In this debate, many issues can be organised around a central question: if male circumcision is considered as an intervention to help reduce the HIV acquisition rates, when in the male life‐cycle should health authorities recommend that circumcision be performed? There seem to be three obvious points: soon after birth, just before sexual debut and at some point after sexual debut (sexual adulthood). Each point has highly interconnected advantages and disadvantages from medical, public health and ethical perspectives (table 1). Although promoting male circumcision at all ages simultaneously is possible in principle, limits of human and material resources in the health systems of developing countries may necessitate a less ambitious approach.
Table 1Ethical, medical and public health perspectives on male circumcision
As a measure of protection against HIV infection, circumcising soon after birth could have some important advantages. Some studies indicate that the protective effect is greater when circumcision takes place early in a man's life, presumably due to the thickening of the skin on the head of the penis.26
Another possible advantage is cost: neonatal circumcision could be integrated into existing reproductive health clinics, postnatal care services or programmes to prevent mother‐to‐child transmission of HIV. Neonatal circumcision also avoids lost days from school and work, associated with circumcision at later ages.
Circumcising at an early age can also avoid the thorny problem of risk compensation. Risk compensation is the common psychological phenomenon of an increase in risky behaviour due to a decrease in perceived risk.27
Just as some car drivers tend to take more risks on the road when they are wearing a seatbelt,28
men may engage more often in unsafe sex if they believe circumcision protects them from acquiring HIV. However, if circumcision takes place at an early age, it is unlikely that the intervention would have an impact on a man's HIV risk perception when he engages in sexual relations more than a decade later.
Although neonatal male circumcision has significant cost and public health advantages, the ethics of neonatal circumcision remain more complicated. As with other controversial paediatric interventions, the issues revolve largely around the issues of autonomy and consent. Neonatal circumcision is a form of non‐consensual surgery, and in the US, autonomy as a principle in medical ethics historically emerged from a legal case of non‐consensual surgery.29
Opponents of neonatal circumcision typically argue that surgical removal of a healthy child's foreskin without his informed consent is always wrong. Although parents regularly practice proxy decision‐making for their children when choosing other (and sometimes invasive) therapeutic interventions, and some other prevention measures are mandatory (ie, vaccinations), opponents of neonatal circumcision commonly argue that parents should wait until the child is old enough to make an autonomous decision.11
This autonomy‐centred argument is problematic for several reasons. First, it would be unreasonable from public health and ethical perspectives to permit childhood vaccinations, such as those, against diphtheria, tetanus and pertussis, while universally condemning neonatal male circumcision, if (as research may show) the neonatal male circumcision can offer long‐term vaccine‐level protection against HIV transmission, and if the child is living in a high‐HIV‐prevalence setting. In that case, the autonomy‐centred argument would both exclude the use of an intervention with a potentially substantial beneficial population‐level health effect, and restrict commonly accepted parental rights to choose what they believe is in their child's best interest. Furthermore, studies indicate that the perception of risk among young men at sexual debut is highly distorted.30
Many young men could refuse circumcision during adolescence due to not perceiving themselves at risk for HIV infection. Given the vagaries of adolescent decision‐making and the gravity of the decision, parents may reasonably wish to choose circumcision for their infants rather than wait for their sons to decide for themselves.
We should note some important disadvantages to neonatal circumcision as well. Circumcising male infants now, can only have an impact on the HIV epidemic more than a decade later. Other, less invasive and more effective methods of HIV prevention such as topical microbicides for males, pre‐exposure prophylactic drugs or HIV vaccines could be discovered before the children reach sexual debut. In this case, neonatal circumcision would lack some of its intended medical justification by the time the intervention began to exert a protective effect.
In addition, questions can be raised about the cultural acceptability of neonatal circumcision. Many ethnic groups in Africa circumcise, but most do so in early adolescence, because circumcision is often (particularly in rural areas) practised as part of a boy's rite of passage into manhood.31
Among currently circumcising groups, circumcising soon after birth could dramatically alter the social, psychological and cosmological dimensions of the traditional process of circumcision, and some communities may be reluctant to tolerate this degree of cultural change to stem new HIV infections. It could be easier for groups that do not currently circumcise to accept non‐ritualised, neonatal circumcision. In Botswana, circumcision practices were once rites of passage, but these were largely abandoned in the 19th and 20th centuries by the influence of western medical missionaries. A recent cross‐sectional survey in Botswana indicates that 55% of parents believe that if male circumcision offers protection against sexually transmitted diseases (including HIV), it should be performed before the age of 6 years, and 90% felt it should be performed in a hospital setting.32
Implementation of neonatal male circumcision as an HIV‐prevention strategy cannot be ethically sound without community‐based research into the acceptability of different approaches among currently circumcising and non‐circumcising groups.