Which countries circumcise boys

But a closer look reveals that, at least in the industrialized world, the health benefits of circumcision may be negligible. Circumcision, for example, does slightly lower the risk of a urinary-tract infection in male newborns. For every six urinary-tract infections prevented through circumcision , at least one infant is likely to suffer a complication from surgery, such as hemorrhage.

Men without a foreskin do appear less likely to get penile cancer. But the disease is uncommon —affecting roughly one in , men in the US each year—and fairly treatable. For a bit of perspective, women are times more likely to get breast cancer. And while it is true that three randomized trials in Africa found that circumcision more than halved the risk of men getting HIV , it is harder to justify a prophylactic procedure in a place with considerably less HIV risk.

In addition, the trials found that circumcision helped men who have sex with infected women. In America, however, HIV is transmitted primarily via nonsterile syringes or sex between men, and there is no evidence that a foreskin affects either mode. Johnson, a professor of obstetrics and gynecology at the University of Michigan who has authored several reports on the subject.

A closer look at how this religious rite became a national practice reveals some uncomfortable truths about health care in the US. Apparently, all it takes to popularize an elective preventative surgery with questionable health benefits is a mix of perverse incentives, personal bias, and ignorance. First, it helps to know a bit of history.

Although religious practitioners have been snipping foreskins for thousands of years, the medical practice dates from the late 19 th century—a time when the causes of most diseases were poorly understood.

Mystified by everything from epilepsy to madness, some physicians in both America and England began to suspect that the real trouble was phimosis, a condition when an overly tight foreskin hinders normal function.

By removing the foreskin, surgeons believed they could heal all sorts of maladies, from hernias to lunacy. Around the turn of the 20 th century, American epidemiologists were also trying to explain why Jews lived longer than other groups of people. The prevalence of circumcision varies widely in western countries led by the USA 71 per cent , New Zealand 33 per cent , Australia 27 per cent , the UK 21 per cent , France 14 per cent , Germany 11 per cent , Sweden 5 per cent , Italy 3 per cent and Ireland 1 per cent.

The estimate indicates that circumcision is higher among countries where the Muslim or Jewish faith are commonplace, such as Iran per cent , Iraq 99 per cent , West Bank 99 per cent , Yemen 99 per cent , Indonesia 93 per cent , Syria 93 per cent , and Israel 92 per cent.

Sydney's commuting cyclists are twice as happy as people who drive, walk or use public transport to get to work, University of Sydney research reveals. University home. Current students. MC is virtually universal in Jewish and Muslim populations [ 1 , 15 , 17 ]. Data for Muslim population sizes in various countries usually are known more precisely than MC prevalence in those countries [ 18 , 19 ].

Data for the percentage of Jews by country were obtained from the Jewish Virtual Library [ 20 ]. Data for the percentage of Muslims by country were obtained from Pew Research Center reports [ 18 , 19 ]. For each country that lacked survey data for the percentage of circumcised males, the prevalence of MC was estimated from the sum of the numbers of Jewish and Muslim males.

We assumed that Since the statistics on MC in Polynesian countries are not well-documented, estimates of MC prevalence in these countries were based on the proportion of people in each country who are indigenous, as ascertained by Internet searches by the name of the country and population category.

Since the total population of all Pacific Island nations represents about 0. Since MC is performed worldwide to treat adverse medical conditions such as phimosis, paraphimosis, balanoposthitis, and penile cancer [ 4 , 26 — 28 ], no country is likely to have a MC prevalence of zero.

We therefore set the lowest estimate for any country at 0. In Denmark, for example, where non-medical circumcision is rare, a large survey found 4.

Most of these MCs took place after infancy and, given historical opposition to MC in Denmark, were probably for treatment of an adverse medical condition caused by the presence of the foreskin [ 29 ]. In Australia, where MC has been common in infancy for many years, of the In order to estimate the global prevalence of circumcision, we started with known figures for number of males in each country using two different authorities due to limitations in various databanks.

We used CIA data for the total population of each country in the world [ 25 ] and data for sex ratio [ 31 ]. For six very small countries with populations between 48 and Christmas Island, Niue, Norfolk Island, Pitcairn Island, Svalbard, and Tokelauno no data were available, so the average sex ratio for the entire world of 1.

The second source, UN data for males aged 15—64 years [ 32 ], provides the age range used by most surveys that estimate MC prevalence. This database, however, lacks information for 45 countries and territories, many of which are small. Dividing the number of circumcised males by the total number of males in a country gave figures for the fraction of circumcised males in each country. We then summed the number of males in each country to obtain the total number of males in the world.

Following this, we summed the number of circumcised males in each country to obtain a total number of circumcised males globally. Dividing the latter by the former yielded an estimate of the percentage of males globally who are circumcised. Additional file 1 lists alphabetically those countries for which surveys of MC prevalence were available [ 26 , 27 , 29 , 33 — ] and provides reported country estimates, together with size of the survey, age range of males, national or regional survey scope, urban or rural and other demographic information, and the relevant citation.

The estimated percentage of circumcised males for each country or territory appears in Additional file 2 , column 4. Nationally representative survey data in this file had the benefit of involving large numbers, thus increasing the precision of the estimates. However, self-report tends to introduce uncertainty because manhood initiation ceremonies in some traditional settings of sub-Saharan Africa may or may not include complete MC [ ]. Since most of the values obtained were for males aged 15 years of age and over, they reflected MCs that had been performed in infancy or by late adolescence, depending on country and culture.

Purported MC estimates in infancy may be unreliable because they are based on hospital discharge data and many boys are circumcised after discharge of the mother and her baby post-partum, whereas survey data in mature males appear to be more accurate [ 4 ]. This file also shows the percentage of Muslims in each country column 2 and the percentage of Jews column 3 [ 33 ]. Additional file 2 , column 6, shows the total number of circumcised males in each of the countries and territories, calculated from CIA databases as described in the Methods section.

For simplicity, raw values generated by our computations are shown. These are overly precise and should not be taken literally as they are merely working numbers suitable for use in further calculations.

Since CIA data does not give population figures by age group, we used the UN database of number of males aged 15—64 [ 32 ] to determine MC prevalence for a limited number of countries Additional file 3. Table 1 summarizes the percentage of MC prevalence determined for each country and territory in the world.

We then summed the total number for each country, starting first with figures obtained using the CIA database to calculate total males. This yielded an overly precise working figure of 1,,, circumcised males among the total number of 3,,, males in the world, constituting a working value for the purposes of the next calculation. Simple division of the former by the latter figure estimated global MC prevalence at approximately Prevalence estimates were based on religion for countries In only seven countries 2.

In countries with survey data on MC prevalence, the total number of males was 2,,,, i. The percentage of circumcised males in these countries was In 63 countries MC prevalence was greater than the global average of Given that Based on UN data for number of males aged 15—64 as the denominator in our calculation of MC prevalence Additional file 3 , we obtained a figure of The true global MC prevalence is not known precisely and can only be estimated. Nevertheless, some estimates are more reliable than others.

That estimate, based on data through , had some serious deficiencies, not least of which was the assumption, which was acknowledged as a limitation, that only Jews, Muslims, North Americans, and "Tribal Religionists" in Africa were circumcised. There was also poor consideration of populations falling into multiple groups; for example, North American Muslims appeared to have been counted twice. The WHO published online a better attempt to estimate global prevalence in [ 15 ].

This analysis utilized global numbers of Muslims and Jews as a base, and then added MC prevalence of the non-Muslim, non-Jewish populations of 17 countries. A weakness of the approach was that MC prevalence data were likely gathered from a population sample that included Muslims and Jews, resulting in a probable overestimate when applied to the smaller non-Muslim, non-Jewish population.

A second weakness was the relatively small number of countries for which non-religious MCs were considered. Additionally, since there has been a substantial increase in the availability of survey data, such as those compiled by DHS, AIS, and other reputable bodies, as well as publications in peer-reviewed journals, resulting in a stronger information base.

A disproportionate rise in Muslim immigrants as a proportion of the total population of other countries would contribute to increases in MC prevalence in each. While the present study involved the most thorough analysis yet conducted, several limitations should be noted.

All studies to date have suffered from the general difficulty of estimating MC prevalence in the absence of national surveys for every country. Survey data are based on the subpopulation of the total population that participated in the survey.

Large nationally representative surveys were more likely to provide the most accurate estimates of MC prevalence, whereas small surveys in sub-regions of a country have the potential to generate MC prevalence data that deviate from the actual national figure. As an example, a more recent, larger national survey in Brazil found overall MC prevalence to be 1.

This demonstrated that MC prevalence figures from older surveys confined to Sao Paulo [ 50 — 52 ] and Rio de Janeiro [ 49 ] had yielded figures higher than the national average. As well as significant regional variation in MC prevalence in some surveys, there was a higher prevalence noted among individuals and families with higher education and income. Our estimates for MC prevalence in many smaller countries and territories tended to be less precise.

Since those countries were small, however, the estimates for them made little contribution to our estimate of global MC prevalence. We chose, however, not to group these separately because we expected some readers would be interested in seeing estimates for these individual countries or territories.

Using this approach, we assumed, however, that if MC was performed it would have taken place in most males by 15 years of age. We nevertheless recognize that MC incidence may be rising or falling in some countries.

This represents an unavoidable potential limitation to estimates based on CIA data for number of males in each country. We overcame this limitation by using UN estimates of males aged 15—64 in each country. But the drawback of the UN database was that it did not include 45 countries. Nevertheless, those countries that were included likely led us to generate more accurate MC estimates for those than when using CIA figures for total males.

In this regard, our use of a minimum of 0. In relation to religion, examination of countries that had both survey data on proportion of Muslims who were circumcised and data on the Muslim population proportion showed a close match: Comoros The one exception was Albania, where survey data suggested In Albania, and possibly other countries, it is possible that a proportion of Muslims remained uncircumcised, that MC had not taken place by the age of 15 years, or there might have been reporting bias.

Survey data for the UK found From available data, it seems that the bigger the Muslim or Jewish population in a country, the more closely the actual MC prevalence likely matches the percentage of Muslims or Jews.

Perhaps societal or access factors in such countries may be influencing the decision by Muslim or Jewish parents to have their boy circumcised.

Awareness of the health benefits may be rising, as judged by publications and research by Chinese investigators, as well as the development in China of MC devices such as the Shang Ring [ ]. In sub-Saharan Africa, early recognition of the strong correlation between low MC prevalence and higher HIV prevalence prompted epidemiological studies to determine whether the two were linked.

Confirmation of the causal link in several randomized controlled trials led to the promotion of MC for HIV prevention, with over 10 million having already undergone the procedure since [ 10 ]. Figure 2 uses the current data and the most recent country-specific HIV figures [ 9 ] to demonstrate this relationship in Africa. Predicting MC prevalence based upon religion or culture is an approximation at best.

Comparing countries for which both predicted and reported MC rates are available showed that reported MC prevalence generally exceeded religion-based predictions for these particular countries Additional file 2. This may suggest that actual MC prevalence is greater than the value we estimated based on religion or culture in some countries lacking MC survey data.

However, large surveys base MC prevalence on self-reports and even with the use of drawings or photographs to assist men in accurate self-reporting, some men who are not circumcised report that they are, while some who are circumcised report that they are not [ 94 , , ]. For The total number of men in these countries 2. The proportion of males in surveyed countries who were circumcised was Considering that there were 73 countries with survey data As accurately as might reasonably be expected, the present study has determined estimates for the prevalence of MC in every country in the world.

Altogether, our findings suggest that MC prevalence globally is approximately Given the known benefits and low risks of MC [ 4 ] and recent affirmative recommendations in the interests of public health and disease prevention by the American Academy of Pediatrics, the CDC, the WHO and UNAIDS, as well as the large-scale roll out of VMMC by multilateral donors and agencies, the present findings on current prevalence of MC across geographies and cultures may help guide policy development and resource allocation in all countries.

Additional file 1: 46K, xlsx This spreadsheet provides data from published surveys on MC prevalence in all countries for which such studies have been conducted. XLSX 45 kb. This spreadsheet shows data for number of males using CIA data and estimates of number of circumcised males in all countries and territories in the world, as well as basis for the estimate and MC percentage for each.

XLSX 32 kb. This spreadsheet shows data for number of males using UN data for all but 45 countries and territories in the world and estimates of number of circumcised males in all but these 45, as well as basis for the estimate and MC percentage for each. XLSX 29 kb. Competing interests. BM set up the study design and was responsible for the conceptualization of the study. BM led the drafting. JB compiled Fig. BM wrote the initial draft.

All authors contributed to the interpretation and final manuscript drafting and approved the final version of the manuscript. Brian J Morris, Email: ua. Richard G Wamai, Email: ude. Esther B Henebeng, Email: ude. About one-third of males worldwide are circumcised. It is most common among Muslims and Jews , as it is part of religious law in Judaism and is an established practice in Islam. The prevalence of circumcision around the world, therefore, varies significantly by country. A study titled "Estimation of country-specific and global prevalence of male circumcision" looked at sources that contained data for mature males that were circumcised.