Evidence-based circumcision policy for Australia.

The aim was (1) to perform an up-to-date systematic review of the male circumcision (MC) literature and (2) to determine the number of adverse medical conditions prevented by early MC in Australia. Searches of PubMed using "circumcision" with 39 keywords and bibliography searches yielded 278 publications meeting our inclusion criteria. Early MC provides immediate and lifetime benefits, including protection against: urinary tract infections, phimosis, inflammatory skin conditions, inferior penile hygiene, candidiasis, various STIs, and penile and prostate cancer. In female partners MC reduces risk of STIs and cervical cancer. A risk-benefit analysis found benefits exceeded procedural risks, which are predominantly minor, by approximately 200 to 1. It was estimated that more than 1 in 2 uncircumcised males will experience an adverse foreskin-related medical condition over their lifetime. An increase in early MC in Australia to mid-1950s prevalence of 85% from the current level of 18.75% would avoid 77,000 cases of infections and other adverse medical conditions over the lifetime for each annual birth cohort. Survey data, physiological measurements, and the anatomical location of penile sensory receptors responsible for sexual sensation indicate that MC has no detrimental effect on sexual function, sensitivity or pleasure. US studies found that early infant MC is cost saving. Evidence-based reviews by the AAP and CDC support early MC as a desirable public health measure. Although MC can be performed at any age, early MC maximizes benefits and minimises procedural risks. Parents should routinely be provided with accurate, up-to-date evidence-based information in an unbiased manner early in a pregnancy so that they have time to weigh benefits and risks of early MC and make an informed decision should they have a son. Parental choice should be respected. A well-trained competent practitioner is essential and local anaesthesia should be routinely used. Third party coverage of costs is advocated.

Early infant male circumcision: Systematic review, risk-benefit analysis, and progress in policy.

AIM: To determine whether recent evidence-based United States policies on male circumcision (MC) apply to comparable Anglophone countries, Australia and New Zealand. METHODS: Articles in 2005 through 2015 were retrieved from PubMed using the keyword "circumcision" together with 36 relevant subtopics. A further PubMed search was performed for articles published in 2016. Searches of the EMBASE and Cochrane databases did not yield additional citable articles. Articles were assessed for quality and those rated 2+ and above according to the Scottish Intercollegiate Grading System were studied further. The most relevant and representative of the topic were included. Bibliographies were examined to retrieve further key references. Randomized controlled trials, recent high quality systematic reviews or meta-analyses (level 1++ or 1+ evidence) were prioritized for inclusion. A risk-benefit analysis of articles rated for quality was performed. For efficiency and reliability, recent randomized controlled trials, meta-analyses, high quality systematic reviews and large well-designed studies were used if available. Internet searches were conducted for other relevant information, including policies and Australian data on claims under Medicare for MC. RESULTS: Evidence-based policy statements by the American Academy of Pediatrics (AAP) and the Centers for Disease Control and Prevention (CDC) support infant and later age male circumcision (MC) as a desirable public health measure. Our systematic review of relevant literature over the past decade yielded 140 journal articles that met our inclusion criteria. Together, these showed that early infant MC confers immediate and lifelong benefits by protecting against urinary tract infections having potential adverse long-term renal effects, phimosis that causes difficult and painful erections and "ballooning" during urination, inflammatory skin conditions, inferior penile hygiene, candidiasis, various sexually transmissible infections in both sexes, genital ulcers, and penile, prostate and cervical cancer. Our risk-benefit analysis showed that benefits exceeded procedural risks, which are predominantly minor, by up to 200 to 1. We estimated that more than 1 in 2 uncircumcised males will experience an adverse foreskin-related medical condition over their lifetime. Wide-ranging evidence from surveys, physiological measurements, and the anatomical location of penile sensory receptors responsible for sexual sensation strongly and consistently suggested that MC has no detrimental effect on sexual function, sensitivity or pleasure. United States studies showed that early infant MC is cost saving. The evidence supporting early infant MC has further strengthened since the positive AAP and CDC reviews. CONCLUSION: Affirmative MC policies are needed in Australia and New Zealand. Routine provision of accurate, unbiased education, and access in public hospitals, will maximize health and financial benefits.

Heroin use impairs smoking cessation among Australian prisoners.

BACKGROUND: Prisoners have extremely high rates of smoking with rates 3-4 times higher than the general community. Many prisoners have used heroin. The aims of this study were to investigate the impact of heroin use on smoking cessation and the social determinants of health among prisoners. METHODS: Secondary analysis of data from a randomised controlled trial of a multi-component smoking cessation intervention involving 425 Australian male prisoners. Inmates who, prior to imprisonment, used heroin regularly were compared to those who did not use heroin regularly. Self-reported smoking status was validated at baseline and each follow-up by measuring carbon monoxide levels. Readings exceeding 10 ppm were defined as indicating current smoking. RESULTS: Over half (56.5%) of the participants had ever used heroin while 37.7% regularly (daily or almost daily) used heroin in the year prior to entering prison. Prisoners who regularly used heroin had significantly worse social determinants of health and smoking behaviours, including lower educational attainment, more frequent incarceration and earlier initiation into smoking. Prisoners who regularly used heroin also used and injected other drugs significantly more frequently. At 12-month follow-up, the smoking cessation of prisoners who had regularly used heroin was also significantly lower than prisoners who did not regularly use heroin, a finding confirmed by logistic regression. CONCLUSIONS: Regular heroin use prior to imprisonment is an important risk factor for unsuccessful attempts to quit smoking among prisoners and is also associated with worse social determinants of health, higher drug use, and worse smoking behaviours. More effective and earlier smoking cessation interventions are required for particularly disadvantaged groups. TRIAL REGISTRATION: This trial is registered with the Australian New Zealand Clinical Trials Registry 12606000229572.

(Re)introducing medicinal cannabis.

• After considering extensive scientific and medical evidence, a New South Wales Legislative Council multiparty committee recommended that medicinal cannabis should lawfully be made available for selected-use pharmacotherapy. • The evidence indicates that cannabis has genuine medicinal utility in patients with certain neuropathic conditions, with acceptable levels of risk from mostly mild side effects. • The potential medical benefits of cannabis pharmacotherapy have largely been overlooked, with research and society's attention, in most parts of the world, being directed towards the hazards of its recreational use. • The NSW Government has since dismissed the unanimous and compassionate recommendations of their committee.

Recommendation by a law body to ban infant male circumcision has serious worldwide implications for pediatric practice and human rights.

BACKGROUND: Recent attempts in the USA and Europe to ban the circumcision of male children have been unsuccessful. Of current concern is a report by the Tasmanian Law Reform Institute (TLRI) recommending that non-therapeutic circumcision be prohibited, with parents and doctors risking criminal sanctions except where the parents have strong religious and ethnic ties to circumcision. The acceptance of this recommendation would create a precedent for legislation elsewhere in the world, thereby posing a threat to pediatric practice, parental responsibilities and freedoms, and public health. DISCUSSION: The TLRI report ignores the scientific consensus within medical literature about circumcision. It contains legal and ethical arguments that are seriously flawed. Dispassionate ethical arguments and the United Nations Convention on the Rights of the Child are consistent with parents being permitted to authorize circumcision for their male child. Uncritical acceptance of the TLRI report's recommendations would strengthen and legitimize efforts to ban childhood male circumcision not just in Australia, but in other countries as well. The medical profession should be concerned about any attempt to criminalize a well-accepted and evidence-based medical procedure. The recommendations are illogical, pose potential dangers and seem unworkable in practice. There is no explanation of how the State could impose criminal charges against doctors and parents, nor of how such a punitive apparatus could be structured, nor how strength of ethnic or religious ties could be determined. The proposal could easily be used inappropriately, and discriminates against parents not tied to the religions specified. With time, religious exemptions could subsequently be overturned. The law, governments and the medical profession should reject the TLRI recommendations, especially since the recent affirmative infant male circumcision policy statement by the American Academy of Pediatrics attests to the significant individual and public health benefits and low risk of infant male circumcision. SUMMARY: Doctors should be allowed to perform medical procedures based on sound evidence of effectiveness and safety with guaranteed protection. Parents should be free to act in the best interests of the health of their infant son by having him circumcised should they choose.

Smoking and other drug characteristics of aboriginal and non-aboriginal prisoners in australia.

Introduction and Aim. Although tobacco and alcohol use have declined substantially in the Australian community, substance use among prisoners remains high. The aim was to compare the smoking, drug, and alcohol characteristics, sociodemographic profile, and general health of Aboriginal and non-Aboriginal male prisoners in a smoking cessation intervention. Design and Methods. This study was a descriptive cross-sectional analysis of data from 425 male prisoners who joined a quit smoking trial conducted at 18 correctional centres in NSW and Queensland using data collected by standardised self-report instruments. Results. Average age was 33 years with 15% from Aboriginal descent. Compared to non-Aboriginal prisoners, Aboriginal prisoners were significantly more likely to have left school with no qualifications, to have been institutionalised as a child, to be previously incarcerated, and commenced smoking at a younger age. The tobacco use profile of both groups was similar; most of them had a medium to high level of nicotine dependence, smoked roll your own tobacco, and were "serious" about quitting. Discussion and Conclusion. Despite differences in terms of sociodemographic characteristics and offending history, the smoking characteristics of Aboriginal and non- Aboriginal prisoners were similar. Incarceration offers an opportunity to encourage smoking cessation and reduction of drug use.

Should male circumcision be advocated for genital cancer prevention?

The recent policy statement by the Cancer Council of Australia on infant circumcision and cancer prevention and the announcement that the quadrivalent human papillomavirus (HPV) vaccine will be made available for boys in Australia prompted us to provide an assessment of genital cancer prevention. While HPV vaccination of boys should help reduce anal cancer in homosexual men and cervical cancer in women, it will have little or no impact on penile or prostate cancer. Male circumcision can reduce cervical, penile and possibly prostate cancer. Promotion of both HPV vaccination and male circumcision will synergistically maximize genital cancer prevention.

The challenges of reducing tobacco use among prisoners.

ISSUE: The prevalence of smoking among prisoners is exceptionally high and is often comorbid with alcohol and drug problems, mental illness and other health problems. This review paper summarises the literature and available research related to smoking prevalence and smoking cessation initiatives among prisoners and identifies areas of need for further research and intervention. APPROACH: This paper highlights three studies conducted in the New South Wales prison system which attempt to address these high rates of smoking including a feasibility study, a focus group study and a randomised controlled trial. KEY FINDINGS: The challenges of making systems-level changes to address these high rates of smoking are discussed including a recent National Summit on Tobacco Smoking in Prisons. IMPLICATIONS: Dissemination of research findings has assisted in highlighting the importance of tobacco smoking among prisoners and the need to develop culturally and setting appropriate smoking cessation initiatives for prisoners. CONCLUSIONS: As one of the most marginalised and socially disadvantaged populations in Australia, prisoners represent an important population to target for smoking cessation programs and interventions. This paper highlights a number of initiatives undertaken to address this problem and suggests directions for the future.

Male circumcision for HIV prevention: current evidence and implementation in sub-Saharan Africa.

Heterosexual exposure accounts for most HIV transmission in sub-Saharan Africa, and this mode, as a proportion of new infections, is escalating globally. The scientific evidence accumulated over more than 20 years shows that among the strategies advocated during this period for HIV prevention, male circumcision is one of, if not, the most efficacious epidemiologically, as well as cost-wise. Despite this, and recommendation of the procedure by global policy makers, national implementation has been slow. Additionally, some are not convinced of the protective effect of male circumcision and there are also reports, unsupported by evidence, that non-sex-related drivers play a major role in HIV transmission in sub-Saharan Africa. Here, we provide a critical evaluation of the state of the current evidence for male circumcision in reducing HIV infection in light of established transmission drivers, provide an update on programmes now in place in this region, and explain why policies based on established scientific evidence should be prioritized. We conclude that the evidence supports the need to accelerate the implementation of medical male circumcision programmes for HIV prevention in generalized heterosexual epidemics, as well as in countering the growing heterosexual transmission in countries where HIV prevalence is presently low.