

4 to 8 years (1)

5 to 7 years (2)

5 to 7 years (1)

8 to 11 years (1)

5 to 7 years (1)

8 to 11 years (2)

8 to 11 years (1)

Traditional provider (1)

Urologist/surgeon (2)

General practitioner (1)

Traditional provider (1)

Medical facility

(1)

Home (1)

Medical facility

(2)

Medical facility

(2)

Medical facility

(3)

Home (2)

Medical facility

(1)

Home (1)

Backyard (1)

Medical facility

(1)

Singapore (1)

5–25% (1)

8 to 11 years (1)

Religious practitioner (1)

Respondents could give more than one answer.

Medical facilities include hospitals, health centres and

dispensaries.

Religious buildings included churches, mosques and synagogues.

Data missing from 55

Ghanaian attendees at a WHO workshop.

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Table A7. Anaesthesia, surgical management and circumcision procedure among children

Children (1 to 7 years)

Children (8 to 11 years)

Post-surgical

management

Follow-up visit (2)

Written instructions (1)

Routine medication (3)

Medication as treatment

(2)

No data

Routine medication (1)

Follow-up visit (5)

Written instructions (1)

Routine medication (2)

Medication as treatment

(3)

Follow-up visit (2)

Routine medication (2)

Medication as treatment

(1)

Follow-up visit (1)

Routine medication (2)

Follow-up visit (2)

Written instructions (1)

Routine medication (1)

Follow-up visit (1)

Routine medication (1)

N E O N ATA L A N D C H I L D M A L E C I R C U M C I S I O N : A G L O B A L R E V I E W

Country

Egypt (4)

Anaesthesia

None (1)

Topical (2)

Local (2)

General (3)

No data

Local (1)

General (1)

None (3)

Topical (3)

Local (4)

General (3)

Procedure

Dorsal slit (1)

Mogen clamp (2)

Forceps guided (1)

Post-surgical management

Follow-up visit (3)

Written instructions (1)

Routine medication (3)

Medication as treatment (2)

No data

Routine medication (1)

Follow-up visit (5)

Written instructions (1)

Routine medication (2)

Medication as treatment (3)

Anaesthesia

None (1)

Topical (1)

Local (1)

General (4)

No data

General (1)

None (2)

Topical (3)

Local (3)

General (2)

Procedure

Dorsal slit (1)

Mogen clamp (2)

Forceps guided (1)

Middle East and North Africa

Morocco (1)

Oman (1)

Pakistan (5)

No data

Forceps guided (1)

Dorsal slit (3)

Forceps guided (2)

Dissection (1)

Traditional methods (1)

Tools made by traditional

provider (1)

Forceps guided (2)

No data

Forceps guided (1)

Dorsal slit (2)

Forceps guided (1)

Dissection (1)

Saudi Arabia (2)

Local (1)

General (2)

Follow-up visit (2)

Routine medication (2)

Medication as treatment (1)

Follow-up visit (1)

Routine medication (2)

Follow-up visit (2)

Written instructions (1)

Routine medication (1)

Follow-up visit (1)

Routine medication (1)

Local (1)

General (2)

Forceps guided (2)

Sudan (2)

Turkey (2)

Local (2)

General (1)

Local (1)

General (2)

Mogen clamp (1)

Dorsal slit (1)

Plastibell (1)

Alisklamp (1)

Sleeve resection (1)

Dorsal slit (1)

Topical (1)

Local (2)

Mogen clamp (1)

Local (2)

Dorsal slit (1)

General (1)

Alisklamp (1)

Sleeve resection (1)

Local (1)

Dorsal slit (1)

United Arab Emirates (1) Local (1)

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UNAIDS

Sub-Saharan Africa

Central African

Republic (1)

Ghana (55)

Local (1)

General (1)

None (31)

Topical (2)

Local (25)

General (14)

No data

Dorsal slit (14)

Plastibell (6)

Mogen clamp (1)

Gomco clamp (7)

Forceps guided (45)

Freehand (5)

Dorsal slit (6)

Plastibell (3)

Mogen clamp (2)

Gomco clamp (1)

Forceps guided (10)

Gomco clamp (1)

Forceps guided (1)

Dorsal slit (1)

Follow-up visit (1)

Follow-up visit (50)

Written instructions (17)

Routine medication (20)

Medication as treatment (17)

Local (1)

General (1)

None (23)

Topical (2)

Local (27)

General (15)

No data

Dorsal slit (14)

Plastibell (6)

Mogen clamp (1)

Gomco clamp (7)

Forceps guided (44)

Freehand (5)

Dorsal slit (6)

Plastibell (3)

Mogen clamp (2)

Gomco clamp (1)

Forceps guided (10)

Gomco clamp (1)

Forceps guided (1)

Dorsal slit (1)

Follow-up visit (1)

No data

Nigeria (11)

None (3)

Topical (5)

Local (9)

General (9)

General (1)

Local (1)

Follow-up visit (8)

Routine medication (8)

Medication as treatment (4)

None (2)

Topical (3)

Local (7)

General (8)

General (1)

Local (1)

Follow-up visit (7)

Routine medication (6)

Medication as treatment

(4)

Medication as treatment

(1)

Follow-up visit (1)

Medication as treatment

(1)

No data

South Africa (2)

United Republic of

Tanzania (1)

Asia

Bangladesh (1)

Medication as treatment (1)

Follow-up visit (1)

Medication as treatment (1)

None (1)

Local (1)

General (1)

General (2)

No data

None (1)

Local (1)

General (1)

General (2)

No data

Hong Kong SAR (2)

India (2)

Dorsal slit (1)

Dorsal slit (2)

Forceps guided (1)

Dorsal slit (1)

Plastibell (1)

Dorsal slit (1)

No data

Follow-up visit (2)

Routine medication (1)

Follow-up visit (2)

Routine medication (1)

Follow-up visit (2)

Written instructions (1)

Routine medication (1)

Follow-up visit (1)

No data

Dorsal slit (1)

Follow-up visit (1)

Follow-up visit (2)

Written instructions (1)

Routine medication (1)

Follow-up visit (2)

Written instructions (1)

Routine medication (1)

Follow-up visit (1)

No data

Malaysia (3)

Topical (1)

Local (2)

No data

None (1)

Topical (1)

Local (2)

No data

Dorsal slit (2)

Traditional with

leaves (1)

Dorsal slit (1)

No data

Philippines (1)

Singapore (1)

Numbers in brackets represent the number of respondents.

Respondents could give more than one answer.

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N E O N ATA L A N D C H I L D M A L E C I R C U M C I S I O N : A G L O B A L R E V I E W

Complications

As found in the published literature, the most commonly reported complication of circumcision

was excess bleeding, followed by wound infection (Tables A8 and A9). Other commonly reported

complications included insufficient and excessive skin removal and haematoma/abnormal swelling.

There was some evidence from Ghana and Nigeria, where sufficient data were available, that

complications rates were higher in children than in neonates/infants. The perceived complication

risk was very variable both between and within countries. This is consistent with the observation

that a large number of countries stated that complications were often not routinely recorded.

Where recording systems were in place the most common methods were through recording in

the patient’s medical notes or in hospital/health centre registers.

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UNAIDS

Table A8. Circumcision complications among neonates and infants

Overall risk of

complications

(per 1000

procedures)

Recording of complications

Not routinely recorded (4)

In the patient’s medical records (2)

Country

Most common complication

Middle East and North Africa

<1 (2)

Egypt (6)

Excess bleeding (2)

1–5 (2)

Insufﬁcient skin removal (1)

6–10 (1)

Wound infection (1)

21–50 (1)

Haemorrhage (1)

Bleeding (1)

Oman (1)

Excess bleeding (1)

6–10 (1)

Pakistan (5)

Haematoma/abnormal swelling (1)

<1 (2)

Wound infection (3)

11–20 (1)

Frenal oozing (1)

5–20 (1)

Qatar (1)

Excess bleeding (1)

<1 (1)

Saudi Arabia (5) Excess bleeding (2)

11–20 (2)

Wound infection (1)

21–50 (1)

Bleeding (1)

Sudan (1)

Excess bleeding (1)

51–100 (1)

Syrian Arab

Excess bleeding (1)

<1 (1)

Republic (1)

Turkey (2)

Excess bleeding (1)

6–10 (1)

Post-circumcision phimosis (1)

United Arab

Emirates (3)

Insufﬁcient skin removal (1)

1–5 (2)

11–20 (1)

In the patient’s medical records (1)

Not routinely recorded (3)

In the patient’s medical records (1)

At follow-up visits (1)

Recorded by urologists (1)

In the patient’s medical records (5)

Not routinely recorded (1)

Complications recorded at 1 day and 7

days post-surgical visit (1)

Routinely recorded (1)

Not routinely recorded (1)

In the patient’s medical records (1)

Recorded by the surgeon performing the

procedure (1)

Not routinely recorded (28)

Recorded in the health centre register (5)

Sub-Saharan Africa

Ghana (57)

Excess bleeding (1)

Nigeria (19)

Excess bleeding (7)

Excessive skin removal (2)

Insufﬁcient skin removal (2)

Wound infection (4)

<1 (13)

1–5 (6)

6–10 (8)

21–50 (2)

<1 (2)

1–5 (7)

6–10 (4)

21–50 (2)

51–100 (2)

South Africa (4)

United Republic

of Tanzania (1)

Zimbabwe (1)

Asia

Bangladesh (1)

Hong Kong SAR (1)

India (2)

Malaysia (2)

Philippines (1)

Singapore (1)

Excess bleeding (2)

Wound infection (1)

Excess bleeding (1)

Wound infection (1)

Haematoma/abnormal

swelling (1)

Wound infection (1)

No data

1–5 (2)

6–10 (1)

3–9 (1)

<1 (1)

6–10 (1)

<1 (1)

1–5 (1)

<1 (2)

No data

<1 (1)

Not routinely recorded (7)

In the patient’s medical records (3)

Recorded in the health centre register (2)

Reported to the supervising doctor (1)

Recorded during follow-up (1)

Only complications presenting to hospital

are recorded (2)

Not routinely recorded (1)

In the patient’s medical records (2)

Not routinely recorded (1)

In the patient’s medical records (1)

Not routinely recorded (1)

In the patient’s medical records (1)

Not routinely recorded (2)

Not routinely recorded (1)

No data

Numbers in brackets represent the number of respondents.

Respondents could give more than one

answer.

Data missing from the 56 Ghanaian attendees at a WHO workshop.

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N E O N ATA L A N D C H I L D M A L E C I R C U M C I S I O N : A G L O B A L R E V I E W

Table A9. Circumcision complications among children

Overall risk of

complications

(per 1000

procedures)

<1 (1)

1–5 (1)

21–50 (1)

No data

21–50 (1)

<1 (1)

1–5 (1)

6–10 (1)

11–20 (1)

1–5 (1)

6–10 (1)

1–5 (1)

Country

Middle East and North Africa

Egypt (4)

Excess bleeding (1)

Wound infection (2)

Morocco (1)

Oman (1)

Pakistan (5)

No data

Excess bleeding (1)

Wound infection (2)

Most common

complication

Recording of

complications

Not routinely recorded (2)

In the patient’s medical

records (1)

No data

In hospital records (1)

Not routinely recorded (2)

In the patient’s medical

records (1)

At follow-up visits (1)

In the patient’s medical

records (2)

Not routinely recorded (1)

At follow-up visits (1)

Not routinely recorded (1)

Saudi Arabia (2)

Sudan (2)

Turkey (2)

United Arab Emirates (1)

Sub-Saharan Africa

Central African Republic (1)

Ghana (55)

Insufﬁcient skin removal

(1)

Wound infection (1)

Excess bleeding (1)

No data

Nigeria (11)

South Africa (2)

Excess bleeding (4)

Insufﬁcient skin removal (1)

Wound infection (1)

Haematoma/abnormal

swelling (1)

Excess bleeding (1)

No data

<1 (11)

1–5 (2)

6–10 (7)

11–20 (2)

21–50 (1)

1–5 (1)

6–10 (1)

11–20 (4)

21–50 (2)

<1 (1)

11–20 (1)

21–50 (1)

6–10 (1)

1–5 (1)

11–20 (1)

<1 (2)

No data

Not routinely recorded (44)

In the health centre register

(6)

United Republic of Tanzania (1) No data

Asia

Bangladesh (1)

Excess bleeding (1)

Hong Kong SAR (2)

Wound infection (1)

India (2)

Malaysia (3)

Haematoma/abnormal

swelling (1)

Wound infection (2)

Not routinely recorded (3)

In the patient’s medical

records (1)

Hospital register (2)

At follow-up visits (1)

In the patient’s medical

records (1)

Not routinely recorded (1)

In the patient’s medical

records (1)

In the patient’s medical

records (1)

In the patient’s medical

records (1)

At follow-up visits (1)

Not routinely recorded (1)

No data

Philippines (1)

Singapore (1)

No data

Numbers in brackets represent the number of respondents.

Respondents could give more than one

answer.

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UNAIDS

SURVEY OF MALE CIRCUMCISION PRACTICES & POLICIES

Male circumcision is the most common surgical procedure worldwide. There is

currently increasing interest in male circumcision following results from three ran-

domised controlled trials showing a reduced risk of HIV acquisition in men.

The London School of Hygiene & Tropical Medicine is currently conducting a

survey of male circumcision practices globally. This survey is funded by the Bill

& Melinda Gates Foundation.

We would greatly appreciate your co-operation in this survey by responding to

the following questions about male circumcision practices and policies in your

country.

Please email the completed questionnaire to [email protected] or fax to

+44 207 636 8739

Date (day/month/year):

. . . . . . . . . . . . . . .

. . . . . . . . . . . . . .

Name:

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Country:

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

District/ Province:

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(please state the district/ province in which you work or have experience of male circumcision)

Institution:

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Position/Title:

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Email address:

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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N E O N ATA L A N D C H I L D M A L E C I R C U M C I S I O N : A G L O B A L R E V I E W

SECTION 1: Background

Q1a

Is male circumcision widely practiced in your country?

Q1b

Approximately what proportion of males are circumcised in your country

and district/province?

a) Country:

b) District/ Province:

Q1c

What is the most common age for male circumcision in your country?

Q1d

What is your professional experience (if any) with male circumcision?

(please check all that apply)

No experience

Service delivery

Health policy

Provision of circumcision training

Research

Other: Please specify:

Thank you in advance for your time in completing this questionnaire, which will be acknowledged

in the final report.

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UNAIDS

SECTION 2: Circumcision among boys aged up to 1 year

Q2a

Does neonatal and/or infant male circumcision occur in your country?

If you answered ‘No’ please skip to Section 3, page 9.

If you answered ‘Yes’ please answer the questions below

Q2b

At what age are male neonates and infants typically circumcised in your

country?

If you answered ‘on a speciﬁc day after birth’, please specify the day:

Q2c

(i) Approximately what percentage of males in your country and/or your

district/province have been circumcised by age 1 year?

a) Country:

b) District/ province:

(ii) Approximately what percentage of deliveries in your country and/or

your district/province occurs in medical settings (e.g. hospitals, clinics)?

a) Country:

Proportion delivered in medical setting

b) District/ province:

Proportion delivered in medical setting

Q2d

Who carries out the neonatal/infant male circumcision procedure? (please

check all that apply)

General practitioner

Urologist/surgeon

Clinical Ofﬁcer

Nurse

Midwife

Obstetrician

Traditional provider

Religious provider

Other (please specify)

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Q2e

Of these, which is the most common type of provider? (Please select one

option from the dropdown list)

Q2f

What training in male circumcision, if any, do the providers of neonatal/

infant circumcision have? Please provide information for all types of

provider if the training varies for different providers.

General practitioner

Urologist/surgeon

Clinical Ofﬁcer

Nurse

Midwife

Obstetrician

Traditional provider

Religious provider

Other (speciﬁed in Q2d)

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UNAIDS

Q2g

Where does the neonatal/infant circumcision procedure take place?

(please check all acceptable locations, not only the most common)

At hospital

At health centre/dispensary

At other health facility

At home

In a Church/ Synagogue /Mosque

At another location (please specify)

Q2h

Which types of anaesthesia are commonly used for medical circumcision?

(please check all that apply)

i) Neonatal (birth to 1 month)

None

Topical (e.g. EMLA 5% cream)

Local (e.g. penile nerve block with lidocaine)

General

Other (please specify)

ii) Infants (1 month to 1 year)

None

Topical (e.g. EMLA 5% cream)

Local (e.g. penile nerve block with lidocaine)

General

Other (please specify)

Q2i

Which procedures are most commonly used? (please check all that apply)

i) Neonatal (up to 1 month)

Dorsal slit

Plastibell

Mogen clamp

Gomco clamp

Forceps guided

Other (please specify)

ii) Infants (1 month to 1 year)

Dorsal slit

Plastibell

Mogen clamp

Gomco clamp

Forceps guided

Other (please specify)

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Q2j

Please describe post-surgical management including management of

complications (please check all that apply)

i) Neonatal (up to 1 month)

Follow-up visit (please specify when)

Written instructions to parents (please attach a copy if possible)

Medications provided routinely

Medications provided as additional treatment as needed only

ii) Infants (1 month to 1 year)

Follow-up visit (please specify when)

Written instructions to parents (please attach a copy if possible)

Medications provided routinely

Medications provided as additional treatment as needed only

Q2k

Are complications typically recorded? If so, how?

Q2l

What is the overall risk of complication for neonates/infants per 1000

procedures? (please estimate if not known)

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UNAIDS

Q2m

(i) Which is the most common complication?

Please specify complication if ‘other’ was selected in the list above:

(ii) How often (roughly) does each complication occur?

(please answer for all complications if possible)

Approx # per 1000 procedures

Excess bleeding.

Wound infection

Haematoma/abnormal swelling

Accidental injury to penis

Excessive skin removal

Insufﬁcient skin removal

Anaesthesia complications

Other (speciﬁed above)

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Q2n

What is the typical cost of a male circumcision for different types of

providers?

Please specify currency:

i) Neonatal (up to 1 month)

Type of provider (1):

Most common unit cost:

Range: Minimum cost

to maximum cost

Please check all the items included in this cost:

Fee to provider

Surgical costs (consumables & equipment)

Follow-up

Type of provider (2):

Most common unit cost:

Range: Minimum cost

to maximum cost

Please check all the items included in this cost:

Fee to provider

Surgical costs (consumables & equipment)

Follow-up

Type of provider (3):

Most common unit cost:

Range: Minimum cost

Fee to provider

Surgical costs (consumables & equipment)

Follow-up

ii) Infants (1 month to 1 year)

Type of provider (1):

Most common unit cost:

Range: Minimum cost

to maximum cost

Please check the items included in this cost:

Please check all the items included in this cost:

Fee to provider

Surgical costs (consumables & equipment)

Follow-up

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UNAIDS

Q2n

What is the typical cost of a male circumcision for different types of

providers? (continued)

Type of provider (2):

Most common unit cost:

Range: Minimum cost

to maximum cost

Please check all the items included in this cost:

Fee to provider

Surgical costs (consumables & equipment)

Follow-up

Type of provider(3):

Most common unit cost:

Range: Minimum cost

to maximum cost

Please check all the items included in this cost:

Fee to provider

Surgical costs (consumables & equipment)

Follow-up

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SECTION 3: Male circumcision among boys aged 1-11 years

Q3a

Does male circumcision occur among boys aged 1-11 years in your

country?

If you answered ‘No’ please skip to Section 4, page 15.

If you answered ‘Yes’ please answer the questions below

Q3b

At what age are boys of 1-11 years typically circumcised in your country?

(please check one response only)

between the ages of 1-4 years

between the ages of 5-7 years

between the ages of 8-11 years

immediately after leaving elementary school at age

years

at a speciﬁc age of

between the ages of

years

and

years

Q3c

Approximately what percentage of boys in your country and your

district/province have been circumcised by age 12 years old?

a) Country:

b) District/ province:

Q3d

Who carries out the circumcision procedure for children aged 1-11 years

(please check all that apply)

General practitioner

Urologist/surgeon

Clinical Ofﬁcer

Nurse

Midwife

Obstetrician

Traditional provider

Religious provider

Other (please specify)

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UNAIDS

Q3e

Of these, which is the most common type of provider for boys aged 1-11

years? (please select one answer from the dropdown list)

Q3f

What training in male circumcision, if any, do these providers have?

Please provide information for all types of provider if the training varies

for different providers.

General practitioner

Urologist/surgeon

Clinical Ofﬁcer

Nurse

Midwife

Obstetrician

Traditional provider

Religious provider

Other (speciﬁed in Q3d)

Q3g

Where does the circumcision procedure take place? (please check all

acceptable locations not only the most common)

At hospital

At health centre/dispensary

At other health facility

At home

In a Church/ Synagogue /Mosque

At another location (please specify)

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Q3h

Which types of anaesthesia are commonly used for medical circumcision?

(please check all that apply)

i) Children (age 1-7 years)

None

Topical (e.g. EMLA 5% cream)

Local (e.g. penile nerve block with lidocaine)

General

Other (please specify)

ii) Prepuberty (age 8-11 years)

None

Topical (e.g. EMLA 5% cream)

Local (e.g. penile nerve block with lidocaine)

General

Other (please specify)

Q3i

Which procedures are most commonly used? (please check all that apply)

i) Children (age 1-7 years)

Dorsal slit

Plastibell

Mogen clamp

Gomco clamp

Forceps guided

Other (please specify)

ii) Prepuberty (age 8-11 years)

Dorsal slit

Plastibell

Mogen clamp

Gomco clamp

Forceps guided

Other (please specify)

Q3j

Please describe post-surgical management (please check all that apply)

i) Children (age 1-7 years)

Follow-up visit (please specify when)

Written instructions to boy and/or parents (please attach if possible)

Medications provided routinely

Medications provided as additional treatment as needed only

ii) Prepubertal (age 8-11 years)

Follow-up visit (please specify when)

Written instructions to boy and/or parents (please attach if possible)

Medications provided routinely

Medications provided as additional treatment as needed only

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UNAIDS

Q3k

Are complications recorded? If so,how?

Q3l

What is the overall risk of complications for boys aged 1-11 years per

1000 procedures? (please estimate if not known)

Q3m

(i) Which is the most common complication?

Please specify complication if ‘other’ was selected in the list above:

(i) How often (roughly) does each complication occur? (please answer for

all complications if possible)

Approx # per 1000 procedures

Excess bleeding.

Wound infection

Haematoma/abnormal swelling

Accidental injury to penis

Excessive skin removal

Insufﬁcient skin removal

Anaesthesia complications

Other (speciﬁed above)

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Q3n

What is the typical cost of a male circumcision for different types of

providers?

Please specify currency:

i) Children (aged 1-7 years)

Type of provider (1):

Most common unit cost:

Range: Minimum cost

to maximum cost

Please check all the items included in this cost:

Fee to provider

Surgical costs (consumables & equipment)

Follow-up

Type of provider (2):

Most common unit cost:

Range: Minimum cost

to maximum cost

Please check all the items included in this cost:

Fee to provider

Surgical costs (consumables & equipment)

Follow-up

Type of provider (3):

Most common unit cost:

Range: Minimum cost

to maximum cost

Please check all the items included in this cost:

Fee to provider

Surgical costs (consumables & equipment)

Follow-up

ii) Pre-puberty (aged 8-11 years)

Type of provider (1):

Most common unit cost:

Range: Minimum cost

to maximum cost

Please check all the items included in this cost:

Fee to provider

Surgical costs (consumables & equipment)

Follow-up

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UNAIDS

Q3n

What is the typical cost of a male circumcision for different types of

providers? (continued)

Type of provider (2):

Most common unit cost:

Range: Minimum cost

Fee to provider

Surgical costs (consumables & equipment)

Follow-up

Type of provider (3):

Most common unit cost:

Range: Minimum cost

Fee to provider

Surgical costs (consumables & equipment)

Follow-up

to maximum cost

Please check all the items included in this cost:

to maximum cost

Please check all the items included in this cost:

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N E O N ATA L A N D C H I L D M A L E C I R C U M C I S I O N : A G L O B A L R E V I E W

SECTION 4: MALE CIRCUMISION AMONG ADOLESCENTS

AND ADULTS

Q4a

Does circumcision occur among males aged 12 or older in your country?

If you answered ‘No’ please skip to Section 5, page 18.

If you answered ‘Yes’ please answer the questions below

Q4b

Who carries out the circumcision procedure for males aged 12 years or

older (please check all that apply)

General practitioner

Urologist/surgeon

Clinical Ofﬁcer

Nurse

Traditional provider

Religious provider

Other (please specify)

Q4c

Which is the most common provider for males aged 12 years or older?

(please select one from the dropdown list)

General practitioner

Urologist/surgeon

Clinical Ofﬁcer

Nurse

Traditional provider

Religious provider

Other (please specify)

Q4d

What training in male circumcision, if any, do these providers have?

Please provide information for all types of provider if the training varies

for different providers.

General practitioner

Urologist/surgeon

Clinical Ofﬁcer

Nurse

Traditional provider

Religious provider

Other (speciﬁed in Q4b)

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UNAIDS

Q4e

Where does the adolescent/adult circumcision procedure take place?

(please check all acceptable locations not only the most common)

At hospital

At health centre/dispensary

At other health facility

At home

In a Church/ Synagogue /Mosque

At another location (please specify)

Q4f

Which type of anaesthesia is often used for adolescent/adult medical

circumcision? (please check all that apply)

None

Topical (e.g. EMLA 5% cream)

Local (e.g. penile nerve block with lidocaine)

General

Other (please specify)

Q4g

Which procedures are most commonly used? (please check all that apply)

Dorsal slit

Plastibell

Mogen clamp

Gomco clamp

Forceps guided

Other (please specify)

Q4h

Please describe post-surgical management (please check all that apply)

Follow-up visit (please specify when)

Written instructions to client (please attach a copy if possible)

Medications provided routinely

Medications provided as additional treatment as needed only

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Q4i

What is the typical cost of an adolescent/adult male circumcision for each

type of provider?

Please specify currency:

Type of provider (1):

Most common unit cost:

Range: Minimum cost

to maximum cost

Please check all the items included in this cost:

Fee to provider

Surgical costs (consumables & equipment)

Follow-up

Type of provider (2):

Most common unit cost:

Range: Minimum cost

to maximum cost

Please check all the items included in this cost:

Fee to provider

Surgical costs (consumables & equipment)

Follow-up

Type of provider (3):

Most common unit cost:

Range: Minimum cost

to maximum cost

Please check all the items included in this cost:

Fee to provider

Surgical costs (consumables & equipment)

Follow-up

101

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UNAIDS

SECTION 5: MALE CIRCUMISION POLICIES AND LEGISLATION

Q5a

(i) Is there any current legislation or regulations regarding male

circumcision in your country?

If you answered ‘No’ please go to question 5b below.

If you answered ‘Yes’ please answer parts (ii) and (iii) in the boxes below

(ii) If you answered yes to the question above, please provide a reference

to this legislation or regulation e.g. a parliamentary bill, Ministry of Health

directive, local government order

Reference:

(iii) If you answered yes to the question above, please provide brief details

of the current legislation or regulations.

i) For neonates and infants (age up to 1 year)

ii) For children and pre-pubescent boys (age 1-11 years)

Q5b

Is there typically a procedure of informed consent?

i) For age up to 1 year

If you answered yes, please describe and attach the information sheet if

possible:

ii) For ages 1-11 years

If you answered yes, please describe and attach the information sheet if

possible:

ii) For ages 12 years and older

If you answered yes, please describe and attach the information sheet if

possible:

102

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Finally, please could you let us have contact details of others in your country who

might be able to provide further details on male circumcision in different settings

Name:

Position:

Email address:

Telephone/fax number:

Name:

Position:

Email address:

Telephone/fax number:

Name:

Position:

Email address:

Telephone/fax number:

We would also greatly appreciate if you could list any relevant publications on

male circumcision from your country

Thank you very much for taking the time to complete this questionnaire. We look forward

to sending you our final report.

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NOTES

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UNAIDS is an innovative joint venture of the United Nations, bringing together the efforts and resources

of the UNAIDS Secretariat and ten UN system organizations in the AIDS response. The Secretariat head-

quarters is in Geneva, Switzerland—with staff on the ground in more than 80 countries. The Cosponsors

include UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, ILO, UNESCO, WHO and the World Bank.

Contributing to achieving global commitments to universal access to comprehensive interventions for HIV

prevention, treatment, care and support is the number one priority for UNAIDS. Visit the UNAIDS website

at www.unaids.org

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CH-1211 GENEVA 27

SWITZERLAND

Tel.: (+41) 22 791 36 66

Fax: (+41) 22 791 48 35

e-mail: [email protected]

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