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There is now grade 1 evidence that male circumcision (MC) reduces the risk of a man acquiring HIV. Modelling studies indicate MC could in the next 10 years save up to 2 million lives in those African countries with high HIV prevalence. Several African countries are now scaling up public health MC programmes. The most effective immediate public health MC programmes in Africa will need to target 18-20 years old men. In the longer term there is a need for infant circumcision programmes. In order to implement more widespread MC there is a need to make the surgical procedures as simple as possible so that safe operations can be performed by paramedical staff. The WHO Manual of Male Circumcision under local anaesthetic was written with these objectives in mind. Included in the manual are three adult techniques and four paediatric procedures. The adult procedures are the dorsal slit, the forceps guided and the sleeve resection methods. Paediatric methods included are the plastibell technique, the Mogen and Gomco shield method and a standard surgical dorsal slit procedure. Each method is described in a step by step manner with photographic and line drawing illustrations. In addition to the WHO manual of surgical technique a teaching course has been developed and using this course it has been possible in one week to train a circumcision surgeon who has had no or minimal previous surgical experience. Further scaling will require training of circumcision surgeons, monitoring performance, training the trainer workshops as well as advocacy at national, international and government meetings. In addition to proceeding with standardised methods work is in progress to assess novel techniques in adults such as stay on ring devices and policies are being formulated as to how to assess new devices. Also work is in progress to explore efficiencies in surgical processing by task sharing. Proper informed consent and safety remain paramount and great care has to be taken as programmes in Africa scale up. In continental China where the HIV epidemic is at a much earlier stage there may be a case for considering infant circumcision but great care will be needed to ensure that there is no harm.

Adult male circumcision (MC) has been shown to reduce the transmission of HPV, HSV, and HIV significantly during vaginal intercourse. However, the benefits of adult MC for men in military service have been poorly documented. Soldiers in war time have additional challenges in maintaining good penile hygiene, rendering uncircumcised men vulnerable to inflammation and infection; these maladies not only negatively impact these individuals, but also undermine the overall military strength. Adult MC can provide some long-term benefits for these military service men. Many African countries have already taken a special interest in adult MC for their military forces, resulting in increased numbers of these surgeries among this special population of men. In this review, we discuss the history of adult MC in the military along with the current trends and economic significance.

Purpose: Studies undertaken in England and Scotland have identified a decrease in the number of circumcision operations being performed during childhood. The aims of this study were two-fold. Firstly, to determine the trend in circumcision operations performed in boys in Northern Ireland over a ten year period. Secondly, to compare the number of operations performed by paediatric surgeons with the number performed by general surgeons over the same period., Method: Data were collected from the Northern Ireland Department of Health and Social Services and Public Safety. A retrospective analysis was conducted of the number of circumcisions performed in boys aged between 0 and 13 years for the year beginning 1(st) September 1991 to the 1(st) of September 1992 and for the year beginning 1(st) September 2001 until the 1(st) of September 2002., Results: 769 circumcisions were performed in the year 1991 to 1992 compared with 264 in the year 2001 to 2002, representing a 66% decrease. In the ten year study period, the number of circumcisions performed by general surgeons fell by 71% whilst specialist paediatric surgeons performed 56% less., Conclusions: The decrease in rates of circumcision in boys aged 0 to 13 years in Northern Ireland is consistent with trends in the remainder of the United Kingdom. The results also suggest a greater decrease in the proportion of circumcisions being performed by general surgeons in district general hospitals compared to those performed by paediatric surgeons.

People who use and abuse alcohol and other drugs are an important population to target for HIV prevention because they are more likely to engage in sexual behaviors that increase their likelihood of acquiring or transmitting HIV. A variety of biomedical approaches to HIV prevention have been evaluated or currently are being studied. These approaches include an anti-HIV vaccine; topical protection treatments; and additional biomedical and barrier approaches, such as controlling sexually transmitted diseases, male circumcision, diaphragm use, and substance abuse treatment. The article also reviews topical versus oral antiretrovirals to prevent HIV transmission, antiretroviral treatment as prevention, and the role of alcohol and other drug use in HIV prevention.

Background: It has been suggested that too many English boys undergo circumcision. This report describes how circumcision rates have changed in England between 1997 and 2003, including data on complication rates and on how age, medical indication and surgical specialty affect postoperative haemorrhage rates., Methods: Data were extracted from the Hospital Episode Statistics database of admissions to National Health Service hospitals in England. Patients were included in the study if an Office of Population Censuses and Surveys version 4 code for circumcision was present in any of the operative procedure fields of the database; 75 868 boys below 15 years of age were included in the study., Results: Circumcision rates declined by about 20 per cent, from 2.6 per 1000 boys per year in 1997 to 2.1 in 2003. Between 2000 and 2003, circumcision rates remained static at 2.1 per 1000 boys per year. Circumcision rates fell by 31.2 per cent for boys aged 0-4 years, 9.3 per cent for boys aged 5-9 years and increased by 7.7 per cent in boys aged 10-14 years; 90.2 per cent of circumcisions were done for phimosis and 1.2 per cent of boys experienced a complication., Conclusion: Circumcision rates in England continued to fall up until 2000, particularly in those aged under 5 years, in whom pathological phimosis is rare. The circumcision rate remains five times higher than the reported incidence of Phimosis., (Copyright 2006 British Journal of Surgery Society Ltd.)

Purpose: There has been a move toward conservative management of foreskin problems. The aim of this study was to examine overall trends for circumcision in Scotland to see if there has been a decrease in the number of operations performed., Methods: Retrospective analysis looking at the number of circumcisions performed each year over a 10-year period (1990 to 2000), in the 0 to 13-year age group. The principal indication for circumcision in each case was ascertained as were the number of preputioplasties performed over the corresponding period., Results: A total of 15,605 circumcisions were performed during the 10-year period; 10,888 (69.8%) for phimosis, 2,724 (17.5%) for nonmedical/religious reasons, and 1993 (12.8%) for all other indications. There was a 33.7% decrease in total number of circumcisions performed between the first and second halves of the study period. The fall in operations performed is almost solely attributable (94.5%) to a reduction in number of procedures carried out for phimosis. There was a corresponding increase in preputioplasties performed over the study period., Conclusions: There has been a steady decrease in circumcision rates in Scotland. This is in keeping with greater appreciation of pathologic phimosis as distinguished from a healthy nonretractile foreskin, which does not require circumcision.

Objective: To investigate the high circumcision rate in South Korea and its rapid increase in the short period since its introduction., Subjects and Methods: From January to December 2000, 5434 South Korean males (or their parents) aged 0-92 years were interviewed in detail about their circumcision status, their age at circumcision, and the possible effect of circumcision on their sexuality. In addition, 267 practising medical doctors were surveyed about their basic understanding of circumcision and phimosis., Results: Currently the circumcision rate for high-school boys is > 90% and for those > 70 years old is < 10%. The circumcision rate in 1945 was < 0.1%. When averaged over the whole population, the present South Korean circumcision rate is approximately 60%; the rate has increased dramatically with time and particularly in the past 20 years, when the estimated number of male circumcisions has exceeded the number of male births. Although circumcision in South Korea has been strongly influenced by American culture, it has never been predominantly neonatal. The age at circumcision has continued to decrease and boys are now circumcised at approximately 12 years old. Of those who were circumcised long after they had been sexually active, > 80% reported no noticeable difference in sexuality, but a man was twice as likely to have experienced diminished sexuality than improved sexuality. Of the doctors who were surveyed, 41% carried out circumcision but, unlike in America, gynaecologists and paediatricians rarely did so. Among the doctors, basic knowledge on circumcision and phimosis was generally lacking, regardless of whether they practised circumcision or not. Amongst the factors contributing to the high circumcision rate was the mistaken notion held by both doctors and the general public that circumcision is directly correlated with industrialization and general progress of living standards. Many doctors believe the out-dated and sometimes controversial benefits of circumcision, i.e. prevention of cervical cancer and sexually transmitted diseases, and improved sexuality. Thus the vast majority of doctors recommend circumcision regardless of the patient's age. Peer pressure was also an important contributing factor., Conclusion: South Korea has an unusual history of circumcision. The mistaken and out-dated notions about circumcision and lack of knowledge of phimosis by physicians seem to be a leading contributory factor to the extraordinarily high circumcision rate.

Ritual circumcision, an ancient tradition with deep religious significance, is practiced by many cultures including those of the Jewish faith. As with any surgical procedure, there are some risks involved. Parents who choose to have their child circumcised in a ritual manner would benefit from the teaching that an informed nurse could provide in order to make an informed choice.

Nonmedical circumcision can no longer be considered routine in a new era of children's rights and more careful scrutiny of the medical necessity of surgical procedures. Although the minor procedure has been practised for centuries, custom and cultural factors may have had greater influence on the incidence of circumcision than the prevalence of problems such as penile cancer and urinary-tract infection that it was thought to prevent.

Systematic ablation of the prepuce of male children is a sexual mutilation based on the principle of metaphysical sacrifice. It is a painful but partial excision carried out on an organ destined to give pleasure, in order to purchase the right to use what's left. All the other justifications from hygiene to reinforced virility are spurious and have no scientific value. Circumcision is still imposed by African customs and most of monotheistic religions; it is an out-model practice which is destined to vanish as is the Chinese custom of foot-binding of young girls. In the meantime, we can suggest temporary measures which make their mark without mutilation.

Although urologists have played a key role in performing clinical studies providing the rationale for newborn circumcision, they have not had primary responsibility for the decision to perform the procedure. Recent confirmatory evidence that newborn circumcision has significant preventive health benefits has called attention to previous urologic articles. This review summarizes the contributions of urologists to the controversy on circumcision of newborns over the past sixty years and emphasizes the importance of clinical objectivity in this field.

American parents and health care professionals are faced with medical/ethical dilemmas regarding whether or not to respect the natural integrity of the male newborn's body. In the English-speaking countries, where circumcision of infants was initially adopted to prevent masturbation, medical "reasons" were postulated to justify a practice most of the world has never considered. This resulted in a spectrum of medical recommendations for surgical removal of normal genital tissue in all male newborns to prevent diseases (foreskin inflammation, urinary tract infections, and sexually transmitted diseases) that could be effectively treated medically without the risks of surgery. Only by denying the existence of excruciating pain, perinatal encoding of the brain with violence, interruption of maternal-infant bonding, betrayal of infant trust, the risks and effects of permanently altering normal genitalia, the right of human beings to sexually intact and functional bodies, and the right to individual religious freedoms can human beings continue this practice.

Presented is a model of providing parents with honest, unbiased education toward informed participation and consent relative to neonatal circumcision. Historical perspective and current understanding of medical benefits, risk, possible complications, alternatives, and expected after-care is explored. Particulars of how and why parents, who have the legal right and responsibility, decide about circumcision are discussed. Whether that decision is based on interpretation of medical opinion, parenting values, cultural mores, or religious beliefs, certified nurse-midwives (CNMs) must be able to advocate for families who make choices different from their own. For those CNMs incorporating circumcision into their practice, a survey revealed that 85% of California ACNM members support this. The 10-year experience of one midwifery service is detailed.

Follow-up research on women's work and health in two rural areas of Sudan in 1989 identified several areas of change since the 1970s. Health improvements due to better access to education and health services were noted. However, interethnic contacts have led to some experimentation with the severe form of female circumcision in one area while health education and the Islamic movement have contributed to a decline in popularity of it in another area. Further, the structure of agricultural development has resulted in changes in women's participation in agriculture and polygyny rates, which have had impacts on birth rates.

Despite the fact that circumcision of the new-born male has been practiced for at least 6,000 years, the procedure remains controversial. Circumcision rates in the United States remain among the highest of any nation in the industrialized world, yet there is little descriptive data on the demographic characteristics of newborns who are circumcised. New York State's hospital discharge data were used to examine demographic patterns for the procedure for the period 1980-1986. Circumcision was less common in New York City than in other areas of New York State, and was more common in private hospitals than in public hospitals. Whites had the highest rate of circumcision (70%), while Hispanics had the lowest (25%). Newborns under Medicaid coverage were more likely to be circumcised in voluntary hospitals than in public hospitals (45% vs 33%). We conclude that circumcision rates vary depending on a variety of factors, some of which may be attributable to the physician and others to family and society.

Vesicoureteral reflux has the potential to cause irreversible renal damage if undiagnosed and untreated. It is important to have a high index of suspicion for the existence of a urinary tract infection in infants and children with any nonspecific generalized illness. Once a UTI is documented, appropriate antibiotic therapy must be started and continued until the urinary tract has been adequately evaluated radiographically. If vesicoureteral reflux is found to exist, appropriate medical or surgical therapy must be instituted to prevent further episodes of pyelonephritis.

Ritual circumcision of males has been practiced for millennia, but was limited to fewer than 20 per cent of the world's population. About a century ago, only the English-speaking countries adopted non-religious circumcision as a prophylactic or therapeutic panacea for myriad ailments. Since these "health" claims are now known to be unsubstantiated, the English-speaking countries either abandoned the practice or reduced the frequency of its performance; the only exception is the United States. This article examines the background for this enigma and suggests solutions.