Effect Of Male Circumcision Research Articles

(200) Anatomic Maps of Erogenous Sensation & Pleasure in the Penis: Do Circumcised Men Report These Differently Than Uncircumcised Men?

Abstract Introduction For thousands of years male circumcision (MC) has been performed for cultural, religious, aesthetic, and public health reasons, and it continues to be among the most common surgical procedure performed worldwide. The effects of MC on sexual function remains controversial, despite recent systematic reviews demonstrating no adverse effects. A key area of debate regarding MC has been the impact of MC on penile sensation. Existing literature evaluating changes in penile sensitivity and pleasure following MC have primarily focused on the penis glans and the frenulum-area of the shaft. Additionally, studies describing the effects of MC on orgasm have focused on the changes in ease of reaching orgasm/ejaculatory latency. In truth, although patients rely on providers to counsel them about what results they might expect to occur with MC, the effects of MC on erogenous sensation and other orgasm-related domains of sexual function are still not well understood. Objective We sought to expand on the existing literature by assessing erogenous sensation throughout the entire penis surface area, and to evaluate differences in reported orgasm function among circumcised and uncircumcised men. Methods Adult male subjects recruited from a paid anonymous online survey platform (QualtricsTM, USA) were shown anatomic illustrations of a penis whose entire surface area was divided into 12 different regions. Subjects were instructed to identify regions they found pleasurable when touched during sex, and to rate each on a 1-10 scale. Subjects were also asked to characterize their typical orgasm across the following six domains: 1. Lead-time, 2. Orgasm duration, 3. Perceived body-location(s) of orgasm-sensation, 4. Classification of orgasm experience as a single or multiple-peak event, 5. Refractory period duration, and 6. Overall satisfaction. Comparisons between circumcised and uncircumcised men were performed with a 2-tailed T-test. The Benjamini-Hochberg Procedure with FDR=0.05 was applied to control for multiple comparisons. Results The survey was completed by 227 circumcised (mean age ± SD, 46.6 ± 17.7y) and 175 uncircumcised men (47.8 ± 18.1y). There were no significant differences in ratings across all twelve regions among circumcised and uncircumcised cohorts. However, when subjects were asked to identify which regions gave pleasure when touched during sex, significantly more circumcised (vs. uncircumcised) men reported a preference for the penis-tip (38% vs 17%, p=0.024) and the middle third of their ventral shaft (63% vs 48%, p=0.036). There were no significant differences in reported experience with orgasm quality and function across all six queried domains among circumcised and uncircumcised cohorts. Conclusions Our findings suggest that both circumcised and uncircumcised men experience pleasure in their penis and experiences with orgasm function similarly. Although we often think of the tip of the penis as being the “most erogenous” location for men, we found that scored erogeneity was generally similar across the entire length of the penis. Although overall erogeneity ratings did not differ, we found that circumcised men reported more areas of their penis as “pleasurable when touched during sex”, as compared to their uncircumcised counterparts. These findings will be important to share with patients and their families considering MC. Disclosure No

Association of medical male circumcision and sexually transmitted infections in a population-based study using targeted maximum likelihood estimation

BackgroundEpidemiological theory and many empirical studies support the hypothesis that there is a protective effect of male circumcision against some sexually transmitted infections (STIs). However, there is a paucity of randomized control trials (RCTs) to test this hypothesis in the South African population. Due to the infeasibility of conducting RCTs, estimating marginal or average treatment effects with observational data increases interest. Using targeted maximum likelihood estimation (TMLE), a doubly robust estimation technique, we aim to provide evidence of an association between medical male circumcision (MMC) and two STI outcomes.MethodsHIV and HSV-2 status were the two primary outcomes for this study. We investigated the associations between MMC and these STI outcomes, using cross-sectional data from the HIV Incidence Provincial Surveillance System (HIPSS) study in KwaZulu-Natal, South Africa. HIV antibodies were tested from the blood samples collected in the study. For HSV-2, serum samples were tested for HSV-2 antibodies via an ELISA-based anti-HSV-2 IgG. We estimated marginal prevalence ratios (PR) using TMLE and compared estimates with those from propensity score full matching (PSFM) and inverse probability of treatment weighting (IPTW).ResultsFrom a total 2850 male participants included in the analytic sample, the overall weighted prevalence of HIV was 32.4% (n = 941) and HSV-2 was 53.2% (n = 1529). TMLE estimates suggest that MMC was associated with 31% lower HIV prevalence (PR: 0.690; 95% CI: 0.614, 0.777) and 21.1% lower HSV-2 prevalence (PR: 0.789; 95% CI: 0.734, 0.848). The propensity score analyses also provided evidence of association of MMC with lower prevalence of HIV and HSV-2. For PSFM: HIV (PR: 0.689; 95% CI: 0.537, 0.885), and HSV-2 (PR: 0.832; 95% CI: 0.709, 0.975). For IPTW: HIV (PR: 0.708; 95% CI: 0.572, 0.875), and HSV-2 (PR: 0.837; 95% CI: 0.738, 0.949).ConclusionUsing a TMLE approach, we present further evidence of a protective association of MMC against HIV and HSV-2 in this hyper-endemic South African setting. TMLE has the potential to enhance the evidence base for recommendations that embrace the effect of public health interventions on health or disease outcomes.

The Contrasting Evidence Concerning the Effect of Male Circumcision on Sexual Function, Sensation, and Pleasure: A Systematic Review.

IntroductionActive debate concerns whether male circumcision (MC) affects sexual function, penile sensation, or sexual pleasure.AimTo perform a systematic review examining the effect of MC on these parameters.MethodsPRISMA-compliant searches of PubMed, EMBASE, the Cochrane Library, and Google Scholar were performed, with “circumcision” used together with appropriate search terms. Articles meeting the inclusion criteria were rated for quality by the Scottish Intercollegiate Guidelines Network system.Main Outcome MeasureEvidence rated by quality.ResultsSearches identified 46 publications containing original data, as well as 4 systematic reviews (2 with meta-analyses), plus 29 critiques of various studies and 15 author replies, which together comprised a total of 94 publications. There was overall consistency in conclusions arising from high- and moderate-quality survey data in randomized clinical trials, systematic reviews and meta-analyses, physiological studies, large longitudinal studies, and cohort studies in diverse populations. Those studies found MC has no or minimal adverse effect on sexual function, sensation, or pleasure, with some finding improvements. A consensus from physiological and histological studies was that the glans and underside of the shaft, not the foreskin, are involved in neurological pathways mediating erogenous sensation. In contrast to the higher quality evidence, data supporting adverse effects of MC on function, sensation, or pleasure were found to be of low quality, as explained in critiques of those studies.ConclusionThe consensus of the highest quality literature is that MC has minimal or no adverse effect, and in some studies, it has benefits on sexual functions, sensation, satisfaction, and pleasure for males circumcised neonatally or in adulthood.Morris BJ, Krieger JN. The Contrasting Evidence Concerning the Effect of Male Circumcision on Sexual Function, Sensation, and Pleasure: A Systematic Review. Sex Med 2020;8:577–598.

Canadian Urological Association guideline on the care of the normal foreskin and neonatal circumcision in Canadian infants (full version).

Circumcision is the oldest planned operative procedure in the history of the human civilization, but there continues to be a lack of consensus and strong opposing views on whether universal neonatal circumcision should be adopted as a public health measure. The recent American Academy of Pediatrics (AAP) guideline on male circumcision (MC) reversed its prior stand, stating that the “health benefits of newborn male circumcision outweigh the risks,” and justify access to the procedure if the parents so choose.1 This recommendation was primarily based on the impressive results from African trials demonstrating the protective effect of MC against human immunodeficiency virus (HIV) and sexually transmitted infections (STIs). A review of the literature on MC shows evidence of a vehement debate, often clouded by strong personal biases and lack of high-quality evidence. Creation of a guideline specific to the need of Canadian infant males is, therefore, difficult given the level of evidence provided for each potential benefit, the lack of data directly applicable to the Canadian population, the inability to quantify the true complication rate of routine circumcisions accurately, uncertainty about the health benefits of a circumcision compared with other health interventions, the ethical issues and acceptability of a surgical procedure done by parental consent for future benefits, and the costs of training and implementation of any universal neonatal circumcision policy in Canada.

Effect of male circumcision on risk of sexually transmitted infections and cervical cancer in women.

Effect of male circumcision on risk of sexually transmitted infections and cervical cancer in women.

Male Circumcision and Risk of HIV Transmission from Male to Women

Male circumcision has proved to be protective for male to male HIV transmission. The effect of male circumcision on female partner's HIV status is still uncertain from previous studies. This systematic review aimed to assess whether circumcision status of an HIV-infected male changes the risk of HIV transmission to his female sexual partner. We analyzed findings from one randomized controlled trial and 4 cross sectional study and found no significant evidence in support of our hypothesis that male circumcision prevents HIV transmission in female. Due to high methodological and clinical heterogeneity, meta-analysis was not done. Qualitative synthesis revealed lack of existing good quality study to address this question. Four of five studies reported no association between male circumcision and HIV transmission. One cohort study reported protective effect of male circumcision on their female partner's HIV. Only one subpopulation of RCT (resume to sexual activity before wound healing) reported increased HIV transmission in female whose male partner is circumcised. Effect of male circumcision on HIV transmission is still blurred. Large scale randomized trial is needed to answer this question. Until then, the prevention programs should also emphasize other measures of HIV transmission.Medicine Today 2016 Vol.28(1): 22-26

Expertise and Ideology in Statistical Evaluation of Circumcision for Protection against HIV Infection

Aim: To critically evaluate data and arguments by Van Howe defending his stance opposing male circumcision (MC), in particular his meta-regression analyses evaluating the ability of MC to reduce HIV infection risk in heterosexual populations within and outside Africa. Methods: We performed metaregression analysis of log odds of HIV infection between uncircumcised and circumcised men using a single covariate (MC prevalence) in the meta-regression model involving the metareg package in STATA 13 for 103 populations worldwide and for populations within Africa. The meta-regression of log odds and MC prevalence was fitted to a line, as were empirical Bayes estimates resulting from post-estimation. Results: Our critical evaluation of Van Howe’s arguments attempting to undermine the scientific evidence in support of the benefits of MC in protection of men against HIV during heterosexual intercourse, as well as other infections and conditions, together with his use of statistics to support his beliefs, revealed serious flaws, obfuscation and missing data. We therefore performed our own meta-regression analysis using a trivariate model. Doing so revealed that for MC prevalences of 50%, 75% and 100% for general populations within Africa, odds ratios for HIV risk in uncircumcised vs. circumcised men were 1.35, 1.58 and 1.85, respectively. Our meta-regression analysis of data for all countries yielded similar findings. For a general population outside Africa with 100% MC prevalence, OR was 1.5. Van Howe failed to acknowledge that since MC prevalence in US whites (91%) and blacks (76%) exceeds 75% his results support MC having a protective effect in those population groups. Conclusions: The protective effect of MC against HIV infection during heterosexual intercourse applies to populations both within and outside Africa. The debate engineered by MC opponents, and led by Van Howe, now appears to have run its course. The scientific evidence has prevailed.

Relationship between circumcision and human papillomavirus infection: a systematic review and meta-analysis.

Male circumcision (MC) is reported to reduce human papillomavirus (HPV) prevalence in men. However, the efficacy remains imprecise. The aim of this study was to conduct a systematic review and meta-analysis to assess the relationship between MC and genital HPV infection and genital warts. PUBMED, EMBASE, and Web of Science were searched from inception to March 22, 2015. We identified 30 papers, including a total of 12149 circumcised and 12252 uncircumcised men who were evaluated for the association of circumcision with genital HPV or genital warts. Compared with men who were not circumcised, circumcised men may have had significantly reduced odds of genital HPV prevalence (odds ratio [OR]: 0.68; 95% confidence interval [95% CI]: 0.56–0.82). There was no significant association between MC and genital HPV acquisition of new infections (OR: 0.99; 95% CI: 0.62–1.60), genital HPV clearance (OR: 1.38; 95% CI: 0.96–1.97), and prevalence of genital warts (OR: 1.17; 95% CI: 0.63–2.17). This meta-analysis suggests that circumcision reduces the prevalence of genital HPV infections. However, no clear evidence was found that circumcision was associated with decreased HPV acquisition, increased HPV clearance, or decreased the prevalence of genital warts. More studies are required to evaluate adequately the effect of MC on the acquisition and clearance of HPV infections and prevalence of genital warts.

PL04.1 Male circumcision for sti prevention: how well does it work and how is it done?

Interest in the possible association between male circumcision (MC) and sexually transmitted infections (STIs), including HIV, began in earnest in 1980s with studies exploring the tripartite relationship of circumcision, genital ulcer disease and HIV. The interest gathered momentum in the 1990s with more studies exploring these associations beyond within and Africa. In 2002, the first randomised controlled trial (RCT) was initiated in Kisumu, Kenya, with two others following shortly after in Orange Farm, South Africa and Rakai, Uganda. Although the RCTs focused primarily on MC and HIV, they also explored associations of MC and different STIs. This presentation focuses on the association between MC and human papillomavirus (HPV), herpes simplex virus type 2 (HSV-2), syphilis, Neisseria gonorrhoeae , Chlamydia trachomatis and Trichomonas vaginalis reported by the three RCTs as well as in systematic reviews, meta-analyses and other studies that followed. The protective effect of MC against HPV was consistent across the three trials; in addition, the Uganda trial found that female partners of circumcised men had lower rates of HPV infection. While results from the RCTs were somewhat inconsistent on the association between MC and gonorrhoeae, HSV-2, syphilis, chlamydia and trichomoniasis, several meta-analyses and post-RCT studies have reported that MC protects against most of these conditions. As a result of these benefits, several MC devices have been developed to fast-track the provision of MC services, notably PrePex and ShangRing that have been pre-approved by the World Health Organization.

Analysis of Longitudinal Multivariate Outcome Data From Couples Cohort Studies: Application to HPV Transmission Dynamics

We consider a specific situation of correlated data where multiple outcomes are repeatedly measured on each member of a couple. Such multivariate longitudinal data from couples may exhibit multi-faceted correlations that can be further complicated if there are polygamous partnerships. An example is data from cohort studies on human papillomavirus (HPV) transmission dynamics in heterosexual couples. HPV is a common sexually transmitted disease with 14 known oncogenic types causing anogenital cancers. The binary outcomes on the multiple types measured in couples over time may introduce inter-type, intra-couple, and temporal correlations. Simple analysis using generalized estimating equations or random effects models lacks interpretability and cannot fully use the available information. We developed a hybrid modeling strategy using Markov transition models together with pairwise composite likelihood for analyzing such data. The method can be used to identify risk factors associated with HPV transmission and persistence, estimate difference in risks between male-to-female and female-to-male HPV transmission, compare type-specific transmission risks within couples, and characterize the inter-type and intra-couple associations. Applying the method to HPV couple data collected in a Ugandan male circumcision (MC) trial, we assessed the effect of MC and the role of gender on risks of HPV transmission and persistence. Supplementary materials for this article are available online.

Swazi men’s perception of the protective effect of male circumcision and its implications for HIV prevention strategy

Background: For years, male circumcision (MC) has been known to reduce the risk of sexually transmitted infections (STIs). Of late, MC has been recognised and recommended as a complementary HIV preventive measure in high prevalent areas. The objective of this study was to to assess the perceptions of Swazi men about the protective effect of circumcision against STIs including HIV, and its implication to the mass MC strategy for HIV prevention. Methods: An explorative qualitative study was conducted targeting men aged ≥18 years seeking services at Family Life Association of Swaziland clinic in Mbabane, Swaziland. Unstructured individual face-to-face interviews were conducted for 17 men. Results: Results showed that Swazi men perceived the protective effect of MC differently, ranging from perceptions of ineffectiveness and unworthy, especially against HIV, to perceptions of total protection and a solution to all STIs. Perceptions were influenced by the ongoing circumcision campaigns, individual knowledge of biological sciences, misconceptions as well as life experiences. Promiscuous men were more likely to have a positive perception and acceptance of the procedure than their non-promiscuous counterparts. Conclusion: Swazi men hold mixed perceptions about MC, accounting for its relatively low uptake. The relatively low uptake of circumcision does not necessarily imply failure of the strategy but rather a natural selection of the most relevant and at-risk portion of the population. It is recommended that more effort be put towards correcting misconceptions and convincing those who still hold a negative perception about the procedure.

Transmission of Bloodborne Infections by Circumcision Procedure

Male circumcision is surgical removal of the foreskin (prepuce) which covers the distal part of the penis. It is also performed for females in certain countries by partial or total removal of the external genitalia in order to inhibit sexual feelings. Male circumcision is well documented to have protective effect against HIV transmission. However, the male and female procedures carried a risk for bloodborne infections such as HIV, hepatitis B virus, and hepatitis C virus. The use of unsterilized instruments is the main cause of disease transmission. Several reports from sub-Saharan Africa revealed that HIV infection could be transmitted during circumcision procedures for both male and female. Though the beneficial effects of male circumcision outweigh the risk of blood-borne infection.

Risk factors for HIV infection among circumcised men in Uganda: a case-control study.

IntroductionMale circumcision (MC) reduces the risk of HIV infection. However, the risk reduction effect of MC can be modified by type of circumcision (medical, traditional and religious) and sexual risk behaviours post-circumcision. Understanding the risk behaviours associated with HIV infection among circumcised men (regardless of form of circumcision) is critical to the design of comprehensive risk reduction interventions. This study assessed risk factors for HIV infection among men circumcised through various circumcision approaches.MethodsThis was a case-control study which enrolled 155 cases (HIV-infected) and 155 controls (HIV-uninfected), all of whom were men aged 18–35 years presenting at the AIDS Information Center for HIV testing and care. The outcome variable was HIV sero-status. Using SPSS version 17, multivariable logistic regression was performed to identify factors independently associated with HIV infection.ResultsOverall, 83.9% among cases and 56.8% among controls were traditionally circumcised; 7.7% of cases and 21.3% of controls were religiously circumcised while 8.4% of cases and 21.9% of controls were medically circumcised. A higher proportion of cases than controls reported resuming sexual intercourse before complete wound healing (36.9% vs. 14.1%; p<0.01). Risk factors for HIV infection prior to circumcision were:being in a polygamous marriage (AOR: 6.6, CI: 2.3–18.8) and belonging to the Bagisu ethnic group (AOR: 6.1, CI: 2.6–14.0). After circumcision, HIV infection was associated with: being circumcised at >18 years (AOR: 5.0, CI: 2.4–10.2); resuming sexual intercourse before wound healing (AOR: 3.4, CI: 1.6–7.3); inconsistent use of condoms (AOR: 2.7, CI: 1.5–5.1); and having sexual intercourse under the influence of peers (AOR: 2.9, CI: 1.5–5.5). Men who had religious circumcision were less likely to have HIV infection (AOR: 0.4, 95% CI: 0.2–0.9) than the traditionally circumcised but there was no statistically significant difference between those who were traditionally circumcised and those who were medically circumcised (AOR: 0.40, 95% CI: 0.1–1.1).ConclusionsBeing circumcised at adulthood, resumption of sexual intercourse before wound healing, inconsistent condom use and having sex under the influence of peers were significant risk factors for HIV infection. Risk reduction messages should address these risk factors, especially among traditionally circumcised men.

Male circumcision and the incidence and clearance of genital human papillomavirus (HPV) infection in men: the HPV Infection in men (HIM) cohort study

BackgroundReported associations of male circumcision (MC) with human papillomavirus (HPV) infection in men have been inconsistent.Methods4,033 healthy men were examined every six months for a median of 17.5 months. In each study visit, exfoliated cell specimens from the coronal sulcus/glans penis, penile shaft, and scrotum were collected and combined into one sample per person for HPV DNA detection. Samples were tested for 37 HPV types. Cox proportional hazards models were used to evaluate the association between MC and the incidence and clearance of HPV infections and specific genotypes.ResultsThe overall incidence of new HPV infections did not differ by MC status (for any HPV, adjusted hazard ratio (aHR) 1.08, 95% confidence interval (CI) 0.91-1.27). However, incidence was significantly lower among circumcised versus uncircumcised men for HPV types 58 (p = 0.01), 68 (p < 0.001), 42 (p = 0.01), 61 (p < 0.001), 71 (p < 0.001), 81 (p = 0.04), and IS39 (p = 0.01), and higher for HPV types 39 (p = 0.01) and 51 (p = 0.02). Despite the lack of an overall association in the risk of HPV clearance by MC (for any HPV, aHR 0.95, 95% CI 0.88-1.02), median times to clearance were significantly shorter among circumcised than uncircumcised men for HPV types 33 (p = 0.02) and 64 (p = 0.04), and longer for HPV types 6 (p < 0.001), 16 (p < 0.001), and 51 (p = 0.02).ConclusionsMC is not associated with the incidence and clearance of genital HPV detection, except for certain HPV types. The use of a single combined sample from the penis and scrotum for HPV DNA detection likely limited our ability to identify a true effect of MC at the distal penis.

Male circumcision decreases high‐risk human papillomavirus viral load in female partners: A randomized trial in Rakai, Uganda

Male circumcision (MC) reduces high-risk human papillomavirus (HR-HPV) infection in female partners. We evaluated the intensity of HR-HPV viral DNA load in HIV-negative, HR-HPV-positive female partners of circumcised and uncircumcised men. HIV-negative men and their female partners were enrolled in randomized trials of MC in Rakai, Uganda. Vaginal swabs were tested for HR-HPV genotypes by Roche HPV Linear Array which provides a semi-quantitative measure of HPV DNA by the intensity of genotype-specific bands (graded:1-4). We assessed the effects of MC on female HR-HPV DNA load by comparing high intensity linear array bands (3-4) to low intensity bands (1-2) using an intention-to-treat analysis. Prevalence risk ratios (PRR) of high intensity bands in partners of intervention versus control arm men were estimated using log-binomial regression with robust variance. The trial included 335 women with male partners in the intervention arm and 340 in the control arm. At enrollment, the frequency of HR-HPV high intensity linear array bands was similar in both study arms. At 24 months follow-up, the prevalence of high intensity bands among women with detectable HR-HPV was significantly lower in partners of intervention arm (42.7%) than control arm men (55.1%, PRR = 0.78, 95% CI 0.65-0.94, p = 0.02), primarily among incident HR-HPV infections (PRR = 0.66, 95% CI 0.50-0.87, p = 0.003), but not persistent infections (PRR = 1.02, 95% CI 0.83-1.24). Genotypes with high HR-HPV band intensity were more likely to persist (adjHR = 1.27 95% CI 1.07-1.50), irrespective of male partner circumcision status. MC reduces HR-HPV DNA load in newly infected female partners.

Male circumcision and HIV prevention

It is reported that there is grade I evidence that male circumcision reduces the risk of men acquiring human immunodeficiency virus (HIV) infection. This is based on three large randomised controlled trials (RCTs) on male circumcision that were undertaken in Africa, at Orange Farm, South Africa; Rakai, Uganda; and Kisumu, Kenya. The findings were published in The Lancet and The Journal of Infectious Diseases between 2007 and 2009. Over 10 000 men were circumcised at the three sites. The reported protective effect of male circumcision against HIV were Orange Farm (60%), Rakai (48%), and Kisumu (53%). 1

Using the Economics of Certification to Improve the Safety and Quality of Male Circumcision in Developing Countries

Although male circumcision (MC) has been a widespread practice in some regions, while relatively new in others, it has recently ascended in popularity as a HIV-reduction intervention, particularly in areas with high rates of HIV but low rates of MC. However, the uptake and potential effectiveness of MC may be hampered by uneven levels of provider training and procedure skill within developing country settings. Indeed, this procedure that is otherwise considered simple and safe has witnessed complication rates as high as 25-35% in some areas, leaving some men with irreversible injuries. To improve the transparency of procedure quality for prospective patients, I borrow from a classic economics approach and advocate a new application in the form of provider certification. Building on some experience in the healthcare systems and economic rationale of high-income counties, I explore the potential for certifying providers of MC in low-income countries and compare and contrast three models of implementation: government agency, private certifiers and private MC device manufacturers. The hope is that increased transparency of provider quality through any or all three types of certifying programmes can better assist local men as they navigate this otherwise complex and unclear medical care market. As more resources are being devoted to MC scale up, I argue that certification should be considered for incorporation as a means of complementing both current and future efforts in order to enhance the effectiveness of MC campaigns. The two models based on privatized certification, as opposed to having the local government underwrite the intervention, may prove most useful when public or philanthropic funding is volatile or incomplete for a given location. The timing for MC campaign adoption and desired speed of scale up may vary across countries in ways that international assistance efforts cannot always immediately and flexibly adapt to. As such, the role of the diverse MC provider marketplace and accompanying quality-revelation mechanisms may take on different levels of importance and expediency across settings as individual countries move forward with their respective HIV prevention campaigns. The subsequent challenge is to creatively design solutions that are sustainable and applicable within diverse host-country environments and expectations. This is where I believe some economic insights are currently lacking in the MC dialogue. Although I believe the three certification models exhibit much potential for enhancing medical care delivery in developing countries, they are not without their challenges, and implementation would not necessarily be a simple process. Local levels of medical knowledge, public and private resource constraints and the integrity of local business transactions and government practices would likely influence the nature and success of a certification intervention. However, with sufficient model adaptability and partnerships across public and private sectors, I argue that many of these implementation issues could be proactively addressed. Creative and careful certification structures should ultimately improve the MC circumstances across a variety of developing countries.

Male Circumcision and Genital Human Papillomavirus

Human papillomavirus (HPV) infection is the principal cause of invasive cervical cancer. There is some evidence that male circumcision (MC) may protect against HPV infection and related disease in both men and women. The purpose of this study was to conduct a systematic review of the literature to assess the association between MC and genital HPV infection indicators including genital warts. A systematic search of Medline was conducted to identify all relevant studies from February 1971 to August 2010. Effect estimates were included in random effects models. A total of 21 studies with 8046 circumcised and 6336 uncircumcised men were included in the meta-analysis. MC was associated with a statistically significant reduced odds of genital HPV prevalence (odds ratio = 0.57, 95% confidence interval: 0.42-0.77). This association was also observed for genital high-risk HPV prevalence in 2 randomized controlled trials (odds ratio = 0.67, 95% confidence interval: 0.54-0.82). No associations were found between MC and genital HPV acquisition of new infections, genital HPV clearance, or genital warts. This meta-analysis shows a robust inverse association between MC and genital HPV prevalence in men. However, more studies are needed to adequately assess the effect of MC on the acquisition and clearance of HPV infections. MC could be considered as an additional one-time preventative intervention likely to reduce the burden of HPV-related diseases both in men and women, particularly among those countries in which HPV vaccination programs and cervical screening are not available.

‘It brought joy in my home as in the area of my wife.’ How recently circumcised adult men ascribe value to and make sense of male circumcision

The present study used a phenomenological approach to explore the everyday-life experiences of male circumcision (MC) and to learn how recently circumcised men ascribe value to and make sense of MC. Thirteen recently circumcised Zambian men were identified through the snowball technique and interviewed using a semi-structured interviewer's guide. Findings indicate that the post-operational experience of adult MC smoothly fits into the everyday-life experience of the men interviewed and is perceived and experienced as a broader social health issue, which largely transcends both the personal HIV risk of the individual male and the private sphere. The study provides three important lessons for MC programmes: (1) the broad social aspects of MC put forward by the interviewees suggest the potential for a popular intervention and, consequently, a large uptake of MC; (2) findings suggest that in addition to emphasising the HIV protective effect of MC, MC promotion should also highlight the social, sexual and romantic values perceived and experienced by the interviewees of this study; (3) the analysis reveals potentially harmful misconceptions about the health benefits of MC, demonstrating the importance of proper pre- and post-circumcision counselling as well as public health messages related to MC.

The Medical Benefits of Male Circumcision

The Medical Benefits of Male Circumcision