Declining Rates in Male Circumcision amidst Increasing Evidence of its Public Health Benefit

Hubert H. Humphrey Fellowship Program, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America.
PLoS ONE (Impact Factor: 3.23). 02/2007; 2(9):e861. DOI: 10.1371/journal.pone.0000861
Source: PubMed


Recent experimental evidence has demonstrated the benefits of male circumcision for the prevention of human immunodeficiency virus (HIV) infection. Studies have also shown that male circumcision is cost-effective and reduces the risk for certain ulcerative sexually transmitted diseases (STDs). The epidemiology of male circumcision in the United States is poorly studied and most prior reports were limited by self-reported measures. The study objective was to describe male circumcision trends among men attending the San Francisco municipal STD clinic, and to correlate the findings with HIV, syphilis and sexual orientation.
A cross sectional study was performed by reviewing all electronic records of males attending the San Francisco municipal STD clinic between 1996 and 2005. The prevalence of circumcision over time and by subpopulation such as race/ethnicity and sexual orientation were measured. The findings were further correlated with the presence of syphilis and HIV infection. Circumcision status was determined by physical examination and disease status by clinical evaluation with laboratory confirmation. Among 58,598 male patients, 32,613 (55.7%, 95% Confidence Interval (CI) 55.2-56.1) were circumcised. Male circumcision varied significantly by decade of birth (increasing between 1920 and 1950 and declining overall since the 1960's), race/ethnicity (Black: 62.2%, 95% CI 61.2-63.2, White: 60.0%, 95% CI 59.46-60.5, Asian Pacific Islander: 48.2%, 46.9-49.5 95% CI, and Hispanic: 42.2%, 95% CI 41.3-43.1), and sexual orientation (gay/bisexual: 73.0%, 95% CI 72.6-73.4; heterosexual: 66.0%, 65.5-66.5). Male circumcision may have been modestly protective against syphilis in HIV-uninfected heterosexual men (PR 0.92, 95% C.I. 0.83-1.02, P = 0.06).
Male circumcision was common among men seeking STD services in San Francisco but has declined substantially in recent decades. Male circumcision rates differed by race/ethnicity and sexual orientation. Given recent studies suggesting the public health benefits of male circumcision, a reconsideration of national male circumcision policy is needed to respond to current trends.

10 Reads
  • Source
    • "However, the rate of circumcision in the African American non- Hispanic population in our sample (36%) is lower than the national average (73%; Xu et al., 2007) and lower than STD clinics in other cities, for example, African Americans in STD clinics in New York (58%–68%; McKinney et al., 2008) and San Francisco (62.2%; Mor et al., 2007). This study raises an additional question: Is the lower rate of circumcision seen in African Americans in the MDC STD clinic driven by lower rates of circumcision in African Americans or by Haitians, both of whom may be reported as " African American. "
    [Show abstract] [Hide abstract]
    ABSTRACT: The objectives of this study were assessment of the prevalence of male circumcision (MC) among patients attending the Miami-Dade County (MDC) sexually transmitted diseases (STDs) clinic and exploration of attitudes of MC among Hispanic STD clinic attendees. Prevalence of MC was assessed by a review of 500 clinic records. Attitudes toward MC were explored during focus group sessions. The overall rate of MC was 27%. Men associated acceptability of MC with sexual performance, their partner's anticipated responses to MC, and scientific proof of STD protection; whereas women focused on experiences with previous partners and hygiene. We found a low rate of circumcision in males attending the MDC STD clinic. Approximately half of the Hispanic men and women in focus groups also found MC acceptable or desirable. Spanish Los objetivos del estudio fueron determinar la prevalencia de la circuncisión masculina (CM) en pacientes atendidos en la clínica de transmisión sexual del Departamento de Salud del Condado de Miami-Dade (STD) y la exploración de actitudes hacia la CM entre pacientes Hispanos de esta clínica. La prevalencia de CM se estimó mediante la revisión de 500 historias clínicas y se exploró las actitudes hacia la CM mediante grupos focales. La tasa de CM fue de 27%. Los hombres asociaron positivamente la CM con el buen desempeño sexual, con una respuesta positiva a la CM por parte de sus parejas y con la evidencia científica que señala que la CM proteje contra las enfermedades de transmisión sexual, las mujeres se centraron en experiencias previas y en higiene. Conclusiones: Encontramos una tasa baja de CM en los hombres que atienden la clínica de enfermedades de transmisión sexual sin embargo aproximadamente la mitad de los hombres y mujeres Hispanos encontraron la CM aceptable o deseable.
    Hispanic Health Care International 12/2012; 10(4). DOI:10.1891/1540-4153.10.4.199
  • Source
    • "Topical oestrogen has been shown to hasten wound healing [16] and could also be used before and after circumcision to reduce the postoperative wound healing time. Furthermore, whilst male circumcision is undoubtedly effective [17], [18], implementing it is a daunting task, particularly in countries like India, China and most of South-East Asia where it is culturally unacceptable [15]. In such cases, topical oestrogen could provide a medical alternative to circumcision to reduce HIV infection. "
    [Show abstract] [Hide abstract]
    ABSTRACT: With the growing incidence of HIV, there is a desperate need to develop simple, cheap and effective new ways of preventing HIV infection. Male circumcision reduces the risk of infection by about 60%, probably because of the removal of the Langerhans cells which are abundant in the inner foreskin and are the primary route by which HIV enters the penis. Langerhans cells form a vital part of the body's natural defence against HIV and only cause infection when they are exposed to high levels of HIV virions. Rather than removing this natural defence mechanism by circumcision, it may be better to enhance it by thickening the layer of keratin overlying the Langerhans cells, thereby reducing the viral load to which they are exposed. We have investigated the ability of topically administered oestrogen to induce keratinization of the epithelium of the inner foreskin. Histochemically, the whole of the foreskin is richly supplied with oestrogen receptors. The epithelium of the inner foreskin, like the vagina, responds within 24 hours to the topical administration of oestriol by keratinization, and the response persists for at least 5 days after the cessation of the treatment. Oestriol, a cheap, readily available natural oestrogen metabolite, rapidly keratinizes the inner foreskin, the site of HIV entry into the penis. This thickening of the overlying protective layer of keratin should reduce the exposure of the underlying Langerhans cells to HIV virions. This simple treatment could become an adjunct or alternative to surgical circumcision for reducing the incidence of HIV infection in men.
    PLoS ONE 06/2008; 3(6):e2308. DOI:10.1371/journal.pone.0002308 · 3.23 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: This thesis presents data on two separate areas relevant to the prevention of HIV and sexually transmitted infection (STI) transmission in homosexual men. These data arise from the community-based Health in Men (HIM) cohort of HIV-negative homosexual men in Sydney. First, the association of circumcision status with HIV and STIs was examined. Older age, ethnicity and country of birth were demographic factors independently associated with circumcision status. Self-report was a valid measure of circumcision status in this population. Overall, being circumcised was associated with a non-significant reduced risk of HIV seroconversion in the HIM cohort (HR 0.76, 95% CI 0.41-1.41, p=0.381). Among the one-third of participants predominantly practising the insertive role in anal intercourse (AI), being circumcised was associated with a significantly reduced risk of HIV infection (HR 0.15, 95% CI 0.03-0.80, p=0.026). Circumcised HIM participants also had a lower risk of incident syphilis (HR 0.35, 95% CI 0.15-0.84, p=0.019), however circumcision status had no significant effect on the remainder of prevalent and incident STIs examined. Second, risk factors for pharyngeal gonorrhoea and chlamydia were investigated. The BD ProbeTec nucleic acid amplification test (NAAT) had a positive predictive value (PPV) for pharyngeal gonorrhoea diagnosis of only 30.4% (95% CI 25.2-36.1%) when compared to a previously validated NAAT targeting the gonococcal porA pseudogene. Pharyngeal gonorrhoea was common in HIM, mostly occurred without concurrent anogenital infection and may frequently spontaneously resolve. Infection was independently associated with younger age (p-trend=0.001), higher number of male partners (p-trend=0.002), contact with gonorrhoea (p<0.001) and insertive oro-anal sex with casual partners (p-trend=0.044). Pharyngeal chlamydia was less common but a high prevalence/incidence ratio suggested that infection may persist in the pharynx for long periods. Pharyngeal chlamydia was independently associated with receptive penile-oral sex with casual partners (p-trend=0.009). In conclusion, circumcision may have a role as an HIV prevention intervention among the subgroup of homosexual men who predominantly practise insertive rather than receptive AI. Regular screening of the pharynx including a validated supplemental NAAT for gonorrhoea diagnosis may prevent much transmission to anogenital sites, whereas chlamydia occurs too infrequently in the pharynx to recommend routine screening in homosexual men. Declaration relating to disposition of project thesis/dissertation I hereby grant to the University of New South Wales or its agents the right to archive and to make available my thesis or dissertation in whole or in part in the University libraries in all forms of media, now or here after known, subject to the provisions of the Copyright Act 1968. I retain all property rights, such as patent rights. I also retain the right to use in future works (such as articles or books) all or part of this thesis or dissertation. I also authorise University Microfilms to use the 350 word abstract of my thesis in Dissertation Abstracts International (this is applicable to doctoral theses only).
Show more

Preview (3 Sources)

10 Reads
Available from