Circumcision and Sexually Transmitted Diseases

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Circumcision and
Sexually Transmitted Diseases

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Hutchinson

In the nineteenth century, syphilis was as incurable and deadly as AIDS is now. English doctors, keen to introduce circumcision, assured people that it provided protection against "the pox". Instead of innocent Africans, they used innocent Jews to prove their case, claiming that Jewish men were highly resistant (if not immune) to syphilis because their foreskins had been removed. A physician, Jonathan Hutchinson, recorded the incidence of venereal cases among his Jewish and gentile patients during 1854 and came up with the following table:

Venereal cases

Gonorrhoea

Syphilis

Non-Jews

272

107

(39.3%)

165

(60.6%)

Jews

58

47

(81%)

11

(19%)

On the basis of these figures he claimed he had demonstrated a conclusion "long entertained by many surgeons of experience": that "the circumcised Jew is … very much less liable to contract syphilis than an uncircumcised person", and the reason was obvious: circumcision rendered “the delicate mucous membrane of the glans hard and skin-like”. Sensuous pleasure was devalued in those days, and the structure of the skin little understood. Even so, Mr Hutchinson did not look for a non-injurious alternative, but urged the speedy adoption of routine infant circumcision.

It was a flimsy foundation on which to erect such an ambitious therapeutic edifice. As much as gentile venereal cases comprised more syphilis than gonorrhoea (60.6 to 39.3 per cent), Jewish cases were much more of gonorrhoea than syphilis (81 to 19 per cent). Ingeniously, Hutchinson proposed that the high rate of gonorrhoea among the Jews proved that less promiscuity could not have been the reason for the difference. In fact, the statistics revealed nothing about the relative susceptibility of cut and intact men to venereal infection, and could as readily be used to show that circumcision increased the likelihood of getting gonorrhoea. Comparing those figures with the numbers of Jews and goyim in London at that time actually shows that Jews had a higher rate of syphilis than others.

- adapted from Darby: "A Surgical Temptation", pp 262-3

Victoria's legacy

Around the beginning the 20th century, Sexually Transmitted Diseases/Infections (STDs/STIs, then known as Venereal Disease or VD) were still among the most feared of diseases. The last stages of untreated syphillis were madness and death, and there was no effective treatment. Such treatments as there were involved mercury, and so were themselves highly toxic. The treatment for gonococcal salpingitis (inflammation of the urethra), involved a hard tube (bougie) inserted up the penis, which was painful.

Now, with 20/20 hindsight, it seems almost inevitable that circumcision would be wheeled in as a preventative measure, as it was for the almost equally feared "masturbation insanity" before it, and cancer and AIDS afterwards.

During and after the World Wars, when our boys were bringing home VD from the fleshpots of Europe and Asia Minor, circumcision rates of baby boys increased.

Yet the weight of evidence is that circumcision does not protect against STDs.

Laumann

The Laumann study of 1511 men who answered the National Health and Social Life Survey is flawed (by relying on self-report to establish both circumcision status and disease history). However, it found no significant differences in STD rates between circumcised and intact men, except for one STD: 25.1/1000 (26/1033) circumcised men reported having suffered from the commonest STD, chlamydia, while no intact men (out of 353) did so. Conclusion:

...we have discovered that circumcision provides no discernible prophylactic benefit and may in fact increase the likelihood of STD contraction...

Tsen et al. found similarly:

We found no evidence that uncircumcised men are particularly susceptible to clinical infections with sexually transmitted diseases, such as HPV or herpes. Circumcised cases in our study were more likely than uncircumcised cases to report a history of genital warts (20.5% vs 8.2%); and among controls there was little difference in the history of warts by circumcision status (5.9% vs 6.3%). These findings are consistent with those of Aynaud et al. [21], who observed similar proportions of HPV-associated lesions in circumcised and uncircumcised men."

- Tsen HF, Morgenstern H, Mack T, Peters RK.
"Risk factors for penile cancer:
results of a population-based case-control study
in Los Angeles County (United States)"
Cancer Causes Control 2001 Apr;12(3):267-277.

 

Castellsagué and chlamydia

As with Castellsagué's other study using the same data, this study pools data from five different countries, in only one of which circumcision is common, then claims it has corrected for this anomaly by removing the data for that country - which removes the vast majority of the circumcised men.

Am J Epidemiol. 2005 Sep 21; [Epub ahead of print]

Chlamydia trachomatis Infection in Female Partners of Circumcised and Uncircumcised Adult Men.

Castellsagué X, Peeling RW, Franceschi S, de Sanjose S, Smith JS, Albero G, Diaz M, Herrero R, Munoz N, Bosch FX.

Abstract: Male circumcision has been shown to reduce the risk of acquiring and transmitting a number of venereal infections. [false] However, little is known about the association between male circumcision and the risk of Chlamydia trachomatis infection in the female partner. The authors pooled data on 305 adult couples enrolled as controls in one of five case-control studies of invasive cervical cancer conducted in Thailand, the Philippines, Brazil, Colombia, and Spain between 1985 and 1997.

Women provided blood samples for C. trachomatis and Chlamydia pneumoniae antibody detection; a type-specific microfluorescence assay was used. Multivariate odds ratios were computed for the association between male circumcision status and chlamydial seropositivity in women. Compared with women with uncircumcised partners, those with circumcised partners had a 5.6-fold reduced risk of testing seropositive for C. trachomatis (82% reduction; odds ratio = 0.18, 95% confidence interval: 0.05, 0.58). The inverse association was also observed after restricting the analysis to monogamous women and their only male partners (odds ratio = 0.21, 95% confidence interval: 0.06, 0.72). In contrast, seropositivity to C. pneumoniae, a non-sexually-transmitted infection, was not significantly related to circumcision status of the male partner. [false] These findings suggest that male circumcision could reduce the risk of C. trachomatis infection in female sexual partners. [And therefore Carthage must be destroyed.]

PMID: 16177149 [PubMed - as supplied by publisher]

"Finally, our results may be driven by the large contribution of circumcised men from the study in the Philippines. It is possible that the observed associations were mediated by other practices or characteristics of the recruited couples in the Philippines that we were not able to identify or quantify. However, it is reassuring that the direction and statistical significance of the overall association remained virtually unchanged after we excluded the couples from the Philippines (OR Ό 0.11, 95 percent CI: 0.01, 0.91)."

In fact:

N

+/intact

%

+/cut

%

Thailand

45

15/39

38.5

1/6

16.7

Philippines

107

3/8

37.5

21/99

21.2

Brazil

66

11/61

18.0

0/5

0

Colombia

29

16/27

59.3

0/2

0

Spain

53

17/52

32.7

0/1

0

All women

 

68/187

33.2

22/113

19.5

They only had 14 circumcised men outside the Philippines, and only 8 intact ones inside! It's just crazy to draw any conclusions from such a skewed sample, and to calculate odds ratios from such a tiny sample.

How telling that "reassuring" is: how he WANTS circumcision to be protective!

One less case with an intact partner in the Philippines, or one more with a circumcised partner in any of the other countries, would nullify the correlation in that country.

"In contrast, seropositivity to C. pneumoniae, a non-sexually-transmitted infection, was not significantly related to circumcision status of the male partner."

Actually, C. pneumoiae. is positively associated with having a CIRCUMCISED partner:

 

N

+/intact

%

+/cut

%

All women

305

116/192

60.4

89/113

78.8

p < 0.001 (highly significant)

 

And to the contrary:

Male Circumcision and Women's Risk of Incident Chlamydial, Gonococcal, and Trichomonal Infections.

Sexually Transmitted Diseases. 35(7):689-695, July 2008.

TURNER, ABIGAIL NORRIS PhD *; MORRISON, CHARLES S. PhD +; PADIAN, NANCY S. PhD ++; KAUFMAN, JAY S. PhD *; BEHETS, FRIEDA M. PhD *; SALATA, ROBERT A. MD [S]; MMIRO, FRANCIS A. MBChB, FRCOG [//]; CHIPATO, TSUNGAI MD [P]; CELENTANO, DAVID D. ScD #; RUGPAO, SUNGWAL MD, MSc **; MILLER, WILLIAM C. MD, PhD *

Abstract:
Background: Male circumcision (MC) decreases the risk of human immunodeficiency virus (HIV) acquisition in men. We explored associations between MC of the primary sex partner and women's risk of acquisition of chlamydial (Ct), gonococcal (GC), or trichomonal (Tv) infections.

Methods: We analyzed data from a prospective study on hormonal contraception and incident human immunodeficiency virus/sexually transmitted infection (STI) among women from Uganda, Zimbabwe, and Thailand. At enrollment and each follow-up visit, we collected endocervical swabs for polymerase chain reaction identification of Ct and GC; Tv was diagnosed by wet mount. Using Cox proportional hazards models, we compared time to STI acquisition for women according to their partner's MC status.

Results: Among 5925 women (2180 from Uganda, 2228 from Zimbabwe, and 1517 from Thailand), 18.6% reported a circumcised primary partner at baseline, 70.8% reported an uncircumcised partner, and 9.7% did not know their partner's circumcision status. During follow-up, 408, 305, and 362 participants had a first incident Ct, GC, or Tv infection, respectively. In multivariate analysis, after controlling for contraceptive method, age, age at coital debut, and country, the adjusted hazard ratio (HR) comparing women with circumcised partners with those with uncircumcised partners for Ct was 1.25 [95% confidence interval (CI) 0.96-1.63]; for GC, adjusted HR 0.99 (95% CI 0.74-1.31); for Tv, adjusted HR 1.05 (95% CI 0.80-1.36), and for the 3 STIs combined, adjusted HR 1.02 (95% CI 0.85-1.21).

Conclusions: MC was not associated with women's risk of acquisition of Ct, GC, or Tv infection in this cohort.

 

Another flawed study

Circumcision Status and Risk of Sexually Transmitted Infection in Young Adult
Males: An Analysis of a Longitudinal Birth Cohort

David M. Fergusson, Joseph M. Boden and L. John Horwood
Pediatrics 2006;118;1971-1977
DOI: 10.1542/peds.2006-1175

ABSTRACT
OBJECTIVES. Previous research suggests that male circumcision may be a protective factor against the acquisition of sexually transmitted infections; however, studies examining this question have produced mixed results. The aim of this study was to examine the association between circumcision status and sexually transmitted infection risk using a longitudinal birth cohort study.
METHODS. Data were gathered as part of the Christchurch Health and Development Study, a 25-year longitudinal study of a birth cohort of New Zealand children. Information was obtained on: (1) the circumcision status of males in the cohort before 15 years old, (2) measures of self-reported sexually transmitted infection from ages 18 to 25 years, and (3) childhood, family, and related covariate factors.
RESULTS. Being uncircumcised had a statistically significant bivariate association with self-reported sexually transmitted infection. Adjustment for potentially confounding factors, including number of sexual partners and unprotected sex, as well as background and family factors related to circumcision, did not reduce the association between circumcision status and reports of sexually transmitted infection. Estimates of the population-attributable risk suggested that universal neonatal circumcision would have reduced rates of sexually transmitted infection in this cohort by 48.2%.
CONCLUSIONS. These findings suggest that uncircumcised males are at greater risk of acquiring sexually transmitted infection than circumcised males. Male circumcision may reduce the risk of sexually transmitted infection acquisition and transmission by up to one half, suggesting substantial benefits accruing from routine neonatal circumcision. ["And therefore Carthage must be destroyed"]

...

Circumcision Status
Circumcision status was assessed though parental report at age 4 months and through medical charts collected at 1 year of age. Parents were questioned at the age 4-month assessment as to whether their child had been circumcised. On the basis of this questioning, 26.1% (N=130) of the males in the sample were classified as having been circumcised. In addition, medical charts were collected at each assessment that included a record of whether the child had been circumcised in a hospital. On the basis of these records, an additional 24 males were classified as having been circumcised before age 15 years, providing a total of 154 circumcised males (30.2% of the sample). [So men circumcised outside hospitals would be counted as intact, and it is assumed that all self-reports and parental reports are accurate, when other studies have shown as much as 33% error.]

Self-Reported STIs, Ages 18 to 21 and 21 to 25 Years
At ages 21 and 25 years, cohort members were questioned about a range of sexual activities and practices that they had engaged in since the previous assessment and the consequences of these activities and practices, including whether they had been diagnosed with an STI at any time since the previous assessment. Cohort members who responded “yes” were then asked to provide details of the infection, including the age at which it was contracted, the type of STI contracted (ie, according to a formal medical diagnosis), and the treatment (if any) provided. Fourteen cohort members (2.7%) reported a medically diagnosed STI at the age-21 assessment, and 34 cohort members (6.6%) reported an STI at the age-25 assessment. Six cohort members (1.2%) reported an STI at both the age-21 and -25 assessments.
The details provided of the self-reported STIs were as follows: 22 cases (52.4% of the cases) were reported to have been Chlamydia, 13 (31.0% of the cases) were reported to have been genital warts, 4 (9.5% of the cases) were reported to have been genital herpes, 2 (4.8% of the cases) were reported to have been gonorrhea, 5 (11.9% of the cases) were reported as nonspecific urethral infections, and 1 case (2.4% of the cases) was described as a co-occurrence of genital herpes and genital warts. There were no self-reported cases of HIV infection, syphilis, or genital ulcerative disease among the cohort members. [It is assumed that all the men tell the truth about contracting an embarassing infection, or that circumcised and intact men do so with equal frequency. Only for Chlamydia do the figures for an individual STI reach significance.]

... Table 1 shows that, at both times, uncircumcised males were at increased risk of STI. [IT DOES NOT. Both 95% Confidence Interval ranges pass through 1.0 - no association.] ...

...

TABLE 1 Associations Between Circumcision Status and STI for Ages 18 to 21 and 21 to 25 Years

Measure

Circumcision Status

OR
(95% CI)

 

Circumcised (n=154)

Noncircumcised (n=356)

 

Reporting STI at ages 18–21 y, %

1.3 [2 men]

3.5 [12 men]

2.68 (0.59–12.1)

[If one more of the 18-21 year olds with an STI had been circumcised, the percentages would be 1.9 and 3.0 and the odds ratio would fall to 1.58. If two more had, it would fall to 1.08 - no association between circumcision and STI at all. But even as things stand, the fact that the range of 95% Confidence Intervals includes 1.0 means that we can have no confidence that there is any association at all. An OR below 1.0 - such as 0.59 - means a positive correlation between circumcision and STI - suggesting if we were gullible, that circumcision promotes STI!]

Reporting STI at ages 21–25 y, %

3.4 [5 men]

8.5 [30 men]

2.61 (0.99–6.89)

[ In the older age-range, there would be no association if 4-5 more men were circumcised. But again, the fact that the range of 95% Confidence Intervals includes 1.0 means that we can have no confidence that there is any association at all.] ]

Pooled estimate of STI risk ages 18–25 y

4.6 [7 men]

10.4 [37 men]

2.66a (1.17-6.11)

a Pooled OR estimated from random effects model, Wald c2 test of significance of effect of circumcision, c2 (1)=5.41 (P<.05).

[The two groups are the same men, being counted twice, doubling any inaccuracies, such as erroneous reports of circumcision status. There are also twice as many noncircumcised (intact) men, so any non-linear effects will disproportionately impact upon them. The lower bound of the the 95% CI, 1.17 is very low, meaning the association is slight. The significance of the figures is further reduced by the proportions of the men who were not sexually active (with others). Their circumcision status obviously has no bearing on their chance of contracting an STI, so the effective sample size is smaller.]



... These estimates suggest that had all members of this cohort been circumcised, the overall rate of STI within the cohort would have been reduced by 50%.

[This ignores the low absolute rate of STIs. The proper figure to measure the effectiveness of circumcision is the Number Needed to Treat (NNT), i.e. the number of circumcisions required to prevent one STD. For the 18-21-year-olds this is 48.66, for the older men the NNT is 20.59. Multiply those figures by the cost of circumcision (with 21 or 25 years of interest since birth), and the total cost to prevent each STD is some thousands of dollars, compared with a few dollars to treat with antibiotic - and the benefits of leaving the men to enjoy their own foreskins.]

...a potential limitation of this research is that the assessment of STI was based on self-report, and this is likely to underestimate the true prevalence of these conditions. The prevalence estimates of STI reported in this article are, thus, likely to be lower-limit estimates of the true but nonobserved prevalence of STIs. However, whereas underreporting of STIs may bias estimates of the prevalence of STIs downward, it is unlikely to bias estimates of the association between STIs and circumcision, because there is no reason to believe that the reporting accuracy of STIs will vary with circumcision status.

[...but the fact is, we have no idea. Maybe circumcised men are more defensive about the idea that there is anything wrong with their penises, for example. It has been suggested that people with an anti-sex mindset are more likely to have their sons circumcised, especially when they have to buck the trend because the incidence of circumcision is low (and declining), as it was in Christchurch in 1973, and people raised in that environment would be more ashamed of admitting to an STI. But the incidence of STIs is so low that random elements can have a strong effect.]

...The public health issues raised by these findings clearly involve weighing the longerterm benefits of routine neonatal circumcision in terms of reducing risks of infection within the population, against the perceived costs of the procedure.

[Perceived by whom? Weigh in the risks, the pain, the ethical issues, and the value of the foreskin to its owner (and not to some present day man who can't remember having one) and it's a no-brainer: leave the babies alone.]


This study generated headlines worldwide saying the likes of "Circumcision may reduce STD risk - study". One rebuttal appeared in the news. Others were published as Post-publication Peer Reviews (P3Rs). Prof Fergusson responded by admitting that his result was anomalous, and took on board the fact that it would take 20 circumcisions to prevent one minor STD.

 

This New Zealand study addesses the failings of that one.

Journal of Paediatrics
March, 2008

Circumcision and risk of sexually transmitted infections in a birth cohort

Dickson NP, van Roode T, Herbison P, Paul C.

Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand.

OBJECTIVE: To determine the impact of early childhood circumcision on sexually transmitted infection (STI) acquisition to age 32 years.

STUDY DESIGN: The circumcision status of a cohort of children born in 1972 and 1973 in Dunedin, New Zealand was sought at age 3 years. Information about STIs was obtained at ages 21, 26, and 32 years. The incidence rates of STI acquisition were calculated, taking into account timing of first sex, and comparisons were made between the circumcised men and uncircumcised men. Adjustments were made for potential socioeconomic and sexual behavior confounding factors where appropriate.

RESULTS: Of the 499 men studied, 201 (40.3%) had been circumcised by age 3 years. The circumcised and uncircumcised groups differed little in socioeconomic characteristics and sexual behavior. Overall, up to age 32 years, the incidence rates for all STIs were not statistically significantly different - 23.4 and 24.4 per 1000 person-years for the uncircumcised and circumcised men, respectively. This was not affected by adjusting for any of the socioeconomic or sexual behavior characteristics.

Although our results are consistent with the lack of a protective effect, they are at variance with the recently published report by Fergusson et al, who, using data from another New Zealand cohort, found that circumcision reduced by more than one-half the risk of any STI up to age 25 years. Because both studies have particular strengths for examining this question, it is important to consider reasons for the discrepant findings. A lower proportion of the Christchurch sample (30.2%) was circumcised than the proportion of our Dunedin sample (40.2%; who were born 5 years earlier). This difference is in keeping with trends in circumcision in New Zealand at the time. This might have introduced a difference in characteristics between the circumcised men and uncircumcised men in the Christchurch compared with the Dunedin cohort, so residual confounding is more likely in the Christchurch analysis. But because adjustment for confounding increased the protective effect found in that study, this is an unlikely explanation. Another difference was that in the Christchurch study only 8.5% of men reported an STI between ages 18 and 25 years, which was less than half the 19.9% reported in our Dunedin study up to age 26 years. The reasons for this are not clear, but possibly the computer-presented questions in the latter study promoted disclosure. Finally, as noted, the Christchurch study was a relatively small sample; thus their estimate of the protective effect of circumcision lacks precision, with wide confidence intervals, and is compatible with only a small increase in risk.

CONCLUSIONS: These findings are consistent with recent population-based cross-sectional studies in developed countries, which found that early childhood circumcision does not markedly reduce the risk of the common STIs in the general population in such countries. [In this case, not even "markedly" - does not reduce it at all, and could increase it.]

 

This is in sharp contrast with a similar, but much larger British study:

Male circumcision in Britain: findings from a national probability sample survey
Dave SS, Fenton KA, Mercer CH, Erens B, Wellings K, Johnson AM.
Sex Transm Infect 2003;79:499-500

...We used data from the 2000 British National Survey of Sexual Attitudes and Lifestyles (Natsal 2000) - a large-scale, stratified, probability sample survey -- to estimate the prevalence of male circumcision in Britain and investigate its association with ... reported STI diagnosis.

Table 1 Cumulative incidence of reported previous STI dianosis by circumcision status among men aged 16-44 years in Britian (Natsal 2000)

Uncircumcised% (95% CI)

Circumcised% (95% CI)

OR for being circumcised (95% CI)

p Value

Any STD

10.8 (9.8 to 12.0)

11.1 (9.0 to 13.7)

1.03 (0.80 to 1.34)

0.815 ...

[There were apparently 913 circumcised and 4833 intact subjects.]

...We did not find any significant differences in the proportion of circumcised and uncircumcised British men reporting ever being diagnosed with any STI (11.1% compared with 10.8%, p = 0.815), bacterial STIs (6.4% cf 5.9%, p = 0.628), or viral STIs (4.7% cf 4.5%, p = 0.786) (table 1Go). We also found no significant associations between circumcision and being diagnosed with any one of the seven specific STIs.

 

And a large Australian one:

Circumcision in Australia: prevalence and effects on sexual health.

J Richters, AM Smith, RO de Visser, AE Grulich, and CE Rissel
Int J STD AIDS, August 1, 2006; 17(8): 547-54.

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),... More than half (59%) of the men were circumcised. Circumcision was less common among younger men (32% aged <20)... After correction for age, circumcision was unrelated to reporting STI, but appeared to protect against penile candidiasis. [...or rather, negatively correlated with penile candidiasis.]

 

Australian and New Zealand Journal of Public Health, 34:2, pp160-4

Circumcision in Australia: further evidence on its effects on sexual health and wellbeing

Jason A. Ferris, Juliet Richters, Marian K. Pitts, Julia M. Shelley, Judy M. Simpson. Richard Ryall and Anthony M. A. Smith

ABSTRACT

Objective: To report on the prevalence and demographic variation in circumcision in Australia and examine sexual health outcomes in comparison with earlier research.

Methods: A representative household sample of 4,290 Australian men aged 16–64 years completed a computer-assisted telephone interview including questions on circumcision status, demographic variables, reported lifetime experience of selected sexually transmissible infections (STIs), experience of sexual difficulties in the previous 12 months, masturbation, and sexual practices at last heterosexual encounter.

Results: More than half the men (58%) were circumcised. Circumcision was less common (33%) among men under 30 and more common (66%) among those born in Australia. After adjustment for age and number of partners, circumcision was unrelated to STI history except for non-specific urethritis (higher among circumcised men, OR=2.11, p<0.001 [i.e. the risk is more than twice as great, with high significance.]) and penile candidiasis (lower among circumcised men, OR=0.49, p<0.001).

Circumcision was unrelated to any of the sexual difficulties we asked about (after adjusting for age) except that circumcised men were somewhat less likely to have worried during sex about whether their bodies looked unattractive (OR=0.77, p=0.04). [This has been called "sociosomatic". They are victims of prejudice.] No association between lack of circumcision [curious expression!] and erection difficulties was detected. [Did they look for a correlation between circumcision and erectile difficulties?] After correction for age, circumcised men were somewhat more likely to have masturbated alone in the previous 12 months (OR=1.20, p=0.02).

Conclusions: Circumcision appears to have minimal protective effects on sexual health in Australia.

 

And another, from the US military...

This abstract was submitted for The XV International AIDS Conference, 2004 (Poster Exhibition)
Abstract no. TuPeC4861

Prevalence of male circumcision and its association with HIV and sexually transmitted infections in a U.S. navy population
A G Thomas, L N Bakhireva, S K Brodine, R A Shaffer
Naval Health Research Center, DHAPP, San Diego, CA, United States
P.O. Box 85122

Background: Lack of male circumcision has been found to be a risk factor for HIV and sexually transmitted infection (STI) in several studies performed in developing countries. However, the few studies conducted in developed nations have yielded inconsistent results. Policy regarding circumcision of male infants as a prevention measure against HIV/STI remains a controversial topic. This study describes the prevalence of circumcision and its association with HIV and STI in a U.S. military population.

Methods: This is a case-control study of male HIV infected U.S. military personnel (n= 232) recruited from 7 military medical centers and male U.S. Navy controls (n=516) from a general aircraft carrier population. Cases and controls completed similar self-administered HIV behavioral risk surveys. Case circumcision status was abstracted from medical charts while control status was reported on the survey. Cases and controls were frequency matched on age. Multiple logistic regressions were constructed separately to evaluate the role of circumcision in the acquisition of HIV and STI.

Results: The proportion of circumcised men did not significantly differ between cases (84.9%) and controls (81.8%). Prevalence of circumcision among men born in the U.S. was higher (85.0%) than those born elsewhere (58.1%). After adjustment for demographic and behavioral risk factors lack of circumcision was not found to be a risk factor for HIV (OR = 0.9; 95% CI: 0.51, 1.7) or STI (OR = 1.08; 95% CI 0.52, 2.26). The odds of HIV infection were 2.6 higher for irregular condom users, 5 times as high for those reporting STI, 6.2 times higher for those reporting anal sex, 2.8-3.2 times higher for those with 2-7+ partners, nearly 3 times higher for Blacks, and 3.5 times as high for men who were single or divorced/separated.

Conclusions: Although there may be other medical or cultural reasons for male circumcision, it is not associated with HIV or STI prevention in this U.S. military population.

 

A randomised controlled test from Kenya

J Infect Dis. 2009 Aug 1;200(3):370-378.

Adult Male Circumcision Does Not Reduce the Risk of Incident Neisseria gonorrhoeae, Chlamydia trachomatis, or Trichomonas vaginalis Infection: Results from a Randomized, Controlled Trial in Kenya

Supriya D. Mehta, Stephen Moses, Kawango Agot, Corette Parker, Jeckoniah O. Ndinya-Achola, Ian Maclean, and Robert C. Bailey

Background.We examined the effect of male circumcision on the acquisition of 3 nonulcerative sexually transmitted infections (STIs).

Methods.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. The outcome was first incident nonulcerative STI during 2 years of follow-up. STIs examined were laboratory-detected Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis infection.

Results.There were 342 incident infections among 2655 men followed up. The incidences of infection due to N. gonorrhoeae, C. trachomatis, and T. vaginalis were 3.48, 4.55, and 1.32 cases per 100 person-years, respectively. The combined incidence of N. gonorrhoeae and C. trachomatis infection was 7.26 cases per 100 person-years (95% confidence interval, 6.49–8.13 cases per 100 person-years). The incidences of these STIs, individually or combined, did not differ by circumcision status as a time-dependent variable or a fixed variable based on assignment. Risks for incident STIs in multivariate analysis included an STI at enrollment, multiple sex partners within <30 days, and sexual intercourse during menses in the previous 6 months; condom use was protective.

Conclusions.Circumcision of men in this population did not reduce their risk of acquiring these nonulcerative STIs. Improved STI control will require more-effective STI management, including partner treatment and behavioral risk reduction counseling.

 

No protection to heterosexual men

GENITOURINARY MEDICINE (U.K.), Volume 70, Pages 317-320, October 1994.

Male circumcision and common sexually transmissible diseases in a developed nation setting

B Donovan, I Bassett, N J Bodsworth

Abstract

Objective - To determine whether the circumcision status of men affected their likelihood of acquiring sexually transmissible diseases (STDs).

Design - A cross-sectional study employing an anonymous questionnaire, clinical examination and type specific serology for herpes simplex virus type 2 (HSV-2).

Setting - A public STD clinic in Sydney, Australia.

Subjects - 300 consecutive heterosexual male patients.

Main outcome measure - Associations between circumcision status and past or present diagnoses of STDs including HSV-2 serology and clinical pattern of genital herpes.

Results - 185 (62%) of the men were circumcised and they reported similar ages, education levels and lifetime partner numbers as men who were uncircumcised. There were no significant associations between the presence or absence of the male prepuce and the number diagnosed with genital herpes, genital warts and non-gonococcal urethritis. Men who were uncircumcised were no more likely to be seropositive for HSV-2 and reported symptomatic genital herpes outbreaks of the same frequency and severity as men who were circumcised. Gonorrhoea, syphilis and acute hepatitis B were reported too infrequently to reliably exclude any association with circumcision status. Human immunodeficiency virus infection (rare among heterosexual men in the clinic) was an exclusion criterion.

Conclusions - From the findings of this study, circumcision of men has no significant effect on the incidence of common STDs in this developed nation setting. However, these findings may not necessarily extend to other setting where hygiene is poorer and the spectrum of common STDs is different.

 

No protection to gay men

The Journal of Infectious Diseases 2009;200:000–000

Circumcision and Risk of Sexually Transmissible Infections in a Community-Based Cohort of HIV-Negative Homosexual Men in Sydney, Australia

David J. Templeton, Fengyi Jin, Garrett P. Prestage, Basil Donovan, John C. Imrie, Susan C. Kippax, Phillip H. Cunningham, John M. Kaldor, Adrian Mindel, Anthony L. Cunningham and Andrew E. Grulich

Background. Circumcision status was examined as an independent risk factor for sexually transmissible infections (STIs) in the Health in Men cohort of homosexual men in Sydney.

Methods. From 2001 through 2004, 1427 initially human immunodeficiency virus (HIV)–negative men were enrolled and followed up until mid-2007. All participants were offered annual STI testing. The history of STIs was collected at baseline, and information on sexual risk behaviors was collected every 6 months. At annual face-to-face visits, participants reported STI diagnoses received during the previous year.

Results. Circumcision was not associated with prevalent or incident herpes simplex virus 1, herpes simplex virus 2, or self-reported genital warts. There was also no independent association of circumcision with incident urethral gonorrhea or chlamydia. Being circumcised was associated with a significantly reduced risk of incident (hazard ratio, 0.35 [95% confidence interval, 0.15–0.84]) but not prevalent (odds ratio, 0.71 [95% confidence interval, 0.35–1.44]) syphilis. The association was somewhat stronger among men who reported predominantly insertive unprotected anal intercourse (hazard ratio, 0.10 [95% confidence interval, 0.01–0.82]).

Conclusions. These are the first prospective data obtained from homosexual men to assess circumcision status as a risk factor for STIs. Circumcised men were at reduced risk of incident syphilis but no other prevalent or incident STIs. Circumcision is unlikely to have a substantial public health impact in reducing acquisition of most STIs in homosexual men.

 

No protection from bacterial vaginosis

Sex Transm Infect. 1999 October; 75(5): 347–348.

Bacterial vaginosis is not associated with circumcision status of the current male partner
J. M. Zenilman, A. Fresia, B. Berger, and W. M. McCormack

Abstract

OBJECTIVE: Bacterial vaginosis (BV) is common in sexually active women, and in a large proportion the underlying aetiology is unknown. We evaluated partner circumcision status as a potential risk and hypothesised that women with uncircumcised partners were at increased risk for BV.

METHODS: Retrospective audit of a partner study (272 heterosexual couples) conducted in Baltimore between 1990 and 1992. BV defined by clinical criteria and circumcision status of males was determined by physical examination.

RESULTS: BV was diagnosed in 83 (30%) female partners; 75 (27%) males were uncircumcised. In males and females respectively, gonorrhoea was diagnosed in 20% and 16%, and chlamydia in 7% and 11%. In women with circumcised partners, 58/197 (29%) had BV compared with 25/75 (33%) with uncircumcised partners (p = 0.53).

CONCLUSION: Women with uncircumcised current partners are not at increased risk for BV.

 

Again, no protection from bacterial vaginosis, despite evidence of sexual transmission

Sexually Transmitted Diseases: November 2005 - Volume 32 - Issue 11 - pp 654-658

Risk Factors for Bacterial Vaginosis in Women at High Risk for Sexually Transmitted Diseases

Schwebke, Jane R. MD; Desmond, Renee PhD

Abstract

Objective and Goal: Bacterial vaginosis (BV) is extremely common and is associated with adverse obstetrical and gynecological outcomes. The etiology of the microbiologic changes is unknown. The objective of this study was to determine risk factors associated with incident BV.

Study: 96 women without BV were followed prospectively for 1 year for the development of BV. Thirty-seven of their male partners were also studied.

Results: The incidence rate of BV was 2.33/person-year (95% CI, 1.63-2.50). Median time to development of BV was 81 days. Incident BV was significantly associated with exposure to a new sexual partner (RR, 1.13; 95% CI, 1.02-1.25; P = 0.02) and frequency of vaginal sex since last visit (RR, 1.07; 95% CI, 1.01-1.15; P = 0.03). Use of condoms with occasional partners was protective (RR, 0.80; 95% CI, 0.67-0.98; P = 0.003). In multivariate analysis, sex with a new partner since the prior visit was the only behavior found to be significantly associated with incident BV (RR, 1.74; 95% CI, 1.05-2.87; P = 0.03).

Conclusion: These data support the sexual transmission of BV.

...Risk factors examined in modeling included new partner since last visit, anal sex at least 1 time since last visit, sex with uncircumcised male at least once since last visit, given metronidazole since last visit, douched at least once since last visit, vaginal sex at least 6 times since last visit, more than 1 different partner since last visit, sexual partner had at least 1 other partner in the last 30 days, used condom always with regular partner, and used condom always with occasional partner. For all final analyses, a P value of <0.05 was deemed statistically significant.

Risk factors for males that were examined for the relationship with BV included age at first sex, number of partners in last 30 days, new partners in last 30 days (?1 vs. 0), condom use (always in last 30 months vs. less than always), STD diagnosis (NGU, gonorrhea, or chlamydia), circumcision status, and number of days since last sex.

Table 2 Univariate Repeated-Measures Model of Risk Factors for Development of BV
Factor RR (95% CI) P
Exposed to uncircumcised
male at least once since
last vist
1.07 (0.95-1.21)0.24

[The 95% Confidence Interval passes through 1.0 and P is much greater than 0.05, so exposure to an intact man is not a risk factor for BV]

Table 3 Male Baseline Factors and Their Relationship to Acquisition of BV in the Female Partner
FactorBV+ (n=28)BV- (n=9)P
Circumcised0.38
No7 (25.0)1 (11.1)
Yes21 (75.0)8 (88.9)

[75% of the partners of circumcised men had BV, compared to 89% of the partners of intact men, but with only 8 intact men, The difference is not significant; P is much greater than 0.05, so being partner of an intact man is not a risk factor for BV.]

[The lack of prevention shown by this study is a dog that didn't bark in the night - it goes unreported, while studies that do claim to find prevention are widely publicised.]

 

More data-mining...

The Lancet Global Health, Volume 2, Issue 11, Pages e664 - e671, November 2014

Association between male circumcision and incidence of syphilis in men and women: a prospective study in HIV-1 serodiscordant heterosexual African couples

Pintye J, Baeten JM, Manhart LE, Celum C, Ronald A, Mugo N, Mujugira A, Cohen C, Were E, Bukusi E, Kiarie J, Heffron R

Background
Male circumcision is a primary HIV-1 prevention intervention for men, but whether the procedure reduces the risk of syphilis among men and their female partners is uncertain. We aimed to assess whether male circumcision was associated with incident syphilis in men and in their female partners.

Methods
In this large prospective cohort study, participants were members of Kenyan and Ugandan HIV-1 serodiscordant heterosexual couples enrolled in a randomised safety and efficacy clinical trial of pre-exposure prophylaxis for HIV-1 prevention (the Partners PrEP Study). Participants attended monthly or quarterly follow-up visits for up to 36 months. Annually, syphilis serology testing was done and male circumcision status was assessed. We used multivariate Andersen-Gill survival methods, adjusted for age, sexual behaviour, and plasma HIV RNA levels of the HIV-infected partner.

Findings 4716 HIV-1 serodiscordant couples (38%) with a man with HIV were followed for a median of 2·75 years. At enrolment, 1575 (53%) men with HIV and 560 (32%) men without HIV were circumcised; an additional 69 (4%) men with HIV and 132 (5%) men without HIV were circumcised during study follow-up. 221 incident syphilis infections were reported: 46 (21%) in men with HIV (incidence 1·10 per 100 person-years), 76 (34%) in men without HIV (1·09), 54 (24%) in women with HIV (0·77), and 45 (24%) in women without HIV (1·11). Male circumcision was associated with a 42% reduction in incident syphilis in men (adjusted hazard ratio [aHR] 0·58, 95% CI 0·37—0·91) including a 62% reduction in men with HIV (0·38, 0·18—0·81), and a non-significant reduction in incident syphilis in men without HIV (0·64, 0·36—1·11). [So genital cutting did not reduce syphilis in men without HIV, and was only associated with syphilis in men with HIV, based on a total of 46 men.] In women, circumcision of their male partners was associated with a 59% reduction in incident syphilis (aHR 0·41, 95% CI 0·25—0·69), including a 75% reduction in women without HIV (0·25, 0·08—0·76) and a 48% reduction in women with HIV (0·52, 0·27—0·97). [So, opposite to the men, the association - correlation, not necessarily causation - between circumcision and syphils was stronger in women without HIV than women with HIV. Something is wrong here.]

Interpretation
Male circumcision was associated with decreased risk of incident syphilis in men [no, only men with HIV] and women [but more in women without HIV.]. If confirmed [but it's a big "if"], these results suggest that medical male circumcision could substantially reduce incidence of syphilis and its sequelae.

Funding
Bill & Melinda Gates Foundation and the Eunice Kennedy Shriver National Institute of Child Health and Human Development.

But sure enough, this was followed by a headline:

Times Live (Zambia)
30 October, 2014

The snip cuts risk of syphilis for women

Katharine Child

Researchers analysing data from a trial examining the use of anti-retrovirals as prevention for HIV, have found that circumcision offered high protection to both men and their female partners against syphilis. ...

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