Medical analysis of circumcision

Currently neonatal circumcision is not considered medically necessary according to professional medical organizations in Australia, Canada, the United Kingdom, and the United States. In their view the potential medical benefits of neonatal circumcision (including a lower rate of urinary tract infection in infants, a lower rate of penile cancer in adults, and a lower rate of infection of some sexually transmitted diseases, particularly HIV) do not significantly outweigh the potential medical risks (including bleeding, infection, surgical mishap, and rarely death).

Numerous medical studies have tried to assess the effects of circumcision. These studies are discussed below.

Sexual Effects

The medical evidence on the effects of circumcision on sexuality are somewhat contradictory. Nevertheless, a pattern is beginning to emerge as more research becomes available.

Circumcision was introduced into the Western nations with the intent of preventing "masturbatory insanity" by so sexually altering the penis that masturbation supposedly would be impossible.[1] However, masturbation proved to be possible even without a foreskin.[2]

Doctors have long recognized that the foreskin facilitates penetration of the female partner.[3] [4] The foreskin has a gliding action[5] [6] and that gliding action provides easy penetration. [7] and reduces friction during sexual intercourse.[8] The mobility of the foreskin allows natural lubricants to be retained, and makes the lubricants less exposed to the drying effect of the open air during intercourse.[9]

Lacking a foreskin, a circumcised man's penis is subject to a greater amount of abrasion throughout the day and some believe that this results in keratinization of the glans. This is often thought to diminish sensation as a man ages (however, recent research has shown that this is incorrect [10] [11]).

Winklemann identified the foreskin as a "specific erogenous zone" with nerve endings arranged in rete ridges.[12] Taylor et al. further developed this information with the discovery of a heavily innervated "ridged band" area near the tip of the foreskin.[13] Circumcision invariably removes this ridged band. It appears, therefore, that a diminution of sensory input to the central and autonomic nervous systems is likely to occur as a result of the excision of sensory nerves by circumcision. However, as Moses et al. noted, "it has not been demonstrated that this is associated with increased male sexual pleasure."

Circumcised men are also more likely to suffer erectile dysfunction, according to two studies [14][15] that were published in the Journal of Urology, although a number of other studies found conflicting results. Two prospective studies showed no effect on erectile function [16] [17], and an analysis of a national US survey found that in fact uncircumcised males have a higher rate of erectile dysfunction[18]. Another study from Turkey reported delayed ejaculation after circumcision[19]. A study in China evaluated the effect of circumcision on sexual function, and found that males circumcised in adult life tend to experience more erectile dysfunction, more difficult penetration, and prolonged intercourse.[20]

A survey of women who have had experience with both circumcised and intact males reported that the women tend to prefer an intact male sexual partner.[21] However, this study has been criticised on the grounds that it was performed by an anti-circumcision activist, and subjects were in large part recruited from an anti-circumcision mailing list. Additionally, to avoid dryness and painful intercourse, some couples require artificial lubricants during circumcised sex. A survey of 35 women in the New Zealand Medical Journal shows that male circumcision may affect female sexual response as well [22] (unfortunately, again, the validity of this survey has been questioned on account of the anti-circumcision bias of the investigators). This is sometimes misdiagnosed as dyspareunia, which can be a result of vaginal dryness.[23] However, not all couples experience these effects. A few couples in which the male has an intact foreskin also use lubricants, although this may be rarer.

A 1988 study of new mothers found that 71% preferred a circumcised partner for sexual intercourse, and 83% for giving fellatio. When asked why, 92% responded that it stays cleaner and 90% that it looks sexier. Although some of the women had not had direct contact with an uncircumcised penis, those that did expressed the same preference[24].

Phimosis

Phimosis is the inability to retract the prepuce over the glans penis after separation from the glans has occurred. The foreskin is joined to the glans, and is naturally unretractable when a baby is born. But there are differences of opinion about how long this should continue, and how the foreskin should be treated if it remains too tight for too long. Gairdner[25] published data regarding the age of first foreskin retraction in 1949 that is now thought to be incorrect. Unfortunately, this data still is presented in medical textbooks and taught in medical schools.[26] Many doctors, therefore, are misinformed about the natural developent of the foreskin, and this contributes to the mis-diagnosis of the normal non-retractile foreskin of childhood as pathological disease. Rickwood et al. write in their 2000 paper "Towards evidence based circumcision of English boys" in the British Medical Journal [27]:

Too many English boys, especially those under 5 years of age, are still being circumcised because of misdiagnosis of phimosis. What is phimosis? At birth, the foreskin is almost invariably non-retractable, but this state is transient and resolves in nearly all boys as they mature through puberty. Such normality, with an unscarred and pliant preputial orifice, is clearly distinguishable from pathological phimosis, a condition unambiguously characterised by secondary cicatrisation of the orifice, usually due to balanitis xerotica obliterans. This problem, the only absolute indication for circumcision, affects some 0.6% of boys, peaks in incidence at 11 years of age, and is rarely encountered before the age of 5. (...) Strictly, only some 0.6% of boys with pathological phimosis need to be circumcised, although more relaxed criteria would allow for a similar proportion affected by recurrent balanoposthitis.

A 1968 Danish study of 9,545 boys, which distinguished between phimosis and preputial adhesion, found that both conditions steadily declined as the boys became older: While the incidence of phimosis was at 8% among 6-7 year olds, it was only at 1% among 16-17 year olds; similarly, the incidence of preputial adhesion was 63% among 6-7 year olds, and only 3% among 16-17 year olds. The author, Jakob Øster, concluded that, "Phimosis is seen to be uncommon in schoolboys, and the indications for operation even rarer if the normal development of the prepuce is patiently awaited. When this policy is pursued, in the majority of cases of phimosis, it is seen to be a physiological condition which gradually disappears as the tissues develop." [28]

In contrast, a 1988 New Zealand study found that 16% of uncircumcised boys surveyed suffered from phimosis (no circumcised boy suffered) [29].

Images of phimosis.[30][31][32][33]

Paraphimosis

The American Academy of Family Physicians says:

"Paraphimosis is a urologic emergency, occurring in uncircumcised males, in which the foreskin becomes trapped behind the corona and forms a tight band of constricting tissue. Often iatrogenically induced, paraphimosis can be prevented by returning the prepuce to cover the glans following penile manipulation. Treatment often begins with reduction of edema, followed by a variety of options, including mechanical compression, pharmacologic therapy, puncture technique and dorsal slit. Prevention and early intervention are key elements in the management of paraphimosis. (Am Fam Physician 2000;62:2623-6,2628.)"[34]

The article goes on to say that the cause is most often iatrogenic (caused by doctors). It further stated:

"Rare causes of paraphimosis include self-inflicted injury to the penis (such as piercing a penile ring into the glans and paraphimosis secondary to penile erections."

Several different techniques are mentioned of dealing with this condition, and these are listed by the article in the American Family Physician, and also in the anti-circumcision site CIRP. [35] One procedure is minor surgery to make a small slit in the foreskin without removing any tissue.[36] Another method of treating paraphimosis is called the "Dundee technique." [37] Circumcision remains the preferred treatment in many cases.

Images of paraphimosis. [38][39]

Balanitis

Balanitis is inflammation of the glans penis. Balanitis involving the foreskin or prepuce is termed balanoposthitis. The most common complication of balanitis is phimosis, or inability to retract the foreskin from the glans penis.[40] Balanitis afflicts young boys generally only where a difficult to retract tight foreskin is present. It is generally believed to be more frequent in uncircumcised boys.[41]

Uncircumcised men with poor personal hygiene are most affected by balanitis. Lack of aeration and irritation because of smegma and discharge surrounding the glans penis causes inflammation and edema. Adherence of the foreskin to the inflamed and edematous glans penis causes phimosis.[42]

Inflammation has numerous causes, including irritation by environmental substances, physical trauma, and infection by a wide variety of pathogens, including bacteria, virus, yeast, or fungus — each of which require a particular treatment.

Good medical practice includes careful diagnosis with the aid of a good patient history, swabs and cultures, and pathologic examination of a biopsy. Only then can the proper treatment be prescribed.[43]

Many studies of balanitis do not examine the subjects' genital washing habits; a 1993 study by Birley et al. did so and found that excessive genital washing with soap may be a strong contributing factor to balanitis.[44]

Escala and Rickwood, in a 1989 examination of 100 cases of balanitis in childhood, concluded: "[T]he risk in any individual, uncircumcised boy appears to be no greater than 4%." [45].

Zoon's Balanitis also know as Balanitis Circumscripta Plasmacellularis or plasma cell balanitis (PCB) is an idiopathic, rare, benign penile dermatosis [46] for which circumcision will suffice for the management and treatment of. [47][48]

Images of balanitis [49][50][51][52]

Skin diseases

Researchers from the Imperial College School of Medicine, Chelsea & Westminster Hospital, London, England reported the results of their study of 357 patients referred for genital skin disease:

The most common diagnoses were psoriasis (n=94), penile infections (n=58), lichen sclerosus (n=52), lichen planus (n=39), seborrheic dermatitis (n=29), and Zoon balanitis (n=27). Less common diagnoses included squamous cell carcinoma (n=4), bowenoid papulosis (n=3), and Bowen disease (n=3). The age-adjusted odds ratio for all penile skin diseases associated with presence of the foreskin was 3.24 (95% confidence interval, 2.26-4.64). [53]

As this was a retrospective study, the differences between the circumcised and uncircumcised patients may be be related to other factors. Circumcision is more common in the wealthier sections of British society, and it is well known that health and wealth are positively correlated. This would be a confounding variable.

Some American military doctors have recommended prophylactic circumcision because of the difficult conditions during wartime. For example, a United States Army report regarding World War II noted that in case of penile lesions, the foreskin may "invite secondary infection". The sexually transmitted disease chancroid, now very uncommon, was also associated with phimosis, which could hardly occur in circumcised males, and "soldiers in combat were seldom able to practice personal hygiene". (Source: JF Patton, Medical Department, United States Army, Surgery in World War II, Urology , p. 64)

Circumcision and cancer

It is established that childhood circumcision reduces the incidence of penile cancer[54][55][56][57][58]; specifically in the United States the lifetime risk of an uncircumcised man for developing invasive penile cancer (IPC) is one in 600 [59], which is in excess of 3 times higher than for males neonatally circumcised.[60][61][62]

Early studies by circumcision advocates have found a reduced risk of penile cancer in circumcised males, or that their mates had a lower risk of cervical cancer. The idea that circumcision prevents penile cancer was first stated by Dr. Abraham Wolbarst in The Lancet (1932;1:150-3). In 1996, Paul M. Fleiss and Frederick Hodges wrote in a letter to the British Medical Journal in response to a paper on circumcision that relied on Wolbarst [63]:

Epidemiological studies disproved Wolbarst's myth long ago. In North America the rate of penile cancer has been estimated to be 1 in 100000 (...). Maden et al. reported penile cancer among a fifth of elderly patients from rural areas who had been circumcised neonatally and had been born at a time when the rate of neonatal circumcision was about 20% in rural populations. Their study also shows that the rate of penile cancer among men circumcised neonatally has risen in the United States relative to the rise in the rate of neonatal circumcision.

Fleiss and Hodges were heavily criticised for their article. In "Authors ignored main conclusion of study that they cited", Stanton points out:

Paul M Fleiss and Frederick Hodges claim that epidemiological studies long ago disproved the "myth" that neonatal circumcision has a protective effect against penile cancer. They quote only one such study, that of Maden et al, and, curiously, omit its main conclusion--that "absence of neonatal circumcision and potential resulting complications are associated with penile cancer." The odds ratio for those never circumcised compared with those who had undergone neonatal circumcision was 3.2 (95% confidence interval 1.8 to 5.7), while for those circumcised later it was 3.0 (1.4 to 6.6).

The American Cancer Society noted in a 1998 statement (pre-dating more recent studies) [64]:

"[T]he penile cancer risk is low in some uncircumcised populations, and the practice of circumcision is strongly associated with socio-ethnic factors, which in turn are associated with lessened risk. The consensus among studies that have taken these other factors into account is circumcision is not of value in preventing cancer of the penis.

"Proven penile cancer risk factors include having unprotected sexual relations with multiple partners (increasing the likelihood of human papillomavirus infection), and cigarette smoking."

It has also been noted that in spite of the fact that circumcision is only practiced on about 1.6% of boys in Denmark, the penile cancer rate is only 0.82 per 100,000, lower than the up to 2.2 per 100,000 estimated for the United States. According to circumcision opponent Robert S. Van Howe, M.D., Japan and Norway, countries in which fewer than 2 percent of men are circumcised, also have lower rates of penile cancer than the United States.

Some doctors promote non-therapeutic infant circumcision because of its proven effect in preventing penile cancer. Edgar Schoen has said:

In the US, incidence of penile cancer in circumcised men is essentially zero (about one reported case every five years), but it is 2.2 per 100 000 in uncircumcised men (about 1000 cases are reported annually). On the basis of life table analysis, Kochen and McCurdy estimated that an uncircumcised man in the US has a lifetime risk of penile cancer of one in 600.

During the last 50 years in the US, six major series of cancer of the penis encompassing more than 1600 cases have been reported; none of these cancer patients was circumcised in infancy. Human papilloma virus and smegma have been implicated in the aetiology of penile cancer. Of the approximately 50,000 cases of cancer of the penis that have occurred in the US since the 1930s (and which resulted in about 10,000 deaths), only 10 were reported in circumcised men.

(Source: Edgar J Schoen, Benefits of newborn circumcision: is Europe ignoring medical evidence?, Arch Dis Child 1997;77:258-260 ( September ); footnotes deleted.) [65]

In response to this, Rowena Hitchcock of the Department of Paediatric Surgery, John Radcliffe Hospital, Oxford, published a commentary in the same issue saying:

Circumcision as an alternative to hygiene in prevention of penile carcinoma is an oft voiced argument. The author has quoted figures based on the 1971 national cancer survey (US) and extrapolated from the unsupported assumption that all penile carcinomas occurred in uncircumcised males. More recent data calculate the relative risk in the US to be 3.2 times greater in the intact male. Using the author's own source, the quoted incidence of penile carcinoma in the US was one per 100,000 (1969-71). This is a comparable incidence with that in Finland at the same time, where the circumcision rate is less than 1%, of 0.5 per 100,000 (1970) with a 78% relative 20-year survival rate. Thus, I find Marshall's argument at a meeting of the Society for Paediatric Urology, that one would have to perform 140 circumcisions a week, for 25 years, to prevent one case of carcinoma of the penis, enough to prevent me from setting out on such a course.

Cervical cancer and HPV

The claim that circumcision reduces cervical cancer in female partners remains controversial. It was first put forward by Wynder et al. in 1954, with smegma as the hypothesized causative agent, but later relativated because female subjects gave incorrect information about the circumcision status of their partners (even a substantial number of males in the US fail to properly identify their circumcision status). Stern and Neely disproved the hypothesis that smegma causes cervical cancer in female partners in 1962 [66]. In 1996, the American Cancer Society stated: "Research suggesting a pattern in the circumcision status of partners of women with cervical cancer is methodologically flawed, outdated and has not been taken seriously in the medical community for decades."

Cervical cancer has been related to human papillomavirus infection. On this basis, an alternative hypothesis for the reduction of cervical cancer through circumcision has been proposed; namely, that there is a higher HPV infection rate among uncircumcised men. An international group of researchers conducted a study published in the New England Journal of Medicine concluded:

Male circumcision is associated with a reduced risk of penile HPV infection and, in the case of men with a history of multiple sexual partners, a reduced risk of cervical cancer in their current female partners. [67]

The study has elicited a strong response from opponents of forced circumcision. A detailed analysis from the Internet group "Circumstitions" [68], for example, criticized especially the pooling of data from countries with very different circumcision rates. The only country with a high circumcision rate in the sample were the Philippines, so that the comparison of circumcision rate and HPV rate is also a comparison of HPV rate in the Philippines and HPV rate in other countries. According to critics, this makes it crucial to examine other social, economic, demographic and environmental factors in the Philippines that might explain the

There was no statistically significant risk of cervical cancer for partners of uncircumcised men; there was a 0.23 to 0.79 risk (CI 95%) for partners of uncircumcised men with a history of multiple partners (the population of women was previously limited to those with few partners). Critics see this type of limiting of populations to find the one that matches a given hypothesis as problematic and note that again, cultural and reporting differences may explain the difference given that about 80% of circumcised men were from the Philippine sample (it should be pointed out that the Philippines are a highly religious country, so women may be less likely to report having had multiple partners, which again would distort the results, as women who reported having multiple partners were not included in the cervical cancer analysis). Media commentator Dr. Dean Edell summarized the study like this: "If you are an intact male, have had lots of unprotected sex with lots of different women and marry a virgin, your wife may have a real but statistically insignificant increased chance of getting HPV."

Circumcision and Urinary tract infection (UTI)

Infections of the urinary tract (kidneys, ureters, bladder and urethra) can lead to kidney damage if undetected, but can generally be treated effectively with antibiotics. Recent studies find a three to seven times increased risk of uncircumcised UTIs in male infants within the first year of life. A 1998 Canadian population based cohort study by To et al. [69], for example, reported a relative risk of 3.7. The overall incidence of UTIs in infants was low, 1.88 and 7.02 per 1000 respectively. According to the American Medical Association, "There is little doubt that the uncircumcised infant is at higher risk for urinary tract infection (UTI)."

These studies have nevertheless been extensively criticized for their methodology. The American Academy of Pediatrics noted in its 1999 circumcision policy statement:

Few of the studies that have evaluated the association between UTI in male infants and circumcision status have looked at potential confounders (such as prematurity, breastfeeding, and method of urine collection) in a rigorous way. For example, because premature infants appear to be at increased risk for UTI, the inclusion of hospitalized premature infants in a study population may act as a confounder by suggesting an increased risk of UTI in uncircumcised infants. Premature infants usually are not circumcised because of their fragile health status. In another example, breastfeeding was shown to have a threefold protective effect on the incidence of UTI in a sample of uncircumcised infants. However, breastfeeding status has not been evaluated systematically in studies assessing UTI and circumcision status. [70]

T.E. Wiswell's research (carried out in the early 1980s) claimed to find up to 12 times higher incidence of UTIs among uncircumcised infants and claimed that the rate of UTIs was up to 4%, has generated particularly strong controversy and been criticized on methodological grounds, especially its lack of control for confounding variables.[71] It is now generally considered flawed and is now superseded by better designed studies. Some studies which found that most patients admitted with UTI were uncircumcised (e.g. Ginsberg CM, and McCracken GH: Urinary tract infections in young infants. Pediatrics 69:409, 1982 [72]) lacked even a control group that would have allowed a comparison with the general hospital population.

UTIs are usually detected through urine tests. Depending on the method of urine collection, there is a varying risk of false positives through contamination. The bacteria detected may in fact come from the foreskin itself, not the urinary tract. In spite of this, an increased risk of UTI in uncircumcised males is generally considered plausible, a higher likelihood of bacterial colonization being the proposed mechanism.

However, studies of UTI and circumcision do not classify groups of circumcised males according to their mothers' handling of the foreskin, making it impossible to infer any link with specific hygienic practices. It is generally recommended not to retract the foreskin of an infant during hygiene [73]. Hodges and Fleiss claim that "it has been proven that retraction and washing of the infant foreskin can cause urinary tract infections by irritating the mucous membranes and destroying the naturally occurring beneficial flora which protects against pathogens."

If circumcision does indeed reduce the incidence of UTIs, To et al. estimate that 195 circumcisions would be needed to prevent one hospital admission for UTI in the first year of life. The American Academy of Pediatrics recommends breastfeeding to reduce the risk of UTI in children.[74] It does not recommend circumcision for this purpose.

Circumcision and HIV/AIDS

In 1986 Aaron J. Fink, a circumcision advocate, first proposed that circumcision might prevent the distribution of AIDS. He hypothesized that the keratinization of the circumcised penis might prevent HIV infection. Other researchers soon investigated the question whether there is a link between circumcision and HIV infection rates.

After more than 40 studies, the evidence has remained largely inconclusive. The American Medical Association states:

"The data on circumcision status and susceptibility to HIV infection and other sexually transmissible diseases have been recently reviewed. Five of 7 prospective studies involving heterosexual transmission of HIV-1 found a statistically significant association between lack of circumcision and elevated risk for acquisition of HIV." (Report 10 of the Council on Scientific Affairs on Neonatal Circumcision, [75])

Several studies of African populations found a significantly reduced risk of HIV transmission in circumcised males. For example, in a 1988 study published in the New England Journal of Medicine, researchers studied patients appearing at a Nairobi, Kenya, STD clinic. They found "[m]en who were uncircumcised were more likely to have HIV infection (odds ratio, 2.7; P = 0.003)" [76].

At least 16 studies found no statistically significant link between circumcision and HIV transmission, and four studies found an increased risk in circumcised males. [77] Studies have mostly focused on the female-to-male heterosexual transmission. It is axiomatic that possession (or not) of a foreskin does not influence transmission rates associated with the non-insertional partner's acquisition of HIV/AIDS through anal, vaginal, or oral sex, or any partner through pregnancy, nursing, blood transfusions, needle sticks or sharing needles.

Tying AIDS/HIV rates to circumcision status in the abstract has been eschewed by careful scientists and statisticians. One must correct base data that may tend to favor societies that practice other behavior regardless of circumcision or whose behavior in transmission of HIV has less to do with heterosexual sex, wherein the vulnerability of men with foreskins to female-to-male transmission may be demonstrated to anal or oral homosexual sex wherein the mode of transmission of tears in the colon or gums are the primary vectors of spread of the virus.

The ongoing research has been extensively methodologically criticized. The main criticism is that past studies have ignored substantial confounding variables. Perhaps most notably, most studies have not controlled for different socio-sexual behaviors. In their meta-analysis of related studies [78], Vincenzi and Mertens note that "circumcision is not performed randomly". Circumcision in central Africa is primarily a Muslim practice, and Islam requires ritual washing, marital fidelity and periodic abstinence from sex. Similar relationships have been found in other cultures that practice male circumcision [79]. In addition, in many studies, the circumcision status of subjects has not been directly verified. The authors of the meta-analysis conclude that there is not sufficient evidence for a link between circumcision and HIV transmission. Similarly, Van Howe in another 1999 meta-analysis concludes that "the recommendation to routinely circumcise boys in Africa is unfounded and even dangerous." [80]

It should be noted that Van Howe's meta-analysis was seriously flawed, and was criticised by Moses et al. and O'Farrell. A later meta-analysis by Weiss et al. should be consulted instead[81].

Studies have also failed to control for the specific practice of "dry sex" (vaginal lubrication is dried out by various means, presumably to heighten the male's sexual pleasure), which is common among uncircumcised males in sub-Saharan Africa. Dry sex increases HIV infection risk dramatically. Other confounding factors that have been cited as possibly relevant are regionally prevalent diseases and "female circumcision", the effects of which on HIV transmission have not been investigated. It has also been claimed that circumcision changes sexual behavior directly, either leading to more or less risky sexual behavior. Because of these criticisms and the inconclusive results, no medical body has so far accepted circumcision as a means to reduce HIV transmission.

Among industrialized nations, AIDS rates are highest in the three countries which still practice routine infant circumcision at substantial levels (table 2). Circumcision critics point to this data not as evidence that circumcision has any relationship to HIV infections, but that use of safe sex practices far outweighs any beneficial effect circumcision may or may not have. Critics also warn that advertising circumcision as a way to prevent AIDS (e.g. "could potentially save millions of men and their partners", as a unversity press release claims) might be used to promote and justify the belief that safe sex practices are unnecessary.

The position of the circumcision critics has been criticized by circumcision proponents because the predominant modes of HIV/AIDS transmission in industrial societies is not heterosexual intercourse, but through homosexual sex, blood transfusions, needle sticks or sharing needles, which are not addressed in the HIV/AIDS rates. Contrary to the data on the industrial world (table 1), the studies linking circumcision with lower HIV/AIDS incidence in the developing world have mostly focused on the female-to-male heterosexual transmission (tables 2-5). It is axiomatic that possession (or not) of a foreskin does not influence transmission rates associated with the non-insertional partner's acquisition of HIV/AIDS through anal, vaginal, or oral sex, or any partner through pregnancy, nursing, blood transfusions, needle sticks or sharing needles.

Table 2 [CIA World Factbook[82]] data of HIV/AIDS rates (2004)
Nation	HIV/AIDS adult prevalence rate.
USA	0.6%
Australia	0.1%
Canada	0.3%
France	0.4%
Netherlands	0.2%
United Kingdom	0.1%
Germany	0.1%
Sweden	0.1%
Norway	0.1%
New Zealand	0.1%
Finland	0.1%
Japan	0.1%

Some specific studies

In a study published in Lancet in 1989, researchers studied possible risk factors in female-to-male HIV transmission. The researchers found that uncircumcised men (29.0%) were ten times more likely to acquire HIV from a single sexual encounter than circumcised men (2.5%). Uncircumcised men with genital ulcers (52.6%) were four times more likely to become infected than circumcised men with genital ulcers (13.4%).

(Source: Cameron DW, Simonsen JN, D’Costa LJ, Ronald AR, Maitha GM, Gakinya MN, et al. Female to Male Transmission of Human Immunodeficiency Virus Type 1: Risk Factors for Seroconversion in Men. Lancet 1989; 2:403-27.) [83]

Another set of researchers concluded that “In the AIDS belt, lack of male circumcision in combination with risky behavior, such as having multiple sex partners, engaging in sex with prostitutes and leaving chanchroid untreated has led to rampant HIV transmission.”

(Source: "The African AIDS Epidemic," by J. C. Caldwell and Pat Caldwell,

Scientific American, March 1996, p. 62)

Researchers from the University of Manitoba also studied heterosexual HIV transmission in Africa. The researchers concluded that: “There is substantial evidence that circumcision protects males from HIV infection, penile carcinoma, urinary tract infections, and ulcerative sexually transmitted diseases. We could find little scientific evidence of adverse effects on sexual, psychological, or emotional health.”

(Source: S Moses, RC Bailey and AR Ronald, Male circumcision: assessment of health benefits and risks, Sexually Transmitted Infections, Vol. 74, Issue 5, p. 368-373) [84]

Another publication in the New England Journal of Medicine found that “Male circumcision consistently shows a protective effect against HIV infection” and noted that HIV prevalence was 1.7 to 8.2 times higher among uncircumcised heterosexual men than among circumcised heterosexual men.

The most conclusive study regarding the use of male circumcision as a prophylactic against HIV infection is the exhaustive evidence-based study conducted for the Cochrane Review and released in 2003. That study found disabling methodological flaws in all existing studies because of their inability to control for confounding factors and concluded that insufficient evidence exists to recommend circumcision intervention to reduce the risk of contracting HIV.[85]

References

• American Academy of Pediatrics. Circumcision Policy Statement (RE9850). March 1999.
• American Medical Association. Report 10 of the Council on Scientific Affairs (I-99), Neonatal Circumcision. Dec 1999.
• British Medical Association. The Law & Ethics of Male Circumcision - Guidance for Doctors. March 2003.
• Canadian Paediatric Society. Neonatal Circumcision Revisited. 1996 (reaffirmed March 2002)
• The Royal Australasian College of Physicians. Policy Statement On Circumcision. Sep 2002.