The Medical Benefits of Male Circumcision

Abstract

With 2 new states recently joining 16 others in eliminating Medicaid insurance for male circumcision, possible ballot initiatives to ban male circumcision, and the long-awaited American Academy of Pediatrics male circumcision policy statement, there is a need to evaluate the medical risks and benefits of male circumcision, particularly in light of recent medical evidence. Three randomized trials in Africa demonstrated that adult male circumcision decreases human immunodeficiency virus (HIV) acquisition in men by 51% to 60%,1 and the long-term follow-up of these study participants has shown that the protective efficacy of male circumcision increases with time from surgery. These findings are consistent with a large number of observational studies in Africa and in the United States that found male circumcision reduces the risk of HIV infection in men.1 Thus, there is substantial evidence that removal of the foreskin reduces the risk of male heterosexual HIV acquisition. However, the effect of male circumcision on reducing HIV acquisition among men who have sex with men is unclear. There may be protection against insertional but not against receptive anal intercourse, so men practicing both forms of sexual intercourse may have limited protection associated with male circumcision. In addition to HIV, male circumcision has been shown to reduce the risk of other heterosexually acquired sexually transmitted infections (STIs). Two trials demonstrated that male circumcision reduces the risk of acquiring genital herpes by 28% to 34%, and the risk of developing genital ulceration by 47%.1 Additionally, the trials found that male circumcision reduces the risk of oncogenic high-risk human papillomavirus (HR-HPV) by 32% to 35%.1 While some consider male circumcision to be primarily a male issue, one trial also reported derivative benefits for female partners of circumcised men; the risk of HR-HPV for female partners was reduced by 28%, the risk of bacterial vaginosis was reduced by 40%, and the risk of trichomoniasis was reduced by 48%.1,2 It should be noted that no large-scale randomized controlled trial has assessed the benefit of neonatal male circumcision throughout several decades, which is when many of the potential health benefits would be realized. Such a trial is probably not feasible. However, observational data of men predominantly circumcised during childhood support the findings of the 3 randomized trials conducted in Africa1 and the long-term medical benefits of male circumcision. One concern is that the trials of male circumcision conducted in Africa may not be applicable to the United States. Despite 3 decades of safe-sex education in the United States, STIs continue to cause substantial morbidity and mortality. It is estimated that more than 1 million people are living with HIV/AIDS, and more than 50 000 new infections occur annually. Additional estimates suggest that there are 3 million to 5 million annual cases of trichomoniasis in the United States, and the prevalence of bacterial vaginosis among women of reproductive age is approximately 30%. One of the most common STIs is HPV, which causes genital warts, and penile and cervical cancer. Observational studies in the United States show that male circumcision is associated with reduced risk of men acquiring heterosexual HIV and HR-HPV infection.1,3 Thus, STIs are a persistent problem in the United States, and male circumcision may provide individual and societal benefits. The incidence of viral STIs in the United States is disproportionately higher among disadvantaged minority populations such as blacks and Hispanics, who have the lowest rates of male circumcision. For example, in Washington, DC, 7.1% of black males are living with HIV, and heterosexual exposure is the leading mode of transmission among these individuals.4 Medicaid, which disproportionately provides health insurance for black children, is decreasing coverage for male circumcision, making the procedure less accessible, especially for those at the highest risk for these infections.5 In contrast, Medicaid covers immunization against hepatitis B virus during the neonatal period even though it is difficult to predict who will be at high risk of STIs. Using mathematical models and cost-effectiveness analyses, the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organization adopted a policy advocating male circumcision in countries and regions with heterosexual HIV epidemics. In a cost-effectiveness analysis by the Centers for Disease Control and Prevention, neonatal male circumcision in the United States was projected to increase quality-adjusted life-years and estimated to be cost-saving due to reduced HIV infections and subsequent treatment costs.6 If protection from genital herpes, bacterial vaginosis, trichomoniasis, and penile and cervical cancer were considered in the analyses, the economic benefits most likely would be enhanced. Opponents of m