Chapter 15

The Question of Circumcision and HIV/AIDS

Circumcision has been dubbed “a solution in search of a problem”. As soon as one supposed “benefit” is thoroughly discounted another seems to crop up in its place. Never in history has any other body part been put on trial like this, its fate to be condemned to mass annihilation upon suspicion of any supposed transgression.

Since my book was first published in 1985, a huge influx of speculation and action has arisen as to whether or not foreskins or lack of same are related to HIV. A thorough examination of every published article would result in a book ten times the size of this one, so my hope here is to present a valid synopsis with resources for those who wish to delve more deeply.

According to the observations reported by Bongaarts, et al:  “The existence of an ecological correlation between lack of male circumcision and HIV prevalence suggests that circumcision could potentially be an important determinant in the prevention of the spread of HIV, but individual-level data are needed to demonstrate such a relationship.  A review of the epidemiological studies that have evaluated the association between male circumcision status and risk of HIV infection included 21 cross-sectional and two prospective studies in sub Saharan Africa. Of these studies, 14 were conducted among patients recruited at clinics for sexually transmitted diseases (STDs).  Most of these studies of male STD patients showed a protective effect of circumcision against HIV infection, with odds ratios (OR)* between 0.12 to 0.77.  It has been noted that most of the studies were conducted in urban populations and that several had methodological limitations.” 1

“Data from men in the Mwanza region suggest that there is a modest protective effect of male circumcision on the risk of HIV infection among men, with an adjusted OR of 0.62.  A stronger protective effect was observed in urban Mwanza (adjusted OR 0.46) and to a lesser extent in roadside villages (OR 0.65) while in rural areas and islands there was no significant reduction in HIV prevalence among circumcised men.  The overall results from the urban areas and roadside villages are in agreement with findings from other studies in Africa, although the protective effect is smaller than reported in most studies of STD patients.”2

“Male circumcision may have a direct effect on the risk of HIV infection, perhaps because it reduces the risk of preputial lesions and renders the glans penis less vulnerable [6].  It may also have an indirect effect on HIV risk by reducing the risk of STDs, particularly as self-reported STD is an unreliable indicator of STD occurrence.  Anecdotal reports suggest that some men may be circumcised as a traditional remedy for STD, especially genital ulcers, and this may further the association.” 3

“In summary, our analysis between male circumcision and risk of HIV and STD has shown a modest protective effect of circumcision against HIV infection.” 4

According to a study by Gray, Kigozi, et al: 4996 uncircumcised, HIV negative men aged 15-49 years who agreed to HIV testing and counseling were enrolled in this randomized trial in rural Rakai district, Uganda.  Men were randomly assigned to receive immediate circumcision (2474) or have circumcision delayed for 24 months (2552.)  HIV testing, physical exam and interviews were repeated at 6, 12, & 24 months of follow up visits.  90-92% of the participants stayed  in both groups.  .66 cases of HIV per 100 person-years  occurred in the group that had been immediately circumcised, while 1.33 cases of HIV per  100 person-years occurred in the control (non-circumcised) group.  Adverse effects of circumcision occurred in 84 men (3.6%).

In the authors’ words:  “Observational findings do not consistently show protective associations in all studies, and to exclude the possibility of confounding due to differences in sexual risk behaviors and cultural or religious practices associated with circumcision is difficult.  Thus the potential efficacy of circumcision for HIV prevention can be determined only by randomized trials.  One randomized trial done in South Africa was ended early after an interim analysis showed that circumcision after an interim analysis showed that circumcision reduced HIV by 60%, 5  Two other randomized trials, one in Kisumu, Kenya and the other in Rakai, Uganda were also stopped early after interim analyses showed significant efficacy.” 6

Because the trial was ended early, the analysis for the 0-24 month interval was weighted by the preponderance of person-time accrued during the first 12 months.  (Some  men did not return, got circumcised elsewhere or changed their minds.)  Socio-demographic characteristics that were noted during the study included age, marital status, religion, education and sexual risk behavior including number of partners, condom use, alcohol consumption with sex and sex for money or gifts. 7

The authors further state: “Further circumcision programs must emphasize that circumcision provides only partial protection and that there is a critical need to practice safer sex after circumcision (i.e. partner limitation and consistent condom use.)”8

Circumcision also reduced the rate of self-reported symptoms of genital ulcer disease with efficacy of 48%   9 It is not known if circumcision reduces rates of ulcerative infections due to syphilis, herpes simplex virus 2 and hemophilus ducreyi.  Genital ulcer disease is a risk factor for acquisition of HIV.  10, 11, &12

No effects of circumcision were observed on symptoms of discharge or dysuria (painful urination) which is consistent with data from observational studies that indicate a lack of an effect of circumcision on gonorrhea or chlamydia prevalence.  13, 14  Circumcision was also not observed to be protective against urethral infections which are apparently unaffected by the removal of the foreskin.

The 24-month transmission risks were 2.6% in the control group and 1.11% in the intervention group, giving a difference of 1.49%   Therefore these authors estimate that about 67 circumcisions are needed to prevent one HIV infection.  Any long term effectiveness of circumcision or possible need for secondary reductions is not known.    (In the authors’ words:) “Is this appropriate or cost-effective?” 15

Adult male circumcision is not without risk.  In this study moderate to severe adverse events related to surgery were almost 4% and follow up management was needed.

Auvert, Taljaard, et al have reported the following information on their study in Uganda. 3,274 uncircumcised men, ages 18-24 were randomized to a control or an intervention group.  The intervention group was immediately circumcised while the control group was offered circumcision at end of the follow up.  16

20 HIV infections occurred in the circumcised group while 49 infections occurred in the control group.  Condom use, sexual behavior and health seeking behavior can be factors.  The studies were based on observational rather than experimental data.  A causal relationship between male circumcision and protection against HIV infection could not be determined 17  Direct experimental evidence is needed to establish this relationship.  17, 18, & 19

In 2002 a randomized, controlled, blindly evaluated intervention trial was carried out in Orange Farm (near Johannesburg, South Africa)  Men were paid 200 S. African Rand after participating in the study.    Voluntary counseling and testing  was offered.   Blood samples were taken.  Men who were already HIV+ were not included in the statistical analysis. 20

The background characteristics of the participants was recorded as follows: age (less than 21, or over 21), religion (Catholic, Protestant, African traditional, or other, ) ethnic group (Zulu, Sotho, or other), alcohol consumption,  at-risk behavior (lack of condom use), spousal partner, number of non-spousal sexual partners, number of sexual contacts, & health seeking behavior 21,22

The impact of the intervention itself was assessed,  including the recommended 6 week period of abstinence (post-circumcision).  42 days was the median interval of abstinence.  The median age was twenty one years.  Very few of the men were married or living as married and about half were at high-risk behavior. 23

The authors acknowledge that the study has limitations.  It was conducted in one area in sub-Saharan Africa and therefore may not be generalizable to other places.  Some participants were lost during the follow up (due to moving away or otherwise being unreachable, not to HIV), thus leading to a smaller cohort.  24, 25

Participants were followed up for a short period of time.  The study did not explore the long term protective effect of circumcision.  Some believe the keratinization of the glans when not protected by the foreskin, allows for a short drying after sexual contact, reducing the life expectancy of HIV on the penis and reduction of target cells on the foreskin.  The study does not allow for identification of the mechanisms of the protective effect of circumcision on HIV acquisition.  Partial, spurious protection emphasizes the need for a true and effective vaccine for HIV, and effective retroviral treatments. 26, 27 & 28

There are potential risks in promoting circumcision as a way of reducing the risk of HIV infection.  Circumcision can be performed under poor hygienic conditions leading to infection, bleeding and permanent injury or death especially if appropriate treatment during healing is not provided.  During the healing period, sexually active men are likely to be at a higher risk of HIV infection.  Circumcision does not provide full protection.  If misunderstood this could lead to reduction of protection for men who decrease condom use or otherwise engage in riskier behavior.  The authors observed that the intervention group had significantly more sexual contacts due to a perceived effectiveness or belief in immunity due to circumcision.  Circumcision is not a universal cultural practice and culture can be a barrier in policy considerations.  25

Infections were 60% fewer in the treatment group which seems to indicate that circumcised men are less likely to be infected with HIV when having sex with infected women. More research is needed.  There have been flaws in the methodology used.  Circumcised men can still become infected, even though the risk might be lower.  They should still take other steps to prevent themselves from getting HIV. 29, 30

The researchers Halperin and Bailey, whose works have largely pushed for advancement of male circumcision in Africa have observed the following:  “A decade has passed since publication of Cameron and colleagues study that showed a greater than eight fold increased risk of HIV1 infection for uncircumcised men.  Today, many observers of the AIDS pandemic are puzzled by the glaring discrepancies in HIV seroprevalence between different countries and regions, despite the presence of what seem to be similar regions and risk factors.  For example, the November, 1998 UNAIDS/WHO Report on the AIDS Epidemic concludes, ‘It is not fully understood why HIV infection rates take off in some countries while remaining stable in neighboring countries over many years.'” 31

“Four studies reported significant relative risks that ranged from 2.3 to 4.5 after multivariate analyses, and in the other two prospective studies, multivariate risk rates were 3.0 or greater, but were not significant.  Of 38 cross-sectional studies, 27 from eight countries found a significant association between lack of male circumcision and HIV infection, five found found a trend towards an association, five found no association, and one reported an increased risk of infection in men who had been circumcised.  In 1994 Moses and colleagues established that on the basis of the information available at the time the association between lack of male circumcision and HIV infections met all but three of Hill’s criteria for making causal inferences: an additional 17 studies from eight countries have since been published.   That circumcision is partially protective has been documented even in settings in which circumcised men have higher risk profiles for HIV transmission (i.e. more sexual partners, alcohol use and some sexually transmitted infections.) 32, 33

“A wider public discussion has occurred as to why, 20 years into the pandemic, some countries continue to retain fairly low HIV seroprevalence whereas in other places sometimes even neighboring regions rates of infection are many times higher.” 34

“The varying rates of HIV-1 infection: Philippines – 0.6%,  Bangladesh – 0.03 %,  Indonesia,  – 0.05%, Thailand – 2.2%,  Cambodia – 2.4% (have yielded) dramatic discrepancies with 10 to 20 fold differences (which are) not easily explained.” 35
  In response to the observations reported by Halperin and Bailey the following appeared:

“Why does Europe, where the men are largely uncircumcised, enjoy one of the lowest HIV rates in the world, while North America, where men are usually circumcised, suffers one of the highest?”  36

“Until such questions are answered [medical publications] should refrain from promoting the controversial public policy outlined in [the viewpoint that all of Africa should embrace routine male circumcision as a potential AIDS preventative.] 
  “The popular press, famously unable to distinguish between sensational editorials and solid research, has dangerously distorted these reviews.
  “Halperin and Bailey rightly warn that a public misunderstanding of their position might have disastrous effects on HIV containment.  [Publicity and propaganda promoting circumcision as a ‘vaccine’ to prevent AIDS has given people the false assumption that being circumcised gives full protection against AIDS.]” 37

Halperin and Bailey have acknowledged that five cross-sectional studies found no association between male circumcision and HIV infection and one reported an increased risk of infection in men who have been circumcised.

“Whenever there is some evidence that surgery may reduce the risk of developing a particular disease, but there is also evidence the surgery may have no prophylactic effect whatsoever, or even increase the risk of developing that disease, then the surgery should still be done on every person in whom the disease could develop??

Clearly a great many body parts would be candidates for such surgery.  What would the total cost come to and what would be the overall impact on public health??
  Condoms & safe sex practices are preventative measures, but do not involve amputation of healthy erogenous tissue.” 38
  “Medecins Sans Frontieres (MSF)  (Doctors Without Borders), one of the world’s renowned NGOs working on public health has released statistics showing that HIV infection  rate in Malawi has doubled in recent years despite a range of interventions put in place to tackle the spread of the virus have included relentless campaigns on condom use and circumcision.39

Condom Use

“According to the statistics by MSF, HIV rates have doubled in Malawi moving from 10% to 20% in 1 year.  Strangely, this has been the same period that Malawians have been manipulated and forced to go through circumcision in masses with the promise that it reduced the contraction of HIV.  The results which were published on BBC revealed that of every five people, one person is HIV positive  making Malawi the country worst hit by the HIV pandemic of all countries in the world. 40

Kangwele (a researcher from Malawi) has observed: “The research which was conducted long before the championing of the circumcision campaign dispelled the assumptions that circumcision reduces the chances of contracting HIV, the virus that causes AIDS.” 41

“A document which Malawi24 has seen and throws back to a 2010 research on the prevalence rate of HIV among Malawian men established that over 10% of Malawian men who had undergone circumcision were HIV+ compared to only 7% of uncircumcised men.” 42

“The report dubbed “The Malawi Health and Demographic Survey” states on page 207 that the prevalence rate of HIV was higher among circumcised men than the uncircumcised in Malawi.”43

“However, regardless of these statistics the World Bank went ahead to pump $15,000,000  into the circumcision campaign for Malawian men when research had proved to them that circumcision did not reduce the chances of Malawian men contracting HIV.  Recently medical male circumcision has been embroiled in controversy as it has emerged that most men had contracted HIV after being circumcised because they had been told that it would reduce their chances of contracting the virus.” 44

According to study researcher Mickey Daugherty, MD, (a urology resident at the State University of New York Upstate Medical University presentation at The Annual Meeting of the American Urological Association in 2017), “Circumcised participants in a study presented at this  meeting of  were twice as likely as their uncircumcised counterparts to have either of two HPV strains associated with penile cancer.” 45

Daugherty told Infectious Disease News: “Classically, circumcision has been shown to be protective against HPV infection.  We’re not completely sure why, but there was a higher rate of these higher-risk HPV infections in men who are  circumcised.”46

Daugherty said the high proportion of men in the United States who are circumcised could account for the prevalence of HPV in that population.  Nonetheless, he said, “The results show that circumcision alone is not a preventive measure.” 47

The men provided penile swabs which were tested for 37 HPV strains.  The researchers stratified two strains of low-risk HPV linked to genital warts, HPV-6 and HPV-11.  They also stratified two strains of high-risk HPV linked to penile cancer, HPV-16 and HPV-18.  Most participants (77.8%) were circumcised.  Results showed a higher risk for high-risk HPV among circumcised but no significant increase in risk for low-risk HPV in circumcised men. 48

The information presented by Daugherty was subsequently published in JAMA Oncology by J.J. Han, et al.,19 in Journal of Infectious Diseases by B.Y. Hernandez, et al. 50 and in Meeting News Perspective.51

Rodriguez-Diaz reports on a study in Puerto Rico which found “Male circumcision may not make much difference to overall male HIV incidence in Caribbean context.” 52   Researchers concluded, “A blanket roll-out of an MMC (Medical Male Circumcision) program in the context of a Caribbean country such as Puerto Rico would not necessarily make much difference to HIV prevalence in men as a whole.” 53  

Doerner has observed: “An analysis of an online and gay-venue survey of white, British-born gay and bisexual men in the UK has found no association between whether they were circumcised and whether they had HIV.” 54

Intaction** reports: “A study in Israel showed that the HIV rate skyrocketed 55% between 2005-2012. Between 1981 through the end of 2011 there were 6,579 [Israeli] men diagnosed as having HIV or full-blown AIDS.  Of this total, only 1,265 in Israel were homosexual men.  That means there were 5,314 heterosexual circumcised men who contracted HIV leading to this stunning increase.  Authorities attribute the increase to more people having unprotected sex and lack of fear of the disease.  Since Israeli men are all circumcised, it would be logical to assume their willingness to engage in unprotected sex was in part due to the widely publicized belief that circumcision offers protection.  Furthermore, Israel has a much higher HIV infection rate than Japan where most men are intact.”55

“The HIV virus can attack the mucosa at the meatus (urethral opening) or inside the urethra just as easily as the foreskin.  Most men of sexually active age in the United States are already circumcised, but the infection rates are higher in the USA than in other developed countries where circumcision is rare.  Common sense tells us that circumcision is unreliable in protecting against HIV.” 56

Intaction has also shared a list of comments questioning the validity of attempts to support lack of foreskin as an HIV/AIDS preventative: 

“In only three highly controversial, short-term clinical trials circumcision was purportedly shown to reduce risk of HIV by 50-60% in heterosexual males engaging in male/female intercourse.  The results did not show that females had any protection from HIV as a result of their partners being circumcised, nor was transmission prevented in same sex partners.  Drug use and other non-sexual vectors of HIV infection are not prevented by circumcision.  The vast majority of other studies  on the relationship between circumcision and HIV have shown either that circumcision offers no protection or that the results are inconclusive.” 57

“Some say clinical research is fraught with fraud as researchers and academics chase grant money. Others have suggested that touting phony benefits of circumcision will increase unwanted pregnancies and promiscuity.” 58

“The ability to have unrestricted sex is the subtle message behind the African circumcision marketing campaigns.  Meanwhile the drastic reduction in sensitivity caused by circumcision due to the loss of 20,000 nerve endings will make African men engage in riskier behavior to achieve sexual gratification. Pro-circumcision propaganda will decrease use of contraception (i.e. condoms.) 59

A 2008 study examined data from 13 sub-Saharan countries found no association. 60

Another 2008 study found that circumcision made no difference in HIV rates in South Africa 61

A 2007 study concluded that once commercial sex-worker patterns are factored in, male circumcision is not significantly associated with lower rates of HIV. 62

A recently released report from the Zimbabwe Health Demographic Survey found that circumcised Africans had a higher  HIV infection rate (14%) than Africans left intact. (12%) 63

“Researchers in Uganda say circumcision only reduces HIV transmission by 1.3%, not 60% as claimed in previous clinical trials.  Based on a recent male-to-female transmission of HIV study in Uganda, researchers Gregory Boyle and George Hill in a study published by Australia’s Thomson Reuters showed that more women contracted the virus after unprotected intercourse with infected circumcised male partners.  64

“The New York Times reports that the infection rates in Uganda from 2005-2012 have increased while the United States, through its AIDS prevention strategy known as PEPFAR***** (The President’s Emergency Plan for AIDS Relief) spent $1.7 billion in Uganda to fight AIDS.  The results raise questions about the efficacy of a U.S. strategy largely based on circumcision. 65

The following are the findings of yet another report by Intaction:

“The World Health Organization (WHO) wants to have 20 million men in Southern and Eastern Africa circumcised.  WHO officials claim that circumcision will prevent HIV infections.  To convince them to undergo the operation, men are assured that without a foreskin they will be ‘vaccinated against AIDS.’  It is an unprecedented undertaking: never before have aid organizations attempted to surgically alter so many people.  It could end up being an unprecedented disaster.” 66

  “Should the campaign be successful, 3.4 million new HIV infections would be prevented between now and 2025, but critics warn that the mass circumcisions are based on disputed studies and could end up having the opposite of the hoped-for effect: more HIV infections.”67

“The first sign of a connection between foreskin and HIV were in the mid 1980’s. Scientists noticed that fewer circumcised men were infected and construed that the foreskin was a possible point of attack for the virus.  The inner foreskin is an area of concentration of lymphocytes and specialized cells called Langerhans cells.These specialized immune cells actually serve to protect against infection, so while Langerhans cells normally intercept and destroy HIV, under other conditions, for example in the presence of parallel infections, they can relay the virus on the HIV target cells and raise the infection rate.68

“Doctor  Bertran Auvert’s study in South Africa, 1339 men in the Johannesburg township of Orange Farm were voluntarily circumcised.  After the procedure, Auvert compared their infection rate with a control group of 1309 non-circumcised men in the same region.  His hypothesis was that the HIV target cells and thereby the risk of infection could be eliminated along with the foreskin.” 69

“TOTAL NONSENSE”, says the German circumcision expert Wolfgang Buhmann, “To help people in areas with high HIV rates, you have to make it clear to them that sex without a condom is life threatening.  Sex with a condom however is safe, regardless of whether the foreskin is still there or not.  Shades of grey, in-between just create confusion.”70

“Nearly all forms of circumcision are accompanied by significant health risks, particularly when the operation takes place in often unhygienic, traditional settings. In South Africa between 2008 and 2014, approximately half a million boys were treated in hospitals for botched circumcisions, and more than 400 of them died. Even in very good hygienic conditions, medical problems are often noted, including deformed scarring, hemorrhage, wound infection, diminished sensation and other consequences.  The effort to circumcise the majority of men in Southern Africa may, even by a conservative estimate, lead to hundreds of thousands of complications, some of them lifelong.” 71

“In Zimbabwe the government has disclosed that more circumcised men are HIV positive than non-circumcised men.” 72

“The effect of circumcision alone is something we can’t calculate in isolation. HIV tests and condoms are crucial.” 73

“In Southern Africa the pressure to get circumcised is enormous. Posters in the streets depict a horrified African woman tearing at her hair and shouting, ‘What?! You’re not circumcised?!’ Men with intact penises are branded as disease-causing pathogens. Non-circumcised men in Lusaka now have hardly any chance of finding a female partner.” 74

“An investigation in Uganda shows how fatal this development is. For women with circumcised husbands the HIV rate in the six months after the circumcision has drastically increased by 61 %. 75

“Confusing, false, missing information? More HIV due to riskier behaviors by circumcised men? ‘We have no indications that would substantiate such hypotheses,’ says George Sinyangwe of USAID*** in Lusaka, but how can that be? The health report from Malawi has indicated that circumcised men are already showing higher HIV rates than non-circumcised men. Some have contracted the HIV virus not sexually but from contaminated needles, blood transfusions and surgical instruments. Many participants have disappeared and could not be tested or questioned.” 76

Dr. Robert Van Howe, MD, MS, FAAP, professor at Michigan State University, who has been researching this issue for years is convinced: “The circumcision campaign will ultimately increase the number of HIV infections. 73 After returning to Germany, the author of this article, Michael Obert, tried for weeks to obtain an official statement from the WHO. He received no response. 74

Van Howe’s thorough investigation has revealed the following:

Three randomized, controlled trials (RCTs) done in sub-Saharan Africa appeared to show during the study period a 38-66% relative reduction for the circumcised subjects in the risk of heterosexual, female to male only, transmission of HIV. 77, 78 & 79 All three studies were terminated early due to their apparently clear results. However Dowsett and Couch examined the results of the three RCTs but found insufficient evidence to recommend circumcision to prevent HIV infection. 78  Green et al. reviewed the evidence and also found “insufficient data” as well as contrary evidence. 79 & 80

Factors influencing these studies have included:

 . Participant expectation bias – participants believed that circumcision would reduce the risk of HIV.
 . Lead time bias – Men randomized to the intervention arm of the trials (group that was circumcised) were considered to be at risk for becoming infected from the time of the surgery, even though they were told to avoid sexual activity during the period of wound healing.  Men in the control arm (who were not circumcised) were able to be sexually active from the beginning of the study.
  . Selection bias – only men who were interested in a free circumcision were eligible to participate and may not have been representative of the general population.
  . Attrition bias – for every man who became infected with HIV during the trials, 3.5-7.4 men were lost to follow up.  This is a serious methodological problem that could alter the statistical significance of the findings. 81
  . Early termination bias – studies that are terminated early are more likely to overestimate any treatment effect. 82 & 83
  . Duration bias – because men who were not initially circumcised were circumcised at the end of the study, long-term comparison of the effects cannot be accurately extrapolated as some modelers have proposed. 84
  . Source of infection unknown.  If the studies were designed to determine whether circumcision reduced the risk of heterosexually-transmitted HIV, the investigators should have confirmed that the infections were indeed transmitted through heterosexual contact.  They did not.  Using the data reported, it is estimated that about half of the infections of the men in these studies were not sexually transmitted. 85

The cumulative treatment claimed a 38-66% relative risk reduction 86  which is an absolute risk reduction of 1.3%.  This is a small effect which could have resulted from the various forms of bias.  Data released before the trials began found a number of African countries where the prevalence of HIV infection was greater in circumcised men than in intact men.  87 & 88

“Since the mass circumcision campaigns began in Uganda and Kenya, the incidence of new cases of HIV in both countries has increased.” 89, 90 & 91

As with other STIs there is no evidence that circumcision has had any impact on lowering the incidence of HIV infection in the United States.  Of the eight HIV studies in North American heterosexual men, 87, 92-97 only one has found a significant association between circumcision and HIV infection risk.  It actually found that circumcised men were at greater risk of HIV infection. 98 

The HIV epidemic in the U.S. is concentrated among men who have sex with men (MSM) and injection drug users.  A meta-analysis of the studies published on this topic by the CDC found that the risk for HIV infection in MSM is the same in intact and circumcised men.99-102

In another study by Van Howe:  “The notion that circumcision significantly reduces the risk of STIs is a piece of medical folklore dating back to Victorian-era medicine, before a modern understanding of the causes of disease and before the advent of evidence-based medicine.103

“When the results of STI studies are considered in aggregate using meta-analysis, circumcision has been shown to have no significant impact on the risk of gonorrhea, chlamydia, 103 & 104 genital herpes simplex virus infections, human papilloma virus (HPV), 104 or chancroid. 103 & 104 Being circumcised is associated with an increased risk  of non-specific urethritis, 102 & 103 genital discharge syndrome (which includes gonorrhea, chlamydia, and non-specific urethritis). 103  Being circumcised is associated with a slightly lowered risk of genital ulcerative disease (which includes chancroid, syphilis, and genital herpes infection) 103, 104 & 105 and syphilis (primarily in Africa). 104 & 105  However, prospective studies have found a slight increase in the incidence of syphilis in circumcised males. 106 & 107

“In the case of HPV, sampling bias can occur if only the glans of the penis is tested.  Several studies have shown that circumcised men are more likely than intact men to harbor the HPV virus on the shaft of the penis instead of the glans. 107 -113

“There is no evidence that circumcision has reduced the incidence of STIs in the U.S, while the prevalence of chlamydia, gonorrhea and syphilis has declined steadily in Europe since 1980 (where circumcision is rare.)  In the U.S. (with a primarily circumcised adult male population) the incidence of syphilis has increased and the incidence of chlamydia has soared. 114 The incidence of gonorrhea in the U.S. is 20 times higher than in Europe while the incidence of chlamydia in the U.S. is 45 times higher than in Europe 115  A recent study of men visiting public STI clinics found that circumcised men were less likely than intact men to use condoms which may in part explain these STI trends. 116

“Even if circumcision did reduce the risk of STIs, pre-emptive amputation is not a preferred approach to diseases that can readily be cured with a short course of antibiotics or prevented by simple safe-sex behaviors.” 117

Darby and Van Howe have observed and reported on the following, their objective being to conduct a critical review of recent proposals that widespread circumcision of male infants be introduced in Australia as a means of combating heterosexually transmitted HIV infection.  Logic, coherence and fidelity must be applied to the principles of evidence-based medicine.  Such proposals ignore doubts about the robustness of the evidence from the African random-controlled trials as to the protective effect of circumcision as a means of HIV control, but they misrepresent the nature of Australia’s HIV epidemic and exaggerate the relevance of the African random-controlled trials findings.  They also underestimate the risks and harm of circumcision and ignore questions of medical ethics and human rights.  The notion of circumcision as a ‘surgical vaccine’ is criticized as polemical and unscientific. 118

Darby and Van Howe continue to express doubts about the African random controlled trials which claim that circumcision prevents heterosexual HIV transmission from women to men.  The trial was based on three non-double-blinded, non-placebo-controlled, random controlled trials in Africa in which 5,000 men were circumcised.  After 20 months, 64 of the men in the circumcised group had HIV compared to 137 in the non-circumcised group.  The trial contained several forms of bias.  Only men interested in a free circumcision were eligible.  It would have been impossible to blind researchers or subject (as to who received immediate circumcision.) 119 & 120

Garenne found that in 8 countries (Burkina Faso, Cote d’Ivoire, Ethiopia, Ghana, Niger, Rwanda, Tanzania and Zimbabwe) there was no significant difference in HIV seroprevalence between circumcised and uncircumcised men.  In two countries (Kenya and Uganda)  HIV seroprevalence was higher among uncircumcised men, and in three countries (Cameroon, Lesotho and Malawi), HIV seroprevalence was higher among circumcised men.  In Lesotho the difference was striking:  HIV seroprevalence was 22.8% among the circumcised men but only 15.2% among the uncircumcised population.  121

In South Africa where one-third of the male population is circumcised and HIV prevalence is among the highest on record, both Garenne and Connolly et al found no difference in HIV status between circumcised and uncircumcised samples. 121 & 122

“Both the U.S. and Indonesia with predominantly circumcised male populations have a significantly higher incidence of HIV than Australia, Canada, Britain and New Zealand where circumcision is in decline or extremely rare. 121

No convincing biological explanation of circumcision’s protective effect has been proven.  Pro-circumcision speculation has suggested that the interior mucosa of the prepuce is thinner and more prone to tearing. 123   The mucosa of the inner and outer prepuce have been shown to be of the same thickness in some studies but not in others.124

Langerhans cells***** have been believed to be the entry point for the virus.  Actually Langerhans cells repel HIV.  The transmission rate of HIV is low – about 1 per 1,000 unprotected coital acts. 125  Inner foreskin secretes langerin****** which kills numerous pathogens. 126

“Until we understand how circumcision works biologically, we cannot be certain whether the observed reduction in risk of infection in the random-controlled trials is the result of changed anatomy resulting from surgery, changed behavior resulting from counseling and provision of condoms, or various forms of bias.”
  “It is now firmly established that circumcision provides no protection to men who have sex with men and there is evidence from Britain that circumcised gay men may be at greater risk.  The annual number of new HIV diagnoses has remained relatively stable at around  1000 over the past 4 years.  HIV continues to be transmitted primarily through sexual contact between men and of 1185 cases of heterosexually acquired infection newly diagnosed in 2005-2009, 58% were in people (or their partners) from high prevalence countries.”  127, 128 & 129

According to Darby and Van Howe: Based on figures of new HIV exposures (during the early 2000’s) via heterosexual contact. “It would be necessary to circumcise several thousand babies now to prevent one case of HIV from 2030 onward, a proposal that would be ruled out on cost-benefit considerations alone.”   This would be inconsistent with principles of evidence-based medicine:  Infants are not at risk of infection by sexual contact and will not be at risk until they become sexually active in 16-20 years, by which time treatment and prevention options and the virus itself may have altered beyond recognition.  Assuming that the African evidence is reliable and applicable, logically – sexually active adult men who have regular intercourse with numerous female partners and do not always use condoms should consider circumcision for themselves.  Instead some researchers have proposed circumcision of baby boys as a precaution against a risk they will not face until adulthood and against a disease that is very rare among heterosexually active adult men anyway.  If it is still necessary to wear a condom, there seems little point in getting circumcised. 130

Research has confirmed that the WHO recommendations arising from the African random-controlled trials cannot be applied to developed nations.  130 & 131
  “Behavioral factors appear to play a far more important role than whether or not one has a foreskin.”  131

A study by Perera et al found the benefits of neonatal or childhood circumcision to be negligible and the possibility of reduced vulnerability to HIV irrelevant to children.   If uncircumcised boys are more subject to “adverse medical conditions” we should expect this to show up in child health reviews, but the Australian Institute of Health and Welfare found no decline in child health as the incidence of circumcision Australia has fallen, and indeed that child health has improved over the same period.  The RACP**** concluded that there was no medical justification for prophylactic circumcision of minors in Australia.  132 & 133

The harm and risks of circumcision and the ethics of performing amputative surgery on minors, which includes the loss of both sexual satisfaction and psychological well-being, has been ignored by many researchers. “Any consideration of the costs of circumcision will be woefully inadequate if it fails to factor in the value of the foreskin to the individual and the cost of surgical complications and other adverse sequelae, both physical and psychological.” 133

According to the Australian Institute of Health and Welfare: “There is no evidence for the assertion that neonatal circumcision presents a lower incidence of complications than circumcision in adulthood.  The risk of harm is likely to be greater if the operation is performed before the natural separation of foreskin from the glans, and lower in adulthood when the mature size of the penis and final foreskin length can be observed and taken into account.  Males differ so much in these variables that one cut does not fit all.  Also safe anesthesia is normally provided for adults.”  134

The results of these findings pose the issues of medical ethics and human rights.  Does the proposed procedure provide a net therapeutic benefit to the patient, considering the risk, pain and loss of normal function?  Also, does the procedure avoid permanently diminishing the patient in any way that could be avoided?  Will the final result provide a significant net benefit to the patient in proportion to the risk undertaken and the losses sustained?  Will the patient be treated as fairly as we would all wish to be treated?  Lacking life-threatening urgency, will the procedure honor the patient’s right to his or her own likely choice.) Could it wait for the patient’s assent? 134 & 135

Darby and Van Howe also criticize the use of unscientific language.  “Circumcision as a ‘surgical vaccine’ is regrettable and misleading, with no basis in science and is irresponsible in that it may encourage high risk behavior.  Circumcision advocates seem unwilling to acknowledge the difference between amputating body parts to provide limited protection against a rare disease to which the individual is unlikely to be exposed, and giving a person an injection that confers a high level of immunity to common or highly contagious diseases.” 130

“The rapid spread of HIV in Africa was associated with a high level of sexual activity involving numerous concurrent, but often transient sexual partnerships, widespread prostitution, both formal and informal, various forms of polygamy and reluctance to practice safe sex including use of condoms.  It is also probably that a significant proportion of HIV infections are the result of non-sexual transmission such as non-sterile medical procedures.”  136

“Much of Africa has poorly developed health services with the co-presence of numerous other epidemic diseases such as malaria, tuberculosis and other STIs.”137 

“Safe sex education, needle and syringe programs and provision of condoms  appear to be the most successful strategy against AIDS.”  138

Darby & Van Howe have also observed:  “Langerin is a protein based substance which is said to have disease preventative properties.  Langerhans cells which produce Langerins are present in the epithelium (human skin) and are abundant in foreskins.” 139  This is important knowledge since some writers have believed that the foreskin only harbors disease pathogens. 140-142

According to the study by de Witte, et al:  “Human immunodeficiency virus-1 (HIV-1) is primarily transmitted sexually.  Dendritic cells (DCs) in the subepithelium (inner layer of skin) transmit HIV-1 to T cells through the C-type lectin DC-specific intercellular adhesion molecule ICAM)-3-grabbing nonintegrin (DC-SIGN).  However the epithelial Langerhans cells (LOCs) are the first DC subset to encounter HIV-1.  It has generally been assumed that LCs mediate the transmission of HIV-1 to T cells through the C-type lectin Langerin, similarly to transmission by DC-SIGN, Langerin prevents HIV-1 to T cells through the C-type lectin Langerin, similarly to transmission by DC-SIGN on dendritic cells (DCs).  Here we show that in stark contrast to DC-SIGN, Langerin prevents HIV-! transmission by LCs.  HIV-1 captured by Langerin was internalized into Birbeck granules and degraded.  Langerin inhibited LC infection and this mechanism kept LCs refractory to HIV-1 transmission; inhibition of Langerin allowed LC infection and subsequent HIV-1 transmission.  Notably, LCs also inhibited T-cell infection by viral clearance through Langerin.  Thus Langerin is a natural barrier to HIV-1 infection, and strategies to combat infection must enhance, preserve or, at the very least, not interfere with Langerin expression and function.” 143 & 144

Van Howe has also reported the following:
  ” Meta-analyses (have been carried out) on studies of genital discharge syndrome versus genital ulcerative disease, genital discharge syndrome, nonspecific urethritis, gonorrhea, chlamydia, genital ulcerative disease, chancroid, syphilis, herpes simplex virus, human papillomavirus and contracting a sexually transmitted infection of any type.  Chlamydia, gonorrhea, genital herpes and human papillomavirus are not significantly impacted by circumcision.  Syphilis showed mixed results.  Intact men were at greater risk for genital ulcerative disease & lower risk for genital discharge syndrome, nonspecific urethritis, genital warts and the overall risk of any sexually transmitted infection (STI).  In general populations there is no clear or consistent positive impact of circumcision on the risk of individual STIs.  145

Prevention of STIs cannot rationally be interpreted as a benefit of circumcision, and any policy of circumcision for the general population to prevent STIs is not supported by the evidence in the medical literature.  Van Howe has continued to state: “The AAP 1999 Task Force on Circumcision concluded ‘evidence regarding the relationship of circumcision to STD in general is complex and conflicting.'” 146

In 2012 the AAP concluded that “evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks; furthermore, the benefits of newborn male circumcision justify access to this procedure for families who choose it.  Specific benefits from male circumcision were identified for the prevention of UTIs, acquisition of HIV, transmission of some STIs and penile cancer.” 147

Within the body of the statement the committee admitted that they were unable to precisely measure the benefits of infant circumcision and unable to quantify the risks. 
  “While a number of review articles and systematic reviews of the association between male circumcision and individual types of STIs have been published,  many of these need updating while others have methodological shortcomings. 143, 145-152

“Three randomized clinical trials of adult male circumcision in Africa failed to adjust for lead-time bias.  Men who were assigned to immediate circumcision were instructed to either not engage in sexual activity or use condoms with all sexual contacts until the circumcision healed (approximately 4-6 weeks)  Analyses that included these trials were conducted with the reported data and with the data adjusted for a 6 week lead time bias. 143

“Sampling bias (was not considered.)  Circumcised men are more likely to have genital warts or have positive lesions or positive swabs on the penile shaft than intact men. 153-159  Studies that sampled only the glans or urethra would underestimate the incidence and prevalence of HPV infection in circumcised males. 145

A study published by VanBuskirk, et al. reveals that if only the glans is sampled, only 66.1% of the intact men with genital HPV would be identified, while only 45.2% of the circumcised men with genital HPV would be identified. 160 Additionally, patient report of circumcision status can be inaccurate.  148

As to  genital ulcerative disease (GUD) and genital discharge syndrome (GDS):  intact men are more prone to gud and circumcised men are  more prone to GDS.  Non-specific (nongonococcal) urethritis (NSU) is significantly lower in intact males.  With chlamydia and gonorrhea, no significant difference in prevalence has been noted between circumcised and intact males. 160

Genital ulcerative disease is more common in developing countries and is more likely to grow in mucosal surfaces, hence more likely in intact males.
Syphilis has shown a positive association for intact men primarily in populations at high risk for acquiring STIs, while in general populations, there is no significant difference.
Genital Herpes/Herpes Simplex virus type 2 – shows no statistically significant association for circumcised versus intact males.  Chancroid is uncommon in developing nations and is extremely rare in developed nations. No statistically significant relationship has been found in regard to circumcised or intact status.  Genital warts have shown a strong trend of being lower in intact males in general population. 148, 161-164

Prevalence of human papillomavirus has shown conflicting results 149, 151 & 153  Many types may be related to penile cancer with some sampling bias.  There have been barely statistically significant results based on circumcision status (i.e. some men are unsure of their circumcision status and sometimes only the glans was sampled but not the shaft.)  165 & 166  Studies have indicated that the clearance of HPV takes longer from the intact penis 160. 167-169  If this is true, it would be more likely to be detected in intact men.

Among all STIs the prevalence of acquiring any STI is lower in intact men. 143 STIs with genital discharges are more common than genital ulcers, which may explain why the prevalence of any STI is lower in intact males.  It is clear that despite these methodological concerns, the impact of circumcision on the overall risk of contracting any STI is to increase the overall risk of infection.  Because of the highly conflicting amount of data included in this analysis and disparate results on the incidence of infection, more studies  are needed. 143

“The summary effect for the prevalence of every disease was greater in studies of high-risk populations than in general populations.” 143  Calls for population-wide implementation of male circumcision on the grounds that it prevents sti’s are not supported by the findings of these analyses.  A major problem with infant circumcision is the lack of an accurate method of identifying which infants will find themselves in high risk population when they become sexually active.  170

Sexual partners are usually not found randomly but within ones cultural or ethnic group.  110  Circumcision is associated with religious, tribal and cultural factors. Men with a particular circumcision status will likely have sexual partners from within a group that has a predominance of men with the same circumcision status.  The smaller the group, the more quickly the rise and the higher the peak prevalence for a particular STI 172  When circumcision rates are high, intact men would be more likely to be in a smaller ethnic, religious or cultural group and thus have a higher peak prevalence of a disease.  As circumcision prevalence drops, circumcised men would find themselves in the smaller groups that would  be more likely to have a higher peak prevalence of infections. 143

The lack of any significant association between high risk HPV infections and circumcision status undermines the argument made by the few who believe that circumcision reduces cancer risk 173-175  Lack of association between HPV, HSV & other STIs also undermines the analysis published by the same researchers at Johns Hopkins that selectively reported their HPV findings in Africa. 143

The results of these analyses also further undermine the argument of how the increased risk of HIV infection in intact men is biologically plausible.   The plausibility has been based on several assumptions which are purely speculative, that the inner mucosa of the foreskin is thin and more prone to abrasions, the subpreputial space is a breeding ground for sexually transmitted viruses, and that Langerhans cells on the mucosal surface act like HIV virus magnets pulling the virus into the body. 176

The preputial mucosa is not unusually thin. 177 & 178 Circumcised men have a trend toward more penile abrasions (presumably from lack of adequate lubrication). 179 Langerhans cells are quite efficient in killing HIV cells, hence the low rate of transmission through sexual contact (approximately 1 in 1,000 unprotected acts of coitus) and require activated T cells. 180 &  181  Langerhans cells are the first line of mucosal defense.  There is no difference in the incidence and prevalence of HSV or HPV based on circumcision status.     Research has found that the higher viral replication rates and viral load of HPV is on the penile skin rather than in the subpreputial space.  182

Twenty percent or more genital infections in Africa are not spread through sexual contact. 183-190   Data from three African randomized clinical trials in adult males looking for association between circumcision and any incidence of HIV infection 191 & 192 found that apparently half of the infections documented were transmitted through nonsexual means 193   Also, They observed a relatively small number of patients which would effect the validity of results.  143

The control group (which were men without any STIs) may introduce bias  due to differing behavioral patterns.  Most forms of bias are insidious and difficult to measure.  Circumcision status is linked to socioeconomic status, which may impact healthcare-seeking behaviors.  194

In addition the men who were randomized to immediate circumcision were not exposed to STIs for 4-6 weeks following their procedures. Therefore, their exposure to disease was not the same as men who were assigned to later circumcision.  When the reduced exposure time is accounted for, several of the associations found that these trials were no longer statistically significant. 143

Sadly, the promotion of circumcision in Africa has had some tragic consequences.  Circumcision has led many men to believe that they no longer need to use condoms, be faithful to one partner or use any other means of caution in their sexual lives, therefore in many instances it has increased the risk of aids and other STIs.

  “In 2005 came the report, ‘ Male circumcision protects against HIV like a vaccination.’  A sensation!  Hope bubbled up everywhere.  The catalyst for the euphoria was the French Doctor Bertan Auvert.  For his study in South Africa 1339 men in the Johannesburg township of Orange Farm were voluntarily circumcised.  After the procedure Auvert compared their infection rate with a control group of 1309 non-circumcised men in the same region.  His hypothesis was that the HIV target cells, and thereby the risk of infection could be eliminated along with the foreskin.”  195

“After one and a half years he appeared to prove his theory correct.  Among the non-circumcised men in the control group, Auvert assessed 49 cases of HIV while he found only 20 among the circumcised men.  From this the Frenchman inferred an up to 60 percent reduced HIV risk which was soon to become the mantra of the WHO campaign in Africa.” 196 

  However the WHO has also stated: “They are emphatically aware that condoms still need to be used after a circumcision.  This is stressed in the training for local partners run by USAID, the authority which is coordinating the development partnership project for the U.S. government.”&nbsp 197

“We’re not just cutting off foreskins” says George Sinyangwe, the primary health advisor for USAID in Lusaka.  “All men receive information which totally clears up mistaken ideas about the use of the procedure before, during and after their circumcision.”198

  “But is that message about safe sex getting through?   When you have unprotected sex your penis gets tiny cracks into which the virus can penetrate, but circumcision makes your glans hard and tough.” explains Margaret Nkunika.  199

A 28-year-old man commented “I know the protection (via circumcision) amounts to 60 percent, which is better than nothing.  But condoms offer a much higher level of protection, up to 95 percent.”  But the men laugh.  “Using condoms in vaginal intercourse would be like eating candy in its plastic wrapper.” 200

A great many of recent studies warn of “mixed messages.”  Because of the unclear information of the campaign, scientists at the Makere University in Uganda have determined that circumcised men are more likely to take risks sexually than non-circumcised men. 201

  The WHO has stated that while circumcision is supposed to reduce the risk of HIV transmission from women to men, it does not work the same in the other direction.  Male circumcision offers no protection to women. 202

  In Uganda, for women with circumcised husbands the HIV rate in the six months after the circumcision has drastically increased, by 61 percent.  Bertan Auvert  (“the father of the circumcision solution”) has stated,  “I am absolutely convinced that some women will become HIV positive because of the circumcision of their partners because the men fall into a false sense of security.” 203

“Circumcision likewise offers hardly any protection to homosexual men who are among the high risk groups around the world.  Yet one gay man in Zambia has stated  “Most gays in Zambia think that circumcision protects them from HIV too. We are swearing off condoms and dying like flies.” 204

  The Center for Disease Control (CDC) has published misleading headlines such as  “Benefits of Circumcision Outweigh the Risks”and “CDC Endorses Circumcision for Health Reasons.”  205

There is growing opposition by Africans to the current circumcision campaign.  A 2017 on-line press release has stated:  “Is it that the media is hungry to present benefits and call for a universal endorsement for something that really hasn’t happened?   Is this a feeble attempt to manipulate the public opinion, under the assumption that everybody is too lazy to go to the source materials?  The CDC refers people to counseling rather than immediate and universal endorsement.  Their aim is to aid a person through a decision making process.    Sexual orientation and lifestyle choices are factors to be considered.  When parents are asked to decide about circumcision for a newborn, this raises concerns about personal body autonomy,  since a man with a foreskin can elect to be circumcised, but if circumcised as a newborn, cannot easily reverse the decision.    The CDC has recognized that there are advantages and disadvantages to performing male circumcision at various stages of life, but the newborn has no ability to participate in the decision.” 206

The CDC’s stance is based on the African trials on circumcision and HIV.  They recognize that circumcision does not replace the need for condoms and safe sex, nor does it reduce the risk of male-to-female  or male-to-male transmission.  Circumcision also does not reduce the transmission through anal or oral sex or for intravenous drug users.  Circumcision will only curb the transmission of HIV from females to males during vaginal penetration. 207  Therefore the person’s HIV risk behavior, HIV status, sexual preferences and gender of partner must be assessed. 208

The CDC also states: “The prevalence of HIV infection in the U.S. is not as high as in sub-Saharan Africa and most men do not acquire HIV through penile-vaginal sex.  Targeting recommendations for adult male circumcision to men at elevated risk for heterosexuality acquired HIV infection would be more cost effective than offering routine adult male circumcision.  Men may be targeted according to sexual practices or an elevated prevalence of HIV within a geographic region or race/ethnicity group.” 209

The CDC continues by stating: “All sexually active adolescent and adult males should continue to use other proven HIV and sti risk reduction strategies such as reducing the number of partners and correct and consistent use of male latex condoms, and HIV preexposure or postexposure prophylaxis among others.” 210

Finally, according to the CDC: “The foreskin is a highly innervated structure and some authors have expressed concern that its removal may compromise sexual sensation or function.  However, in one survey of 123 men following medical circumcision in the U.S., men reported no change in sexual activity and improved sexual satisfaction, despite decreased erectile function and penile sensation.  A small survey conducted among 15 men before and after circumcision found no statistically significant difference in sexual function or sexual satisfaction.  Other studies conducted among men after adult circumcision have found that relatively few men report that there is a decline in sexual functioning after circumcision.  Most report either improvement or no change.”  211  (Of course what a person can report that he feels or does not feel is highly subjective, and difficult to measure or assess.  Men will be understandably reluctant to report reduced sexual sensation or satisfaction. – R.R.)

“The VMMC Experience Project is a non-for-profit organization to empower Africans to raise their voices on the issue of mass circumcision as provided by Western health organizations.  Its investigation into the ‘voluntary medical male circumcision’ (VMMC) campaign in rural East Africa revealed less than voluntary recruitment methods for circumcision, including $3 vouchers to impoverished men and the targeting of schoolboys without their parents’ consent.  Vulnerable populations such as orphaned children and prison inmates become frequent targets, as the recruiters (called “mobilizers”) are compensated per head.  Some of these boys and men later regret undergoing the procedure.  Others report they never consented at all.”  212

VMCC representatives have stated: “The mass circumcision campaign also results in confusion about HIV immunity.  At least 7 respondents attributed their own infections to misinformation derived from the campaign.  Others have mourned the loss of loved ones to HIV/AIDS following circumcision which they underwent for HIV/AIDS prevention.”213

  Prince Hillary Maloba, a native of Kenya and Uganda, is the Director of the Project.  His uncles are members of the Bagisu, a circumcising tribe with one of the highest HIV rates in Uganda.  “Millions of circumcised men are living with HIV,” he reports.  “Millions of children with circumcised parents are left AIDS orphans.  Now traditionally non-circumcising tribes are being forced to accept circumcision based on blatant lies.”  He concludes,  “We demand the banning of mass circumcision in Africa!” 214

“In other parts of the world there has been widespread condemnation of the practice of infant circumcision.  Norway, Sweden, Finland, Denmark, Iceland and Greenland have all called for a ban on medically unnecessary circumcisions performed on underage boys.  The Danish Medical Association’s 2016 policy on male infant circumcision describes the practice as “ethically unacceptable,” while  the Royal Dutch Medical Society urges a “powerful policy of deterrence.” 215

“In 2013 the Council of Europe adopted a resolution which classifies medically unnecessary circumcisions as a violation of children’s right to physical integrity.  UNICEF’S African infant circumcision initiative is backed by the American agencies USAID and PEPFAR*****.  To some Africans this conjures up images of American colonialism and even a cultural assault. ‘Circumcision’ says Maloba.  ‘We totally reject this.’ “216

A letter has been written to UNICEF by the VMMC Experience Project by Dr. Piotr Czauderna (former president of the Polish Association of Pediatric Surgeons), and Dr. Dean Edell  (Well-known American physician-broadcaster.)  (There has been no response from UNICEF as of Aug. 2017.)  217

In conclusion:  Behavioral factors obviously play the most important role in preventing all types of STIs including HIV.  Having multiple sexual partners, especially with prostitutes and lack of condom use are the most significant factors in acquiring STIs.  However, human behavior cannot truly be controlled in laboratory experiments.  It would be neither ethical nor feasible to isolate people and observe their every action.  Following the surgery of circumcision, or being interviewed and left intact, patients are released to lead their own lives.  Scientists cannot observe, much less control the behavior of their subjects.  Upon follow-up the men are asked about their sexual contacts, frequency of sex, condom use, etc., but subjects may lie or fail to remember their specific actions.  Also,some participants get lost to follow up.  Therefore any study of human behavior is bound to be flawed.  In the studies listed here, men who are sore and recovering from painful genital surgery are almost certainly going to abstain from sex or do it less frequently. 

They may also be more likely to use condoms (due to their soreness.) 

Part of the aim in the ongoing attempt to amputate as many African foreskins as possible is one of doctor control.  Medical professionals are trained to be active in their approach to human health conditions.  Therefore, their aim is to tackle any injury or illness with chemicals and/or surgery.  (Of course in many situations these are the preferred treatments.)  By cutting off foreskins a doctor is in control.  Doctors cannot control (or get paid) for telling people to be responsible for themselves, be it telling them to bathe, eat healthfully, confine their sexual contacts to one healthy and faithful partner, or to use condoms.

  Billions of dollars have been spent on the “Circumcise Africa” campaign.  Africa is a country where millions of people lack the basic necessities of life which most of us in the western world take for granted.  A significant portion of the African populations could have been supplied with food, safe drinking water, housing and access to education with the billions of dollars that have been spent to cut off foreskins.  Since the supposed HIV preventative possibility offered by amputating foreskins is speculative at best, this is especially a tragic and wasteful use of these funds.

Finally, an important consideration for those who refer to the Bible as a source for endorsing circumcision (despite the many passages in the New Testament which clearly define its irrelevance and wrongness for Christians):  Judaeo/Christian values include fidelity within marriage and clearly denounce all types of random, non-committal sexual behavior.  Most STIs do result from sex with multiple partners, frequenting prostitutes, etc.  Whatever spiritual significance may have been attached to circumcision by the ancient Hebrews, one can hardly interpret this as having been some “medical prescription” from God as a license for any rampant sexual risk taking.


* OR stands for “odds ratio” – a measure of association between an exposure and an outcome.
** Intaction is a well-known on-line source of information questioning and opposing genital cutting of all non-consenting infants and children.
*** USAID is the world’s premier international development agency and a catalytic actor driving development results. USAID’s work advances U.S. national security.  The initials stand for “United States Agency for International Development.”
**** RACP stands for “Royal Australasian College of Physicians.”
***** Langerhans cells are dendritic (branching) cells of the skin which stimulate an immune response to foreign substances.
******Langerin is a microscopic structure within a Langerhans which becomes a specific organelle called the Birbeck granule, which is specific for producing an immune response to invasive pathogens (i.e. diseases.)
*******PEPFAR stands for “President’s Emergency Plan for AIDS Relief.”


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  3.   ibid.
  4.   ibid.
  5.   ibid.
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  10. Weiss, H.A., Thomas, S.L., Munabi, S.K., & Hayes, R.J.
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  40. Malawi24 (Blantyre) “Malawi: Circumcision Disaster – Malawi Infection Rate Doubles
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  42. Kangwele, Mike J., Malawi24, July 25, 2015  Malawian Circumcised Men Most Likely to be Infected by HIV, Research Shows
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  53. Rodriguez-Diaz CE, et al.    “More Than Foreskin: Circumcision Status, History of HIV/STI and Sexual Risk in a Clinic-Based Sample of Men in Puerto Rico”
  54.   ibid.
  55. Doerner, R., et al.   “Circumcision and HIV Infection Among Men who Have Sex With Men in Britain: The Insertive Sex Role”     Archives of Sexual Behavior, early online edition, DOI 10.1007/s10508-0061-1, 2013.
  56. Intaction
  57. – “Circumcision Doesn’t Reduce HIV Spread”
  58.   ibid.
  59.   ibid.
  60. Garenne, Michel –   African Journal of AIDS Research 2008, 7(1): 1-8
  61. Connolly C. et al. – “Male Circumcision and its Relationship to HIV Infection in South Africa. Results of a National Survey in 2002”    South African Medical Journal ,2008;98:789-94.
  62. Talbot Jr. – “Size Matters: The Number of Prostitutes and the Global HIV/AIDS Pandemic”       PloS One,  2007, 2(6): e543.
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  64. –  “Circumcision Doesn’t Reduce HIV Spread”
  65.   ibid.
  66.   ibid.
  67. Obert, Michael – (This article originally appeared in German in the July 2015 edition of GEO Magazine. It was then translated by Curtis Murphy. Edited for web by Intaction.  Their sources were not available.)
  68.   ibid.
  69.   ibid.
  70.   ibid.
  71.   ibid.
  72.   ibid.
  73.   ibid.
  74.   ibid.
  75.   ibid.
  76.   ibid.
  77.   ibid.
  78. Auvert, B., Taljaard, D., Lagarde, E., Sobngwi-Tambekou, J., Sitta R., &  Puren A. “Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk”  The ANRS 1265 Trial. PLoS Med. 2005; 2: e298.
  79. Bailey, R.C., Moses, S., Parker, C.B., Agot, K., Maclean, I., Krieger, J.N., et al.   “Male Circumcision for HIV Prevention in Young Men in Kisumu, Kenya: a Randomised Controlled Trial”     Lancet, 2007; 369: 643-656.
  80. Gray, R.H., Kigozi, G., Serwadda, D., Makumbi, F., Watya S, Nalugoda, F. et al.   “Male Circumcision for HIV Prevention in Men in Rakai, Uganda: a Randomised Trial”     Lancet, 2007; 369(9562): 657-66.
  81. Dowsett, G.W. & Couch, M.   “Male circumcision and HIV prevention: Is There Really Enough of the Right Kind of Evidence?”   Reproductive Health Matters, 2007; 15(29): 33-44.
  82. Green, L.W., McAllister, R.G., Peterson, K.W. & Travis, J.W. – “Male Circumcision is not the HIV ‘Vaccine’ We Have Been Waiting For!”   Future HIV Therapy, 2008; 2(3): 193-199.
  83. Green, L.W., Travis, J.W., McAllister, R.G., Peterson, K.W., Vardanyan, A.N., &  Craig A.  ” Male Circumcision and HIV Prevention: insufficient Evidence and Neglected External Validity  American Journal of Preventive Medicine 2010; 39(5): 479-82.
  84. Akl, E.A., Briel, M., You, J.J., Sun, X., Johnston, B.C., Busse, J.W., et al.   “Potential Impact on Estimated Treatment Effects of Information Lost to Follow-up in Randomised Controlled Trials (LOST-IT)”: Systematic Review” British Medical Journal 2012; 344: e2809.
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  87. Williams, B.G., Lloyd-Smith, J.O., Gouws, E., Hankins, C., Getz, W.M., Hargrove, J., et al. – “The Potential Impact of Male Circumcision on HIV in Sub-Saharan Africa” PLoS Med, 2006; 3: e262.
  88. Van Howe, R.S. & Storms, M.R. – “How the Circumcision Solution in Africa Will Increase HIV Infections   Journal of Public Health, Africa, 2011; 2:e4.
  89. Siegfried, N., Muller, M., Deeks, J.J. & Volmink, J.   “Male Circumcision for Prevention of Heterosexual Acquisition of HIV in Men”   Cochrane Database Systematic Review, 2009; 2: CD003362, 23a.
  90. Mishra, V., Medley, A., Hong, R., Yuan Gu, Y. & Robey, B. –   “Levels and Spread of HIV Seroprevalence and Associated Factors: Evidence from National Household Surveys”   DHS Comparative Reports, No. 22. Calverton (MD): Macro International Inc; 2009.
  91. Garenne, M. –   “Long-term Population Effect of Male Circumcision in Generalized HIV Epidemics in sub-Saharan Africa”     African Journal of AIDS Resources, 2008; 7 :1-8.
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  96. Telzak, E.E., Chiasson, M.A., Bevier, P.J., Stoneburner, R.L., Castro, K.G. & Jaffe, H.W. – “HIV-1 Seroconversion in Patients With and Without Genital Ulcer Disease”   Annals of Internal Medicine, 1993; 119: 1181-6.
  97. Laumann, E.O., Masi, C.M., &  Zuckerman, E.W. – “Circumcision in the United States: Prevalence, Prophylactic Effects, and Sexual Practice” –   JAMA, 1997; 277: 1052-7.
  98. Thomas, A.G., Bakhireva, L.N., Brodline, S.K. & Shaffer, R.A. –   “Prevalence of Circumcision and its Association with HIV and Sexually Transmitted Infections in a Male US Navy Population” San Diego (CA): Naval Health Research Center. Report No. 04-10; 2004.
  99. Mor, Z., Kent, C.K., Kohn, R.P. & Klausner, J.D.   “Declining Rates in Male Circumcision Amidst Increasing Evidence of its Public Health Benefit” PLoS ONE, 2007; 2(9): e861.
  100. Warner, L., Ghanem, K.G., Newman, D.R., Macaluso, M., Sullivan, P.S. & Erbelding, E.J. –   “Male Circumcision and Risk of HIV Infection Among Heterosexual African American Men Attending Baltimore Sexually Transmitted Disease Clinics”    Journal of Infectious Diseases, 2009; 199: 59-65.
  101. Rodriguez-Diaz, C.E., Clatts, M.C., Jovet-Toledo, G.G., Vargas-Molina, R.L., Goldsamt, .LA. & García, H. – “More than Foreskin: Circumcision Status, History of HIV/STI, and Sexual Risk in a Clinic-Based Sample of Men in Puerto Rico” Journal of Sexual Medicine, 2012; 9: 2933-7.
  102. Millett, G.A., Flores, S.A., Marks, G., Reed, J.B. & Herbst, J.H. – “Circumcision Status and Risk of HIV and Sexually Transmitted Infections Among Men who Have Sex with Men”     JAMA, 2008 ;300: 1674-84. Errata JAMA. 2009; 301: 1126-9.
  103. Crosby, R.A., Graham, C.A., Mena, L., Yarber, W.L., Sanders, S.A., Milhausen, R.R., et al. –     “Circumcision Status is not Associated with Condom use and Prevalence of Sexually Transmitted Infections Among Young Black MSM”     AIDS Behavior, 2015 Oct 7, Epub ahead of print.

  104. All references listed here from 88. – 102. were resources of the following article:

  105.   Van Howe, Robert, MD, MS, FAAP, –     Doctors Opposing Circumcision website, May 2016
  106. Darby, R.   “A Surgical Temptation: the Demonization of the Foreskin and the Rise of Circumcision in Britain”   Chicago: University of Chicago Press; 2005.
  107. Van Howe, R.S.   “Genital Ulcerative Disease and Sexually Transmitted Urethritis and Circumcision: a Meta-Analysis”   International Journal of STD & AIDS, 2007; 18: 799-809.
  108. Van Howe, R.S. Sexually transmitted infections and male circumcision: a systematic review and meta-analysis   ISRN Urology, 2013: 109846.
  109. Weiss, H.A., Thomas, S.L., Munabi, S.K. & Hayes, R.J.   “Male Circumcision and Risk of Syphilis, Chancroid, and Genital Herpes: A Systematic Review and Meta-Analysis”   Sexually Transmitted Infections, 2006; 82: 101-10.
  110. Tobian, A.A.R., Serwadda, D., Quinn, T.C., Kigozi, G., Gravitt, P.E., Laeyendecker, O., et al. –   “Male Circumcision for the Prevention of HSV-2 and HPV Infections and Syphilis”    New England Journal of Medicine, 2009; 360: 1298-309.
  111. Mehta, S.D., Moses, S., Parker, C.B., Agot, K., Maclean, I. & Bailey, R.C. –   “Circumcision Status and Incident HSV-2 Infection, Genital Ulcer Disease, and HIV Infection”   AIDS, 2012; 26: 1141-9.
  112. Weaver, B.A., Feng, Q., Holmes, K.K., Kiviat, N., Lee, S.K., Meyer, C. et al. –   “Evaluation of Genital Sites and Sampling Techniques for Detection of Human Papillomavirus DNA in Men”      Journal of Infectious Diseases, 2004; 189: 677-85.
  113. VanBuskirk, K., Winer, R.L., Hughes, J.P., Geng, Q., Arima, Y., Lee, S.K., et al. –   “Circumcision and the Acquisition of Human Papillomavirus Infection in Young Men”   Sexually Transmitted Diseases, 2011; 38: 1074-81.
  114. Aynaud, O., Piron, D., Bijaoui, G. & Casanova, J.M. –     “Developmental Factors of Urethral Human Papillomavirus Lesions: Correlation with Circumcision”     British Journal of Urology International, 1999; 84: 57-60.
  115. Aynaud, O., Ionesco, M., Barrasso, R. –     “Penile Intraepithelial Neoplasia. Specific Clinical Features Correlate with Histologic and Virologic Findings”     Cancer, 1994; 74: 1762-7.
  116. Oriel, J.D. ,    “Natural History of Genital Warts” –     British Journal of Venereal Diseases, 1971; 47: 1-13.
  117. Hernandez, B.Y., Wilkens, L.R., Zhu, X., McDuffie, K., Thompson, P., Shvetsov, Y.B., et al. –   “Circumcision and Human Papillomavirus Infection in Men: a Site-Specific Comparison”   Journal of Infectious Diseases, 2008; 197: 787-94.
  118. “Sexually Transmitted Diseases Across Space and Time”   OnlineDoctor (UK) website. n.d.   Available at: –
  119. Crosby, R. & Charnigo, R.J. –   “A Comparison of Condom use Perceptions and Behaviours Between Circumcised and Intact Men Attending Sexually Transmitted Disease Clinics in the United States”   International Journal of STD & AIDS, 2013; 24(3): 175-8.
  120. All references listed from 103-117 were sources for the following article:

  121. Van Howe, Robert, MS, MD, FAAP –   Doctors Opposing Circumcision website, May 2016
  122. Darby, Robert, M.D. & Van Howe, Robert, M.D., MS, FAAP, professor at Michigan State University   “Not a Surgical Vaccine:  There is No Case for Boosting Infant Male Circumcision to Combat Heterosexual Transmission of HIV in Australia”       Australian and New Zealand Journal of Public Health, Volume 35, Issue 5., October 2011, pages 459-465
  123.   ibid.
  124. Garenne, M. – “Long-term Population Effect of Male Circumcision in Generalized HIV Epidemics in sub-Saharan Africa” African Journal of AIDS Research, 2008; 7(1):1-8.
  125. Connolly, C., Simbayi, L.C., Shanmugam, R. & Nqeketo, A. – “Male circumcision and its Relationship to HIV Infection in South Africa: Results of a National Survey in 2002” South African Medical Journal, 2008; 98(10):789-94.
  126.   ibid.
  127. Ganor, Y. & Bomsel, M. – “HIV-1 Transmission in the Male Genital Tract” American Journal of Reproductive Immunology, 2011; 65: 284-291.
  128. Dinh, M.H., McRaven, M.D., Kelley, Z., Penugonda, S. & Hope, T.J. – “Keratinization of the Adult Male Foreskin and Implications for Male Circumcision” AIDS, 2010; 24: 899-906.
  129. Darby and Van Howe Article 2011 vol. 35 no. 5 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH, 465 2011 The Authors. ANZJPH © 2011 Public Health Association of Australia
  130. Chin, J. – “The AIDS Pandemic: The Collision of Epidemiology with Political Correctness”  Oxford (UK): Radcliffe Publishing; 2007.
  131. de Witte, L., Nabatov, A., Pion, M., Fluitsma, D., de Jong, M.A.W.P., de Gruijl, T., et al. – “Langerin as a Natural Barrier to HIV-1 Transmission by Langerhans Cells” Natural Medicine, 2007;13:367-71.
  132. Reid, D., Weatherburn, P., Hickson F., & Stephens, M. – “Know the Score: Findings from the National Gay Men’s Sex Survey 2001” London (UK): Sigma Research, Faculty of Humanities & Social Sciences, University of Portsmouth; 2002.
  133. Darby, Robert, M.D. & Van Howe, Robert, M.D., MS, FAAP, professor at Michigan State University – “Not a Surgical Vaccine:  There is No Case for Boosting Infant Male Circumcision to Combat Heterosexual Transmission of HIV in Australia” Australian and New Zealand Journal of Public Health, Volume 35, Issue 5., October 2011, pages 459-465
  134. McDaid, L.M., Weiss, H.A., & Hart, G.J. – “Circumcision Among Men who have Sex with Men in Scotland: Limited Potential for HIV Prevention” Sexually Transmitted Infections, 2010;86:404-6.
  135. Wei, C., Raymond, H., McFarland, W., Buchbinder S., & Fuchs, J. – “What is the Potential Impact of Adult Male Circumcision on the HIV Epidemic Among men who have Sex with Men (MSM) in San Francisco?” Sexually Transmitted Diseases, 2010;37:1-3.
  136. Royal Dutch Medical Association –   “Non-therapeutic Circumcision of Male Minors” [Internet]. Utrecht (NLD): KNMG; 2010 [cited 2010 Oct 26]. p.6.
  137. Available from: KNMGpublicatie/Nontherapeutic-circumcision-of-male-minors-2010.htm
  138. Royal Australasian College of Physicians – “Circumcision – RACP Position Statement” Sydney (AUSTRALIA): RACP; 2010 September. p. 13.
  139. Australian Institute of Health and Welfare – A Picture of Australia’s Children Canberra (AUSTRALIA): AGPS; 2005.
  140. Cold, C.J. & Taylor, J.R. – “The prepuce” British Journal of Urology International, 1999; 83 Suppl 1: 34-44.
  141. Darby,R. &, Svoboda, J.S. – “A Rose by any Other Name: Rethinking the Similarities and Differences Between Male and Female Genital Cutting” Medical Anthropology Quarterly, 2007;21:301-23.
  142. Beauchamp, T.L. & Childress, J.F. – Principles of Biomedical Ethics – Part II. 6th ed. New York (NY): Oxford University Press; 2009.
  143. Darby, Robert, M.D. & Van Howe, Robert, M.D., MS, FAAP, professor at Michigan State University – “Not a Surgical Vaccine:  There is No Case for Boosting Infant Male Circumcision to Combat Heterosexual Transmission of HIV in Australia” Australian and New Zealand Journal of Public Health, Volume 35, Issue 5., October 2011, pages 459-465
  144. Gisselquist, D. – “Points to Consider: Responses to HIV/ AIDS in Africa, Asia,and the Caribbean”   London (UK): Adonis and Abbey; 2008.
  145. Bowtell, W.D. – “World AIDS Day”   Medical Journal of Australia, 2010;193(11/12):653-4
  146.   ibid.
  147. De Witte. L., et al, –   Langerin is a Natural Barrier to HIV-1 Transmission by Langerhans Cells   Natural Medicine, 2007  PMID: 17334373 (PubMed – indexed for MEDLINE)
  148.   ibid.
  149. (All references from 121 – 144 were resources for the following article:) Darby, Robert, M.D. & Van Howe, Robert, M.D., MS, FAAP, professor at Michigan State University   “Not a Surgical Vaccine:  There is No Case for Boosting Infant Male Circumcision to Combat Heterosexual Transmission of HIV in Australia”   Australian and New Zealand Journal of Public Health, Volume 35, Issue 5., October 2011, pages 459-465
  150. Van Howe, Robert S., M.D. –   “Sexually Transmitted Infections and Male Circumcision: A Systematic Review and Meta-Analysis”   ISRN Urology, Vol 2013, Article ID, 109846, c. 2013
  151.   ibid.
  152. American Academy of Pediatrics Task Force on Circumcision – “Circumcision Policy Statement” Pediatrics, Vol. 103, pp. 686-693, 1999
  153. AAP 2012 Task Force on Circumcision – “Male Circumcision,” Pediatrics, Vol. 130, pp. e756-e785, 2012
  154. Van Howe, R.S. –   “Does Circumcision Influence Sexually Transmitted Diseases?:  A Literature Review”     BJU International, Supplement, vol. 83, supplement 1, pp. 52-62, 1999
  155. Weiss, H.A., Thomas, S.L., Munabi, S.K.  & Hayes, R. J. –   “Male Circumcision and Risk of Syphilis, Chancroid and Genital Herpes: A Systematic Review and Meta-Analysis” Sexually Transmitted Infections, Vol. 82, no. 5, pp. 490-496, 2007
  156. Van Howe, R.S. – “Human Papillomavirus and Circumcision: A Meta-Analysis” Journal of Infection, Vol. 54, No. 5, pp. 490-496, 2007
  157. Van Howe, R.S. –   “Genital Ulcerative Disease and Sexually Transmitted Urethritis and Circumcision: A Meta-Analysis”     International Journal of STD and AIDS, Vol. 18, No. 12, pp. 799-809, 2007
  158. Rehmeyer, C.J. – “Male Circumcision and Human Papillomavirus Studies Reviewed by Infection Stage and Virus Type” The Journal of the American Osteopathic Association, Vol. 111, supplement 3, pp. S11-S18, 2011
  159. Chelimo, T.A., Wouldes, L.D. Cameron, & Elmwood, J.M. – “Risk Factors for Prevention of Human Papillomaviruses (HPV), Genital Warts and Cervical Cancer” Journal of Infection, Vol 66, No. 3, pp. 207-217, 2012
  160. Albero, X, Castellsague, A.R. & Bosch, F.X. –   “Male Circumcision and Genital Human Papillomavirus: a systematic Review and Meta-Analysis” Sexually Transmitted Diseases, Vol 39, pp. 104-113, 2012
  161. Larke, N. –   “Male Circumcision , HIV and Sexually Transmitted Infections: A Review”      British Journal of Nursing, Vol 19, No. 10, pp. 629-634.
  162. Oriel, J.D. – “Natural History of Genital Warts” British Journal of Venereal Diseases, Vol. 47, No. 1, pp. 1-13, 1971
  163. Cook, L.S., Koutsky, L.A. & Holmes, K.K. –   “Circumcision and Sexually Transmitted Diseases” American Journal of Public Health, Vol. 84, No. 2, pp. 197-201, 1994
  164. Weaver, B.A., Feng, Q, Holmes, K.K. et al. –   “Evaluation of Genital Sites and Sampling Techniques for Detection of Human Papillomavirus DNA in Men”    The Journal of Infectious Diseases, Vol. 189, No. 4, pp. 677-685, 2004
  165. VanBuskirk, K., Winer, R.L., Hughes, J.P., et al. – “Circumcision and the Acquisition of Human Papillomavirus Infection in Young Men” Sexual Transmitted Disease, Vol. 38, pp. 1074-1081, 2011
  166. Aynaud, O., Ionesco, M., & Barrasso, R. – “Penile Intraepithelial Neoplasia.  Specific Clinical Features Correlate with Histologic and Virologic Findings” Cancer, Vol. 74, pp. 57-60, 1999
  167. Aynaud, O., Piron D., Bijaoui, G. & Casanova, J.M. – “Developmental Factors of Urethral Human Papillomavirus Lesions: Correlation with Circumcision”     BJU International, Vol. 84, No. 1, pp. 57-60, 1999
  168. Hernandez, B.Y., Shvetsov, Y.B., Goodman, M.T. et al. –   “Reduced Clearance of Penile Human Papillomavirus Infection in Uncircumcised Men” The Journal of Infectious Diseases, Vol. 201, No. 9, pp. 1340-1343, 2010
  169. Barile, M.F., Blumberg, J.M., Kraul, C.W., & Yaguchi, R. – “Penile Lesions Among U.S. Armed Forces Personnel in Japan” Dermatology, vol. 86, p. 273-281, 1962
  170. Cameron, D.W., D’Costa, L.J., Maitha, G.M., et al. – “Female to Male Transmission of Human Immunodeficiency Virus Type 1: Risk Factors for Seroconversion in Men” The Lancet, Vol. 2, No. 8660, p. 403-407, 1989
  171. Nasio, J.M., Nagelkerke, N.J.D., Mwatha, A., Moses, S., Ndinya-Achola, J.O. & Plummer, F.A. – “Genital Ulcer Disease Among STD Clinic Attenders in Nairobi: Association With HIV-1 and Circumcision Status”   International Journal of STD and AIDS, Vol. 7, No. 6, p. 1251-1257, 2009
  172. Van Howe, R.S. – “Errors in Meta-Analysis by Van Howe”   International Journal of STD and AIDS, Vol. 20, No. 3, p. 218-220, 2009
  173. Tobian, A.A.R.; Serwadda, D., Quinn, T.C., et al. – “Male Circumcision for the Prevention of HSV-2 and HPV Infections and Syphilis” The New England Journal of Medicine, Vol. 360, No. 13, pp. 1298-1309, 2009
  174. Auvert, B., Sobngwi-Tambekou, J.; Cutler, E. et al – “Effect of Male Circumcision on the Prevalence of High Risk Human Papillomavirus in Young Men: Results of a Randomized Controlled Trial Conducted in Orange Farm, South   Africa”
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  175. Tobian, A.A., Kigozi, G., Gravitt, P.E., et al. –   “Human Papillomavirus Incidence and Clearance Among HIV-positive and HIV-negative men in Rakai, Uganda”   AIDS, Vol. 26, p. 1555-1565, 2012
  176. Gray, R.H., Serwadda, D., Kong, X., et al. –   “Male Circumcision Decreases Acquisition and Increases Clearance of High-risk Human Papillomavirus in HIV-negative men: A Randomized Trial in Rakai, Uganda” The Journal of Infectious Diseases, Vol. 201, p. 1455-1462, 2010
  177. Lu, B., Wu, C., Nielson, M., et al. – “Factors Associated with Acquisition and Clearance of Human Papillomavirus Infection in a Cohort of U.S. Men: A Prospective Study” The Journal of Infectious Diseases, Vol. 199, No. 3., p. 362-371, 2009
  178. Van Howe, R.S. –   “AAP: ‘Spurious but Entertaining'”   12th International Symposium on Law, Genital Autonomy and Human Rights Helsinki, Finland, September 2012
  179. Laumann, E.O., Gagnon, J.H., Michael, R.T. & Michaels, S. –   “The Social Organization of Sexuality: Sexual Practices in the United States”   The University of Chicago Press, Chicago, IL, USA, 1994
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  181. Morris, B.J, Gray,  R.H., Castellsague, X. et al. –     “The Strong Protective Effect of Circumcision Against Cancer of the Penis,”   Advances in Urology, Vol. 2011, Article ID 812368, 2011
  182. Zetola, N. & Klausner, J.D., – “Male Circumcision Reduces Human Papillomavirus Incidence and Prevalence:  Clarifying the Evidence” Sexually Transmitted Diseases, Vol. 39, pp. 114-115. 2012
  183. Morris, B.J., Mindel, A., Tobian, A.A.R. et al. – “Should Male Circumcision be Advocated for Genital Cancer Prevention?” Asian Pacific Journal of Cancer Prevention, Vol. 13, pp. 4839-4842, 2012
  184. Morris, B.J. & Wamai, R.G. – “Biological Basis for the Protective Effect Conferred by Male Circumcision Against HIV Infection”   International Journal of STD & AIDS, Vol. 23, pp. 153-159, 2012
  185. Dinh, M.H., McRaven, M.D,; Kelley, L., Penugonda, S. & Hope, T.J. – “Keratinization of the Adult Male Foreskin and Implications for Male Circumcision” AIDS, Vol. 24, no. 6, pp. 899-906, 2010
  186. Dinh, M.H., Hirbod, T., Kigosi, G. et al. – “No Difference in Keratin Thickness Between Inner and Outer Foreskins from Elective Male Circumcisions in Rakai, Uganda”  Vol. 7, Article ID e41271, 2012
  187. Bailey, R.C., Neema, S. & Othieno, R. – “Sexual Behaviors and Other HIV Risk Factors in Circumcised and Uncircumcised Men in Uganda” Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology, Vol. 22, No 3, pp. 294-301, 1999
  188. Chin, J. – “The AIDS Pandemic: The Collision of Epidemiology with Political Correctness”   Radcliffe, Oxford, UK, 2007
  189. de Witte, L., Nabatov, A., Pion, M. et al. – “Langerin is a Natural Barrier to HIV-1 Transmission by Langerhans Cells” Nature Medicine, Vol 13, No 3, pp. 367-371, 2007
  190. Flores, R., Beibei, L. et al. – “Correlates of Human Papillomavirus Viral Load with Infection Site in Asymptomatic Men” Cancer Epidemiology Biomarkers and Prevention, Vol. 17, No 12, pp. 3573-3576, 2008
  191. Gisselquist, D., Rothenberg, R., Potterat, J.J. & Drucker, E. – “Non-Sexual Transmission of HIV Has Been overlooked in Developing Countries” British Medical Journal, Vol. 324, no. 7331, Article 235, 2002
  192. Gisselquist, D. & Potterat, J.J. –   “Heterosexual Transmission of HIV in Africa: An Empiric Estimate”   International Journal of STD and AIDS, Vol. 14, No. 3, pp. 162-173, 2003
  193. Gisselquist, D.; Potterat, J.J.; Brody, S. & Vachon, S. – “Let it Be Sexual: How Health Care Transmission of AIDS in Africa was Ignored” International Journal of STD and AIDS, Vol. 14, No. 3, pp. 148-161, 2003.
  194. Gisselquist, D.; Potterat, J.JH. & Brody, S. – “Running on Empty: Sexual Co-Factors are Insufficient to Fuel Africa’s Turbocharged HIV Epidemic”   International Journal of STD and AIDS, Vol 15, No. 7, pp. 442-452, 2004
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  196. Gisselquist, D. – “Denialism Undermines AIDS Prevention in sub-Saharan Africa”     International Journal of STD and AIDS, Vol 19, No 10, pp. 649-655, 2008
  197. Gisselquist, D., Potterat, J.J., St. Lawrence S., et al. – “How to Contain Generalized HIV Epidemics?  A Plea for Better Evidence to Displace Speculation”     International Journal of STD and AIDS, Vol 20, No 7, pp. 443-446, 2009
  198. Gisselquist, D., Potterat, J.J., St. Lawrence, S., et al. – “Repeating a Plea for Better Research and Evidence” International Journal of STD and AIDS, Vol. 22, No 7, pp. 416-417, 2011
  199. Gray, R.H., Kigozi, G., Serwadda, D., et al – “Male Circumcision for HIV Prevention in Men in Rakai, Uganda: a Randomised Trial” The Lancet, Vol. 369, p. 657-666, 2007
  200. Bailey, R.C., Moses, S., Parker, C.B., et al. – “Male Circumcision for HIV Prevention in Young Men in Kisumu, Kenya: A Randomised Controlled Trial The Lancet, Vol. 369, No. 9562, p. 643-656, 2007
  201. Van Howe, R.S. & Storms, M.R. – “How The Circumcision Solution in Africa Will Increase HIV Infections”   Journal of Public Health in Africa, Vol. 2, article e4, 2011
  202. de Vincenzi, I. & Mertens, T. –   “Male Circumcision: A Role in HIV Prevention?”   AIDS, Vol. 8, No. 2, pp. 153-160, 1994.
  203. All references from 147-197 were used as resources for the following article:
    Van Howe, Robert S., M.D.   “Sexually Transmitted Infections and Male Circumcision: A Systematic Review and Meta-Analysis”   ISRN Urology, Vol 2013, Article ID, 109846, c. 2013
  204. Obert, Michael -“Circumcision & HIV-AIDS? – An Unprecedented Disaster”
       Intaction (website)
  205.   ibid.  (Obert’s sources not stated.)
  206.   ibid.
  207.   ibid.
  208.   ibid.
  209.   ibid.
  210.   ibid.
  211. “CDC, Circumcision and Misleading Headlines” –   CircWatch, Dec. 3, 2014so
  212.   ibid.
  213.   ibid.
  214.   ibid.
  215.   ibid.
  216.   ibid.
  217.   ibid.
  218. Press Release, Aug. 1, 2017 – “African Opposition to UNICEF’s Mass Infant Circumcision Campaign:  UNICEF Responds.  So do Africans” Kampala, Uganda, The VMMC Experience Project, Contact: Max Fish,  Website:
  219.   ibid.
  220.   ibid.
  221.   ibid.
  222.   ibid.