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Sexually Transmitted Infections and Male Circumcision: A Systematic Review and Meta-Analysis

The claim that circumcision reduces the risk of sexually transmitted infections has been repeated so frequently that many believe it is true. A systematic review and meta-analyses were performed on studies of genital discharge syndrome versus genital ulcerative disease, genital discharge syndrome, nonspecific urethritis, gonorrhea, chlamydia, genital ulcerative disease, chancroid, syphilis, herpes simplex virus, human papillomavirus, and contracting a sexually transmitted infection of any type.

Chlamydia, gonorrhea, genital herpes, and human papillomavirus are not significantly impacted by circumcision. Syphilis showed mixed results with studies of prevalence suggesting intact men were at great risk and studies of incidence suggesting the opposite. Intact men appear to be of greater risk for genital ulcerative disease while at lower risk for genital discharge syndrome, nonspecific urethritis, genital warts, and the overall risk of any sexually transmitted infection. In studies of general populations, there is no clear or consistent positive impact of circumcision on the risk of individual sexually transmitted infections.

Consequently, the prevention of sexually transmitted infections cannot rationally be interpreted as a benefit of circumcision, and any policy of circumcision for the general population to prevent sexually transmitted infections is not supported by the evidence in the medical literature.

The earliest report of circumcision status as potential risk factor for sexually transmitted infections STIs was published in by Hutchinson, who noted that in men who were treated for STIs primarily gonorrhea and syphilis , Jews were less likely to have syphilis [ 1 ].

The claim of reduction of the risk of STIs to justify neonatal circumcision continues today, often supported by selective bibliographies [ 2 — 12 ]. When the entire medical literature is reviewed, these claims become difficult to substantiate. Specific benefits from male circumcision were identified for the prevention of urinary tract infections, acquisition of HIV, transmission of some STIs, and penile cancer. The committee completed its review of the medical literature in April and published its findings in August To shed some light on this contentious issue and whether the conclusion reached by the committee reflects the information available in the medical literature, this paper will provide a systematic review of the association between male circumcision status and the risk for individual types of STIs other than human immunodeficiency virus HIV and the overall risk for any STI.

While a number of the review articles and systematic reviews of the association between male circumcision and individual types of STIs have been published [ 14 — 21 ], many of these need updating, while other have methodological shortcomings.

This is also the first systematic review to explore the overall risk of contracting any STI. The recommendations of Stroup et al.

Inclusion criteria included cohort studies, cross-sectional studies, and case-control studies. The individual STIs included genital discharge syndrome identified in studies as a generic term for gonorrhea, genital infections with Chlamydia trachomatis , and nonspecific nongonococcal urethritis in which the primary symptom was a urethral discharge versus genital ulcerative disease identified in studies as a generic term for syphilis, genital herpes, chancroid, and other genital ulcers noted on physical examination , genital discharge syndrome GDS , nonspecific or nongonococcal urethritis NSU , gonorrhea, genital infections with Chlamydia trachomatis , genital ulcerative disease GUD , chancroid, syphilis, genital herpes or serology for herpes simplex virus type 2 HSV , genital human papillomavirus HPV infections, and an STI of any type.

Studies were also identified by reviewing references in published articles. For inclusion, publications needed to be in a peer-reviewed journal or government publication and present data on the circumcision status of males both with and without a specific STI or an STI in general.

Studies primarily of men having sex with men or HIV-infected men were excluded. Within a study, identifiable men having sex with men and HIV-infected men were excluded from analysis, while heterosexual and HIV-negative men were included.

Articles meeting the inclusion criteria were read to determine the number of circumcised men with the illness, the number of circumcised men without the illness, the number of intact men with the illness, and the number of intact men without the illness.

The primary analysis was performed using raw data, when available, for the published studies. In some cases, the raw data were obtained through back calculation with the information available in the article. Where raw data were not available, reported odds ratios, relative risks, and confidence intervals were used.

When distinct strata of the subjects within a study showed differing outcomes, each strata were considered separately in calculating the summary effect. When data from the same population were published in one or more publications, the study in which the data reported the outcome of interest as a primary result or the most recent report were used.

Analyses of studies assessing disease incidence were conducted separately from studies of disease prevalence. The impact of the type of study population was determined by separating the studies into those studying high-risk populations, such as attendees of sexually transmitted disease clinics and long-distance truck drivers in Africa, and those studying general populations.

The impact of circumcision prevalence in the study population on the association between circumcision status and the prevalence of the various STIs was assessed using meta-regression. Several studies meeting the inclusion criteria contained obvious forms of differential bias.

A number of methods were employed to minimize the bias. Several older studies had inappropriate control groups [ 23 — 25 ]. For example, Hand used men without any exposure to STIs as controls [ 25 ]. The three randomized clinical trials of adult male circumcision in Africa failed to adjust for lead-time bias. Men in these trials who were assigned to immediate circumcision were instructed to either not engage in sexual activity or use condoms with all sexual contacts until the circumcision healed approximately, from 4 to 6 weeks.

Analyses that included these trials were conducted with the reported data and with the data adjusted for a six-week lead-time bias. Other adjustments were needed specifically for the studies of HPV.

Studies of the prevalence of genital HPV infections were separated into those identifying clinical infections with genital warts and those with diagnosis by culture, serology, biopsy, or polymerase chain reaction. Several studies reported separate data for all HPV infections and for infections with high-risk HPV that are potentially oncogenic. Consequently, two separate analyses were run on the latter group. In both analyses, the data from studies reporting only one set of data were used.

In the first analysis, the data on all HPV infections were used, while the second analysis used the data on infections with high-risk HPV. Previous analyses have found that the studies of HPV were prone to two forms of bias [ 16 , 26 — 28 ]. The first was sampling bias. Several studies have found that circumcised men are more likely to have genital warts or have positive lesions or positive swabs on the penile shaft than intact men [ 29 — 35 ].

Consequently, studies that sampled only the glans or the urethra would underestimate the incidence and prevalence of HPV infection in circumcised males. For example, in the study published by VanBuskirk et al.

To adjust for the impact of this sampling bias, separate analyses were performed by multiplying the number of infections identified in studies that only sampled the glans by 1. The second is misclassification bias. Studies that rely on the patient report of circumcision status can often inaccurately identify the circumcision status of the participants. This has also been found to be a significant factor in previous analyses of HPV infections [ 16 , 27 , 28 ]. Finally, a separate analysis was conducted of studies of the prevalence of high-risk HPV in which the circumcision status of males was determined by physical examination and HPV was diagnosed by either serology or culture, biopsy, or polymerase chain reaction, with multiple site sampling including the shaft of the penis.

In one study, two testing methods for syphilis were used: the RPR results were used in this analysis [ 36 ]. DerSimonian and Laird random-effects summary results and between-study heterogeneity were calculated using the general variance-based method [ 37 ]. Poisson regression was used to assess studies of disease incidence. Fixed-effects summary results were calculated using Poisson regression. If between-study heterogeneity was significant , random-effects summary results were calculated using the general variance-based method [ 37 ].

Sensitivity analyses of prevalence data for type of study population were performed through separate analyses for each population type. The impact of the type of study population, performance of a study in Africa, the prevalence of circumcision in the study population, and, for HPV, the sampling only the glans of the penis and determination of circumcision by physical examination was estimated using meta-regression [ 38 ].

To test for potential outliers, the dataset from each publication was individually excluded from the analysis to measure the impact on the chi-square measure of between-study heterogeneity. The exclusion of a study would be justified by a reduction of the between-study heterogeneity chi-square by a statistically significant amount e. Sensitivity analysis was performed with each of these studies excluded and with the two most outlying studies excluded.

Publication bias was assessed using funnel graphs and linear regression analysis as described by Egger and associates [ 39 ], funnel plot regression as described by Macaskill et al. Poisson regression and meta-regression were performed using SAS version 8.

Of these, several reported on redundant study populations [ 44 — 55 ]. Twenty-one studies were identified through searches of bibliographies [ 1 , 23 , 25 , 56 — 73 ].

Several studies had collected the data that would have met the inclusion criteria but did not report their results in a manner to include them in the analyses [ 70 , 74 — 81 ]. The study by Rakwar et al. While this study was focused primarily on HIV infections, it also collected data on circumcision status and the prevalence and the incidence of GUD, GDS, chlamydia, gonorrhea, syphilis, HSV, genital warts, and chancroid.

It did not include the results of these diseases by circumcision status. In a meta-analysis by Weiss et al. The characteristics of the studies included for analysis and the types of STIs they studied are listed in Table 1. In the study by Nasio et al. There were ten studies that documented prevalence rates of GDS. There was one study that documented incidence rates of GDS [ 82 ].

Twelve studies documented the prevalence of NSU. Three studies addressed the incidence and fourteen studies addressed the prevalence of genital Chlamydia trachomatis. Of the studies addressing gonorrhea, three studies looked at incidence and twenty-two looked at the prevalence. Two studies looked at the incidence of GUD, while twelve looked at the prevalence.

For syphilis, there were three studies looking at incidence and twenty-seven studies looking at prevalence. For HSV, four studies looked at incidence and twenty-seven at prevalence.

All four studies of chancroid documented prevalence. Of the studies of genital HPV, fourteen documented the prevalence of visible genital warts, seven documented the incidence, and twenty-one documented the prevalence of HPV infections. Some studies have looked at clearance rates of HPV from the penis, but these were not part of this analysis [ 35 , 55 , 83 , 84 ].

The results of the analyses of incidence data are shown in Table 2. Of note, when adjusted for lead-time bias, no statistically significant differences were noted in GDS, gonorrhea, syphilis, or any STI. GUD was significantly more common in intact men. For chlamydia, HSV, and HPV, intact men were at higher risk, but when adjusted for lead-time bias, the differences were no longer statistically significant.

There was no evidence of significant between-study heterogeneity for any of these analyses. The results of the analyses of prevalence data are shown in Tables 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , and All of the analyses showed significant between-study heterogeneity.

There was a trend for intact men be a lower overall risk for an STI that was statistically significant when a clear outlier studies is removed [ 85 ]. Exclusion of studies did not change the conclusions of summary effect with only a few exceptions. In the analysis of genital warts, the removal of either the study by Oriel [ 29 ] or Wilson [ 23 ] made the negative association between intact men and genital warts statistically significant.

A similar impact was seen in with HPV. In the analysis of any type of HPV, exclusion of the study by Vaccarella et al. In the analysis of the prevalence of chancroid, exclusion of the study by Hart [ 69 ] brought the between-study heterogeneity to within an acceptable range and reversed the trend in the association.

Circumcision and Sexually Transmitted Disease Prevention: Evidence and Reticence

Circumcision is one of the oldest surgical procedures and the most common surgical procedure performed on males. It is practiced for three main reasons: ritual or religious meanings, prophylactic hygienic purposes, and therapeutic indications. Male circumcision is advocated as an efficacious prevention strategy against sexually transmitted diseases.

Three randomized controlled trials have shown that male circumcision provided by well trained health professionals in properly equipped settings is safe. Male circumcision provides only partial protection, and therefore should be only one element of a comprehensive HIV prevention package which includes: the provision of HIV testing and counseling services; treatment for sexually transmitted infections; the promotion of safer sex practices; the provision of male and female condoms and promotion of their correct and consistent use. Voluntary medical male circumcision for HIV prevention in 14 priority countries in eastern and southern Africa.

Despite the wide availability of condoms and the fear of HIV infection, sexually transmitted diseases STDs continue to be a serious public health concern. In the medical literature about preventive measures, circumcision is rarely if ever mentioned as an effective preventive measure: however, articles promoting the routine practice of circumcision invariably mention the surgery's benefit of reducing STDs. One author refers to over medical articles supporting this thesis [ 1 ]. In the present review, the medical literature is examined to determine what influence, if any, circumcision has on STDs. A Medline search was conducted using the keyword 'circumcision' and titles located were examined to determine if they applied to the topic.

The Reason Some Doctors Argue Men Should Get Circumcised

Circumcising your baby boy may protect against future sexually transmitted infections. This finding—published in a March, issue of the New England Journal of Medicine —adds to the evidence that there are health benefits to circumcision, the surgical removal of the penis foreskin, usually performed on newborns shortly after birth. It was already known that circumcision can reduce the risk of penile cancer, a relatively rare disease, as well as the risk of HIV infection. It's not who you are, but what you do Read more More about safer sex. But in the United States, newborn circumcision is an elective procedure, and rates are declining. In , the American Academy of Pediatrics reviewed evidence of the potential risks, benefits, and costs of circumcision, and declined to recommend the procedure for all newborns. Circumcision should never be performed strictly because it seems to reduce the risk of sexually transmitted infections, experts agree, and it's important to note that circumcision should not be considered appropriate protection. Practicing safe sex , including using condoms , is still necessary to provide the best protection, whether a person is circumcised or not. Still, many scientists are hoping that this new research may persuade recommending bodies, both in the United States and around the world, to give the circumcision's benefits another look. Circumcision remains a controversial topic In the United States, infant circumcision is declining.

Can Circumcision Prevent the Spread of Herpes, HPV, Other STDs?

Metrics details. However, the biological mechanisms by which circumcision is protective remain incompletely understood. Furthermore, we provide evidence that the genital microbiome may be an important driver of this immune activation. However, the biological mechanism by which circumcision confers this protection remains poorly understood. The foreskin constitutes a fold of skin that covers the coronal sulcus, glans, and urethral meatus of the non-erect penis, and the distal aspect of the penile shaft on the erect penis.

Back to Lifestyle and exercise.

Supriya D. We examined the effect of male circumcision on the acquisition of 3 nonulcerative sexually transmitted infections STIs. We evaluated the incidence of STI among men aged 18—24 years enrolled in a randomized trial of circumcision to prevent human immunodeficiency virus HIV infection in Kisumu, Kenya.

Circumcised men at twice the risk for cancer-causing HPV, study shows

All Specialties. Back to all news. Male circumcision reduces HIV risks, as well as some sexually-transmitted infections from heterosexual exposure, according to a recent review study. A systemic review of 60 publications found highly consistent evidence that male circumcision helps protect against herpes simplex virus type 2, chlamydia, syphilis, cervical dysplasia, and even cervical cancer.

SEE VIDEO BY TOPIC: Circumcision - Nucleus Health

To be clear, they think that men should support these efforts, too, because they believe circumcision offers STI protection regardless of gender. But does circumcision really have such a dramatic impact on sexual health? And is it even a good idea to use public health as a justification for routinely cutting off part of the body? It may be that circumcision offers limited HIV protection to straight men in Africa, where the rate of infection is very high as many as 10 percent have it in some countries and effective tools for preventing HIV like condoms and PrEP are scarce. In the United States, however, the situation is radically different. The rate of HIV is much lower to begin with less than one-tenth of one percent of the population has it and safe-sex tools are easier to come by.

Circumcision and STIs

Circumcised men should be as vigilant in preventing oncogenic HPV infection as those who are uncircumcised, new research suggests. Circumcised participants in a study presented at the annual meeting of the American Urological Association were twice as likely as their uncircumcised counterparts to have either of two HPV strains associated with penile cancer, researchers said. Their findings are not consistent with previous research. Daugherty said the high proportion of men in the United States who are circumcised could account for the prevalence of HPV in that population. Nonetheless, he said, the results show that circumcision alone is not a preventive measure. The men provided penile swabs, which were tested for 37 HPV strains. In all, 2. Most participants

Until recently, no studies have examined the impact of circumcision on overall STD incidence. The data indicate that circumcised men may be a higher risk for an.

The claim that circumcision reduces the risk of sexually transmitted infections has been repeated so frequently that many believe it is true. A systematic review and meta-analyses were performed on studies of genital discharge syndrome versus genital ulcerative disease, genital discharge syndrome, nonspecific urethritis, gonorrhea, chlamydia, genital ulcerative disease, chancroid, syphilis, herpes simplex virus, human papillomavirus, and contracting a sexually transmitted infection of any type. Chlamydia, gonorrhea, genital herpes, and human papillomavirus are not significantly impacted by circumcision. Syphilis showed mixed results with studies of prevalence suggesting intact men were at great risk and studies of incidence suggesting the opposite. Intact men appear to be of greater risk for genital ulcerative disease while at lower risk for genital discharge syndrome, nonspecific urethritis, genital warts, and the overall risk of any sexually transmitted infection.

Circumcision Combats HIV, STI Rates

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Мой Бог.

Она часто работала с ним допоздна и, единственная из всех сотрудников, нисколько его не боялась. Соши посмотрела на него с укором и сердито спросила: - Какого дьявола вы не отвечаете.

Я звонила вам на мобильник. И на пейджер. - На пейджер, - повторил Джабба.

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