Man's Lifetime Research Articles

Interpersonal relations

I trust that you, like me, are thrilled to be living in what must be considered the most exciting, dynamic and challenging era of this century. But like you, I am not that naïve to realise that it is an easy one free of problems. Never before in the lifetime of man has the need for a better understanding of communication and culture and their effect on interpersonal relations been so essential. Intercultural relations hinges on effective intercultural communication and for this to happen it is essential to understand the terms culture and communication. Culture can be defined as learned behaviours of a group living in a geographical area - i.e., behaviours related to knowledge, values and beliefs, attitudes, religions, concepts of self and the universe, hierarchies of status, spatial relations, time concepts, ethnicity, language, etc. Culture is variable, everchanging, gradually but continuously, and to further complicate understanding, there are individual differences within any given culture. Communication is, of course, the act of communicating - the act of understanding and being understood. Intercultural communication, therefore, is the act of communication when the message sender is from one culture and the message receiver is from another culture. Successful intercultural communication is the establishment and sharing of common meanings in the sender- receiver (Meanings are in people, not in messages). This process is obviously complicated and influenced by cultural factors, such as those mentioned above, not to mention language differences and patterns of thinking

Effects of men's lifetime adverse events experience on violence, HIV risk, and wellbeing: insights from three countries.

To assess men's experiences of adverse events in both child and adulthood and their effects on violence, HIV risk, and well being in three sub-Saharan countries. We conducted cross-sectional surveys from 2017 to 2018 with men (all 18+) recruited via the PLACE methodology at community hotspots and HIV service sites in Eswatini (n = 1091), South Africa (n = 932), and Malawi (n = 611). Prevalence of men's adverse events in childhood (e.g. beaten at home often) and adulthood (e.g. robbed at gunpoint) was described. We examined associations between cumulative effects of these events on health outcomes, via log binomial regression. About 70% of men in each country experienced adverse events in childhood, while adult experience varied from 47 to 64%. There was a dose-response effect of cumulative exposure. Among men with 0, 1-2, and 3+ traumas, for example, 22, 35, and 52% reported depression/anxiety in Malawi, and 8, 17, and 27% perpetrated intimate partner violence (IPV) in South Africa. In multivariate analyses, experiencing at least one event in both childhood and adulthood (vs. neither) was significantly associated with various health outcomes (e.g. multiple sexual partnerships: adjusted risk ratio or aRR = 2.40 in Malawi; IPV perpetration: aRR = 3.59 in South Africa; depression/anxiety: aRR = 1.37 in Eswatini). Men who experienced adverse events in childhood or adulthood faced increased HIV risk/negative health outcomes. More events were associated with worse outcomes. Interventions for men addressing trauma in both childhood and adulthood are essential for their (and their partners') health and well being.

Gender differences in clinical and biochemical parameters of patients consecutively hospitalized for unipolar depression

Major Depressive Disorder (MDD) is a medical illness twice as common in women than in men lifetime. Purpose of this study is to identify gender differences in clinical and biochemical parameters in subjects affected by MDD to implement individualized treatment strategies. We recruited 234 patients (112 males and 122 females) consecutively hospitalized for MDD in Milan (Italy). Data were obtained through a screening of the clinical charts and blood analyses. Univariate analyses, binary logistic regressions and a final logistic regression model were performed. The final logistic regression model showed that female patients (compared to males) had lower plasmatic levels of hemoglobin (p = 0.020) and uric acid (p = 0.002), higher levels of cholesterol (p < 0.001), had been treated with a lower number of antidepressants (p = 0.011), presented lower red blood cells (p < 0.001) and showed more frequently comorbidity with hypothyroidism (p = 0.036). Univariate analyses identified also that women had an earlier age at onset (p = 0.043), were less likely to have comorbidity with diabetes (p = 0.002) and were less frequently treated with a psychiatric polytherapy (p < 0.001). Finally, female patients had achieved more frequently remission in the last depressive episode (p = 0.001) and were more likely to have family history for psychiatric disorders (p < 0.001) than males. Female patients globally have a better response to treatments, but they seem to be more vulnerable to specific metabolic abnormalities as showed by more frequent hypercholesterolemia and lower plasma levels of uric acid. These results have to be confirmed by further studies.

Intimate Partner Violence Victimization and Depressive Symptoms in Sichuan, China: Are There Gender Variations?

An emerging body of research has linked intimate partner violence (IPV) victimization with negative mental health outcomes among women in postreform China. However, limited scholarly attention has been given to the independent effects of multiple types of IPV victimization on depressive symptoms among men and women. Little is known if these independent effects will vary by gender in China where research on the association between IPV victimization and mental health did not emerge until fairly recently. Given this research paucity, this study aims to (a) examine the independent effects of different types of lifetime IPV victimization among married men and women in Sichuan province on their self-reported past 30-day depressive symptoms and (b) explore possible gender variations in these effects. The data utilized in this study came from a subsample of married men (N = 1,083) and women (N = 1,185) from the Third Survey of Chinese Women's Social Status 2010, a representative sample of adults aged 18 to 64 in Sichuan province. Statistical analyses indicate that all types of lifetime IPV victimization are significantly and positively associated with past 30-day depressive symptoms for women, whereas for men lifetime experiences of general controlling behavior and sexual IPV were not statistically associated with depressive symptoms. Moreover, the effects of multiple types of IPV victimization on depressive symptoms do not significantly vary by gender. Bearing this gender-neutral pattern in mind, health professionals, governmental officials, and researchers are strongly encouraged to focus on both married men and women in their IPV and mental health intervention, prevention, and treatment endeavors in postreform China.

HIV prevalence correlated with circumcision prevalence and high-risk sexual behavior in India's states: an ecological study.

Background: HIV prevalence varies between 0% and 1.6% in India's states. The factors underpinning this variation are poorly defined. Methods: We evaluated the relationship between HIV prevalence by state and a range of risk factors in the Indian 2015 National Family Health Survey. Pearson's correlation was used to assess the relationship between HIV prevalence and each variable. The prevalence of each risk factor was compared between five high-HIV-prevalence states (>1% prevalence) and a large low-HIV-prevalence state (Uttar Pradesh; HIV prevalence, 0.06%). Results: There was an association between HIV prevalence and men's mean lifetime number of partners (r = 0.55; P = 0.001) and men reporting sex with a non-married, non-cohabiting partner (r = 0.40; P = 0.014). In general, men in high-prevalence states were less likely to be circumcised and (with the exception of Chandigarh) use condoms at last sex. In two high prevalence states (Mizoram and Nagaland), men reported a higher number of lifetime partners and a higher prevalence of multiple partners and high-risk sex in the past year. Conclusions: Variation in circumcision prevalence and sexual behavior may contribute to the large variations in HIV prevalence by state in India.

HIV prevalence correlated with circumcision prevalence and high-risk sexual behavior in India's states: an ecological study

Background: HIV prevalence varies between 0% and 1.6% in India's states. The factors underpinning this variation are poorly defined. Methods: We evaluated the relationship between HIV prevalence by state and a range of risk factors in the Indian 2015 National Family Health Survey. Pearson’s correlation was used to assess the relationship between HIV prevalence and each variable. The prevalence of each risk factor was compared between five high-HIV-prevalence states (>1% prevalence) and a large low-HIV-prevalence state (Uttar Pradesh; HIV prevalence, 0.06%). Results: There was an association between HIV prevalence and men's mean lifetime number of partners (r = 0.55; P = 0.001) and men reporting sex with a non-married, non-cohabiting partner (r = 0.40; P = 0.014). In general, men in high-prevalence states were less likely to be circumcised and (with the exception of Chandigarh) use condoms at last sex. In two high prevalence states (Mizoram and Nagaland), men reported a higher number of lifetime partners and a higher prevalence of multiple partners and high-risk sex in the past year. Conclusions: Variation in circumcision prevalence and sexual behavior may contribute to the large variations in HIV prevalence by state in India.

HIV prevalence correlated with circumcision prevalence and high-risk sexual behavior in India's states: an ecological study

Background: HIV prevalence varies between 0% and 1.6% in India's states. The factors underpinning this variation are poorly defined. Methods: We evaluated the relationship between HIV prevalence by state and a range of risk factors in the Indian 2015 National Family Health Survey. Pearson’s correlation was used to assess the relationship between HIV prevalence and each variable. The prevalence of each risk factor was compared between five high-HIV-prevalence states (&gt;1% prevalence) and a large low-HIV-prevalence state (Uttar Pradesh; HIV prevalence, 0.06%). Results: There was an association between HIV prevalence and men's mean lifetime number of partners (r = 0.55; P = 0.001) and men reporting sex with a non-married, non-cohabiting partner (r = 0.40; P = 0.014). In general, men in high-prevalence states were less likely to be circumcised and (with the exception of Chandigarh) use condoms at last sex. In two high prevalence states (Mizoram and Nagaland), men reported a higher number of lifetime partners and a higher prevalence of multiple partners and high-risk sex in the past year. Conclusions: Variation in circumcision prevalence and sexual behavior may contribute to the large variations in HIV prevalence by state in India.

Perspective on Prostate Cancer Screening.

Undoubtedly, no biomarker has had more profound impact on our approach to cancer detection, staging, and monitoring after treatment than the prostate-specific antigen (PSA)7 test. PSA is a serine protease produced by the prostate epithelium, secreted into seminal fluid, and measurable in peripheral blood by immunoassay laboratory techniques detecting both free unbound forms and that bound to the protease inhibitor α1-antichymotrypsin. The introduction of the PSA test as a diagnostic means to monitor and detect prostate cancer during the 1980s was based on discoveries in the laboratories of Kuriyama, Wang, and Papsidero, together with observations in clinical cohorts never exposed to screening by Stamey, Catalona, and others, noting that men with prostate cancer (or benign prostatic hyperplasia) had higher PSA concentrations compared with healthy controls (1). The PSA test was far more sensitive than assays of prostatic acid phosphatase and digital rectal examination. These findings set off a rapid widespread introduction of the PSA test in clinical practice, mainly in the US, which contributed to a dramatic surge in prostate cancer incidence in the US during the late 1980s through the mid-1990s. There is clear evidence from large population-based randomized trials—the European Randomized Study of Screening for Prostate Cancer (ERSPC) and the Goteborg randomized screening trial—that early detection (and concomitant management) by PSA screening reduces a man's risk of dying from prostate cancer. Indeed, extensive use of PSA testing has importantly contributed to a 40% to 50% decline in prostate cancer mortality in the US between 1993 and 2015. However, the widespread use of PSA testing of asymptomatic men, combined with liberal criteria to perform a prostate biopsy, has led to important harms associated with the overdiagnosis of tumors that would never have caused symptoms or harm during a man's lifetime, as well as consequential risk of unnecessary treatment. …

Germline Genetics of Prostate Cancer: Time to Incorporate Genetics into Early Detection Tools.

Prostate cancer (PCa) remains the most common solid malignancy in men, and its prevalence makes understanding its heritability of paramount importance. To date, the most common factors used to estimate a man's risk of developing PCa are age, race, and family history. Despite recent advances in its utility in multiple malignancies (e.g., breast and colon cancer), genetic testing is still relatively underutilized in PCa. Multiple highly penetrant genes (HPGs) and single-nucleotide polymorphisms (SNPs) have been show to increase a patient's risk of developing PCa. Mutations in the former, like DNA damage repair genes, can confer a 2- to 3-fold increased risk of developing PCa and can increase the risk of aggressive disease. Similarly, PCa-risk SNPs can be used to create risk scores (e.g., genetic or polygenic risk scores) that can be used to further stratify an individual's disease susceptibility. Specifically, these genetic risk scores can provide more specific estimates of a man's lifetime risk ranging up to >6-fold higher risk of PCa. It is becoming increasingly evident that in addition to the standard family history and race information, it is necessary to obtain genetic testing (including an assessment of HPG mutation status and genetic risk score) to provide a full risk assessment. The additional information derived thereby will improve current practices in PCa screening by risk-stratifying patients before initial prostate-specific antigen testing, determining a patient's frequency of visits, and even help identify potentially at-risk family members.

What Trauma Looks Like for Incarcerated Men: A Study of Men's Lifetime Trauma Exposure in Two State Prisons.

While it is understood that high rates of trauma exposure are common among incarcerated male populations, there is limited data on the nature of the trauma exposure. This study sought to develop foundational knowledge about the trauma experiences of incarcerated men in order to provide a basis for further theory building in this area. This study used a quantitative-qualitative approach to examine the trauma histories of a randomly selected sample of 67 men incarcerated in the Missouri Department of Corrections. The analyses revealed several patterns among study participants, including near universal trauma exposure in adolescence with the most frequent exposures involving witnessing or being proximate to violent deaths of family and friends. The mean age of exposure for all trauma exposure types measured was 17 years old. We found that for this group of incarcerated men, trauma exposures in childhood tended to result more from community violence than child maltreatment (e.g., abuse and neglect by caregivers). The study results suggested that further research may be needed into the effects of close proximity to violent death during this particular window in adolescent development. Neuroscience research has shown that this is a "sensitive period" in brain development with potential negative outcomes in early adulthood, including emotional regulation deficits that can potentially lead to increased risk of arrest. Further research on trauma exposure within this population is needed both to appropriately serve men while in prison or in the process of reentering society and to support efforts to reduce mass incarceration.

Abstract 379: Circulating tumor cells (CTCs) in clinically localized prostate cancer (PCa): searching a prognostic tool

Abstract Background If PCa screening has reduced advanced disease and disease-specific mortality, the tradeoff is an over-diagnosis of cases that would not have caused clinical consequences during a man's lifetime if left untreated. Conversely, a vast numbers of men, which harbor occult extra-prostatic extension, develop recurrence after surgery. Despite it looks like an addressable question by quantifying Circulating Tumor Cells (CTCs), unlike breast cancer, in which prognostic and predictive impact of tumor cells in peripheral blood or bone marrow (Disseminated Tumor Cells, DTCs) was largely provided, their role in localized PCa is far from clear. Methods From July 2011 to August 2013, we quantify the tumor burden at diagnosis in peripheral blood of 153 PCa patients stage T2a-T3b, enrolled at three clinical sites (Roma, Orbassano and Padova). All the patients were candidate to undergo radical prostatectomy because of positive biopsy for cancer. Two labs (Orbassano and Padova) performed the CellSearch assay. In patients enrolled in Roma (Janus trial, a phase II study for the use of zoledronic acid as neoadjuvant treatment of invasive PCa), we evaluated in parallel the DTCs. Results We used data obtained in patients enrolled in Orbassano (n = 50) and Roma (n = 15) as training set, meanwhile we used patients of Padova (n = 88) as validation set. Consistently with previous reports (Kraan, Sleijfer et al. 2011) reporting low inter-test and inter-lab variability, the baseline CTC count in the two sets did not significantly differ (Mann-Whitney Rank Sum Test, p = 0.170), so that they were further analyzed altogether. Overall, we found that 74 out of 153 PC patients (48,4%) had at least 1 CTC per 7.5 ml of peripheral blood; 45 PC (29,4%) patients had &amp;gt; 2 cells and 21 PC patients (13,7%) had &amp;gt; 3 cells. Interestingly, 8 out of 153 PC patients (5,2%) had &amp;gt; 5 cells at the first blood draw, before surgery. When we synchronously detected CTCs and DTCs, we found consistent results in 64% of patients (Wilcoxon signed Rank Test, p = 0.339). Conclusions Even when the PCa is pathologically organ confined at surgery, it was reported 5% to 20% of these patients harbor foci of micro-metastatic disease that will later manifest itself as recurrent disease. Here we show CTCs by CellSearch assay in close to 50% of biopsy-confirmed PCa patients, obtaining evidence of a systemic disease. Prospective studies will be required to investigate whether CTC-status is associated with worst outcome in the M0 setting of PCa, as already provided in early breast cancer patients (Lucci, Hall et al. 2012). Citation Format: Elisabetta Rossi, Antonella Facchinetti, Vittorio Aneloni, Emanuel Zilio, Massimo Dal Bianco, Alice Zoccoli, Daniele Santini, Diletta Garrou, Francesco Porpiglia, Rita Zamarchi. Circulating tumor cells (CTCs) in clinically localized prostate cancer (PCa): searching a prognostic tool. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 379. doi:10.1158/1538-7445.AM2015-379

Lifetime risk of being diagnosed with, or dying from, prostate cancer by major ethnic group in England 2008-2010.

BackgroundIn the UK, a man’s lifetime risk of being diagnosed with prostate cancer is 1 in 8. We calculated both the lifetime risk of being diagnosed with and dying from prostate cancer by major ethnic group.MethodsPublic Health England provided prostate cancer incidence and mortality data for England (2008–2010) by major ethnic group. Ethnicity and mortality data were incomplete, requiring various assumptions and adjustments before lifetime risk was calculated using DevCan (percent, range).ResultsThe lifetime risk of being diagnosed with prostate cancer is approximately 1 in 8 (13.3 %, 13.2–15.0 %) for White men, 1 in 4 (29.3 %, 23.5–37.2 %) for Black men, and 1 in 13 (7.9 %, 6.3–10.5 %) for Asian men, whereas that of dying from prostate cancer is approximately 1 in 24 (4.2 %, 4.2–4.7 %) for White men, 1 in 12 (8.7 %, 7.6–10.6 %) for Black men, and 1 in 44 (2.3 %, 1.9–3.0 %) for Asian men.ConclusionsIn England, Black men are at twice the risk of being diagnosed with, and dying from, prostate cancer compared to White men. This is an important message to communicate to Black men. White, Black, and Asian men with a prostate cancer diagnosis are all as likely to die from the disease, independent of their ethnicity. Nonetheless, proportionally more Black men are dying from prostate cancer in England.Electronic supplementary materialThe online version of this article (doi:10.1186/s12916-015-0405-5) contains supplementary material, which is available to authorized users.

Prostate Cancer Epidemiology in a Rural Area of North Western Greece

Epirus is a rural area of North-Western Greece. We reviewed data from 4 hospitals for 4.975 patients who underwent prostate biopsy in Epirus in the twelve year period from 1999 to 2010. Two six-year periods were compared (1999-2004 and 2004-2010). All cases of prostate cancer confirmed by biopsy were recorded and age-standardized incidence rates per 100,000 males were calculated. We also recorded the clinical stage for patients diagnosed in our hospital and correlated this with PSA and Gleason scores. Percentage of positive prostate biopsies was also calculated. There were a total of 1714 new cases during 1999-2010 and the mean annual age-adjusted incidence was 34/100,000. The mean incidences during 1999-2004 and 2005-2010 were 26/100,000 and 42/100,000, respectively. The mean age at diagnosis was 74. The most common Gleason score was 6 and the prevalent clinical stage was T2. Median PSA at diagnosis was 10.8 ng/ml. There was a significant difference between stage cT4 and all other stages regarding PSA value (p=0.000). A positive correlation was found between Gleason score and PSA (p=0.013). These results are in accordance with the incidence rise recorded in neighboring countries of South-East Europe. However we should keep in mind the risk of overdiagnosis and the detection of low-risk cancers that would not have caused morbidity or death during a man's lifetime anyway.

On the estimation of survival time and contributory risk factors in the elderly participants in the Tehran lipid and glucose study. A 10-year follow- up

In the increasing population of the elderly in Iran, so far no prospective health studies have been undertaken. This study was conducted to identify the risk factors of survival time of the elderly of ages above 60 years. Material and Methods: Individuals above 60 years old were recruited in the primary phase of the Tehran Lipid and Glucose Study (TLGS) during 1998-2001. They were followed up for 10 years and their vital status were registered (1998-2008). Age and sex mortality rates for age groups (60-69, 70-79, 80 + ) were calculated and by using Cox proportional hazard model the hazard rates were estimated. Results: Out of 929 males, 154 (17%) and out of 869 women 85(10%) died during the follow-up years. Cox model showed that diabetes on an average reduces 4.4 years and 2.5 years and smoking reduces 5 and 6.6 years of males' and females' survival time, respectively. BMI>33Kg/m 2 and dis-lipoproteinemia reduce 4.5 years and 4 years of women's life span. Tehranian native men on an average live 3 years shorter than other male residents. In addition, hypertension and history of MI, stroke or sudden death of father, brother or son reduce 3.3 years and 4.1 years of men's life time. Conclusion: The elderly population is in need of a healthy ageing to be gained from prevention and intervention. Identification of life time reducing risk factors of elderly helps the policymakers to develop some protocols to increase the life span of the population.

O2-S4.06 Exploring enema practices among men who have sex with men in the USA: implications for sexual health

PurposeRecent literature has suggested that use of hygiene products (ie, douching) by women and men prior to sexual activity, changes the biological makeup of vaginal and anal tissue, potentially affecting...

Prostate-Specific Antigen, Risk Factors, and Prostate Cancer: Confounders Nestled in an Enigma

Prostate-Specific Antigen, Risk Factors, and Prostate Cancer: Confounders Nestled in an Enigma

Cost Effectiveness of 5-Alpha Reductase Inhibitors for the Prevention of Prostate Cancer in Multiple Patient Populations

Although 5-alpha reductase inhibitors (5ARIs) have demonstrated that they reduce the risk of prostate cancer (PCa), they have not demonstrated cost effectiveness in the patient populations in which they have been examined. A decision-analytic model was created to explore economic benefits from a third-party payer perspective of the use of 5ARIs in preventing PCa in men with different risk factors for developing the disease. A Markov model was developed to simulate a cohort of men annually through health states (e.g. healthy male, benign prostatic hyperplasia [BPH], PCa, PCa recurrence) over a man's lifetime. Men with risk factors were treated with a 5ARI and compared with patients given no chemoprevention. Men from the general population were examined along with higher-risk men who had been referred to a PCa centre. Baseline risk was estimated via published risk data, risk factor analyses and risk equations. Clinical efficacy, morality, costs and utilities were obtained from published literature. Outcomes of the model included number of prostate cancers, incremental costs, incremental QALYs, incremental cost per QALY and number needed to treat. Along with sensitivity and scenario analyses, a validation of outcomes was performed. All costs were valued in $US, year 2009 values. Costs were discounted at 3% per annum. Men receiving 5ARIs benefited through a reduction in the number of PCas. Assuming a cost-effectiveness threshold of $US50 000 per QALY, chemoprevention with 5ARIs was cost effective ($US37 900 per QALY) in men from the general population who were aged 50 years with elevated prostate-specific antigen (PSA), and who were aged 50 years with PCa family history and elevated PSA ($US31 065 per QALY). Chemoprevention with 5ARIs was not cost effective in men aged 50 years with no additional risk factors, men aged 50 years with abnormal digital rectal examinations (DREs), and men aged 50 years with a family history ($US86 511, $US85 577 and $US84 950 per QALY, respectively). In higher-risk men, chemoprevention could be expected to be cost effective ($US18 490 to $US11 816 per QALY, depending on risk scenario). Results were sensitive to changes in utilities, assumed PCa risk reduction with 5ARIs, and patient age. When considering common risk factors associated with PCa, prevention with 5ARIs is expected to be cost effective in 50-year-old men with elevated PSA. As a man's risk increases, the cost effectiveness of 5ARI chemoprevention improves.

How do masculinity, paternity leave, and mortality associate? –A study of fathers in the Swedish parental &amp; child cohort of 1988/89

One of the proposed causes for the gender gap in longevity is the attitudes and practices culturally prescribed for men, often conceptualised as 'masculinity'. It has also been suggested that paternity leave, indicating a change from breadwinning to caring, could benefit men's lifetime health. In this study, the objective was to examine associations between 'masculinity' (assessed at the age of 18-19 years), paternity leave (1988-1990), and mortality patterns (1991-2008) based on a population of Swedish men who had a child in 1988/89 (N=72,569). 'Masculinity' was measured during the compulsory military conscription process by a psychologist based on leisure and occupational interests, and paternity leave was measured in fulltime days by registry data. The main finding was that low 'masculinity' ranking increased the risk of all-cause mortality, and mortality from alcohol and violent causes, while taking paternity leave between 30 and 135 days decreased the risk of all-cause mortality. However, the weak association found between 'masculinity' and paternity leave indicates that entering a caring role as a father is not predicted by 'masculinity' assessed in late adolescence, and that the studied phenomena influence male mortality independently of each other.

MEDICAID COVERAGE OF NEWBORN CIRCUMCISION: A HEALTH PARITY RIGHT OF THE POOR

We applaud Leibowitz et al. for describing the adverse impact on public health of the withdrawal by 16 states of Medicaid coverage for male circumcision.1 However, we are alarmed by a subsequent letter by anticircumcision lobbyists, in which the evidence regarding circumcision is thoroughly misrepresented.2 Their claims flatly contradict the bulk of the legitimate medical literature demonstrating that male circumcision protects against urinary tract infections, HIV, HSV-2, syphilis, chancroid, thrush, bacterial accumulation, human papillomavirus, penile (and possibly prostate) cancer, local inflammation (balanitis), phimosis, paraphimosis, sexual problems with age, and, in female partners, human papillomavirus, cervical cancer, HSV-2, chlamydia, and bacterial vaginosis.3 The evidence for several of these conditions now includes data from randomized controlled trials and rigorous meta-analyses. Two recent randomized controlled trials also show no adverse effect on sensitivity, sexual function, or satisfaction.4 Risks associated with medical circumcision of infants are extremely low (0.3%–0.6%) and the majority of complications are minor and easily treated.3 Moreover, this procedure remains as popular as ever in the United States, with the majority of male infants being circumcised. Green et al. display a disturbing lack of understanding of basic epidemiology. A valid test of whether circumcision protects against HIV infection or penile cancer is not by comparing rates between different countries! Moreover, the flaws in their arguments denying circumcision's protection against HIV infection have been exposed previously in a detailed 48-author commentary.5 In contrast to their claim about applicability of data from Africa to the United States, the degree of protection that circumcision affords against heterosexual HIV infection confirmed in 3 large randomized controlled trials is now observed in heterosexual men in the United States.6 This protection probably extends, moreover, to insertive anal intercourse.7 Circumcision also protects against urinary tract infections throughout life.8 The accumulated lifetime prevalence in US men is up to 14%.9 But the highest rate (1%–4%) is during infancy, where circumcision affords a 10-fold protective effect.3 This is observed consistently in the literature. Properly conducted cost-benefit analyses have indicated that, over a man's lifetime, infant circumcision provides a positive cost benefit, especially when diseases and medical problems in female partners are also considered.10 In this new political era in the United States, with its hope for better health care generally, Medicaid coverage for circumcision is a health care parity right of the poor. It must be retained by the majority of states, and must be reinstated by those states that have previously withdrawn it.

The CAG repeat polymorphism within the androgen receptor gene and maleness.

The androgen testosterone and its metabolite dihydrotestosterone exert their effects on gene expression and thus effect maleness via the androgen receptor (AR). A diverse range of clinical conditions starting with complete androgen insensitivity has been correlated with mutations in the AR. Subtle modulations of the transcriptional activity induced by the AR have also been observed and frequently assigned to a polyglutamine stretch of variable length within the N-terminal domain of the receptor. This stretch is encoded by a variable number of CAG triplets in exon 1 of the AR gene located on the X chromosome. First observations of pathologically elongated AR CAG repeats in patients with X-linked spino-bulbar muscular atrophy showing marked hypoandrogenic traits were supplemented by partially conflicting findings of statistical significance also within the normal range of CAG repeat length: an involvement of prostate tissue, spermatogenesis, bone density, hair growth, cardiovascular risk factors and psychological factors has been demonstrated. The highly polymorphic nature of glutamine residues within the AR protein implies a subtle gradation of androgenicity among individuals within an environment of normal testosterone levels providing relevant ligand binding to ARs. This modulation of androgen effects may be small but continuously present during a man's lifetime and, hence, exerts effects that are measurable in many tissues as various degrees of androgenicity and represents a relevant effector of maleness. It remains to be elucidated whether these insights are important enough to become part of individually useful laboratory assessments.