Male circumcision: get the timing right.

872 CMAJ, April 19, 2011, 183(7) © 2011 Canadian Medical Association or its licensors The most commonly performed surgical procedure in the world — male circumcision — is done for therapeutic, prophylactic, religious, cultural and social reasons. Discussions of male infant circumcision for health reasons are always split. Proponents suggest there are significant potential health benefits including a decreased risk for some sexually transmitted infections, a decrease in HPV-related penile cancer and reduced phimosis, paraphimosis. On the other hand, opponents comment on the complication rate of 1.5% and only modest benefits, while noting that it is a painful procedure for neonates with possible long-lasting effects such as lowering the threshold for pain, and that it is based on tradition not evidence. For more than a decade, the American, Canadian and Australian pediatric specialists organizations have not recommended routine infant circumcision, noting that the existing evidence was insufficient to support it. Each of these organizations regularly reviews its guideline statements to determine if positions need to be updated. The question now is whether the findings from the randomized trials of adult male circumcision in sub-Saharan Africa that show circumcision halves the risk of acquiring HIV and decreases risk for HSV-2, and high-risk HPV in heterosexual African adult men push these organizations to change their positions on routine infant circumcision. The Paediatrics & Child Health Division of the Royal Australasian College of Physicians was the first back with its review (September 2010) and said no to routine male infant circumcision. Should Canadian and American pediatric specialty organizations change their positions? As is the case with Australia, it’s not clear how relevant these African studies are for Canada and other low HIV prevalence countries. All the sub-Saharan studies were conducted in countries with a high HIV prevalence. Even at baseline the study populations had an HIV incidence of 1.3%; Canada’s baseline incidence is 0.013%. A recent analysis in the United States estimated that neonatal circumcision would only reduce the 1.87% lifetime risk of HIV among all males by about 16%. Second, none of the sub-Saharan African studies examined infant circumcision; all involved adult male circumcision. There is no new evidence that infant circumcision provides any added benefit to the neonate, infant or young