Circumcision and HIV

Circumcision is a procedure that removes the foreskin from the human penis. In the most common form of the operation, the foreskin is extended with forceps, then a circumcision device may be placed, after which the foreskin is excised. Topical or locally injected anesthesia is generally used to reduce pain and physiologic stress. It is usually elective, performed as preventive healthcare, a religious rite, or cultural practice. It is also an option for cases of phimosis, other pathologies that do not resolve with other treatments, and chronic urinary tract infections (UTIs). The procedure is contraindicated in cases of certain genital structure abnormalities or poor general health.

Circumcision is associated with reduced rates of sexually transmitted infections and urinary tract infections. This includes decreasing the incidence of cancer-causing forms of human papillomavirus (HPV) and significantly reducing HIV transmission among heterosexual men within high risk populations. The World Health Organization (WHO) and UNAIDS recommend circumcision as part of a comprehensive HIV transmission program in areas with high endemic rates of HIV. The WHO does not recommend circumcision for HIV prevention in men who have sex with men; effectiveness of using circumcision to prevent HIV in the developed world is unclear. Neonatal circumcision also decreases the risk of rare penile cancer. Complication rates are higher when the procedure is performed on older people. A 2010 review found circumcisions performed by medical providers to have a typical complication rate of 1.5% for babies and 6% for older children, with few cases of severe complications. Bleeding, infection, and the removal of either too much or too little foreskin are the most common acute complications. Meatal stenosis is the most common long term complication. Major medical organizations hold widely variant perspectives on the bioethics, cost-effectiveness, and the prophylactic efficacy related to the elective circumcision of minors. The World Health Organization (WHO), UNAIDS, and American medical organizations take the position that it carries prophylactic health benefits which outweigh small risks, while European medical organizations generally hold the belief that in these situations its medical benefits are not counterbalanced by risk.

Prophylactic circumcision originated in England during the 1850s, becoming initially established as a way to preventing sexually transmitted infections. Beyond use as a prophylactic or treatment option in healthcare, circumcision also plays a major role in many of the world's cultures and religions; it is most prominently performed in Judaism and Islam. Circumcision is among the most important commandments in Judaism. There are varying cultural, ethical, and social views on the practice. Campaigns of Jewish ethnic, cultural, and religious persecution have repeatedly included bans on the practice as an attempted means of forceful assimilation, conversion, and ethnocide, including in the Maccabean Revolt. It has also played a major role in Christian history and theology, although among the vast majority of Christian denominations it is not considered a practice that is obligatory or recommended for religious reasons. Circumcised men are presently estimated to constitute around 38% of the world's male population. It is widespread in Australia, Canada, Africa, parts of Southeast Asia, the United States, South Korea, and New Zealand. It is relatively rare for non-religious reasons in Latin America, parts of Southern Africa, Europe, and most of Asia. The origin of circumcision is not known with certainty; the oldest documentation comes from ancient Egypt.

Uses

Elective

Around half of all circumcisions worldwide are performed for reasons of prophylactic healthcare. In the United States neonatal circumcision is among the most common types of elective surgery.

Prophylactic usage in high-risk populations

There is a consensus among the world's major medical organizations that circumcision is an efficacious intervention for HIV prevention in high risk populations if carried out by medical professionals under safe conditions. In 2007, the WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS) stated that they recommended adolescent and adult circumcision as part of a comprehensive program for prevention of HIV transmission in areas with high endemic rates of HIV, as long as the program includes " informed consent, confidentiality, and absence of coercion" ― known as voluntary medical male circumcision, or VMMC. In 2010, this was expanded to routine neonatal circumcision, as long as those undergoing the procedure received assent from their parents. In 2020, the World Health Organization again concluded that male circumcision is an efficacious intervention for HIV prevention and that the promotion of male circumcision is an essential strategy, in addition to other preventive measures, for the prevention of heterosexually acquired HIV infection in men. Eastern and southern Africa had a particularly low prevalence of circumcised males. This region has a disproportionately high HIV infection rate, with a significant number of those infections stemming from heterosexual transmission. As a result, the promotion of prophylactic circumcision has been a priority intervention in that region since the WHO's 2007 recommendations.

The International Antiviral Society–USA also suggests circumcision be discussed with men who have insertive anal sex with men, especially in regions where HIV is common. There is evidence that circumcision is associated with a reduced risk of HIV infection for such men, particularly in low-income countries.

The finding that circumcision significantly reduces female-to-male HIV transmission has prompted medical organizations serving communities affected by endemic HIV/AIDS to promote circumcision as an additional method of controlling the spread of HIV.

Prophylactic usage in developed countries

Major medical organizations hold widely varying positions on the prophylactic efficacy, bioethics, and cost-effectiveness of elective circumcision of minors in the context of developed countries. Literature on the matter is polarized, with the cost-benefit analysis being highly dependent on the kinds and frequencies of health problems in the population under discussion and how circumcision affects them.

The World Health Organization (WHO), UNAIDS, and American medical organizations take the position that it carries prophylactic health benefits which outweigh small risks, while European medical organizations generally hold the belief that in these situations its medical benefits are not counterbalanced by risk. The procedure's relationship to other prophylactic procedures, along with the concepts of group rights, consent, and religious freedom, are frequently discussed in academic literature. Public health advocates of circumcision consider it to have a net health benefit, and therefore feel that increasing the circumcision rate is imperative. They recommend performing it during the neonatal period when it is less expensive and has a lower risk of complications. The American Academy of Pediatrics and Centers for Disease Control and Prevention stated that the benefits of circumcision outweigh the risks. In 2014, the CDC recommended circumcision in a policy statement.

Similarly, the World Health Organization in 2010 stated:

Religious, cultural, and ethnic circumcision

Worldwide, around half of all circumcisions are performed for religious or cultural reasons. Circumcision plays a major role in many of the world's cultures and religions. When performed for religious reasons, it is most common among Muslims and Jews (among whom it is near-universal) and the members of the Coptic, Ethiopian, and Eritrean Orthodox Churches. Circumcision is an integral or established practice for members of these faiths, as well as amongst Samaritans and Druze. Male circumcision is also widely practiced among Christian communities in the Anglosphere countries, Oceania, South Korea, the Philippines, the Middle East and Africa. The United States and the Philippines are the largest majority Christian countries in the world to extensively practice circumcision. In some African and Eastern Christian denominations male circumcision is an integral or established practice, and require that their male members undergo circumcision.

Pathologies

Circumcision is also used to treat various pathologies. These include pathological phimosis, refractory balanoposthitis and chronic or recurrent urinary tract infections (UTIs).

Contraindications

Circumcision is contraindicated in certain cases.

These include infants with certain genital structure abnormalities, such as a misplaced urethral opening (as in hypospadias and epispadias), curvature of the head of the penis (chordee), or ambiguous genitalia, because the foreskin may be needed for reconstructive surgery. Circumcision is contraindicated in premature infants and those who are not clinically stable and in good health. If an individual is known to have or has a family history of serious bleeding disorders such as hemophilia, it is recommended that the blood be checked for normal coagulation properties before the procedure is attempted.

Technique

The foreskin extends out from the base of the glans and covers the glans when the penis is flaccid. Proposed theories for the purpose of the foreskin are that it serves to protect the penis as the fetus develops in the mother's womb, that it helps to preserve moisture in the glans, and that it improves sexual pleasure. The foreskin may also be a pathway of infection for certain diseases. Circumcision removes the foreskin at its attachment to the base of the glans. For adult medical circumcision, superficial wound healing takes up to a week, and complete healing 4 to 6 months. For infants, healing is usually complete within one week.

Removal of the foreskin

For infant circumcision, devices such as the Gomco clamp, Plastibell and Mogen clamp are commonly used in the USA. These follow the same basic procedure. First, the amount of foreskin to be removed is estimated. The practitioner opens the foreskin via the preputial orifice to reveal the glans underneath and ensures it is normal before bluntly separating the inner lining of the foreskin ( preputial epithelium) from its attachment to the glans. The practitioner then places the circumcision device (this sometimes requires a dorsal slit), which remains until blood flow has stopped. Finally, the foreskin is amputated. For older babies and adults, circumcision is often performed surgically without specialized instruments, and alternatives such as Unicirc or the Shang ring are available.

Pain management

The circumcision procedure causes pain, and for neonates this pain may interfere with mother-infant interaction or cause other behavioral changes, so the use of analgesia is advocated. Ordinary procedural pain may be managed in pharmacological and non-pharmacological ways. Pharmacological methods, such as localized or regional pain-blocking injections and topical analgesic creams, are safe and effective. The ring block and dorsal penile nerve block (DPNB) are the most effective at reducing pain, and the ring block may be more effective than the DPNB. They are more effective than EMLA (eutectic mixture of local anesthetics) cream, which is more effective than a placebo. Topical creams have been found to irritate the skin of low birth weight infants, so penile nerve block techniques are recommended in this group.

For infants, non-pharmacological methods such as the use of a comfortable, padded chair and a sucrose or non-sucrose pacifier are more effective at reducing pain than a placebo, but the American Academy of Pediatrics (AAP) states that such methods are insufficient alone and should be used to supplement more effective techniques. A quicker procedure reduces duration of pain; use of the Mogen clamp was found to result in a shorter procedure time and less pain-induced stress than the use of the Gomco clamp or the Plastibell. The available evidence does not indicate that post-procedure pain management is needed. For adults, topical anesthesia, ring block, dorsal penile nerve block (DPNB) and general anesthesia are all options, and the procedure requires four to six weeks of abstinence from masturbation or intercourse to allow the wound to heal.

Effects

Sexually transmitted diseases

Human immunodeficiency virus

There is strong evidence that circumcision reduces the risk of men acquiring HIV infection in areas of the world with high rates of HIV. This evidence is principally derived from three randomized controlled studies conducted in Africa in 2002. Evidence among heterosexual men in sub-Saharan Africa shows an absolute decrease in risk of 1.8% which is a relative decrease of between 38% and 66% over two years, and in this population studies rate it cost-effective. Whether it is of benefit in developed countries is undetermined.

There are plausible explanations based on human biology for how circumcision can decrease the likelihood of female-to-male HIV transmission. The superficial skin layers of the penis contain Langerhans cells, which are targeted by HIV; removing the foreskin reduces the number of these cells. When an uncircumcised penis is erect during intercourse, any small tears on the inner surface of the foreskin come into direct contact with the vaginal walls, providing a pathway for transmission. When an uncircumcised penis is flaccid, the pocket between the inside of the foreskin and the head of the penis provides an environment conducive to pathogen survival; circumcision eliminates this pocket. Some experimental evidence has been provided to support these theories.

The WHO and the UNAIDS state that male circumcision is an efficacious intervention for HIV prevention, but should be carried out by well-trained medical professionals and under conditions of informed consent (parents' consent for their infant boys). The WHO has judged circumcision to be a cost-effective public health intervention against the spread of HIV in Africa, although not necessarily more cost-effective than condoms. The joint WHO/UNAIDS recommendation also notes that circumcision only provides partial protection from HIV and should not replace known methods of HIV prevention.

Male circumcision provides only indirect HIV protection for heterosexual women. The WHO does not recommend circumcision as a protection for male-to-male HIV transmission. Evidence is lacking with regards to circumcision reducing HIV risk for receptive anal intercourse.

Human papillomavirus

Human papillomavirus (HPV) is the most commonly transmitted sexually transmitted infection, affecting both men and women. While most infections are asymptomatic and are cleared by the immune system, some types of the virus cause genital warts, and other types, if untreated, cause various forms of cancer, including cervical cancer, and penile cancer. Genital warts and cervical cancer are the two most common problems resulting from HPV.

Circumcision is associated with a reduced prevalence of oncogenic types of HPV infection, meaning that a randomly selected circumcised man is less likely to be found infected with cancer-causing types of HPV than an uncircumcised man. It also decreases the likelihood of multiple infections. there was no strong evidence that it reduces the rate of new HPV infection, but the procedure is associated with increased clearance of the virus by the body, which can account for the finding of reduced prevalence.

Although genital warts are caused by a type of HPV, there is no statistically significant relationship between being circumcised and the presence of genital warts.

Other infections

Studies evaluating the effect of circumcision on the rates of other sexually transmitted infections have generally, found it to be protective. A 2006 meta-analysis found that circumcision was associated with lower rates of syphilis, chancroid and possibly genital herpes. A 2010 review found that circumcision reduced the incidence of HSV-2 (herpes simplex virus, type 2) infections by 28%. The researchers found mixed results for protection against trichomonas vaginalis and chlamydia trachomatis, and no evidence of protection against gonorrhea or syphilis. It may also possibly protect against syphilis in MSM.

Phimosis, balanitis and balanoposthitis

Phimosis is the inability to retract the foreskin over the glans penis. At birth, the foreskin cannot be retracted due to adhesions between the foreskin and glans, and this is considered normal (physiological phimosis). Over time the foreskin naturally separates from the glans, and a majority of boys are able to retract the foreskin by age three. Less than one percent are still having problems at age 18. If the inability to do so becomes problematic (pathological phimosis) circumcision is a treatment option. This pathological phimosis may be due to scarring from the skin disease balanitis xerotica obliterans (BXO), repeated episodes of balanoposthitis or forced retraction of the foreskin. Steroid creams are also a reasonable option and may prevent the need for surgery including in those with mild BXO. The procedure may also be used to prevent the development of phimosis. Phimosis is also a complication that can result from circumcision.

An inflammation of the glans penis and foreskin is called balanoposthitis, and the condition affecting the glans alone is called balanitis. Most cases of these conditions occur in uncircumcised males, affecting 411% of that group. The moist, warm space underneath the foreskin is thought to facilitate the growth of pathogens, particularly when hygiene is poor. Yeasts, especially ''Candida albicans'', are the most common penile infection and are rarely identified in samples taken from circumcised males. Both conditions are usually treated with topical antibiotics (metronidazole cream) and antifungals (clotrimazole cream) or low-potency steroid creams. Circumcision is a treatment option for refractory or recurrent balanoposthitis, but in the twenty-first century the availability of the other treatments has made it less necessary.

Urinary tract infections

A UTI affects parts of the urinary system including the urethra, bladder, and kidneys. There is about a one percent risk of UTIs in boys under two years of age, and the majority of incidents occur in the first year of life. There is good but not ideal evidence that circumcision of babies reduces the incidence of UTIs in boys under two years of age, and there is fair evidence that the reduction in incidence is by a factor of 310 times (100 circumcisions prevents one UTI). Circumcision is most likely to benefit boys who have a high risk of UTIs due to anatomical defects, and may be used to treat recurrent UTIs.

There is a plausible biological explanation for the reduction in UTI risk after circumcision. The orifice through which urine passes at the tip of the penis (the urinary meatus) hosts more urinary system disease-causing bacteria in uncircumcised boys than in circumcised boys, especially in those under six months of age. As these bacteria are a risk factor for UTIs, circumcision may reduce the risk of UTIs through a decrease in the bacterial population.

Cancers

Circumcision has a protective effect against the risks of penile cancer in men, and cervical cancer in the female sexual partners of heterosexual men. Penile cancer is rare in most developed countries, with about 1 new case per 100,000 people per year in developed countries, and higher incidence rates per 100,000 in sub-Saharan Africa (for example: 1.6 in Zimbabwe, 2.7 in Uganda and 3.2 in Eswatini). The number of new cases is also high in some South American countries including Paraguay and Uruguay, at about 4.3 per 100,000. It is least common in Israeli Jews—0.1 per 100,000—related in part to the very high rate of circumcision of babies.

Penile cancer development can be detected in the carcinoma ''in situ'' (CIS) cancerous precursor stage and at the more advanced invasive squamous cell carcinoma stage. Childhood or adolescent circumcision is associated with a reduced risk of invasive squamous cell carcinoma in particular. There is an association between adult circumcision and an increased risk of invasive penile cancer; this is believed to be from men being circumcised as a treatment for penile cancer or a condition that is a precursor to cancer rather than a consequence of circumcision itself. Penile cancer has been observed to be nearly eliminated in populations of males circumcised neonatally.

Important risk factors for penile cancer include phimosis and HPV infection, both of which are mitigated by circumcision. The mitigating effect circumcision has on the risk factor introduced by the possibility of phimosis is secondary, in that the removal of the foreskin eliminates the possibility of phimosis. This can be inferred from study results that show uncircumcised men with no history of phimosis are equally likely to have penile cancer as circumcised men. Circumcision is also associated with a reduced prevalence of cancer-causing types of HPV in men and a reduced risk of cervical cancer (which is caused by a type of HPV) in female partners of men. As penile cancer is rare (and may become increasingly rare as HPV vaccination rates rise), and circumcision has risks, the practice is not considered to be valuable solely as a prophylactic measure against penile cancer in the United States.

There is some evidence that circumcision is associated with lower risk of prostate cancer. A 2015 meta-analysis found a reduced risk of prostate cancer associated with circumcision in black men. A 2016 meta-analysis found that men with prostate cancer were less likely to be circumcised.

Women's health

A 2017 systematic review found consistent evidence that male circumcision prior to heterosexual contact was associated with a decreased risk of cervical cancer, cervical dysplasia, HSV-2, chlamydia, and syphilis among women. The evidence was less consistent in regards to the potential association of circumcision with women's risk of HPV and HIV.

Sexual effects

Circumcision does not affect sexual function, sensation, desire, or pleasure.The American Academy of Pediatrics Task Force on Circumcision "Technical Report" (2012) addresses sexual function, sensitivity and satisfaction without qualification by age of circumcision. Sadeghi-Nejad ''et al.'' "Sexually transmitted diseases and sexual function" (2010) addresses adult circumcision and sexual function. Doyle ''et al.'' "The Impact of Male Circumcision on HIV Transmission" (2010) addresses adult circumcision and sexual function. Perera ''et al.'' "Safety and efficacy of nontherapeutic male circumcision: a systematic review" (2010) addresses adult circumcision and sexual function and satisfaction. Although consistently rejected in the academic literature and by major medical organizations, there are various popular misconceptions and cultural myths that circumcision benefits or adversely affects sexual function and libido. A 2013 systematic review published in the '' Asian Journal of Andrology'' found that circumcision did not appear to adversely affect or prevent pain with intercourse, premature ejaculation, time until ejaculation, erectile dysfunction or difficulties with orgasm. However, the study found that the existing evidence is insufficient to make conclusive determinations. The effect of circumcision on sexual partners' experiences is unclear as this has not been well studied.

Adverse effects

Neonatal circumcision is generally a safe, low-risk procedure when done by an experienced practitioner.

The most common acute complications are bleeding, infection and the removal of either too much or too little foreskin. These complications occur in approximately 0.13% of procedures, with bleeding being the most common acute complication in the United States. Minor complications are reported to occur in three percent of procedures. Severe complications are rare. A specific complication rate is difficult to determine due to scant data on complications and inconsistencies in their classification. Complication rates are greater when the procedure is performed by an inexperienced operator, in unsterile conditions, or when the child is at an older age. Significant acute complications happen rarely, occurring in about 1 in 500 newborn procedures in the United States. Severe to catastrophic complications, including death, are so rare that they are reported only as individual case reports. Where a Plastibell device is used, the most common complication is the retention of the device occurring in around 3.5% of procedures. Other possible complications include buried penis, chordee, phimosis, skin bridges, urethral fistulas, and meatal stenosis. These complications may be partly avoided with proper technique, and are often treatable without requiring surgical revision. The most common long-term complication is meatal stenosis, this is almost exclusively seen in circumcised children, it is thought to be caused by ammonia producing bacteria coming into contact with the meatus in circumcised infants. It can be treated by meatotomy.

Effective pain management should be used during the procedure. Inadequate pain relief may carry the risks of heightened pain response for newborns. Newborns that experience pain due to being circumcised have different responses to vaccines given afterwards, with higher pain scores observed. For adult men who have been circumcised, there is a risk that the circumcision scar may be tender.

It is unclear what the psychological outcomes of circumcision are. Studies have shown positive, neutral, or negative effects. There is debate in the literature over whether the pain of circumcision has lasting psychological impact, with only weak underlying data available. There is no good evidence that circumcision affects cognitive abilities.

Prevalence

Present

Circumcision is one of the world's most widely performed medical procedures.

Approximately 38% of males worldwide are circumcised as of 2016. Around half for reasons of prophylactic healthcare and half for religious or cultural reasons. It is most often practiced between infancy and the early twenties. This is an increase from 2007, when WHO estimated that 664,500,000 males aged 15 and over were circumcised (30–33% global prevalence), and that 70% of circumcised men were Muslim. A study on male circumcision prevalence in 118 developing countries found that 69% of circumcised men were Muslim.

Circumcision is most common in the Australia, Canada, Israel, New Zealand, the Muslim world, South Korea, the United States, and parts of Southeast Asia and Africa. It is relatively rare for non-religious reasons in Europe, Latin America, parts of Southern Africa and Oceania and most of non-Muslim Asia. Prevalence is near-universal in the Middle East and Central Asia. Non-religious circumcision in Asia, outside the Republic of Korea and the Philippines, is fairly rare, and prevalence is generally low (less than 20%) across Europe. Estimates for individual countries include Taiwan at 9% and Australia 58.7%. Prevalence in the United States and Canada is estimated at 75% and 30% respectively. Prevalence in Africa varies from less than 20% in some southern African countries to near universal in North and West Africa.

Rates of circumcision over time have varied by country. As of 2021, ''Wolters Kluwer Health'' estimates that around 80% of male neonates are circumcised before leaving the hospital in the United States, with the large majority of these being for prophylactic reasons. Circumcision incidence in the U.S. has likely risen since 2012, when the AAP released a policy statement that was more positive on the topic. Hospital discharge surveys in the U.S. show lower numbers, although this is likely due to miscoding, circumcisions performed after hospital discharge, and those performed later in life. Canada has seen a slow decline since the early 1970s, possibly influenced by past statements from the AAP and the Canadian Pediatric Society in the 1970s that stated it was not medically necessary. In Australia, the rate declined in the 1970s and 80s, but has been increasing slowly as of 2004. In the United Kingdom, prevalence was likely to have been 20–30% in the 1940s but declined at the end of that decade. One possible reason may have been a 1949 ''British Medical Journal'' article which argued that there was no good medical reason for routine circumcision. The overall prevalence of circumcision in South Korea has increased markedly in the second half of the 20th century, rising from near zero around 1950 to about 60% in 2000, with the most significant jumps in the last two decades of that time period.

Medical organizations can affect the neonatal circumcision rate of a country by influencing whether the costs of the procedure are borne by the parents or are covered by insurance or a national health care system. Policies that require the costs to be paid by the parents yield lower circumcision rates. The decline in the rates in the UK is one example; another is that in United States, with states where insurance or Medicaid covers the costs having higher rates. Changes to policy are driven by the results of new research, and moderated by the politics, demographics, and culture of the communities.

Future

''(Yosha & Bolnick & Koyle, 2012)'' projects a "worldwide increase in circumcision rates in the first half of the twenty-first century."

They attribute this increase in global incidence and prevalence predominately to:

* Increasingly positive statements by major medical organizations surrounding prophylactic usage.
* Population growth in societies that have a high circumcision incidence.
* Population decreases (or lower rates of growth) in societies that have a low circumcision incidence.
* Public health projects by international medical organizations, including by the World Health Organization, which have encouraged it as part of a comprehensive means of HIV/AIDS prevention.

History

Circumcision is the world's oldest planned surgical procedure, suggested by anatomist and hyperdiffusionist historian Grafton Elliot Smith to be over 15,000 years old, pre-dating recorded history. There is no firm consensus as to how it came to be practiced worldwide. One theory is that it began in one geographic area and spread from there; another is that several different cultural groups began its practice independently. In his 1891 work ''History of Circumcision'', physician Peter Charles Remondino suggested that it began as a less severe form of emasculating a captured enemy: penectomy or castration would likely have been fatal, while some form of circumcision would permanently mark the defeated yet leave him alive to serve as a slave. Other explanations for its origin include it acting as a religious sacrifice or a rite of passage marking a boy's entrance into adulthood.

The history of the migration and evolution of the practice of circumcision is followed mainly through the cultures and peoples in two separate regions. In the lands south and east of the Mediterranean, starting with Sudan and Ethiopia, the procedure was practiced by the ancient Egyptians and the Semites