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PubMed2006

Acceptability of male circumcision for prevention of HIV/AIDS in sub-Saharan Africa: a review.

Based on epidemiological, clinical and experimental evidence, male circumcision (MC) could have a significant impact on the HIV epidemic in selected areas. We reviewed studies of the acceptability of MC in sub-Saharan Africa to assess factors that will influence uptake of circumcision in traditionally non-circumcising populations. Thirteen studies from nine countries were identified. Across studies, the median proportion of uncircumcised men willing to become circumcised was 65% (range 29-87%). Sixty nine percent (47-79%) of women favored circumcision for their partners, and 71% (50-90%) of men and 81% (70-90%) of women were willing to circumcise their sons. Because the level of acceptability across the nine countries was quite consistent, additional acceptability studies that pose hypothetical questions to participants are unnecessary. We recommend pilot interventions making safe circumcision services available in conjunction with current HIV prevention strategies and evaluating the safety and acceptability of circumcision.

Africa South of the Sahara↗
PubMed2005

No association between female circumcision and prolonged labour: a case control study of immigrant women giving birth in Sweden.

OBJECTIVE: Several authors' associate female genital circumcision with obstructed and prolonged labour, but the World Health Organization recently stated that no scientific evidence confirms such a relationship. The object of this study was to compare the duration of the second stage of labour between circumcised and non-circumcised women in a high-income community in Europe. METHODS: Sixty-eight circumcised nulliparous women originally from the Horn of Africa were compared to a group of 2486 non-circumcised nulliparous who gave birth at a university hospital setting in Sweden, 1990-1996. Defibulation was routinely performed during labour. FINDINGS: Circumcised women were found to have had second stage labour, which was significantly statistically shorter (35/53 min, respectively, p < or = 0.001) and a lower risk of prolonged labour than the non-circumcised group. CONCLUSIONS: Prolonged labour does not seem to be associated to female genital circumcision in affluent societies with high standards of obstetric care.

Case-Control Studies↗
PubMed2006

Human papillomavirus and circumcision: a meta-analysis.

BACKGROUND: Determine the relationship of circumcision status to the risk for genital infection with human papillomavirus (HPV). METHODS: A MEDLINE search and a review of references in published articles were used to identify publications from peer-reviewed journals in Index Medicus with data on circumcision status in patients with and without HPV infections. Inclusion criteria included diagnosis by culture, biopsy, or PCR, determination of circumcision status by physical examination, and multiple site sampling including the shaft of the penis. A meta-analysis was performed with sensitivity analyses. RESULTS: Sixteen articles contained data on circumcision status in patients with and without HPV infections. Eight studies used accurate diagnostic methods. Only three articles satisfied the strict inclusion criteria. There was no significant association between circumcision status and HPV infection (random-effects model summary effect OR=1.20, 95%CI=0.80-1.79) in these three studies. If the eight studies using accurate diagnostic methods are adjusted for the method of determining circumcision status and failure to sample the penile shaft using meta-regression the summary effects odds ratio is 1.25 (95%CI=0.95-1.67). CONCLUSIONS: The medical literature does not support the claim that circumcision reduces the risk for genital HPV infection. To correctly assess the risk of HPV infection in circumcised males, the penile shaft needs to be sampled for HPV infection.

Circumcision, Male↗
PubMed2004

Circumcision in adults: effect on sexual function.

OBJECTIVES: To evaluate the effects of adult circumcision on sexual function in men circumcised only for religious or cosmetic reasons. METHODS: The study group consisted of 42 male patients with a median age of 22.3 years (range 19 to 28) referred for circumcision from June 2002 to January 2003. Of the 42 men, 39 desired circumcision for religious reasons. Before circumcision, their sexual performance was evaluated using the Brief Male Sexual Function Inventory (BMSFI) and ejaculatory latency time. The BMSFI evaluation and ejaculatory latency time measurements were repeated after a postoperative interval of at least 12 weeks. The scores in the five main sections of the BMSFI and the ejaculatory latency times before and after circumcision were analyzed. RESULTS: The differences in the mean BMSFI scores were not statistically significant in any of the five sections. However, the mean ejaculatory latency time was significantly longer after circumcision (P = 0.02). CONCLUSIONS: Adult circumcision does not adversely affect sexual function. The increase in the ejaculatory latency time can be considered an advantage rather than a complication.

Adult↗
PubMed2001

The medicalization of female "circumcision": harm reduction or promotion of a dangerous practice?

In recent decades the practice of female "circumcision" has come under intense international scrutiny, often conceptualized as a violation of women's basic right to health. Although the adverse health consequences of female "circumcision" form the basis of opposition to the practice, anti-circumcision activists, as well as many international medical associations, largely oppose measures to improve its safety. The debate over medicalization of female "circumcision" has, up until now, been cast as a moral dilemma: to protect women's health at the expense of legitimating a destructive practice? Or to hasten the elimination of a dangerous practice while allowing women to die from preventable conditions? This paper seeks to re-examine this debate by conceptualizing medicalization of female "circumcision" as a harm-reduction strategy. Harm reduction is a new paradigm in the field of public health that aims to minimize the health hazards associated with risky behaviors, such as intravenous drug use and high-risk sexual behavior, by encouraging safer alternatives, including, but not limited to abstinence. Harm reduction considers a wide range of alternatives, and promotes the alternative that is culturally acceptable and bears the least amount of harm. This paper evaluates the applicability of harm reduction principles to medical interventions for female "circumcision," and draws parallels to other harm reduction programs. In this light, arguments for opposing medicalization of female "circumcision", including the assertion that it counteracts efforts to eliminate the practice, are critically evaluated, revealing that there is not sufficient evidence to support staunch opposition to medicalization. Rather, it appears that medicalization, if implemented as a harm-reduction strategy, may be a sound and compassionate approach to improving women's health in settings where abandonment of the practice of "circumcision" is not immediately attainable.

Circumcision, Female↗
PubMed2000

Should hemophiliac patients be circumcised?

Social and cultural integration of hemophilic boys into society is one of the most important cornerstones of modern hemophilia therapy. Circumcision, a traditional procedure, is an important ritual for Muslims and Jews and an important social problem for the hemophiliac patient and his family. The aim of this study was to evaluate the psychosocial dimension of circumcision and the opinions of parents and children. A total of 105 hemophiliac patients and parents were interviewed and surveyed. Of these, 94% of the parents of uncircumcised patients wanted circumcision for their children. Most parents saw circumcision as a mandatory procedure. Hemophilic boys (60%) and their parents (82%) have an inferiority complex because the boys are unable to be circumcised. Bleeding risk is the primary reason of anxiety (70%). The parents of all the circumcised patients were happy after circumcision. In conclusion, circumcision is an important social problem of hemophilic patients that needs to be solved.

Adolescent↗
PubMed1993

History of circumcision, medical conditions, and sexual activity and risk of penile cancer.

BACKGROUND: Epidemiological evidence suggests lack of neonatal circumcision as the strongest risk factor for penile cancer, but the role of sexually transmitted diseases in the etiology of penile cancer has remained unclear. PURPOSE: To further clarify risk factors for penile cancer, we examined the role of circumcision, personal characteristics and habits (such as smoking), sexually transmitted diseases, past sexual activity, and medical conditions of the penis. METHODS: A population-based, case-control study was conducted in western Washington state and in the province of British Columbia. We interviewed 110 men with penile cancer diagnosed from January 1979 to July 1990 and 355 control subjects from the general population, frequency matched to case subjects on age and date of diagnosis. Tumor tissue from 67 case subjects was tested for human papillomavirus (HPV) DNA by polymerase chain reaction. Results of blood tests from 69 case subjects and 208 control subjects were available for study. STATISTICALLY SIGNIFICANT RESULTS: Relative to men circumcised at birth, the risk for penile cancer was 3.2 times greater among men who were never circumcised and 3.0 times greater among men who were circumcised after the neonatal period. For current smokers, the risk was 2.8 times that of men who never smoked. The risk among men reporting a history of genital warts was 5.9 times that of men reporting no such history. Of 67 tumors tested for HPV DNA, 49% were positive; the majority of these positive tumors (70%) were type 16, which has been associated with anogenital carcinoma. Relative risks (RRs) associated with a reported history of penile rash or penile tear were 9.4 and 3.9, respectively. Among men not circumcised at birth, RRs associated with presence of smegma and difficulty in retracting the foreskin were 2.1 and 3.5, respectively. Twenty-eight percent of case subjects, compared with only 10% of control subjects, reported 30 or more sexual partners, and men with HPV-positive tumors were more likely to report a greater number of sexual partners. CONCLUSIONS: These results suggest that the absence of neonatal circumcision and potential resulting complications are associated with penile cancer. Additionally, medical conditions of the penis, sexual activity, infection with HPV, and smoking may increase the risk for penile cancer. IMPLICATIONS: A larger study would allow examination of interrelationships of circumcision, infection with HPV, and smoking as risk factors.

Aged↗
PubMed2001

Male circumcision and HIV infection in four cities in sub-Saharan Africa.

OBJECTIVES: To explore the role of male circumcision in the spread of HIV infection in four urban populations in sub-Saharan Africa. DESIGN AND METHODS: A cross-sectional population based study was conducted in four cities in sub-Saharan Africa with different levels of HIV infection. HIV prevalence among adults was relatively low in Cotonou (Benin) and in Yaoundé (Cameroon), and exceeded 25% in Kisumu (Kenya) and in Ndola (Zambia). In each city, a random sample was taken of men and women aged 15-49 years from the general population. Consenting study participants were interviewed about their sociodemographic characteristics and their sexual behaviour, and were tested for HIV, herpes simplex virus type 2, syphilis, gonorrhoea and chlamydial infection. Men underwent a genital examination. RESULTS: In Cotonou and in Yaoundé, the two low HIV prevalence cities, 99% of men were circumcised. In Kisumu 27.5% of men were circumcised, and in Ndola this proportion was 9%. In Kisumu, the prevalence of HIV infection was 9.9% among circumcised men and 26.6% among uncircumcised men. After controlling for socio-demographic characteristics, sexual behaviour and other sexually transmitted infections, the protective effect of male circumcision remained with an adjusted odds ratio of 0.26 (95% confidence interval = 0.12-0.56). In Ndola, the prevalence of HIV infection was 25.0% in circumcised men and 26.0% in uncircumcised men. The power was insufficient to adjust for any differences in sexual behaviour. CONCLUSIONS: The differences in epidemic spread of HIV are likely to be due to differences in the probability of transmission of HIV during sexual exposure as well as differences in sexual behaviour. Male circumcision is one of the factors influencing the transmission of HIV during sexual intercourse, and this study confirms the population level association between HIV and lack of male circumcision, as well as a strong individual level association in Kisumu, the only city with sufficient power to analyze this association.

Adolescent↗
PubMed1992

Another look at the circumcision debate: opinions of nursing-home caregivers.

Little is known about the pros and cons of circumcision in older men. While the American Academy of Pediatrics suggests there are potential medical benefits of circumcision, early and mid-life concerns guide this reasoning. This article's study was devised to investigate the impact of non-circumcision on elderly, institutionalized males. Caregivers from two nursing homes were asked their opinions about and experiences with caring for uncircumcised males. Survey results indicate that these caregivers strongly support routine neonatal circumcision. Even though nursing-home caregivers are prepared to provide personal hygiene for their male patients, they believe circumcision prevents infection and makes hygiene easier. The caregivers preferred neonatal circumcision over adult circumcision because they believed circumcision to be less painful for a neonate. Included in this article are recommendations for future research.

Aged↗
PubMed2001

Varieties of male circumcision: a study from Kenya.

BACKGROUND: Because male circumcision has been linked to a lower risk of HIV infection, it is advocated tentatively as a possible preventive intervention. Most studies, however, have relied on men's self-reports of their circumcision status. GOAL: To document varied techniques of male circumcision in one area of Kenya and the visible results. STUDY DESIGN: Researchers interviewed men who had performed or undergone various forms of circumcision. They also did genital observations on a subsample of respondents. RESULTS: All the men reported undergoing circumcision during adolescence, and most were able to tell which technique was used. According to the circumcisers, in type A, approximately 4 cm of the prepuce is removed; in type B, 1 to 2 cm of the prepuce and some of its inner surface are removed. Types A and B result in the same genital appearance. In type C, 1 to 2 cm of the prepuce and some of the inner surface are removed. The remaining prepuce is slit and suspended below the penile shaft. CONCLUSIONS: Asking a man "Are you circumcised?" is not sufficient. Classifying his circumcision status requires both a genital examination and an understanding of the precise local surgical techniques used. Even in a small geographic area, considerable variety may exist in the techniques of cutting, removing, altering, or leaving different portions of the foreskin. Each variation may affect the transmission of HIV and other infections.

Adolescent↗
PubMed1995

Incidence of neonatal circumcision in Atlanta, 1985-1986.

We reviewed Atlanta area hospital records to determine the following regarding neonatal circumcision: incidence in July 1985; incidence after publicized serious complications of circumcision in August 1985; medical record documentation; and the complication rate. After stratified sampling from hospital birth logs, we abstracted information from medical charts and calculated weighted estimates and P values. The circumcision incidence was 89.3% in July 1985, 87.5% in September 1985, and 84.3% in September 1986. Circumcision was recorded on the medical record face sheet for 84.3% of circumcised boys. The complication rate was 3.1%; no serious complications were recorded. We conclude the following: circumcision incidence was high during the study period; publicity regarding adverse outcomes may have decreased the subsequent incidence of the procedure; hospital discharge data, which rely on medical record face sheet information, underestimate the true incidence of neonatal circumcision; and neonatal circumcision is usually safe, but serious complications may occur.

Adult↗
PubMed1999

Sexual behaviors and other HIV risk factors in circumcised and uncircumcised men in Uganda.

OBJECTIVE: To study the differences in sexual practices, hygienic behaviors, and other HIV risk factors between circumcised and uncircumcised men. DESIGN: A cross-sectional study of men >17 years of age selected by single stage cluster sampling in the Industrial Borough, Mbale, Uganda. METHODS: Using a structured questionnaire, 188 circumcised and 177 uncircumcised consenting Ugandan men were interviewed in one of four native languages during April and May, 1997. RESULTS: Among non-Muslims, circumcised men had a higher risk profile than uncircumcised men in that they were more likely to drink alcohol in conjunction with sex (odds ratio [OR], 1.86: 95% confidence interval [CI], 1.09-3.16), to have sexual contacts with women on the first day of meeting (OR, 2.37; 95% CI, 1.39-4.04), to have had sexual contacts in exchange for money or gifts (OR, 2.08; 95% CI, 1.21-3.09), to have experienced episodes of pain on urination or to have experienced penile discharge (OR, 1.68; 95% CI, 1.07-2.64), had an earlier age at sexual debut (15.7 versus 16.9 years), and had more extramarital sex partners in the last year (1.13 versus 0.62). Circumcised men also reported a preference for nonwet sex. Muslims generally had a lower risk profile than other circumcised men except they were less likely to have ever used a condom (OR, 0.34; 95% CI, 0.15-0.78) or to have used a condom during the last sex encounter (OR, 0.37; 95% CI, 0.14-0.87). CONCLUSIONS: These results suggest that differences between circumcised and uncircumcised men in their sex practices and hygienic behaviors do not account for the higher risk of HIV infection found among uncircumcised men. Further consideration should be given to male circumcision as a prevention strategy in areas of high prevalence of HIV and other sexually transmitted diseases. Studies of the feasibility and acceptability of male circumcision in traditionally noncircumcising societies are warranted.

Adult↗
PubMed2003

Outpatient management of phimosis following newborn circumcision.

PURPOSE: We reviewed our experience in treating patients with a trapped penis due to phimosis following newborn circumcision. The outcome of treatment of this condition at the outpatient clinic was examined. Possible etiological factors leading to this complication were determined. METHODS: A total of 521 pediatric patients underwent Gomco circumcision while under local anesthesia at our outpatient clinic between 1994 and 1999. Phimosis was noted in 15 patients (2.9%), and an additional 13 patients were referred to our clinic with phimosis after undergoing circumcision elsewhere. These 28 patients underwent treatment for the phimosis at the outpatient clinic. The phimotic ring was manually dilated with a fine hemostat. Careful traction with sterile gauze was then used to reduce the phimotic band below the glans penis. No evidence of glans ischemia was noted. Mild edema of the pericoronal skin collar was common. Cases referred after age 6 months or those weighing more than 14 pounds were treated as an elective outpatient surgical procedure. RESULTS: Three patients had recurrence of the phimosis. These cases were managed with manual retraction of the prepuce at the clinic. At 1 month followup 27 patients had resolution of the phimosis. One infant was lost to followup. Factors contributing to development of phimosis after newborn circumcision were reviewed. Ten of the patients had obvious poor penile skin attachment with concealment of the penis even after resolution of the phimosis. Phimosis occurred more frequently in older patients undergoing circumcision-15 patients were older than 1 month at circumcision. Mean body weight of the latter group at circumcision was 12 pounds. CONCLUSIONS: Phimosis with a trapped penis is an infrequent but important complication of circumcision. This condition is more likely to occur in older infants and those with poor attachment of the penile skin to the shaft. Early recognition allows outpatient treatment with excellent results, avoiding operative intervention with general anesthesia.

Ambulatory Care↗
PubMed2006

Male circumcision and risk of syphilis, chancroid, and genital herpes: a systematic review and meta-analysis.

OBJECTIVES: Male circumcision is associated with reduced risk of HIV infection. This may be partly because of a protective effect of circumcision on other sexually transmitted infections (STI), especially those causing genital ulcers, but evidence for such protection is unclear. Our objective was to conduct a systematic review and meta-analyses of the associations between male circumcision and infection with herpes simplex virus type 2 (HSV-2), Treponema pallidum, or Haemophilus ducreyi. METHODS: Electronic databases (1950-2004) were searched using keywords and text terms for herpes simplex, syphilis, chancroid, ulcerative sexually transmitted diseases, or their causative agents, in conjunction with terms to identify epidemiological studies. References of key articles were hand searched, and data were extracted using standardised forms. Random effects models were used to summarise relative risk (RR) where appropriate. RESULTS: 26 articles met the inclusion criteria. Most syphilis studies reported a substantially reduced risk among circumcised men (summary RR = 0.67, 95% confidence interval (CI) 0.54 to 0.83), although there was significant between study heterogeneity (p = 0.01). The reduced risk of HSV-2 infection was of borderline statistical significance (summary RR = 0.88, 95% CI 0.77 to 1.01). Circumcised men were at lower risk of chancroid in six of seven studies (individual study RRs: 0.12 to 1.11). CONCLUSIONS: This first systematic review of male circumcision and ulcerative STI strongly indicates that circumcised men are at lower risk of chancroid and syphilis. There is less association with HSV-2. Potential male circumcision interventions to reduce HIV in high risk populations may provide additional benefit by protecting against other STI.

Chancroid↗
PubMed1998

Male circumcision: assessment of health benefits and risks.

OBJECTIVES: Globally approximately 25% of men are circumcised for religious, cultural, medical, or parental choice reasons. However, controversy surrounds the procedure, and its benefits and risks to health. We review current knowledge of the health benefits and risks associated with male circumcision. METHODS: We have used, where available, previously conducted reviews of the relation between male circumcision and specific outcomes as "benchmarks", and updated them by searching the Medline database for more recent information. RESULTS: 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. Surgical risks associated with circumcision, particularly bleeding, penile injury, and local infection, as well as the consequences of the pain experienced with neonatal circumcision, are valid concerns that require appropriate responses. CONCLUSION: Further analyses of the utility and cost effectiveness of male circumcision as a preventive health measure should, in the light of this information, be research and policy priorities. A decision as to whether to recommend male circumcision in a given society should be based upon an assessment of the risk for and occurrence of the diseases which are associated with the presence of the foreskin, versus the risk of the complications of the procedure. In order for individuals and their families to make an informed decision, they should be provided with the best available evidence regarding the known benefits and risks.

Circumcision, Male↗
PubMed2000

Circumcision and STD in the United States: cross sectional and cohort analyses.

BACKGROUND: Male circumcision status has been shown to be associated with sexually transmitted disease (STD) acquisition in some, but not all, studies. Most studies have been cross sectional. OBJECTIVES: We examined the association between circumcision status and the prevalence and incidence of gonorrhoea, chlamydia, and syphilis. METHODS: We analysed cross sectional and cohort study data from a multicentre controlled trial in the United States. Between July 1993 and September 1996, 2021 men visiting public inner city STD clinics in the United States were examined by a clinician at enrolment and 1456 were examined at follow up visits 6 and 12 months later. At each visit, men had laboratory tests for gonorrhoea, chlamydia, and syphilis and were examined for circumcision status. We used multiple logistic regression to compare STD risk among circumcised and uncircumcised men adjusted for potentially confounding factors. RESULTS: Uncircumcised men were significantly more likely than circumcised men to have gonorrhoea in the multivariate analyses, adjusted for age, race, and site, in both the cross sectional (odds ratio (OR), 1.3; 95% confidence interval (CI), 0.9 to 1.7) and in the cohort analysis (OR, 1.6; 95% CI, 1.0 to 2.6). There was no association between lack of circumcision and chlamydia in either the cross sectional (OR, 1.0; 95% CI 0.7-1.4) or the cohort analysis (OR, 0.9; 95% CI 0.5-1.5). The magnitude of association between lack of circumcision and syphilis was similar in the cross sectional (OR, 1.4; 95% CI 0.6 to 3.3) and cohort analysis (OR, 1.5; 95% CI 0.4 to 6.1). CONCLUSION: Uncircumcised men in the United States may be at increased risk for gonorrhoea and syphilis, but chlamydia risk appears similar in circumcised and uncircumcised men. Our results suggest that risk estimates from cross sectional studies would be similar to cohort findings.

Adult↗
PubMed2006

Circumcision in Australia: prevalence and effects on sexual health.

The results from a telephone survey in 2001-02 of a probability sample of Australian households including 10,173 men aged 16-59 (response rate 69.4%) are used to assess the prevalence of circumcision across social groups in Australia and examine lifetime history of sexually transmissible infection (STI), sexual difficulties in the last year, sexual practices including masturbation, and sexual attitudes. More than half (59%) of the men were circumcised. Circumcision was less common among younger men (32% aged <20) and more common among the Australian born (69%). After correction for age, circumcision was unrelated to reporting STI, but appeared to protect against penile candidiasis. Circumcision was unrelated to most sexual difficulties, but circumcised men were less likely to report physical pain during intercourse or trouble keeping an erection; reasons for this are unknown. There were no significant differences in practices at last sexual encounter with a female partner or in masturbation alone. Circumcised men had somewhat more liberal sexual attitudes. Neonatal circumcision was routine in Australia until the 1970s. It appears not to be associated with significant protective or harmful sexual health outcomes. This study provides no evidence about the effects on sexual sensitivity.

Adolescent↗
PubMed2000

The highly protective effect of newborn circumcision against invasive penile cancer.

OBJECTIVE: We determined the relation between newborn circumcision and both invasive penile cancer (IPC) and carcinoma in situ (CIS) among adult male members of a large health maintenance organization. SUBJECTS AND METHODS: Circumcision status was ascertained by a combination of pathology reports, medical record review, and questionnaires for 213 adult male members of a large prepaid health plan who were diagnosed with IPC or CIS. RESULTS: Of 89 men with IPC whose circumcision status was known, 2 (2.3%) had been circumcised as newborns, and 87 were not circumcised. Of 118 men with CIS whose circumcision status was known, 16 (15.7%) had been circumcised as newborns. CONCLUSIONS: Our results confirm the highly protective effect of newborn circumcision against IPC and the less protective effect against CIS.

Age of Onset↗