Review: A critical evaluation of arguments opposing male circumcision for HIV prevention in developed countries.
ABSTRACT Abstract A potential impediment to evidence-based policy development on medical male circumcision (MC) for HIV prevention in all countries worldwide is the uncritical acceptance by some of arguments used by opponents of this procedure. Here we evaluate recent opinion-pieces of 13 individuals opposed to MC. We find that these statements misrepresent good studies, selectively cite references, some containing fallacious information, and draw erroneous conclusions. In marked contrast, the scientific evidence shows MC to be a simple, low-risk procedure with very little or no adverse long-term effect on sexual function, sensitivity, sensation during arousal or overall satisfaction. Unscientific arguments have been recently used to drive ballot measures aimed at banning MC of minors in the USA, eliminate insurance coverage for medical MC for low-income families, and threaten large fines and incarceration for health care providers. Medical MC is a preventative health measure akin to immunisation, given its protective effect against HIV infection, genital cancers and various other conditions. Protection afforded by neonatal MC against a diversity of common medical conditions starts in infancy with urinary tract infections and extends throughout life. Besides protection in adulthood against acquiring HIV, MC also reduces morbidity and mortality from multiple other sexually transmitted infections (STIs) and genital cancers in men and their female sexual partners. It is estimated that over their lifetime one-third of uncircumcised males will suffer at least one foreskin-related medical condition. The scientific evidence indicates that medical MC is safe and effective. Its favourable risk/benefit ratio and cost/benefit support the advantages of medical MC.
- SourceAvailable from: PubMed Central[Show abstract] [Hide abstract]
ABSTRACT: We critically evaluate a recent article by Van Howe involving 12 meta-analyses that concludes, contrary to current evidence, that male circumcision increases the risk of various common sexually transmitted infections (STIs). Our detailed scrutiny reveals that these meta-analyses (1) failed to include results of all relevant studies, especially data from randomized controlled trials, (2) introduced bias through use of inappropriate control groups, (3) altered original data, in the case of human papillomavirus (HPV), by questionable adjustments for "sampling bias," (4) failed to control for confounders through use of crude odds ratios, and (5) used unnecessarily complicated methods without adequate explanation, so impeding replication by others. Interventions that can reduce the prevalence of STIs are important to international health. Of major concern is the global epidemic of oncogenic types of HPV that contribute to the burden of genital cancers. Meta-analyses, when well conducted, can better inform public health policy and medical practice, but when seriously flawed can have detrimental consequences. Our critical evaluation leads us to reject the findings and conclusions of Van Howe on multiple grounds. Our timely analysis thus reaffirms the medical evidence supporting male circumcision as a desirable intervention for STI prevention.ISRN urology. 01/2014; 2014:684706.
Article: Urological aspects of HIV and AIDS.[Show abstract] [Hide abstract]
ABSTRACT: The use of highly active antiretroviral therapy (HAART) in HIV-infected people has led to a dramatic decrease in the incidence of opportunistic infections and virus-related malignancies such as non-Hodgkin lymphoma and Kaposi sarcoma, but not cervical or anal cancer. Advanced-stage cervical cancer is associated with a high incidence of urological complications such as hydronephrosis, renal failure, and vesicovaginal fistula. Adult male circumcison can significantly reduce the risk of male HIV acquisition. Although HAART does not completely eradicate HIV, compliance with medication increases life expectancy. HIV infection or treatment can result in renal failure, which can be managed with dialysis and transplantation (as for HIV-negative patients). Although treatment for erectile dysfunction-including phosphodiesterase 5 inhibitors, intracavernosal injection therapy, and penile prosthesis-can increase the risk of HIV transmission, treatment decisions for men with erectile dysfunction should not be determined by HIV status. The challenges faced when administering chemotherapy to HIV-infected patients with cancer include late presentation, immunodeficiency, drug interactions, and adverse effects associated with compounded medications. Nonetheless, HIV-infected patients should receive the same cancer treatment as HIV-negative patients. The urologist is increasingly likely to encounter HIV-positive patients who present with the same urological problems as the general population, because HAART confers a prolonged life expectancy. Performing surgery in an HIV-infected individual raises safety issues for both the patient (if severely immunocompromised) and the surgeon, but the risk of HIV transmission from patients on fully suppressive HAART is small.Nature Reviews Urology 10/2013; · 4.79 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: The objective of this review was to assess the trend in the US male circumcision rate and the impact that the affirmative 2012 American Academy of Pediatrics policy statement might have on neonatal circumcision practice. We searched PubMed for the term circumcision to retrieve relevant articles. This review was prompted by a recent report by the Centers for Disease Control and Prevention that found a slight increase, from 79% to 81%, in the prevalence of circumcision in males aged 14 to 59 years during the past decade. There were racial and ethnic disparities, with prevalence rising to 91% in white, 76% in black, and 44% in Hispanic males. Because data on neonatal circumcision are equivocal, we undertook a critical analysis of hospital discharge data. After correction for underreporting, we found that the percentage had declined from 83% in the 1960s to 77% by 2010. A risk-benefit analysis of conditions that neonatal circumcision protects against revealed that benefits exceed risks by at least 100 to 1 and that over their lifetime, half of uncircumcised males will require treatment for a medical condition associated with retention of the foreskin. Other analyses show that neonatal male circumcision is cost-effective for disease prevention. The benefits of circumcision begin in the neonatal period by protection against infections that can damage the pediatric kidney. Given the substantial risk of adverse conditions and disease, some argue that failure to circumcise a baby boy may be unethical because it diminishes his right to good health. There is no long-term adverse effect of neonatal circumcision on sexual function or pleasure. The affirmative 2012 American Academy of Pediatrics policy supports parental education about, access to, and insurance and Medicaid coverage for elective infant circumcision. As with vaccination, circumcision of newborn boys should be part of public health policies. Campaigns should prioritize population subgroups with lower circumcision prevalence and a higher burden of diseases that can be ameliorated by circumcision.Mayo Clinic Proceedings 01/2014; · 5.79 Impact Factor
For Peer Review Only
A critical evaluation of arguments opposing male
circumcision for HIV prevention in developed countries
AIDS Care - Psychology, Health & Medicine - Vulnerable Children and
Manuscript ID: Draft
Journal Selection: AIDS Care
circumcision, HIV, evidence-based evaluation, public health policy,
Note: The following files were submitted by the author for peer review, but cannot be converted to
PDF. You must view these files (e.g. movies) online.
Main text 4420
Number of references: 123
A critical evaluation of arguments opposing male
circumcision for HIV prevention in developed countries
Brian J. Morrisa*, Robert C. Baileyb, Jeffrey D. Klausnerc, Joya Banerjeed, Richard G.
Wamaie, Jake H. Waskettf, Arleen Leibowitzg, Daniel T. Halperinh, Laurie Zolothi, Helen A.
Weissj, Catherine A. Hankinsk
aSchool of Medical Sciences and Bosch Institute, Sydney Medical School, University of
Sydney, NSW 2006, Australia
bDivision of Epidemiology and Biostatistics, University of Illinois at Chicago, Chicago, IL,
cDivisions of AIDS & Infectious Diseases, University of California, San Francisco, CA
dGlobal Youth Coalition on HIV/AIDS, South Africa
eDepartment of African-American Studies, Northeastern University, Boston, MA, USA
fCircumcision Independent Reference and Commentary Service, Radcliffe, Manchester M26
gUCLA School of Public Affairs, Department of Public Policy, University of California Los
Angeles, CA 90095-1656, USA
hDepartment of Global Health and Population, Harvard School of Public Health, Boston,
MA 02115, USA
iCenter for Bioethics, Science and Society, Fienberg School of Medicine, Northwestern
University, Chicago, IL 60611, USA
jMRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine,
London WC1E 7HT, UK
Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population
Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
Footnote on title page:
*Corresponding author. E-mail: email@example.com;
Tel: +61-2-9351 3688; Fax: +61-2-9351 2227
A potential impediment to evidence-based policy development on medical male circumcision
(MC) for HIV prevention in all countries worldwide is the uncritical acceptance by some of
arguments used by opponents of this procedure. Here we evaluate recent co-published
statements of 17 individuals opposed to MC. We find that these statements misrepresent
good studies, selectively cite references, and draw erroneous conclusions. In marked contrast,
the scientific evidence shows MC to be a simple, low-risk procedure with very little or no
adverse long-term effect on sexual function, sensitivity, sensation during arousal, or overall
satisfaction. Unscientific arguments have recently been used to drive ballot measures aimed
at banning MC of minors in the USA, eliminate insurance coverage for medical MC for low-
income families, and threaten large fines and incarceration for health care providers. Medical
MC is a preventative health measure akin to immunization, given its protective effect of over
60% against HIV infection, and various other conditions. Protection afforded by neonatal
MC against common medical conditions starts in infancy and extends throughout life.
Besides protection in adulthood against acquiring HIV, MC also reduces morbidity and
mortality from multiple other STIs and genital cancers in men and their female sexual
partners. It is estimated that over their lifetime one-third of uncircumcised males will suffer
at least one foreskin-related medical condition. The scientific evidence presented indicates
that medical MC is safe and effective. Its favourable risk/benefit ratio supports the
advantages of medical MC.
While circumcision of males has been practiced for millennia, a small but vocal minority in
modern society consider it to be a practice that should be opposed. Often these individuals
falsely equate expert religious, cultural or medical male circumcision (MC) with tribal
female genital cutting (commonly termed “female genital mutilation”), which, in its most
extreme form, if applied equally to the male, would mean excision of the entire penis. In
recent years there has been a rise in heterosexual HIV cases in developed countries (National
Centre in HIV Epidemiology and Clinical Research [NCHECR, 2010; Centers for Disease
Control and Prevention [CDC], 2011), accompanied by declines in the proportion of new
cases from other main modes of transmission – anal intercourse amongst men who have sex
with men (MSM) and from contaminated needles used by people who inject drugs. This led
to arguments by HIV experts in Australia in support of the need to bring about a substantial
turnaround in the low infant MC rates in Australia in order to prevent a future epidemic of
heterosexually acquired HIV (Cooper, Wodak & Morris, 2010). In response, a compendium
of opinion pieces by 17 individuals expressing their opposition have been published (Boyle
& Hill, 2011; Chin, 2011; Conroy, 2011; Darby, 2011; Forbes, 2011; Lyons, Pitts, Smith &
Grierson, 2011; Paix, 2011; Travis, Buckley, Mason, McGrath, Van Howe & Williams,
2011). The information in these provide an excellent opportunity to consider the arguments
for and against MC in developed countries.
Many of the previous claims and analyses directed at opposing the roll-out of medical MC
for HIV prevention in sub-Saharan Africa (Van Howe, 1999; Green, McAllister, Peterson &
Travis, 2008; Gisselquist et al., 2009; Green et al., 2010; Van Howe & Storms, 2011) have
been shown to be seriously flawed (Moses, Nagelkerke & Blanchard, 1999; O'Farrell &
Egger, 2000; Wamai et al., 2008; Banerjee et al., 2011; Morris et al., 2011; Wamai & Morris,
2011; Wawer et al., 2011). Yet Boyle and Hill present some of the same specious arguments
(Boyle & Hill, 2011). One of the critiques (Wamai et al., 2008) was by 48 authors, including
experts from major universities worldwide, the WHO, UNAIDS and the World Bank. In sub-
Saharan Africa numerous observational studies (Weiss et al., 2008) and three randomized
controlled trials (RCTs) (Auvert et al., 2005; Bailey et al., 2007; Gray et al., 2007) showed
that medical MC has a 60% protective effect against HIV. Follow-up has indicated that by 5
years after the trials began there has been a steady increase in the protective effect of MC to
73% (Kong et al., 2011). Moreover, recent data from a large-scale MC roll-out in a high-
prevalence HIV population in the trial site in South Africa, has demonstrated 76% protection
(Auvert et al., 2011).
Claims and meta-analyses by Van Howe attempting to discredit the benefits of MC in
protecting against a variety of other conditions have been refuted (Schoen, 1997; Bailis,
1998; Castellsague, Albero, Cleries & Bosch, 2007; Schoen, 2007; Waskett & Morris, 2007;
Waskett & Morris, 2008; Waskett, Morris & Weiss, 2009). Despite such efforts by
responsible scientists in countering the fallacies with valid scientific evidence, flawed
publications by MC opponents are often cited by individuals unfamiliar with the field. For
example, Paix cites a dated opinion piece by Van Howe and other opponents (Fleiss, Hodges
& Van Howe, 1998) which displays fanciful reasoning in claiming that MC increases risk of
HIV and other STIs, and that the foreskin has various protective as well as other functions,
since disproven by research.
Various claims by opponents of medical MC were developed into arguments by Travis and
his colleagues to support disallowing Medicaid for infant medical MC in the USA (Green,
McAllister, Peterson & Travis, 2009). A decline in Medicaid funding for medical MC, as
indeed has occurred in an increasing number of US states, poses a danger to public health,
especially amongst the poor (Leibowitz, Desmond & Belin, 2009; Morris, Bailis, Waskett,
Wiswell & Halperin, 2009).
The references cited in support of the arguments in the opinion pieces include potentially
non-objective sources such as questionable websites, old publications containing information
that has now been superseded, outlier studies, non-peer-reviewed book reviews or policy
statements by pediatric bodies placed on the Internet and that have led to publication of peer-
reviewed critiques in journals refuting them, journal articles that have similarly been
discredited by published critiques (as cited above), and an article in an obscure journal,
Thymos: Journal of Boyhood Studies. The latter has previously published articles arguing
that the age of consent should be lowered. and that adult-child sex be permitted. Articles in
credible journals are cited as well, but the information in these is frequently misrepresented.
We take this opportunity to evaluate in more detail the validity of the claims made regarding
the relationship between MC and HIV risk in men and in women in developed countries,
sexual function and sensation, condom use, and infant deaths from MC. We also discuss the
ethical and legal issues, whether medical MC should be delayed beyond infancy, cost-benefit
analyses for medical MC, and the distortion of expert reviews of the evidence. When taken
together we find the claims in this set of opinion pieces are at odds with the bulk of the
quality peer-reviewed published scientific evidence.
Sexual function, sensation and satisfaction
Opponents argue that MC is "mutilating" and impairs sexual function and sensitivity (Paix,
2011; Travis et al., 2011). This can lead vulnerable men, especially those with sexual
difficulties, to believe that their infant circumcision is responsible for their problems or that
sex might be better if they use devices to “restore” a pseudo-foreskin, not realizing that doing
so can have adverse consequences (Walter & Streimer, 1990). Sexual dysfunction, especially
with age, is either more common (Laumann, Maal & Zuckerman, 1997; Richters, Smith, de
Visser, Grulich & Rissel, 2006) or no different (Collins et al., 2002; Masood et al., 2005;
Ferris et al., 2010) in uncircumcised compared with circumcised men.
The claim of reduced sexual function and sensitivity is not supported by multiple high quality
scientific research studies that relied on empirical measurements. These have found no
difference in penile sensitivity (Masters & Johnson, 1966; Collins et al., 2002; Bleustein,
Fogarty, Eckholdt, Arezzo & Melman, 2005), sensation during arousal (Payne, Thaler,
Kukkonen, Carrier & Binik, 2007), sexual satisfaction (Collins et al., 2002; Fink, Carson &
deVellis, 2002), premature ejaculation (Son, Song, Kim & Paick, 2010) or intravaginal
ejaculatory latency time (Waldinger et al., 2005; Waldinger, McIntosh & Schweitzer, 2009)
between circumcised and uncircumcised men. A study in Turkey documented an increase in
pudendal evoked potentials (electrical signals of nerves following a stimulus) from 42.0 ms
before to 44.7 ms after circumcision, this being accompanied by an increase in sexual
satisfaction (Senol, Sen, Karademir, Sen & Saraçoğlu, 2008). Data from two large RCTs
showed that medical MC does not diminish sexual function, sensitivity or satisfaction
(Kigozi et al., 2008; Krieger et al., 2008). In one of these trials the men randomized to
receive circumcision reported better sensitivity and sexual experience after having been
circumcised (Krieger et al., 2008). Most of the female partners of the men preferred the
appearance of a circumcised penis and found increased sexual pleasure and satisfaction after
their male partner’s circumcision (Krieger et al., 2008). Reports of improved sexual function,
pleasure and satisfaction in men and their female sexual partners after medical MC have
continued to accumulate (Kigozi et al., 2009; Breda, 2011; Westercamp, Bailey & Agot,
Yet instead of such research findings, Travis et al. cite a study funded by the National
Organization of Circumcision Information Resource Centers (NOCIRC) that reported the
orifice rim of the foreskin had a higher sensitivity than any other part of the penis (Sorrells et
al., 2007). The study in question has been discredited on multiple grounds, including study
design, subjects in the Methods section accounted for in the Results section, observer bias,
and statistical analyses that were shown to be erroneous. The latter included failure to correct
for the multiple testing that led to the single, marginal P value that would otherwise have
been rendered non-significant (Waskett & Morris, 2007). In claiming that medical MC
impairs sexual function Forbes cites an anomalous Korean study (Kim & Pang, 2007) that
has been shown to be flawed (Willcourt, 2007).
In a small study of 70 circumcised and 11 uncircumcised US men, each ranked the ventral
surface of the penis (underside of glans and shaft) highest for degree of “sexual pleasure”
and “orgasm intensity”, followed by the upper surface and sides of the penis, the foreskin
being less important (Schober, Meyer-Bahlburg & Dolezal, 2009). In another study,
sensation of the penis during arousal did not differ between circumcised and uncircumcised
men aged 18–45 (Payne, Thaler, Kukkonen, Carrier & Binik, 2007). More circumcised
participants reported an increase in their level of arousal, while more uncircumcised men
reported being unaffected by the erotic stimulus (a movie). Sensitivity of the penis to touch
decreased during arousal in both groups, as would obviously be required for penetration.
Deaths from infant MC
Travis et al. claim that infant medical MC results in 0.9 deaths per 10,000 circumcisions per
year (Travis et al., 2011), citing as support a theoretical article in Thymos that 100 boys die
from circumcision each year in the USA (Bollinger, 2010). Death statistics do not support
this claim – in reality mortality is approximately one per million circumcisions, even decades
ago when surgical procedures and anesthetics were not as good as today (Speert, 1953;
Wiswell & Geschke, 1989). Bollinger’s argument relies on the assumption that the difference
between male and female infant mortality rates in the USA is due entirely to medical MC. In
addition to the fact that male infant mortality across developed countries is higher than that
of female infants for a variety of reasons (Drevenstedt, Crimmins, Vasunilashorn & Finch,
2008), an obvious flaw in this argument is the same sex difference in infant mortality seen in
countries regardless of whether neonatal MC rates are low or high (see Table 1).
Table 1. Infant mortality (IM) rates (deaths per 1,000 live births) for selected countries for
which neonatal MC rate is known.i
MC rate (male)
Israel > 90% 4.12
Nigeria 80–90% 97.4
USA 60–80% 6.72
Australia < 20% 4.93
UK < 5% 5.07
France < 5% 3.61
Finland < 1% 3.73
HIV infection in men
Travis et al. argue that the USA has both high MC prevalence and high HIV incidence, and
conclude that MC is therefore an unreliable means of protection against HIV infection. This
argument is not supported by the fact that the majority of incident HIV infections in the USA
and other developed countries, such as Australia, are in MSM, for whom most HIV sexual
acquisition is through receptive anal intercourse, a mode of HIV acquisition that MC would
not be expected to affect. Nevertheless, there have been reports of lower HIV in circumcised
MSM (Kreiss & Hopkins, 1993; Buchbinder et al., 2005; Fox, 2007), especially in analyses
of data for men who were ‘insertive-only’. This was first shown in a Sydney study that found
89% lower HIV prevalence in insertive-only circumcised MSM (Templeton et al., 2009).
Meta-analyses have found HIV in circumcised MSM who were ‘insertive-only’ to be 29%
lower in one study (Millett, Flores, Marks, Reed & Herbst, 2008) and 73% lower in an
analysis by the Cochrane Collaboration (Wiysonge et al., 2011). These data also qualify the
claim by Boyle & Hill that MC does not prevent HIV in homosexual men. Most MSM
engage in either exclusive receptive anal intercourse or a mixture of receptive and insertive,
as documented in the studies above. Because a smaller proportion of MSM are insertive-
only, the most recent statistics for MSM as a whole have generally not shown an association
between MC and HIV protection.
Another common route of acquisition in developed countries is injecting drugs with
contaminated needles. MC would not be expected to offer any protection against this mode
of transmission either.
Comparisons made between countries are, moreover, inherently unreliable. HIV risk and
vulnerability are multifactorial, so failure to isolate correctly the effect of a specific variable
of interest inevitably is a result of confounding. Examples are factors such as differences in
sex education and condom usage (Wallace & Vienonen, 1989; David, Morgall, Osler,
Rasmussen & Jensen, 1990; Michael et al., 1998; Weinberg, Lottes & Aveline, 1998; Brick,
1999; Dodge, Sandfort, Yarber & de Wit, 2005). Also, differences in standards of health care
lead to differences in diagnosis and survival, affecting the apparent HIV prevalence.
In studies of heterosexual men in the USA much lower HIV prevalence has been noted
among those who are circumcised (Telzak et al., 1993; Kassler & Aral, 1995; Moses, Bailey
& Ronald, 1998; Sullivan et al., 2007; Warner et al., 2009; Smith et al., 2010; Tobian, Gray
& Quinn, 2010). Since most US males are circumcised as infants, these data also counter the
claim by Darby that there is no evidence that neonatal MC protects against HIV (Darby,
The high rate of medical MC in the USA may have moderated the prevalence of HIV
(Addanki, Pace & Bagasra, 2008). In 2005, 1.2 M infant boys (56%) were circumcised
before discharge from hospital, regional differences ranging from 75% to 31%, with lower
rates observed in US states where Hispanics account for a large share of the births (Merrill,
Nagamine & Steiner, 2008). A reduction in reimbursement by public and private health
insurance for medical MC (Leibowitz, Desmond & Belin, 2009; Morris, Bailis, Waskett,
Wiswell & Halperin, 2009), and a decline in rate of uptake of medical MC, could reverse the
benefit observed in the USA to date (Sullivan et al., 2007). In Australia, infant MC rates
plummeted after the 1970s. The prevalence of HIV and other STIs against which MC
protects would probably have been lower if routinely offered infant medical MC had
remained at the high pre-1970s levels.
It has also been claimed that because heterosexual contact accounts for only a small
proportion of HIV cases in developed countries that medical MC is irrelevant. In fact, the
actual figures were under-stated by Lyons et al. as only being 0.5% of HIV infections in
Australia (Lyons, Pitts, Smith & Grierson, 2011), whereas the source they cite (NCHECR,
2010) states the number of new HIV diagnoses for which exposure to HIV was attributed to
heterosexual contact increased from 841 in 2000–2004 to 1,185 in 2005–2009, accounting
for 20.1% and 23.4% of diagnoses in each respective period. After excluding cases that were
acquired in a high prevalence country, the number of cases from heterosexual contact were
527 in 2000–2004 and 703 in 2005–2009, a 33% increase (this being 38% in men and 28% in
women). The highest number of new HIV infections in 2005–2009 acquired from
heterosexual contact was in Australian-born individuals, namely 31% of the total. In the
USA, 9.6% of new cases in 2009 were reported to be from heterosexual intercourse (CDC,
2011). These figures may be instructive in the context of a rising proportion of
uncircumcised males in sexually active age groups of men in Australia (Richters, Smith, de
Visser, Grulich & Rissel, 2006; Ferris et al., 2010), as a result of the sharp decline in infant
medical MC that took place in the 1970s and 1980s.
Travis et al. also misquote statistics by saying that African Americans have the highest MC
prevalence in the USA, when a national survey found that the highest MC prevalence (89%)
is in non-Hispanic white US men (Xu, Markowitz, Sternberg & Aral, 2007), the population
with the lowest rates of heterosexually acquired HIV infection (CDC, 2011).
Regarding the association of MC with other STIs in developed countries a study in Seattle
found half the prevalence of syphilis in circumcised MSM, with syphilis being completely
absent in those who were insertive-only (Jameson, Celum, Manhart, Menza & Golden, 2009)
and in Sydney insertive-only MSM had a 10-fold lower prevalence of syphilis (Templeton,
Millett & Grulich, 2010). A survey of 10,000 Australian men found the prevalence of
Candida yeast infection was significantly lower, by 50%, in circumcised, mostly
heterosexual, men (Richters, Smith, de Visser, Grulich & Rissel, 2006; Ferris et al., 2010).
HIV risk to women
Forbes and Boyle & Hill refer to a study in Africa (Wawer et al., 2009) in claiming that MC
increases the risk of HIV infection in women. They omitted to report, however, that this
finding pertained to HIV-positive men who resumed sex before full wound healing, despite
counselling against doing so. Even then, there was no statistical difference in HIV acquisition
in the female partners of either circumcised or uncircumcised men. Such selective citing of
non-significant data is questionable. In fact, the potential risk posed by resuming sex too
early during the wound healing period actually support the premise that MC should be
performed in infancy, when risk of sexual acquisition of HIV does not exist.
Contrary to Forbes and Boyle & Hill, MC confers long-term indirect and potential direct
positive impacts on women (Hankins, 2007). The indirect effects will come from the lowered
HIV prevalence in men (UNAIDS, 2009). There is less evidence on direct effects, but a
meta-analysis of all studies found HIV to be 20% lower in the female partners of HIV-
positive circumcised as opposed to uncircumcised men (Weiss, Hankins & Dickson, 2009).
Subsequent data have shown acquisition risk in such women to be 38% lower (Baeten et al.,
2010). In a general population setting, modelling predicted that MC would confer a 46%
reduction in the rate of male-to-female HIV transmission (Hallett et al., 2011). These
findings underscore the considerable potential of MC to produce population-level effects in
both men and women.
Travis et al. claim that condoms are 95 times more effective than circumcision and that MC
is more costly than providing free condoms (Travis et al., 2011). These claims are erroneous,
first because, according to a Cochrane systematic review, condoms are 80% effective (Weller
& Davis, 2001). Although highly effective, condoms must be used consistently and correctly,
including during foreplay. They are often unpopular, especially within long-term sexual
partnerships. In the USA 16% of men and 24% of women reported never having used
condoms during heterosexual sex with a non-primary partner (Sanchez et al., 2006). Only
25% of young people in Australia at higher risk of HIV exposure reported always using
condoms and 25% had never used them (Kang et al., 2006). A survey of senior high school
students in Australia found that over the past decade there had been an increase in the
number of sexual partnerships, but no increase in condom use (Agius, Pitts, Smith &
While condom use should be encouraged for a host of reasons, condoms are not a magic
bullet. WHO/UNAIDS recommend the use of a combination of effective methods, including
both MC and condoms.
A systematic review of cost-effectiveness studies (Galárraga, Colchero, Wamai & Bertozzi,
2009) offers no support for the claim concerning comparative costs made by Travis and co-
authors. Medical MC is a one-time, permanent procedure that confers lifelong partial
protection against HIV, whereas condoms must be used correctly and consistently every time
a person has sex for an entire lifetime. Cost of neonatal MC in the USA averages $165,
whereas cost later in childhood or adulthood is an order of magnitude greater (Schoen, Colby
& To, 2006). The total cost for 1.2 M neonatal MCs performed annually in the USA is
US$150–270 million (Schoen, Colby & To, 2006). Assuming approximations of 10 million
sexually-active, condom-using men, 100 acts of sexual intercourse per year, and a cost of $1
for each condom, unadjusted for inflation, the annual national expenditure for condoms in the
USA would be approximately $5 billion. This amount far exceeds the annual cost of neonatal
MC in the USA.
Circumcision should be delayed?
Chin claims there are no benefits of MC until the circumcised boy gets older (Chin, 2011),
but infant MC protects immediately against urinary tract infections, balanitis, foreskin
injuries and hygiene-related problems. Neonatal MC protects against the possibility of
phimosis when older (a condition in which the foreskin never retracts, causing pain,
problems with urine flow, and difficulty with erections in the teen years and later) and may
be much more effective in protecting against penile cancer than is MC later in life (Larke,
Thomas, Dos Santos Silva & Weiss, 2011; Morris et al., 2011). Infant MC is much simpler,
quicker, cheaper, more convenient, lower risk, and provides a better cosmetic outcome than
circumcision later in childhood or in adolescence or adulthood (Schoen, Oehrli, Colby &
Machin, 2000; Sansom et al., 2010; Tobian, Gray & Quinn, 2010; Weiss, Larke, Halperin &
Schenker, 2010; WHO, 2010). Wound healing is also quicker (Bermudez, Canning &
Liechty, 2011). There are, moreover, a multitude of other reasons why MC should not be
delayed (Morris, 2010). Parents must make many decisions about what is in the best interests
of their children at every step of their development. The decision about infant MC (UNAIDS,
2007) is one of numerous such decisions that also include vaccination, health care, shelter,
nutritious food, clothing, school attendance, love, guidance and counselling.
Travis et al. say MC costs more than it saves (Travis et al., 2011) and, Forbes (Forbes, 2011)
claims, without presenting supportive analyses, that the benefits and risks are evenly
balanced. On the contrary, MC is cost-effective in developing countries (Uthman, Popoola,
Uthman & Aremu, 2010) and in a developed country, a cost-benefit analysis by the CDC
found that infant MC in the USA was cost-saving for HIV prevention (Sansom et al., 2010).
When one factors in the vast array of other medical conditions against which infant MC
protects over the lifetime and the fact that 1 in 3 uncircumcised males will be affected by at
least one of these during their life (Morris, Bailis, Castellsague, Wiswell & Halperin, 2006;
Morris, 2007), the cost-benefit of MC might reasonably be expected to be substantial.
Deaths, mostly from genital cancers and HIV, are a notable outcome of the lack of MC for
some uncircumcised men and their female partners.
Ethical and legal arguments
Some of the arguments used by the opponents are based on ethics, consent and other
philosophical considerations, usually coupled with statements, such as those made by Forbes
(Forbes, 2011), that benefits and risks are evenly balanced or that MC is somehow harmful.
Such statements can be compared to the anti-vaccination lobby’s dangerous misinformation
that has outraged health authorities (Health Care Complaints Commission, 2010), reduced
the uptake of childhood immunization, and revitalized the spread of vaccine-preventable –
and often fatal – diseases (Wallace, 2009; Wikipedia, 2011). Yet vaccination is accepted,
despite the risk of serious complications for some vaccines being higher than that for infant
MC (Wikipedia, 2011). Further, the benefits of MC exceed risks by a large margin (Morris,
Bailis, Castellsague, Wiswell & Halperin, 2006; Morris, 2007).
If prophylactic infant MC were in fact “legal battery” as claimed by Travis et al. then court
decisions reflecting this should exist. But there are none. It is therefore apparent that the legal
system upholds the rights of parents to make decisions in the best interest of their child. This
right has also been upheld by the Californian legal system which struck out the 2011 ballot
initiative to ban MC of minors in San Francisco. It has, moreover, been argued that any
health professional who has advised parents not to have their infant son circumcised should
consider the possible consequences for themselves of the boy experiencing subsequent
foreskin-related medical problems, morbidity or death (Russell, 2005).
Distortions of evidence by MC opponents
Conroy misquotes the extensive report arising from a consultation meeting conducted by the
CDC in Atlanta in April 2007 (Smith et al., 2010). This meeting included a cross-section of
all relevant stakeholders. The prominent MC opponent Van Howe presented his case but his
arguments did not feature in the subsequent meeting report (Smith et al., 2010).
Conroy also cites another CDC report (CDC, 2008) and an extensive expert literature review
(Morris, 2007) in claiming that the evidence favouring MC for HIV prevention in countries
like the USA and Australia is based on “opinion or other inconclusive, low-quality
evidence”. Such a statement implying that no high quality data exist is at odds with each of
these scholarly reviews. Such a claim is untenable, given the enormous body of high quality
research that provides conclusive, robust evidence of the protective effect of MC in
developed countries, as discussed above. Indeed, the protective effect of MC against STIs in
developed countries per act of sexual intercourse by a man with an infected woman is on a
par with that in developing countries (Telzak et al., 1993; Kassler & Aral, 1995; Moses,
Bailey & Ronald, 1998; Sullivan et al., 2007; Warner et al., 2009; Smith et al., 2010; Tobian,
Gray & Quinn, 2010).
Evidence favouring MC for HIV prevention was reviewed by a Cochrane committee which
concluded that “inclusion of male circumcision into current HIV prevention guidelines is
warranted” and that “no further trials are required” (Siegfried, Muller, Deeks & Volmink,
2009). It seems, however, that there would never be enough evidence to convince opponents
of MC. For example, Forbes, who chaired the committee responsible for the Royal
Australasian College of Physicians 2010 policy statement on infant MC, is quoted as saying
that the College will never endorse infant MC no matter how strong the evidence (Sikora,
Those who support MC and those who oppose it likely differ with respect to the importance
they place on different values – for example the value of preserving body parts that are not
diseased versus the value of surgical interventions to prevent disease. In order to have a
reasoned policy debate it is, however, important to separate these “values” discussions from
factual discussions (Robert & Zeckhauser, 2011). Scientists are able to evaluate extensive
and sometimes apparently conflicting information, and use discerning scientific analyses to
arrive at evidence-based conclusions, as a result of their training in the detection of poor
quality research and dismissal of fallacious arguments. Failure to reach a valid conclusion
based on the evidence can, in public health, lead to erroneous policy decisions, and
ultimately, lives lost. Misguided policy can result in unnecessary morbidity and mortality. In
the case of MC many lives have been lost from preventable diseases such as AIDS, cervical
cancer and penile cancer, and much suffering has ensued because of failure to implement
evidence-based policies on medical MC. This situation has not been helped by the
misinformation and specious arguments of MC opponents who have misrepresented and
distorted the findings of scientific research on medical MC. As the late US Senator Daniel
Patrick Moynihan was fond of saying, "Everyone is entitled to their own opinions, but they
are not entitled to their own facts".
Addanki, K.C., Pace, D.G., & Bagasra, O. (2008). A practice for all seasons: male
circumcision and the prevention of HIV transmission. J Infect Dev Ctries, 2, 328–
Agius, P.A., Pitts, M.K., Smith, A.M., & Mitchell, A. (2010). Sexual behaviour and related
knowledge among a representative sample of secondary school students between
1997 and 2008. Aust N Z J Public Health, 34, 467–481.
Auvert, B., Taljaard, D., Lagarde, E., Sobngwi-Tambekou, J., Sitta, R., & Puren, A. (2005).
Randomized, controlled intervention trial of male circumcision for reduction of HIV
infection risk: The ANRS 1265 Trial. PLoS Med, 2, (e298) 1112–1122.
Auvert, B., Taljaard, D., Rech, D., Lissouba, P., Singh, B., Shabangu, D., Nhlapo, C.,
Otchere-Darko, J., Mashingo, T., Phatedi, G., Taljaard, R., Tsepe, M., Chakela, M.,
Mkhwanazi, A., Pthangase, P., Billy, S., & Lewis, D.A. (2011). Effect of the Orange
Farm (South Africa) male circumcision roll-out (ANRS-12126) on the spread of HIV.
6th IAS Conference on HIV Pathogenesis, Treatment and Prevention, 17–20 July,
Rome, Italy, WELBC02.
Baeten, J.M., Donnell, D., Kapiga, S.H., Ronald, A., John-Stewart, G., Inambao, M.,
Manongi, R., Vwalika, B., & Celum, C. (2010). Male circumcision and risk of male-
to-female HIV-1 transmission: a multinational prospective study in African HIV-1-
serodiscordant couples. AIDS, 24 737–744.
Bailey, R.C., Moses, S., Parker, C.B., Agot, K., Maclean, I., Krieger, J.N., Williams, C.F.,
Campbell, R.T., & Ndinya-Achola, J.O. (2007). Male circumcision for HIV
prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet,
Bailis, S.A. (1998). Circumcision and infectious disease. (Letter). Pediatr Infect Dis J, 17,
Banerjee, J., Klausner, J.D., Halperin, D.T., Wamai, R., Schoen, E.J., Moses, S., Morris, B.J.,
Bailis, S.A., Venter, F., Martinson, N., Coates, T.J., Gray, G., & Bowa, K. (2011).
Circumcision denialism unfounded and unscientific. [Critique of Green et al., “Male
circumcision and HIV prevention: Insufficient evidence and neglected external
validity”]. Am J Prevent Med, 40, e11–e12.
Bermudez, D.M., Canning, D.A., & Liechty, K.W. (2011). Age and pro-inflammatory
cytokine production: Wound-healing implications for scar-formation and the timing
of genital surgery in boys. J Pediatr Urol, 7, 324-331.
Bleustein, C.B., Fogarty, J.D., Eckholdt, H., Arezzo, J.C., & Melman, A. (2005). Effect of
neonatal circumcision on penile neurological sensation. Urology, 65, 773–777.
Bollinger, D. (2010). Lost boys: An estimate of U.S. circumcision-related infant deaths.
Thymos: J Boyhood Studies, 4, 78–90.
Boyle, G.J., & Hill, G. (2011). Matters arising: "The case for boosting infant male
circumcision in the face of rising heterosexual transmission of HIV" ... and now the
case against. (Letter). Med J Aust, 194, 99.
Breda, M. (2011). Safety, satisfaction, and HIV risk one-year following male circumcision
(MC): a retrospective clinical data review from rural Kenya. 6th IAS Conference on
HIV Pathogenesis, Treatment and Prevention, 17–20 July, Rome, Italy, TUPE381.
Brick, P. (1999). How does Europe do it? Fam Life Matters, Winter (36), 3.
Buchbinder, S.P., Vittinghoff, E., Heagerty, P.J., Celum, C.L., Seage, G.R., 3rd., Judson,
F.N., McKirnan, D., Mayer, K.H., & Koblin, B.A. (2005). Sexual risk, nitrite inhalant
use, and lack of circumcision associated with HIV seroconversion in men who have
sex with men in the United States. J Acquir Immune Defic Syndr, 39, 82–89.
Castellsague, X., Albero, G., Cleries, R., & Bosch, F.X. (2007). HPV and circumcision: A
biased, inaccurate and misleading meta-analysis. J Infect, 55, 91–93.
Centers for Disease Control and Prevention. (2008). HIV/AIDS Science Facts. Male
Circumcision and Risk for HIV Transmission and Other Health Conditions:
Implications for the United States.
Centers for Disease Control and Prevention. (2011). Diagnoses of HIV infection and AIDS in
the United States and Dependent Areas, 2009. vol 21, from
Chin, J.J. (2011). Matters arising: "The case for boosting infant male circumcision in the face
of rising heterosexual transmission of HIV" ... and now the case against. (Letter).
Med J Aust, 194, 100–101.
Collins, S., Upshaw, J., Rutchik, S., Ohannessian, C., Ortenberg, J., & Albertsen, P. (2002).
Effects of circumcision on male sexual function: Debunking a myth? J Urol, 167,
Conroy, N. (2011). Matters arising: "The case for boosting infant male circumcision in the
face of rising heterosexual transmission of HIV" ... and now the case against. (Letter).
Med J Aust, 194, 99.
Cooper, D.A., Wodak, A.D., & Morris, B.J. (2010). The case for boosting infant male
circumcision in the face of rising heterosexual transmission of HIV. Med J Aust, 193,
Darby, R.L. (2011). Matters arising: "The case for boosting infant male circumcision in the
face of rising heterosexual transmission of HIV" ... and now the case against. (Letter).
Med J Aust, 194, 100.
David, H.P., Morgall, J.M., Osler, M., Rasmussen, N.K., & Jensen, B. (1990). United States
and Denmark: different approaches to health care and family planning. Stud Fam
Plann, 21, 1–19.
Dodge, B., Sandfort, T.G., Yarber, W.L., & de Wit, J. (2005). Sexual health among male
college students in the United States and the Netherlands. Am J Health Behav, 29,
Drevenstedt, G.L., Crimmins, E.M., Vasunilashorn, S., & Finch, C.E. (2008). The rise and
fall of excess male infant mortality. Proc Natl Acad Sci USA, 105, 5016–5021.
Ferris, J.A., Richters, J., Pitts, M.K., Shelley, J.M., Simpson, J.M., R. Ryall, R., & Smith,
A.M.A. (2010). Circumcision in Australia: further evidence on its effects on sexual
health and wellbeing. Aust NZ J Publ Hlth, 34, 160–164.
Fink, K.S., Carson, C.C., & deVellis, R.F. (2002). Adult circumcision outcomes study: Effect
on erectile function, penile sensitivity, sexual activity and satisfaction. J Urol, 167,
Fleiss, P.M., Hodges, F.M., & Van Howe, R.S. (1998). Immunological functions of the
human prepuce. Sex Transm Infect, 74, 364–367.
Forbes, D.A. (2011). Matters arising: "The case for boosting infant male circumcision in the
face of rising heterosexual transmission of HIV" ... and now the case against. (Letter).
Med J Aust, 194, 97.
Fox, M. (2007). Analysis: AIDS vaccines experts confused, dismayed., from
Galárraga, O., Colchero, M.A., Wamai, R.G., & Bertozzi, S.M. (2009). HIV prevention cost-
effectiveness: a systematic review. BMC Public Health, 9, (Suppl 1), S5.
Gisselquist, D., Potterat, J.J., St Lawrence, J.S., Hogan, M., Arora, N.K., Correa, M.,
Dinsmore, W.W., Mehta, G., Millogo, J., Muth, S.Q., Okinyi, M., & Ounga, T.
(2009). How to contain generalized HIV epidemics? A plea for better evidence to
displace speculation. Int J STD AIDS, 20, 443–446.
Gray, R.H., Kigozi, G., Serwadda, D., Makumbi, F., Watya, S., Nalugoda, F., Kiwanuka, N.,
Moulton, L.H., Chaudhary, M.A., Chen, M.Z., Sewankambo, N.K., Wabwire-
Mangen, F., Bacon, M.C., Williams, C.F., Opendi, P., Reynolds, S.J., Laeyendecker,
O., Quinn, T.C., & Wawer, M.J. (2007). Male circumcision for HIV prevention in
men in Rakai, Uganda: a randomised trial. Lancet, 369, 657–666.
Green, L.W., McAllister, R.G., Peterson, K.W., & Travis, J.W. (2008). Male circumcision is
not the ‘vaccine’ we have been waiting for! Future HIV Ther, 2, 193–199.
Green, L.W., McAllister, R.G., Peterson, K.W., & Travis, J.W. (2009). Medicaid coverage of
circumcision spreads harm to the poor. Am J Publ Hlth, 99, 584.
Green, L.W., Travis, J.W., McAllister, R.G., Peterson, K.W., Vardanyan, A.N., & Craig, A.
(2010). Male circumcision and HIV prevention insufficient evidence and neglected
external validity. Am J Prev Med, 39, 479–482.
Hallett, T.B., Alsallaq, R.A., Baeten, J.M., Weiss, H., Celum, C., Gray, R., & Abu-Raddad,
L. (2011). Will circumcision provide even more protection from HIV to women and
men? New estimates of the population impact of circumcision interventions. Sex
Transm Infect, 87, 88–93.
Hankins, C. (2007). Male circumcision: Implications for women as sexual partners and
parents. Reprod Health Matters, 15, 62–67.
Health Care Complaints Commission. (2010). Public warning about the Australian
Vacciantion Network (AVN), from http://www.hccc.nsw.gov.au/Publications/Media-
Jameson, D.R., Celum, C.L., Manhart, L., Menza, T.W., & Golden, M.R. (2009). The
association between lack of circumcision and HIV, HSV-2, and other sexually
transmitted infections among men who have sex with men. Sex Transm Dis, 37, 145–
Kang, M., Rochford, A., Johnston, V., Jackson, J., Freedman, E., Brown, K., & Mindel, A.
(2006). Prevalence of Chlamydia trachomatis infection among 'high risk' young
people in New South Wales. Sex Health, 3, 253–254.
Kassler, W.J., & Aral, S.O. (1995). Beyond risk groups: behavioral correlates of HIV
seroconversion in sexually transmitted disease clinic patients. XI Int Mtg Int Soc STD
Res, abstract #017.