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. 1998 Oct;74(5):368–373. doi: 10.1136/sti.74.5.368

Male circumcision: assessment of health benefits and risks

S Moses, R C Bailey, A R Ronald
PMCID: PMC1758146  PMID: 10195035

Abstract

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. 




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Selected References

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  1. Agarwal S. S., Sehgal A., Sardana S., Kumar A., Luthra U. K. Role of male behavior in cervical carcinogenesis among women with one lifetime sexual partner. Cancer. 1993 Sep 1;72(5):1666–1669. doi: 10.1002/1097-0142(19930901)72:5<1666::aid-cncr2820720528>3.0.co;2-m. [DOI] [PubMed] [Google Scholar]
  2. Altschul M. S. Larger numbers needed. Pediatrics. 1987 Nov;80(5):763–764. [PubMed] [Google Scholar]
  3. Aynaud O., Ionesco M., Barrasso R. Penile intraepithelial neoplasia. Specific clinical features correlate with histologic and virologic findings. Cancer. 1994 Sep 15;74(6):1762–1767. doi: 10.1002/1097-0142(19940915)74:6<1762::aid-cncr2820740619>3.0.co;2-1. [DOI] [PubMed] [Google Scholar]
  4. Bassett I., Donovan B., Bodsworth N. J., Field P. R., Ho D. W., Jeansson S., Cunningham A. L. Herpes simplex virus type 2 infection of heterosexual men attending a sexual health centre. Med J Aust. 1994 Jun 6;160(11):697–700. [PubMed] [Google Scholar]
  5. Brown M. S., Brown C. A. Circumcision decision: prominence of social concerns. Pediatrics. 1987 Aug;80(2):215–219. [PubMed] [Google Scholar]
  6. Burger R., Guthrie T. H. Why circumcision? Pediatrics. 1974 Sep;54(3):362–364. [PubMed] [Google Scholar]
  7. Cadman D., Gafni A., McNamee J. Newborn circumcision: an economic perspective. Can Med Assoc J. 1984 Dec 1;131(11):1353–1355. [PMC free article] [PubMed] [Google Scholar]
  8. Caldwell J. C., Caldwell P. The African AIDS epidemic. Sci Am. 1996 Mar;274(3):62-3, 66-8. doi: 10.1038/scientificamerican0396-62. [DOI] [PubMed] [Google Scholar]
  9. Calnan M., Douglas J. W., Goldstein H. Tonsillectomy and circumcision: comparisons of two cohorts. Int J Epidemiol. 1978 Mar;7(1):79–85. doi: 10.1093/ije/7.1.79. [DOI] [PubMed] [Google Scholar]
  10. Cameron D. W., Simonsen J. N., D'Costa L. J., Ronald A. R., Maitha G. M., Gakinya M. N., Cheang M., Ndinya-Achola J. O., Piot P., Brunham R. C. Female to male transmission of human immunodeficiency virus type 1: risk factors for seroconversion in men. Lancet. 1989 Aug 19;2(8660):403–407. doi: 10.1016/s0140-6736(89)90589-8. [DOI] [PubMed] [Google Scholar]
  11. Chao A., Bulterys M., Musanganire F., Habimana P., Nawrocki P., Taylor E., Dushimimana A., Saah A. Risk factors associated with prevalent HIV-1 infection among pregnant women in Rwanda. National University of Rwanda-Johns Hopkins University AIDS Research Team. Int J Epidemiol. 1994 Apr;23(2):371–380. doi: 10.1093/ije/23.2.371. [DOI] [PubMed] [Google Scholar]
  12. Chessare J. B. Circumcision: is the risk of urinary tract infection really the pivotal issue? Clin Pediatr (Phila) 1992 Feb;31(2):100–104. doi: 10.1177/000992289203100207. [DOI] [PubMed] [Google Scholar]
  13. Cook L. S., Koutsky L. A., Holmes K. K. Circumcision and sexually transmitted diseases. Am J Public Health. 1994 Feb;84(2):197–201. doi: 10.2105/ajph.84.2.197. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Craig J. C., Knight J. F., Sureshkumar P., Mantz E., Roy L. P. Effect of circumcision on incidence of urinary tract infection in preschool boys. J Pediatr. 1996 Jan;128(1):23–27. doi: 10.1016/s0022-3476(96)70423-7. [DOI] [PubMed] [Google Scholar]
  15. DODGE O. G., KAVITI J. N. MALE CIRCUMCISION AMONG THE PEOPLES OF EAST AFRICA AND THE INCIDENCE OF GENITAL CANCER. East Afr Med J. 1965 Mar;42:98–105. [PubMed] [Google Scholar]
  16. Dhar G. M., Shah G. N., Naheed B., Hafiza Epidemiological trend in the distribution of cancer in Kashmir Valley. J Epidemiol Community Health. 1993 Aug;47(4):290–292. doi: 10.1136/jech.47.4.290. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Donovan B., Bassett I., Bodsworth N. J. Male circumcision and common sexually transmissible diseases in a developed nation setting. Genitourin Med. 1994 Oct;70(5):317–320. doi: 10.1136/sti.70.5.317. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Gajalakshmi C. K., Shanta V. Association between cervical and penile cancers in Madras, India. Acta Oncol. 1993;32(6):617–620. doi: 10.3109/02841869309092439. [DOI] [PubMed] [Google Scholar]
  19. Green E. C., Zokwe B., Dupree J. D. Indigenous African healers promote male circumcision for prevention of sexually transmitted diseases. Trop Doct. 1993 Oct;23(4):182–183. doi: 10.1177/004947559302300423. [DOI] [PubMed] [Google Scholar]
  20. Grosskurth H., Mosha F., Todd J., Senkoro K., Newell J., Klokke A., Changalucha J., West B., Mayaud P., Gavyole A. A community trial of the impact of improved sexually transmitted disease treatment on the HIV epidemic in rural Tanzania: 2. Baseline survey results. AIDS. 1995 Aug;9(8):927–934. doi: 10.1097/00002030-199508000-00015. [DOI] [PubMed] [Google Scholar]
  21. Hammond G. W., Slutchuk M., Scatliff J., Sherman E., Wilt J. C., Ronald A. R. Epidemiologic, clinical, laboratory, and therapeutic features of an urban outbreak of chancroid in North America. Rev Infect Dis. 1980 Nov-Dec;2(6):867–879. doi: 10.1093/clinids/2.6.867. [DOI] [PubMed] [Google Scholar]
  22. Harkavy K. L. The circumcision debate. Pediatrics. 1987 Apr;79(4):649–650. [PubMed] [Google Scholar]
  23. Hart G. Factors associated with genital chlamydial and gonococcal infection in males. Genitourin Med. 1993 Oct;69(5):393–396. doi: 10.1136/sti.69.5.393. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Hooper R. R., Reynolds G. H., Jones O. G., Zaidi A., Wiesner P. J., Latimer K. P., Lester A., Campbell A. F., Harrison W. O., Karney W. W. Cohort study of venereal disease. I: the risk of gonorrhea transmission from infected women to men. Am J Epidemiol. 1978 Aug;108(2):136–144. doi: 10.1093/oxfordjournals.aje.a112597. [DOI] [PubMed] [Google Scholar]
  25. Kapiga S. H., Lyamuya E. F., Lwihula G. K., Hunter D. J. The incidence of HIV infection among women using family planning methods in Dar es Salaam, Tanzania. AIDS. 1998 Jan 1;12(1):75–84. doi: 10.1097/00002030-199801000-00009. [DOI] [PubMed] [Google Scholar]
  26. Koopman J. S., Longini I. M., Jr The ecological effects of individual exposures and nonlinear disease dynamics in populations. Am J Public Health. 1994 May;84(5):836–842. doi: 10.2105/ajph.84.5.836. [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Laumann E. O., Masi C. M., Zuckerman E. W. Circumcision in the United States. Prevalence, prophylactic effects, and sexual practice. JAMA. 1997 Apr 2;277(13):1052–1057. [PubMed] [Google Scholar]
  28. Maden C., Sherman K. J., Beckmann A. M., Hislop T. G., Teh C. Z., Ashley R. L., Daling J. R. History of circumcision, medical conditions, and sexual activity and risk of penile cancer. J Natl Cancer Inst. 1993 Jan 6;85(1):19–24. doi: 10.1093/jnci/85.1.19. [DOI] [PubMed] [Google Scholar]
  29. Marck J. Aspects of male circumcision in sub-equatorial African culture history. Health Transit Rev. 1997;7 (Suppl):337–360. [PubMed] [Google Scholar]
  30. Mbugua G. G., Muthami L. N., Mutura C. W., Oogo S. A., Waiyaki P. G., Lindan C. P., Hearst N. Epidemiology of HIV infection among long distance truck drivers in Kenya. East Afr Med J. 1995 Aug;72(8):515–518. [PubMed] [Google Scholar]
  31. McCance D. J., Kalache A., Ashdown K., Andrade L., Menezes F., Smith P., Doll R. Human papillomavirus types 16 and 18 in carcinomas of the penis from Brazil. Int J Cancer. 1986 Jan 15;37(1):55–59. doi: 10.1002/ijc.2910370110. [DOI] [PubMed] [Google Scholar]
  32. Mehendale S. M., Rodrigues J. J., Brookmeyer R. S., Gangakhedkar R. R., Divekar A. D., Gokhale M. R., Risbud A. R., Paranjape R. S., Shepherd M. E., Rompalo A. E. Incidence and predictors of human immunodeficiency virus type 1 seroconversion in patients attending sexually transmitted disease clinics in India. J Infect Dis. 1995 Dec;172(6):1486–1491. doi: 10.1093/infdis/172.6.1486. [DOI] [PubMed] [Google Scholar]
  33. Mehendale S. M., Shepherd M. E., Divekar A. D., Gangakhedkar R. R., Kamble S. S., Menon P. A., Yadav R., Risbud A. R., Paranjape R. S., Gadkari D. A. Evidence for high prevalence & rapid transmission of HIV among individuals attending STD clinics in Pune, India. Indian J Med Res. 1996 Dec;104:327–335. [PubMed] [Google Scholar]
  34. Moses S., Bradley J. E., Nagelkerke N. J., Ronald A. R., Ndinya-Achola J. O., Plummer F. A. Geographical patterns of male circumcision practices in Africa: association with HIV seroprevalence. Int J Epidemiol. 1990 Sep;19(3):693–697. doi: 10.1093/ije/19.3.693. [DOI] [PubMed] [Google Scholar]
  35. Moses S., Plummer F. A., Bradley J. E., Ndinya-Achola J. O., Nagelkerke N. J., Ronald A. R. The association between lack of male circumcision and risk for HIV infection: a review of the epidemiological data. Sex Transm Dis. 1994 Jul-Aug;21(4):201–210. doi: 10.1097/00007435-199407000-00004. [DOI] [PubMed] [Google Scholar]
  36. Nasio J. M., Nagelkerke N. J., Mwatha A., Moses S., Ndinya-Achola J. O., Plummer F. A. Genital ulcer disease among STD clinic attenders in Nairobi: association with HIV-1 and circumcision status. Int J STD AIDS. 1996 Oct;7(6):410–414. doi: 10.1258/0956462961918374. [DOI] [PubMed] [Google Scholar]
  37. Newell J., Senkoro K., Mosha F., Grosskurth H., Nicoll A., Barongo L., Borgdorff M., Klokke A., Changalucha J., Killewo J. A population-based study of syphilis and sexually transmitted disease syndromes in north-western Tanzania. 2. Risk factors and health seeking behaviour. Genitourin Med. 1993 Dec;69(6):421–426. doi: 10.1136/sti.69.6.421. [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Nsanze H., Fast M. V., D'Costa L. J., Tukei P., Curran J., Ronald A. Genital ulcers in Kenya. Clinical and laboratory study. Br J Vener Dis. 1981 Dec;57(6):378–381. doi: 10.1136/sti.57.6.378. [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Parker S. W., Stewart A. J., Wren M. N., Gollow M. M., Straton J. A. Circumcision and sexually transmissible disease. Med J Aust. 1983 Sep 17;2(6):288–290. doi: 10.5694/j.1326-5377.1983.tb122467.x. [DOI] [PubMed] [Google Scholar]
  40. Piot P., Duncan M., Van Dyck E., Ballard R. C. Ulcerative balanoposthitis associated with non-syphilitic spirochaetal infection. Genitourin Med. 1986 Feb;62(1):44–46. doi: 10.1136/sti.62.1.44. [DOI] [PMC free article] [PubMed] [Google Scholar]
  41. Pridan H., Lilienfeld A. M. Carcinoma of the cervix in Jewish women in Israel, 1960-67. An epidemiological study. Isr J Med Sci. 1971 Dec;7(12):1465–1470. [PubMed] [Google Scholar]
  42. Quigley M., Munguti K., Grosskurth H., Todd J., Mosha F., Senkoro K., Newell J., Mayaud P., ka-Gina G., Klokke A. Sexual behaviour patterns and other risk factors for HIV infection in rural Tanzania: a case-control study. AIDS. 1997 Feb;11(2):237–248. doi: 10.1097/00002030-199702000-00015. [DOI] [PubMed] [Google Scholar]
  43. Roberts J. A. Neonatal circumcision: an end to the controversy? South Med J. 1996 Feb;89(2):167–171. doi: 10.1097/00007611-199602000-00002. [DOI] [PubMed] [Google Scholar]
  44. Sassan-Morokro M., Greenberg A. E., Coulibaly I. M., Coulibaly D., Sidibé K., Ackah A., Tossou O., Gnaore E., Wiktor S. Z., De Cock K. M. High rates of sexual contact with female sex workers, sexually transmitted diseases, and condom neglect among HIV-infected and uninfected men with tuberculosis in Abidjan, Côte d'Ivoire. J Acquir Immune Defic Syndr Hum Retrovirol. 1996 Feb 1;11(2):183–187. doi: 10.1097/00042560-199602010-00010. [DOI] [PubMed] [Google Scholar]
  45. Schoen E. J. The status of circumcision of newborns. N Engl J Med. 1990 May 3;322(18):1308–1312. doi: 10.1056/NEJM199005033221810. [DOI] [PubMed] [Google Scholar]
  46. Seed J., Allen S., Mertens T., Hudes E., Serufilira A., Carael M., Karita E., Van de Perre P., Nsengumuremyi F. Male circumcision, sexually transmitted disease, and risk of HIV. J Acquir Immune Defic Syndr Hum Retrovirol. 1995 Jan 1;8(1):83–90. [PubMed] [Google Scholar]
  47. Serour F., Samra Z., Kushel Z., Gorenstein A., Dan M. Comparative periurethral bacteriology of uncircumcised and circumcised males. Genitourin Med. 1997 Aug;73(4):288–290. doi: 10.1136/sti.73.4.288. [DOI] [PMC free article] [PubMed] [Google Scholar]
  48. Shah K. V. Human papillomaviruses and anogenital cancers. N Engl J Med. 1997 Nov 6;337(19):1386–1388. doi: 10.1056/NEJM199711063371911. [DOI] [PubMed] [Google Scholar]
  49. Simonsen J. N., Cameron D. W., Gakinya M. N., Ndinya-Achola J. O., D'Costa L. J., Karasira P., Cheang M., Ronald A. R., Piot P., Plummer F. A. Human immunodeficiency virus infection among men with sexually transmitted diseases. Experience from a center in Africa. N Engl J Med. 1988 Aug 4;319(5):274–278. doi: 10.1056/NEJM198808043190504. [DOI] [PubMed] [Google Scholar]
  50. Smith G. L., Greenup R., Takafuji E. T. Circumcision as a risk factor for urethritis in racial groups. Am J Public Health. 1987 Apr;77(4):452–454. doi: 10.2105/ajph.77.4.452. [DOI] [PMC free article] [PubMed] [Google Scholar]
  51. Snellman L. W., Stang H. J. Prospective evaluation of complications of dorsal penile nerve block for neonatal circumcision. Pediatrics. 1995 May;95(5):705–708. [PubMed] [Google Scholar]
  52. Spach D. H., Stapleton A. E., Stamm W. E. Lack of circumcision increases the risk of urinary tract infection in young men. JAMA. 1992 Feb 5;267(5):679–681. [PubMed] [Google Scholar]
  53. Taddio A., Katz J., Ilersich A. L., Koren G. Effect of neonatal circumcision on pain response during subsequent routine vaccination. Lancet. 1997 Mar 1;349(9052):599–603. doi: 10.1016/S0140-6736(96)10316-0. [DOI] [PubMed] [Google Scholar]
  54. Taddio A., Stevens B., Craig K., Rastogi P., Ben-David S., Shennan A., Mulligan P., Koren G. Efficacy and safety of lidocaine-prilocaine cream for pain during circumcision. N Engl J Med. 1997 Apr 24;336(17):1197–1201. doi: 10.1056/NEJM199704243361701. [DOI] [PubMed] [Google Scholar]
  55. Taylor J. R., Lockwood A. P., Taylor A. J. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol. 1996 Feb;77(2):291–295. doi: 10.1046/j.1464-410x.1996.85023.x. [DOI] [PubMed] [Google Scholar]
  56. Taylor P. K., Rodin P. Herpes genitalis and circumcision. Br J Vener Dis. 1975 Aug;51(4):274–277. doi: 10.1136/sti.51.4.274. [DOI] [PMC free article] [PubMed] [Google Scholar]
  57. Telzak E. E., Chiasson M. A., Bevier P. J., Stoneburner R. L., Castro K. G., Jaffe H. W. HIV-1 seroconversion in patients with and without genital ulcer disease. A prospective study. Ann Intern Med. 1993 Dec 15;119(12):1181–1186. doi: 10.7326/0003-4819-119-12-199312150-00005. [DOI] [PubMed] [Google Scholar]
  58. Thirumoorthy T., Sng E. H., Doraisingham S., Ling A. E., Lim K. B., Lee C. T. Purulent penile ulcers of patients in Singapore. Genitourin Med. 1986 Aug;62(4):253–255. doi: 10.1136/sti.62.4.253. [DOI] [PMC free article] [PubMed] [Google Scholar]
  59. Tyndall M. W., Ronald A. R., Agoki E., Malisa W., Bwayo J. J., Ndinya-Achola J. O., Moses S., Plummer F. A. Increased risk of infection with human immunodeficiency virus type 1 among uncircumcised men presenting with genital ulcer disease in Kenya. Clin Infect Dis. 1996 Sep;23(3):449–453. doi: 10.1093/clinids/23.3.449. [DOI] [PubMed] [Google Scholar]
  60. Urassa M., Todd J., Boerma J. T., Hayes R., Isingo R. Male circumcision and susceptibility to HIV infection among men in Tanzania. AIDS. 1997 Mar;11(3):73–80. doi: 10.1097/00002030-199703110-00002. [DOI] [PubMed] [Google Scholar]
  61. WILSON R. A. Circumcision and venereal disease. Can Med Assoc J. 1947 Jan;56(1):54–56. [PMC free article] [PubMed] [Google Scholar]
  62. Warner E., Strashin E. Benefits and risks of circumcision. Can Med Assoc J. 1981 Nov 1;125(9):967-76, 992. [PMC free article] [PubMed] [Google Scholar]
  63. Williams N., Kapila L. Complications of circumcision. Br J Surg. 1993 Oct;80(10):1231–1236. doi: 10.1002/bjs.1800801005. [DOI] [PubMed] [Google Scholar]
  64. Wirth J. L. Statistics on circumcision in Canada and Australia. Am J Obstet Gynecol. 1978 Jan 15;130(2):236–239. doi: 10.1016/0002-9378(78)90379-4. [DOI] [PubMed] [Google Scholar]
  65. Wiswell T. E. Circumcision circumspection. N Engl J Med. 1997 Apr 24;336(17):1244–1245. doi: 10.1056/NEJM199704243361709. [DOI] [PubMed] [Google Scholar]
  66. Wiswell T. E., Hachey W. E. Urinary tract infections and the uncircumcised state: an update. Clin Pediatr (Phila) 1993 Mar;32(3):130–134. doi: 10.1177/000992289303200301. [DOI] [PubMed] [Google Scholar]
  67. Wiswell T. E. Routine neonatal circumcision: a reappraisal. Am Fam Physician. 1990 Mar;41(3):859–863. [PubMed] [Google Scholar]
  68. de Vincenzi I., Mertens T. Male circumcision: a role in HIV prevention? AIDS. 1994 Feb;8(2):153–160. [PubMed] [Google Scholar]

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