Circumcision of males (MC) involves removal of the foreskin. It has been practiced for thousands of years by diverse cultural groups globally [1]. In Victorian times medical circumcison became popular to prevent syphilis, phimosis, penile cancer and inferior hygiene [1]. In the 21st century it was approved for protection against HIV in epidemic settings [2, 3, 4, 5]. MC is currently the world’s most widely performed surgical procedure, prevalence globally being 37–39% [6]. In Australia, a 2010 telephone survey found that 33% of Australian men under 30 years of age were circumcised [7]. Recent data show a reduction in early MC prevalence from a peak of 85% in the 1950s to 18.75% in 2019 [8]. In the US, Centers for Disease Control and Prevention (CDC) estimates show an increasing trend in MC prevalence to 92% in white, 76% in black and 44% of Hispanic males aged 14–59 years [9].

Evidence-based reviews of MC were published by the American Academy of Pediatrics (AAP) in 2012 [10, 11], the CDC in 2018 [12, 13], and the Circumcision Academy of Australia in 2012 [14]. (See Supplementary Material 1 for summaries of available circumcision policy statements.) The aim of the present study was to conduct a systematic review of the literature and use this to develop an up-to-date MC policy tailored to the setting of Australia. Data for Australia were used when possible, otherwise information was from mostly from the comparable setting of the US, which is the richest data source.

Articles were retrieved from PubMed using the keyword ”circumcision” together with one of 39 other relevant keywords (Supplementary Material 2), leading to 253 that were included. Additional publications (10 articles and 15 Internet publications) were identified in bibliographies of these. In total 278 publications meeting the inclusion criteria were obtained. Particular priority was given to randomized controlled trials, systematic reviews and meta-analyses. Studies were rated Level 1+, 1++, 1–, 2++, 2+, 2– and 3 by the Scottish Intercollegiate Guidelines Network (SIGN) system [15] (Supplementary Material 3).

In newborn males the inner surface of the foreskin adheres lightly to the underlying glans making foreskin retraction difficult, a condition termed phimosis [16]. During childhood the foreskin gradually separates from the glans. By age five most boys are able to retract their foreskin partially, with some adhesions usually remaining. By puberty full retraction is generally possible [17]. Forceable retraction can be painful, and could injure the foreskin, leading to scarring and persistence of the phimosis [16]. Gentle manipulation during bathing is helpful.

A recent systematic review of phimosis prevalence at all ages found that the condition remained in 3.4% (range 0.5–13%) of uncircumcised males aged $\ge$18 years [18] (SIGN rating: Level 2++). Phimosis can result in pain, especially during erections, sexual dysfunction, increased risk of penile inflammatory conditions such as balanitis and penile cancer. Lichen sclerosus (next section) is usually accompanied by secondary phimosis. Steroid creams can be used [16], but are not always successful (see below), and circumcision is the definitive option [16] (Level 2+). Paraphimosis is an even more serious condition and involves failure of the foreskin to return after retraction. Constriction of the the glans leads to oedema, and in some cases ischaemia with a risk of progression to gangrene. Pararaphimosis is a urological emergency which may require immediate surgery, particularly if not detected in a timely fashion. Adolescent and young adult males may not know that they have phimosis and could suffer in silence.

The most common forms are balanitis and balanoposthitis that affect the glans penis and foreskin of uncircumcised boys [19]. In a meta-analysis, reported prevalence was 68% lower in uncircumcised males [20] (Level 1+). Circumcision was a common treatment for penile inflammation (as well as phimosis), but in recent years steroid creams have become more common [19, 21] (Level 1+). A recent meta-analysis of the devastating penile inflammatory condition lichen sclerosus (old term: balanitis xerotica obliterans) in boys aged 1 month to 15 years, found that steroid treatment for an average of 4 months (range 6 weeks to 5 years) avoided circumcision in just 35% of cases [21] (Level 1+). A commitment to regular application is required, which may limit compliance to prescribed treatment protocols, and there is a risk of side effects from long-term usage. In contrast, circumcision is ~100% effective and protection is lifelong [22].

In a large Australian survey, this fungal infection of the penis (commonly known in Australia as thrush), was reported by 7.7% of uncircumcised vs. 4.9% of circumcised men [7] (Level 2+). In boys of mean age 6.4 years (range 8 months to 18 years), prevalence was 18% in those who were circumcised vs. 44% in the uncircumcised [23]. Of interest, cases of phimosis, balanitis and candidiasis can occur in isolation or simultaneously.

Urinary tract infection (UTI) is more common among uncircumcised boys, especially those with underlying renal tract anomalies [16, 24, 25, 26]. UTIs are common in infancy and often present with the infant febrile, distressed and in pain. In infancy, the prevalence of febrile UTIs is highest (8.7%) in those aged 3 months, 3.3% in those aged 3–6 months and 1.7% in the 6–12 month old age group [16, 27]. Pediatric UTI can lead to significant short and long term morbidity [28]. The younger the infant, the higher the likelihood of progression to sepsis, and greater risk of fatality [29]. A survey in Sydney, Australia, found that by age 7 years, 2.1% of boys have had at least one UTI and another 4.8% have probably had one [30]. The fact that the infant kidney is still growing means greater susceptibility to renal injury and scarring [31, 32], so exposing half to serious, life-threatening conditions later in life [33].

The acute febrile illness results in 25% of boys with UTI being hospitalised and receiving a period of parenteral antibiotics [34, 35]. Older children are more likely to be able to be managed with oral antibiotics on an outpatient basis. Oral administration in infants is difficult and absorption is low, requiring hospitalisation to enable intravenous antibiotic administration [36, 37]. Emergence of resistance to most or all antibiotics, including methicillin, will make treatment of UTI more challenging [38, 39]. Maternal antibiotic use during pregnancy also increases the risk of resistant pathogens during neonatal UTI [40].

Pyelonephritis develops in ~80% of febrile infants and young boys diagnosed with UTI [41, 42]. In the US ~20,000 annual cases of acute pyelonephritis in infancy were prevented by MC [43]. Pyelonephritis leads to renal scarring in 36–52% of cases [41, 44]. Nuclear imaging studies have confirmed that renal scarring occurs following pyelonephritis even in the absence of vesicoureteric reflux (VUR) [45]. In boys without VUR, ~36% have recurrent UTI [46]. The reason is that the aetiology of renal scarring from pyelonephritis is parenchymal infection and inflammation rather than VUR [44, 45]. Permanent kidney damage is seen in 10–15% of boys with high grade VUR [47].

There are strong biological reasons why MC can prevent UTI [16] (Level 2+). Concentration of uropathogenic organisms near the urethral meatus is much higher in uncircumcised male infants than circumcised male infants in the highest risk period of 6 months post-birth [48]. The bacteria adhere to the foreskin’s mucosal surface and readily colonize it [49]. Since uropathogens are substantially lower by 3 weeks after circumcision of boys, it was suggested that by removing the foreskin MC eliminates the haven for organisms responsible for ascending UTI by changing it into an external skin surface [50, 51, 52]. For boys with hydronephrosis, MC is strongly recommended [53, 54].

A systematic review and meta-analysis that included data for 296,837 circumcised and 111,065 uncircumcised males (from 1 randomized controlled trial, 6 cohort studies, 11 case-control studies, 2 cross-sectional studies, 1 retrospective cross-sectional study and 1 retrospective analysis) found that for uncircumcised vs. circumcised boys, relative risk (RR) of UTI was 9.91-fold higher for age 0–1 year, 6.56-fold higher for age 1–16 years, and 3.41-fold higher for males aged over 16 years of age [55] (Level 1++). It calculated that, over the lifetime, 32.1% of uncircumcised males vs. 8.8% circumcised males develop UTI (RR = 3.65). Value for number needed to treat (NNT) was 4.29. Data from bag specimens or clean-catch urine samples were similar to those for studies in which most samples were from suprapubic aspiration or bladder catheterization. Risk reduction from being circumcised was, in older meta-analyses, 10–12 fold in infants [27, 56] (Level 2++), and 8-fold in a study combining infants and older males [57] (Level 2–). The latter reported a cumulative incidence of UTI of 1.1% in uncircumcised infant boys [57]. In boys aged under 5 years of age in Western Sydney, UTI was diagnosed in 6% of those uncircumcised and 1% (n = 2) of the circumcised [58]. Prevalence by age 2 years was 2.2% in a Swedish study [59] and was 3.6% to age 16 in a UK study [60]. Recurrence of UTI was seen in 35% of boys diagnosed with UTI in the first year of life [57]. Most (up to 12%) of recurrence occurs after the age of 12 months. Boys with more than 2 recurrent UTIs often have urinary tract abnormalities. For those with high grade VUR, NNT by circumcision is low [57] (Level 2+). In uncircumcised boys with recurrent UTI MC should be advised for treatment. A past chair of the AAP Task Force on infant MC strongly recommended early MC to avoid risk of renal damage in immature kidneys and of VUR from pyelonephritis [29]. He compared postponing MC to postponing vaccinations. The level of protection that newborn MC affords against UTIs is comparable to that of many vaccines given to children to prevent other infections and diseases [61], an example being vaccination against influenza [62, 63].

A 2021 study of Medical Benefits Scheme (MBS) claims found that early MC in Australia declined from a peak of ~85% in the 1950s to 18.75% in 2019 [8]. The authors concluded that “Medical and surgical authorities may have played an important role in the gradual reduction of procedures over the last decade”. In particular, negative policies instituted in the 1970s following the appointment of paediatricians from the UK to Chairs of pediatrics contributed to these [184]. In the UK, MC is a “mark” of the upper classes. An overall decline in early MC of boys in the UK occurred after 1949 following the withdrawal of coverage by the National Health Service (NHS).

A study examining the US Pediatric Health Information System database of MC prevalence at different ages in US hospitals found an increase in the rate of neonatal MC ensued in response to the AAP’s 2012 affirmative policy in which a literature review led the AAP to conclude that the benefits of MC during the neonatal period outweigh the risks and recommended various means to increase rates, partly because “circumcision during the birth hospitalization in the neonatal period is more resource-effective than postponing until later in infancy” [185]. In the US, up until 2012 there had been a downturn in neonatal MC prevalence. This was attributed to weak paediatric policy statements prior to 2012, increased immigration from countries, particularly Hispanic, in which MC is uncommon, a dimunition in access and affordability owing to non-coverage in some states by Medicaid, and lobbying by MC opponents [186].

RCT findings [187, 188] (Level 1+), a large UK survey [189] (Level 2++), 4 systematic reviews [190, 191, 192, 193] (Level 2++) and 2 Meta-analyses [191, 192] (Level 1+) showed that MC has no adverse effect on sexual function, penile sensitivity, nor sexual sensation, arousal, or pleasure. The most recent meta-analysis found 64% of circumcised vs. uncircumcised men experienced less pain during intercourse, 28% had lower ejaculation latency time, and 58% had less erectile dysfunction [192]. An Australian study found sexual experience in homosexual men circumcised early was unaffected [194] (Level 2++). However, homosexual men circumcised later in life for medical reasons were more likely to report sexual problems. A systematic review critically comparing high quality evidence with evidence of sexual harms from infant MC strongly favoured the former over the latter [78] (Level 2++). A study involving only men who believed their sex life had been diminished by their early MC [195] (Level 2–) was critically evaluated and shown to be flawed owing to recruitment bias, none of the self-selected participants claimed problems having been confirmed by a medical practitioner, “loaded” and subjective questions and exaggerated responses, “cherry-picked” information that contradicted high-quality evidence, and confirmation bias [196].

Quantitative sensory testing found no difference in penile sensitivity between circumcised and uncircumcised men [197]. Using thermal imaging, another study found basal temperature of the penis of circumcised men was higher, and in response to an erotic video, temperature during erection more rapidly reached the same plateau as uncircumcised men, and a greater proportion of circumcised men reported being sexually aroused whereas a greater proportion of uncircumcised men reported being unaffected [198] (Level 2+). Such methods, moreover, revealed the foreskin is not involved in sexual sensitivity, sensation or pleasure [198, 199] (Level 2++). The neuroreceptors responsible are genital corpuscles located in the glans and underside of the distal shaft, thus further ruling out the foreskin as a location of pleasure response [200] (Level 2++). Tugging the foreskin could, via the frenulum, stimulate genital corpuscles in the shaft. Less pain and better erectile function in circumcised men were found in a large Australian survey [201].

Women’s experiences of circumcised vs. uncircumcised male sexual partners were found in systematic reviews to favour the circumcised penis [202, 203] (Level 2++). The reasons were esthetics, ease of vaginal penetration, less dyspareunia, better hygiene, and reduced risk of infection [202, 203].

Considering data relevant to an Australian context, a risk-benefit analysis found that based on data for level of protection and prevalence of conditions for which early MC provides protection and the frequency of procedural complications benefits were calculated to exceed risk by approximately 200 to 1 (Table 1, Ref. [7, 15, 18, 20, 55, 70, 98, 112, 113, 114, 115, 116, 117, 118, 121, 122, 151, 162, 190, 191, 200, 204, 205, 206, 207, 208, 209, 210, 211]). Furthermore, over their lifetime an estimated 80% of uncircumcised males would likely suffer an adverse medical condition attributable to their foreskin.

The Plastibell, Gomco and Mogen devices are commonly used for neonatal MC, the Plastibell being particularly common in Australia. For a detailed description of the technique involved in each of these see: [212]. Circumcision should be indicated for most male neonates. The practioner needs to be aware, however, that there are several contraindications (Table 2).

Risk of an adverse event from MC is $\le$0.5% during infancy [11, 16, 207, 208, 213]. Most adverse events are minor, and can be immediately and easily treated, with complete resolution, but some very rare complications can be severe [16]. In older boys and men complications are 10–20 times higher [207, 208] (Level 2++). Traditional/ritual MC presents a higher risk than medical MC by a competent practitioner [214]. Provider training is essential to reduce risk of complications [215]. A New Zealand birth cohort study found neonatally circumcised males followed from infancy had fewer penile problems than the uncircumcised [216], and no differences in breastfeeding outcomes, health in infancy nor cognitive ability in later childhood [217] (Level 2++). US findings were similar [218, 219].

Risk of post-MC meatal stenosis was low (0.66%) in a recent Meta-analysis [220] (Level 1++). Its diagnosis by visual inspection is subjective, leading to over-estimation of prevalence. Most cases were asymptotic with no obstructive uropathy. An appearance of meatal stenosis at age 3–8 years in boys circumcised neonatally may be an illusion arising from a ventral “meatal web” [221] (Level 2+). Monitoring for meatal stenosis onset by repeated visual inspection found that most cases developed on average 2–4 weeks after neonatal MC and 95% were asymptomatic [222] (Level 2+). This challenges the idea that meatal stenosis is a long-term complication of MC. Diagnosis should only be made on the basis of urine flow rate, evidence of urinary tract blockage, or testing of kidney function.

Meatal examination in the circumcised male is trivial. In uncircumcised infants only 54% had a visible meatus [17], as did 47% of uncircumcised boys aged 3 years [223]. The reason is because non-retractile foreskins are common [224], so impeding visual inspection. Data from a Danish study of meatal stenosis [225] (Level 2+), when examined in detail by others, revealed overall prevalence of 0.12% in uncircumcised males and 0.099% in circumcised males [226]. Prevalence of meatal stenosis increases with age, a major cause being from penile inflammation secondary to lichen sclerosis, a condition much more common in uncircumcised than in circumcised males [19], as was apparent in the Danish study [226].

Circumcision must be performed using adequate anaesthesia and analgesia [16]. For a comprehensive review see [16]. Local anaesthesia is recommended for neonatal MC. After the infant becomes mobile general anaesthesia may be required.

Boys circumcised neonatally without anaesthetic exhibited greater pain and crying response during routine immunisation at age 4–6 months compared with uncircumcised boys and boys who had received topical anaesthesia during their circumcision [227, 228] (Level 2+). A systematic review found there was little effect on breastfeeding or cognitive ability, and that low quality studies reporting associations with sudden infant death syndrome, autism, alexithymia, impaired sexual experience and socio-affective processing contained flaws in study design, statistical analysis, sample size and other factors rendering them unreliable [78] (Level 2++).

The AAP and Canadian Paediatric Society issued joint guidelines in 2000 for prevention and management of pain and stress in the neonate [229] (Level 2++). Anaesthetic techniques were reviewed in the AAP’s 2012 policy statement [11]. Topical administration of eutectic mixture of local anaesthetics (EMLA 5%, an emulsion containing 2.5% lidocaine and 2.5% prilocaine), when applied 60 to 80 minutes before the procedure, was superior to placebo in attenuating MC pain measured by heart rate, oxygen saturation, facial responses, as well as period and characteristics of crying [230, 231] (Level 2+). LMX4 lidocaine 4% is a more recent local anaesthetic cream. Methods more effective than topical creams include dorsal penile nerve block (DPNB) and subcutaneous ring block [232, 233] (Level 1+). Each require training in application and avoidance of complications [234, 235, 236]. In its 2012 policy review, the AAP [11] referred to a landmark ultrasound guided technique developed by Sydney paediatric anaesthetists for correct needle placement during DPNB in children under general anaesthesia [235, 237]. This resulted in lower pain scores in the first postoperative hour and a longer interval should rescue analgesia be required. When the infant is younger than 6 months, general anaesthesia for MC should be avoided [238]. General anaesthesia has inherent risks, albiet low. Local anaesthesia is much cheaper, especially as it does not require the services of an anaesthetist [239]. Another technique is caudal epidural block, which can be used during MC of older children [240] (Level 1+).

The 2012 AAP policy statement mentioned the possible risk of methaemoglobinemia with lidocaine-prilocaine [11], but noted that when methaemoglobin has been measured after lidocaine-prilocaine application, the level, although elevated, was not clinically significant [231]. The AAP nevertheless noted isolated case reports of clinically significant methaemoglobinemia, but those involved prolonged application time or its use in premature infants [11].

The reasons for the decline in early MC in the US has included cessation of Medicaid coverage for the procedure in 18 States. Any such decline was deemed, in the long-term, to result in substantially higher costs because of: (1) the need for more expensive MC to treat medical conditions that could have been prevented had MC been performed shortly after birth [75, 241, 242, 243, 244], (2) the fact that later MC is associated with a 10–20 fold higher risk of complications [208], and (3) treatment required for the wide array of adverse medical conditions that would have likely been prevented or reduced in frequency had the boy been circumcised early [75, 155, 241, 242, 243, 244, 245, 246]. It was estimated by researchers at Johns Hopkins University that if MC declined from the high US levels to a level of 10%, direct costs for treatment of UTIs and STIs would rise to US$4.4 billion for 10 annual birth cohorts [241] (Level 2++). The increase in expenditure was said to be on average US$313 per foregone MC. Indirect costs for just HIV may be more than 4 times the direct medical costs [247]. The CDC reported that in the US MC was cost-saving for HIV prevention in black and Hispanic males in whom HIV prevalence is highest [75]. If one took into account the other conditions prevented by MC, direct and indirect costs would be even higher. For prostate cancer, without MC there would be 24–40% more cases in the US and US$0.8–1.1 billion extra in costs for treatment and terminal care per year [165].

Several US states do not provide Medicaid coverage for elective MC, so making MC unaffordable for poor families. As a result, the decrease in infant MC in the poor has resulted in over 100 additional HIV cases and US$30M in medical treatment costs annually [242]. The MC cost in the birth cohort was US$4,856,000, which was found to be 6% of the cost just for treatment of HIV. In Louisiana [243] and Florida [244], cost savings initially generated by not allowing Medicaid to cover elective infant MC were mitigated by increases in rate and expense of medically indicated MC required later to treat various conditions. Since the Louisiana study only considered costs of later MC of boys aged 0–5 years, lifetime costs would likely be far greater, impacting healthcare systems. Medicaid defunding in Florida was shown to result in a 6-fold increase in publicly-funded MC and to cost US$112M [244]. Florida responded by restoring Medicaid coverage for elective MC [248]. In Australia and New Zealand, the lack of government coverage for non-therapeutic MC in public health systems would similarly be having cost impacts for treatment of medical conditions protected against by neonatal MC. An increase in early MC in Australia to 85% from the current level of 18.75% [8] would avoid 77,000 cases of infections and other adverse medical conditions over the lifetime for each annual birth cohort (Table 1).

Circumcision of males is a legal procedure in virtually all countries worldwide, including Australia, New Zealand, the UK, the USA and Canada. In Australia and New Zealand legality is based on well-established rights of parents to make decisions about medical care for their children. Generally, both parents should agree. Australia has ratified Article 24(3) of the United Nations Convention on the Rights of the Child [249]. Consistent with Australian legislation, Article 24(3) requires that the best interests of the child shall be the primary consideration.

Despite attempts to legislate against circumcision of male minors in Scandinavian countries, circumcision of boys remains legal. A controversial case in Cologne in 2012 concerning a bleeding complication in a Muslim boy circumcised by a Muslim doctor was misconstrued by news media and others as Germany having banned MC, whereas that regional court had ruled the illegality of MC of boys to be among the “undecided questions of law,” concluding that the defendant was not guilty of a criminal, act and was acquitted, with costs ordered to be paid from public funds [250]. An appeal failed. The German Parliament then enacted legislation upholding the legal right of parents to choose MC for their sons, providing that it was performed by a trained professional in a safe environment [251].

An attempt to have infant MC banned in San Francisco was challenged in court and a bill was subsequently passed unanimously by both houses of the California legislature to prevent any future municipal initiatives to ban MC and other medical procedures [252]. Arguments supporting the legality of infant MC were presented by a member of the AAP’s 2012 Task Force on MC [253]. Arguments challenging the legality of MC of minors in the US were considered by legal, bioethics and medical academics to depend on speculative claims, obfuscation of scientific data, failure to appreciate benefits or the higher risks and barriers to later MC, to be inconsistent with evidence that parent-approved MC is legal, ethical (see next section), is in the best interests of the health of the male child, and consistent with the Hippocratic Oath which contains the statement “I will prevent disease whenever I can, for prevention is preferable to cure” [254, 255, 256]. The oft quoted “First do no harm” (Latin: “primum non nocere”) is a mistranslation of the Greek text “ὠ$\phi$$ϵ$$\lambda$$\acute{ϵ}$$ϵ$$\iota$$\nu$$\acute{\eta }$$\mu$ὴ $\beta$$\lambda$$́\alpha$$\pi$$\tau$$ϵ$$\iota$$\nu$”, the English translation of which is “for better or for worse” or “for good or ill”.

Decisions by legislative and judicial bodies in Australia upholding the legality of MC appear in a review by a lawyer and medical experts [257]. That review found a Tasmanian report recommending prohibition [258] to be illogical, dangerous, unworkable, and that doctors should have guaranteed protection in performing medical procedures based on sound evidence of effectiveness and safety [257]. The report has never been presented to the Tasmanian Parliament.

Parents’ reasons for choosing circumcision for a son include better health, hygiene, appearance, culture and religion [259]. Scholarly assessments support circumcision of male minors as being ethical [253, 257, 260, 261, 262, 263, 264, 265, 266]. When considering the wide-ranging protection that MC affords against an array of adverse medical conditions and infections in infancy and childhood, and STIs in adolescent boys who become sexually active, there are cogent arguments as to why it would be unethical to leave boys uncircumcised [257, 263]. Ethicists and others have interpreted Article 24(3) of the United Nations International Convention of the Rights of the Child as mandating MC, since not doing so would be prejudicial to male health [263]. Nevertheless, in line with views published by AAP Task Force member and professor of bioethics Douglas Diekema [267], the AAP’s 2012 infant MC policy states, “parents should weigh health benefits and risks in light of their own religious, cultural, and personal preferences, as the medical benefits alone may not outweigh these other considerations for individual families” [11]. Medical practitioners with a conscientious objection to performing the procedure should refer parents to another doctor.

Accurate information on benefits and risks should be provided to all parents in an unbiassed manner, ideally early in a pregnancy should they be having a son.Parents should be informed that the option of delaying MC beyond early infancy, or leaving it to the boy to decide, will mean missing out on benefits early in life and pose substantial obstacles that may ultimately mean it will not happen, so diminishing the health and other benefits and increasing the risk of adverse medical conditions over his lifespan (Table 3). While some males may resent their parents’ decision to have them circumcised as a baby, others who were not circumcised in infancy may resent their parents’ decision not to have them circumcised, especially if suffering from infections and other medical conditions that may have been avoided by being circumcised.

Opponents of boyhood circumcision have used ethical arguments in support of their cause. A consortium of mostly Northern Europeans alleged that the AAP’s 2012 infant MC policy was culturally biased, arguing that the only relevant benefit was protection against UTI, extent of complications was unknown, and that there “are no compelling reasons for surgery before boys are old enough to decide for themselves” [268]. In response, the AAP Task Force on infant MC found the opinions expressed were “not comprehensive, systematic, or unbiased,” instead containing false and one-sided information, suggested that the “obvious” cultural bias referred to stemmed from “the normality of non-therapeutic MC in the US,” arguing that because “approximately half of US males are circumcised, and half are not,” any bias “is more likely likely to be neutral… so predisposing the AAP Task Force to a more dispassionate analysis of the scientific literature than a culture with a bias that is either strongly opposed to circumcision or strongly in favor of it” [269]. Arguments that the AAP’s policy was unethical and unlawful [35] were shown by academics with expertise in medicine, ethics and law to lack merit, because arguments against MC involve “poor understanding of epidemiology, erroneous interpretation of the evidence, selective citation of the literature, statistical manipulation of data, and circular reasoning” [254, 270]. Similarly, such experts repudiated [255, 271] criticisms of the CDC’s 2014 draft recommendations [272, 273] by pointing out that the strong medical evidence would make it unethical to withhold information about the risks and benefits of MC from parents of boys. They quoted the following from Article 24(1) of the United Nations International Convention on the Rights of the Child: “States Parties recognize the right of the child to the enjoyment of the highest attainable standard of health” and “shall strive to ensure that no child is deprived of his or her right of access to health care services.” A recent systematic review [78] has provided a detailed evaluation of the contrasting arguments and counter-arguments published by MC opponents and proponents.

This review finds that circumcision of boys early in infancy is a low risk procedure providing a lifetime of benefits by protecting against infection and disease. Medical practitioners, nurses and other health professions in Australia have an ethical duty to present clear and unbiased information to parents of boys and to men regarding the range of benefits from MC, the net level of lifetime protection against disease, the low prevalence of procedural risks, that MC is generally performed using local anaesthesia in neonates, and, if need be, to direct parents to competent operators when they choose to proceed. The Circumcision Academy of Australia’s policy recommendations appear in Table 4.

AAP, American Academy of Pediatrics; CDC, Centers for Disease Control and Prevention; HPV, human papillomavirus; LMX4, a topical anesthetic cream containing 4% lidocaine; MC, male circumcision; MSM, men who have sex with men; RCT, randomized controlled trial; RR, relative risk; SIGN, Scottish Intercollegiate Guidelines Network; STIs, sexually transmitted infections; UNAIDS, Joint United Nations Programme on HIV/AIDS; UTI, urinary tract infection; VMMC, voluntary medical MC; VUR, vesicoureteric reflux.

BJM conceived, designed the study, performed literature searches, and prepared the initial draft of the manuscript; AK, NJB, MH, ACS, LS, ERL, ADW and PK provided input to successive drafts.

Not applicable.

Thanks to all the peer reviewers for their opinions and suggestions.

This research received no external funding.

BJM is a Member of the Editorial Board of Journal of Men’s Health. MH is medical director of Quick Medical Pty Ltd, a company that markets medical devices, including circumcision devices, in Australia. All authors are Members of the Circumcision Academy of Australia, a not-for-profit, government registered, medical society that provides accurate, evidence-based information on male circumcision to parents, practitioners and others, as well as contact details of doctors who perform the procedure in Australia and New Zealand; PK is President, BJM is Secretary, NB is Treasurer and MH is Surgical Training Co-ordinator of this organization.