**Update on Neonatal Male Circumcision: A Public Health Perspective Perspective**

**Update on Neonatal Male Circumcision: A Public Health** 

DOI: 10.5772/intechopen.71948

Kriengkrai Srithanaviboonchai

Kriengkrai Srithanaviboonchai Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.71948

#### **Abstract**

Male circumcision (MC) is an effective preventive health intervention. WHO and UNAIDS jointly recommend that the international community considers MC as a potential long-term HIV prevention measure. Neonatal male circumcision (NMC) is a type of MC performed within 1 month after birth. There are several advantages in favor of NMC over circumcision at a later age; it is simpler, safer, and cheaper. Maximum benefits of MC are achieved through NMC. NMC is also more convenient and risk compensation after the surgery is unnecessary. Concerns over NMC include child rights, pain during the surgery, possibility of reduced sexual pleasure, and a long timeframe before achieving HIV reduction benefits. The local HIV epidemic and medical guidelines, policies and strategies, public education and demand creation, finance, readiness of health system, staff training, monitoring and evaluation (M&E), and quality assurance should be considered before and during the implementation of NMC. This chapter uses Thailand as an example of how a country might benefit from introducing NMC as a public health measure. Parents should be informed about the benefits and risks of NMC where service is available to allow them to decide whether their children should be circumcised.

**Keywords:** circumcision, neonatal male circumcision, HIV prevention, STI prevention, Thailand

#### **1. Introduction**

Whether to promote neonatal male circumcision (NMC) as a preventive health measure has long been a contentious subject among health professionals and the general public. NMC has been performed as a modern health intervention in English-speaking countries for health and hygiene since the mid-nineteenth century [1]. Although NMC lessened in popularity in the United Kingdom before World War II [2] and later in the United States over the last few

Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons

decades [3], recent findings in several randomized controlled trials (RCT) confirming that male circumcision reduces heterosexual HIV acquisition [4–6], have renewed interest in NMC and debates continue on whether it should be promoted as a public health measure.

NMC, similar to other clinical procedures, has associated medical benefits and risks. However, current academic debates seem riddled with subjective feelings on the issue rather than a dispassionate analysis of recent scientific findings. Internet searches reveal many scientific articles written from the point of view of certain mind-sets, either concurring with NMC or deprecating NMC. These biases are also true regarding dedicated websites discussing circumcision. These articles and websites fall prey to social acceptability biases, which are not surprising given the sensitive nature of MC due to religious beliefs, cultural or religious rites, and sexuality. This conflicting information creates a lot of confusion among physicians and parents of newborn males. Many parents decide not to circumcise their babies, while many NMCs are routinely performed without support of factual scientific knowledge.

Other factors must be considered besides the theoretical medical benefits and risks for each individual. These include the characteristics of targeted localities, for example, real-life clinical circumstances, readiness of health staff, the local HIV epidemic, finance and costs, and related laws and regulations. The unique situation of each area will determine whether NMC should be promoted as a public health measure. Ethical and legal issues such as child rights are also important to explore.

After circumcision was confirmed as an effective HIV prevention measure, the author led a series of studies to evaluate the possibility of using NMC as a public health measure in Thailand [7–10]. The results and conclusions of those studies have been included in this chapter. The lessons learnt from Thailand might be useful for other countries with similar contexts.

surgeries are categorized and pinpoints the whereabouts of NMC within the broad range of circumcision types. NMC is highlighted and discussed because of its favorable characteristics over other types of circumcision. It should be noted that other terms are used to refer to NMC

Circumcision

Male circumcision Female genital mulaon

Medical male circumcision

> Neonatal male circumcision

Update on Neonatal Male Circumcision: A Public Health Perspective

http://dx.doi.org/10.5772/intechopen.71948

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Circumcision performed within 1 month aer birth

First, the word "male" is intentionally added into the term to make sure that we are specifically talking about circumcision in males. All forms of female genital mutilations, described by some as female circumcision, procedures that intentionally alter or cause injury to the female genital organs for non-medical reasons [11] are excluded from this article. These procedures, which occur in some regions of the world, have no medical benefit and harm girls and women in many ways. The complications can be short and long term and include excessive bleeding, infection, urinary problems, keloid, sexual problems, and psychological trauma [12]. Female genital mutilations are a clear example of human rights violation. Collective efforts to prohibit

The prevalence of global male circumcision is estimated at 39% [13]. MC can be classified as traditional and medical. About half of the circumcisions are performed traditionally and are generally associated with certain religious or cultural beliefs [13]. In Muslim and Jewish

such as "early infant male circumcision" and "newborn male circumcision."

Late male circumcision

Circumcision performed later than 1 month aer birth

*2.1.1. Exclusion of female genital mutilations*

**Figure 1.** Schematic presentation of types of circumcision.

Tradional male circumcision

and eliminate this practice are fully warranted.

*2.1.2. Traditional MC*

This chapter starts by elaborating on how NMC is different from other forms of circumcision and why it is worth be considered as a public health measure. Traditional circumcisions practiced under religious rituals are beyond the scope of this article. An objective summary of the pros and cons of NMC from up-to-date scientific evidence follows. This chapter touches upon important aspects of NMC as a public health measure. The author also discusses his views toward implementation of NMC impartially. Readers should consider this information with care and adapt it to suit their local context. The article ends with recommendations and conclusions. Finally, the author hopes that this article is valuable for those who hope to gain more insight on this very interesting health intervention.
