Statements by Australian medical authorities

Since the early 1970s Australian medical authorities have consistently urged that male infants and boys should NOT be circumcised.

The most recent and authoritative statement was issued by the Royal Australasian College of Physicians in August 2009. This document states clearly:

"the RACP does not recommend that routine circumcision in infancy be performed."

The full outline statement follows.

CURRENT COLLEGE POSITION on CIRCUMCISION

The Paediatrics & Child Health Division, The Royal Australasian College of Physicians (RACP) has prepared this statement on routine circumcision of newborn and infant boys for doctors who are asked to advise on or undertake the procedure and to assist parents who are considering having this procedure undertaken on their male children.

Circumcision of males has been undertaken for religious and cultural reasons for many thousands of years and it remains an important ritual in some religious and cultural groups. In Australia and New Zealand, the circumcision rate has fallen considerably in recent years and it is estimated that currently around 10-15% of newborn male infants are routinely circumcised.

Circumcision is now generally performed with local or general anaesthesia, and when the procedure is undertaken for a medical indication this is usually outside of the neonatal period.

When considering routine infant circumcision, ethical concerns have focused on recognition of the functional role of the foreskin, the non-therapeutic nature of the operation, and the psychological distress felt by some adult males circumcised as infants. The possibility that routine circumcision contravenes human rights has been raised because circumcision is performed on a minor for non-clinical reasons, and is potentially without net clinical benefit for the child.

Recently there has been renewed debate regarding both the possible health benefits and the ethical concerns relating to routine male circumcision. The most important conditions where some benefit may result from circumcision are urinary tract infections, and in adults HIV infection and cancer of the penis. The frequency of these conditions, the level of protection offered by circumcision and complication rate of circumcision do not warrant a recommendation of universal circumcision for newborn and infant males in an Australian and New Zealand context.

After extensive review of the literature the RACP does not recommend that routine circumcision in infancy be performed, but accepts that parents should be able to make this decision with their doctors. One reasonable option is for routine circumcision to be delayed until males are old enough to make an informed choice. In all cases where parents request a circumcision for their child the medical attendant is obliged to provide accurate information on the risks and benefits of the procedure. Up-to-date, unbiased written material summarising the evidence should be widely available to parents. In the absence of evidence of substantial harm, parental choice should be respected. If the operation is to be performed, the medical attendant should ensure this is done by a competent surgeon, using appropriate anaesthesia and in a safe child-friendly environment.

27 August 2009

The policy statement represents the consensus position of the Australasian Association of Paediatric Surgeons, the New Zealand Society of Paediatric Surgeons, the Urological Society of Australasia, the Royal Australasian College of Surgeons and the Paediatric Society of New Zealand.

Full text of statement available from the RACP.

Previous statements by Australian medical authorities

The Australian Pediatric Association recommends that newborn male infants should not, as a routine, be circumcised.

     ” Australian Pediatric Association, 24 April 1971

The ACP should continue to discourage the practice of circumcision in the newborn male infant.

     ” Australian College of Paediatrics, Official statement, 1983

The Australasian Association of Paediatric Surgeons does not support the routine circumcision of male neonates, infants or children in Australia. It is considered to be inappropriate and unnecessary as a routine to remove the prepuce, based on the current evidence available.

We do not support the removal of a normal part of the body, unless there are definite indications to justify the complications and risks which may arise. In particular, we are opposed to male children being subjected to a procedure, which had they been old enough to consider the advantages and disadvantages, may well have opted to reject the operation and retain their prepuce.

     ” The Australasian Association of Paediatric Surgeons, "Guidelines for circumcision", 1996

Royal Australasian College of Physicians statements, 2002 and 2004.

The Division of Paediatrics and Child Health, Royal Australasian College of Physicians (RACP) has prepared this statement on routine circumcision of infants and boys assist parents who are considering having this procedure undertaken on their male children and for doctors who are asked to advise on or undertake it. After extensive review of the literature the RACP reaffirms that there is no medical indication for routine male circumcision.

Review of the literature in relation to risks and benefits shows there is no evidence of benefit outweighing harm for circumcision as a routine procedure.

The policy statement represents the consensus position of the Australasian Association of Paediatric Surgeons, the New Zealand Society of Paediatric Surgeons, the Urological Society of Australasia, the Royal Australasian College of Surgeons and the Paediatric Society of New Zealand.

The full text of statements from medical authorities in Canada, Britain and Scandinavia, all of which reject circumcision, are available at cirp.org.

British Medical Association

In its guidelines on circumcision, the British Medical Association takes a stronger and more critical line against unnecessary surgical interventions in children. It lays down the following principles of good practice:

• The welfare of child patients is paramount and doctors must act in the child's best interests.
• Children who are able to express views about circumcision should be involved in the decision-making process.
• Consent for circumcision is valid only where the people (or person) giving consent have the authority to do so and understand the implications and risks.
• Both parents [Go to reference 4] must give consent for non-therapeutic circumcision.
• Where people with parental responsibility for a child disagree about whether he should be circumcised, doctors should not circumcise the child without the leave of a court.

The BMA also advises that where a problem exists, circumcision should be the last resort, employed only after non-surgical treatments have been tried and failed:

Unnecessarily invasive procedures should not be used where alternative, less invasive techniques, are equally efficient and available. It is important that doctors keep up to date and ensure that any decisions to undertake an invasive procedure are based on the best available evidence. Therefore, to circumcise for therapeutic reasons where medical research has shown other techniques to be at least as effective and less invasive would be unethical and inappropriate.

Male circumcision in cases where there is a clear clinical need is not normally controversial. Nevertheless, normal anatomical and physiological characteristics of the infant foreskin have in the past been misinterpreted as being abnormal. The British Association of Paediatric Surgeons advises that there is rarely a clinical indication for circumcision. [Go to reference 5] Doctors should be aware of this and reassure parents accordingly.

On the question of consent, the BMA insists that in the case of children, both parents must give their consent, and that it must be in writing. Further, if the child is old enough to express an opinion, his wishes and preferences must be taken into account:

The BMA and GMC have long recommended that consent should be sought from both parents. Although parents who have parental responsibility are usually allowed to take decisions for their children alone, non-therapeutic circumcision has been described by the courts as an "important and irreversible" decision that should not be taken against the wishes of a parent. [Go to reference 15] It follows that where a child has two parents with parental responsibility, doctors considering circumcising a child must satisfy themselves that both have given valid consent. If a child presents with only one parent, the doctor must make every effort to contact the other parent in order to seek consent.

Summary of consent issues

• Competent children may decide for themselves.
• The wishes that children express must be taken into account.
• If parents disagree, non-therapeutic circumcision must not be carried out without the leave of a court.
• Consent should be confirmed in writing.

Health benefits of circumcision doubted

In relation to circumcision as a prophylactic measure (to reduce the supposed risk of diseases that may be contracted in the future), the BMA warns that there are no agreed "health benefits" in circumcision of children and that doctors must warn parents that medical opinion is divided.

There is significant disagreement about whether circumcision is overall a beneficial, neutral or harmful procedure. At present, the medical literature on the health, including sexual health, implications of circumcision is contradictory, and often subject to claims of bias in research. Doctors performing circumcisions must ensure that those giving consent are aware of the issues, including the risks associated with any surgical procedure: pain, bleeding, surgical mishap and complications of anaesthesia. All appropriate steps must be taken to minimise these risks. It may be appropriate to screen patients for conditions that would substantially increase the risks of circumcision, for example haemophilia.

Doctors should ensure that any parents seeking circumcision for their son in the belief that it confers health benefits are fully informed of the lack of consensus amongst the profession over such benefits, and how great any potential benefits and harms are. The BMA considers that the evidence concerning health benefit from non-therapeutic circumcision is insufficient for this alone to be a justification for doing it.

The full text of the BMA statement is available here.

Circumcision not relevant to Australian AIDS problem

Circumcision as a response to the AIDS problem in Australia has also been rejected by Australian authorities on AIDS control

Circumcision of sexually active adult men has been in the news lately as the latest tactic against the AIDS epidemic in Africa. Many people are wondering if this means that boys in Australia and other developed countries should also be circumcised as a precaution. The answer is No. Africa has unique problems, arising from the fact that AIDS there is a heterosexual epidemic caused by social and political breakdown, poor health services, failure to take action when the disease first appeared, widespread sexual promiscuity, often involving prostitution, and refusal to use condoms.

In Australia and the rest of the developed countries, AIDS is not an epidemic at all, but a disease that remains confined to specific sub-cultures – homosexual men and intravenous drug users. Unlike in Africa, there is little or no female-to-male transmission, meaning that the average male is not at risk of the disease. In Australia, nearly all cases of HIV have arisen from anal intercourse among men, intravenous drug-taking (using needles), blood transfusions and surgical procedures. In none of these cases would circumcision have made the slightest difference. Studies in developed countries (such as the British Gay Men's Health Survey) show that the incidence of AIDS is actually higher among circumcised men. [1] In Australia, recent studies have found no difference in the incidence of HIV between cut and uncut men. [2]

There is evidence from Africa that men who have unprotected intercourse with an infected female partner have a reduced risk (estimated at 50 to 60 per cent) of HIV if they are circumcised, but this only means that they will take longer to get infected. It certainly does not mean that they have any kind of immunity. Assuming the reduction of risk is 50 per cent, it only means that if an uncircumcised man needs eight sessions of unsafe sex with an infected partner to catch HIV, it will take a circumcised man twelve sessions. Studies in developed countries show that condoms provide a risk reduction of 90 to 95 per cent – without the dangers of surgery, and without losing a valuable body part.

Africa unenthusiastic

Even in Africa there has been strong opposition to the attempts by (largely American) health bureaucrats to foist an American cultural practice (circumcision of infant males) onto indigenous cultures where, if circumcision is practised at all, it is performed as a cultural ritual around puberty. The South African Medical Journal has been particularly vocal, calling the WHO/UNAIDS program costly, ineffective, a violation of accepted principles of bioethics and human rights, culturally insensitive and smacking of medical colonialism.

The real problem is reckless behaviour, not normal human anatomy. You would think that any sensible and ethical health strategy would take anatomy as a given and seek to change behaviour, not attempt to do it the other way around.

Protection against HIV could never be a justification for circumcising infants or children, since they are not sexually active and thus not at any risk of contracting the disease – unless through surgery itself (always risky, and a frequent vector for all kinds of infection.) When the boy is old enough to become sexually active, he will also be old enough to learn about safe sex and how to act responsibly in sexual matters.

The Australian Federation of AIDS organization has stated that circumcision has no role in the management of HIV in Australia. (Australian Federation of AIDS Organisations, Briefing Paper, 23 July 2007, "Male circumcision has no role in the Australian AIDS epidemic".

References

1.  The British Gay Men's Health Survey 2001 found that 5 per cent uncircumcised men were HIV positive, compared with of 6.1 per cent of circumcised men. The report comments: "If circumcised men are less likely to acquire HIV than men with foreskins, then we should expect fewer of the circumcised men to have tested positive than the men with a foreskin. However, more of the circumcised men had tested positive for HIV (6.1%) than had those with a foreskin (5.0%). This small but significant difference is in the opposite direction than predicted if foreskins are contributing to transmission, and was observed in all ethnic groups and across the age range."

David Reid, Peter Weatherburn, Ford Hickson, Michael Stephens, Know the score: Findings from the National Gay Men's Sex Survey 2001 (Sigma Research: University of Portsmouth, 2002), p. 38 Full text available here.

2.  For example, Richters J, Smith AMA, de Visser RO, et al. Circumcision in Australia: prevalence and effects on sexual health. Int J STD AIDS 2006;17:547–54

Further articles available here.

The full text of the AFAO statement is printed below

Male circumcision has no role in the Australian HIV epidemic

Australian Federation of AIDS Organisations Inc
P.O. Box 51
Newtown NSW 2042 Australia

Phone: 61 2 9557 9399
Fax 61 2 9557 9867

Email [email protected]

www.afao.org.au

Briefing paper, 23 July 2007
Male circumcision has no role in the Australian HIV epidemic

Key points

• There is no demonstrated benefit of circumcision in men who have sex with men.
• Correct and consistent condom use, not circumcision, is the most effective means of reducing female-to-male transmission, and vice-versa.
• African data on circumcision is context-specific and cannot be extrapolated to the Australian epidemic in any way.

Background

Male circumcision is a surgical procedure that involves the removal of all or part of the foreskin from the head of the penis. It is an ancient practice that has been performed in some cultures for millennia – well before the advent of sterile surgery. [1] It has ritual significance in some cultures, and so its practice may be ceremonial, performed with non-surgical instruments by elders rather than doctors, and without anaesthesia. [2] It is an irreversible procedure. Different cultures have performed the rite at different stages of life: commonly in preadolescence as part of a ritual of becoming a man; sometimes for older adult men as a sign of status; and in more recent history, in infancy. Cultural identity may also be entwined with non-circumcision. [3]

In the twentieth century in industrialized countries such as Australia and the United States, circumcision became very popular for reasons that are not clear but do not appear to be directly related to religious or specific ethno-cultural affiliation. This trend was reversed in Australia in the 1980s and 90s due to increased acceptance that circumcision provided no medical benefit.

Recent data from three major trials in Africa challenges the notion that it is of no benefit. Adult male circumcision has been found to reduce the risk of acquiring HIV in men by around 55-60% in three randomized controlled studies. [4, 5, 6] These trials were conducted in African countries where HIV is endemic – Uganda, South Africa and Kenya. Heterosexual vaginal intercourse is the predominant mode of HIV transmission in these countries. Circumcision did not provide complete protection against HIV, but researchers concluded that circumcision reduced the risk of HIV acquisition in the study groups. While there were high rates of HIV acquisition in both arms of these studies – the circumcised and the uncircumcised – rates were lower in the former group. [7]

Following the release of these trial results UNAIDS and the World Health Organisation held an international consultation to analyse the data and consider policy implications. Mass circumcision programs are being proposed throughout the sub-Saharan region. [8] While consideration is being given to making such programs culturally sensitive, the proposed implementation of male circumcision raises complex moral problems relating to cultural practice, gender equity, informed consent, and the just allocation of limited resources.

The Australian epidemic

In Australia, receptive anal intercourse is the predominant mode of HIV transmission. There has been some research into whether circumcision status makes a difference in terms of HIV acquired through insertive anal sex, but this research has shown no difference between the two groups. [9] Therefore, circumcision is NOT an HIV risk-reduction strategy for men who have sex with men. (Further research from the Health in Men Study will be reported at the IAS conference in Sydney in July 2007.)

Circumcision to reduce HIV risk for heterosexual men in Australia?

The USA has a growing heterosexual epidemic and very high rates of circumcision. [10] Circumcision does not prevent HIV – in high prevalence areas it reduced the risk of female-to-male transmission. HIV acquisition rates were nevertheless high in both the circumcised and the non-circumcised groups involved in the trials.

The African epidemic

There is some division of opinion as to whether circumcision programs should be implemented in Africa. UNAIDS and the World Health Organisation have accepted that the data show a population-level benefit of circumcision. However, there are social and ethical arguments against such programs, such as:

• A partially effective technology may adversely affect condom use and negotiation.
• Partial efficacy is a difficult concept to communicate to obtain informed consent.
• Risk behaviour may increase as a result of perceived invulnerability to infection.
• Women aged 15-24 are at the greatest risk of HIV acquisition and circumcision and circumcision.
• programs will not reduce infections in women directly for at least 10-20 years.
• Circumcision may reduce women's ability to negotiate condom use.
• Circumcision is a complex cultural practice.
• Circumcision status may become a marker of HIV status, as circumcision of HIV positive men is not being proposed.
• Ritual circumcision itself may be a route of HIV transmission.
• Good penile hygiene (washing under the foreskin) may be as effective in reducing the risk of acquiring HIV and STIs as circumcision in uncircumcised men. [11, 12]
• Circumcision has a 2-10% incidence of complications.
• If circumcised men have sex before wound-healing their vulnerability to HIV infection increases.

References

1. Aggleton P. (2007) '"Just a snip"?: A social history of male circumcision', Reproductive Health Matters.;15 (29): 15-21

2. Niang, CI. & Boiro, H. (2007) '"You can also cut my finger": Social construction of male circumcision in West Africa, a case study of Senegal and Guinea-Bissau'. Reproductive Health Matters. 15 (29): 22-32.

3. Ibid.

4. Auvert B., Taljaard D., Lagarde E., Sobngwi-Tambekou J., Sitta R., et al (2005) 'Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: The ANRS 1265 Trial. PLoS Medicine, 2 (11) e298 doi:10.1371/journal.pmed.0020298.

5. Gray H., Kigali G., Estrada D., et al. (2007) 'Male circumcision for HIV prevention in young men in Racial, Uganda: a randomised trial', Lancet, 369:657-66.

6. Bailey C., Moses S., Parker CB., et al. (2007) 'Male circumcision for HIV prevention in young men in Kyushu, Kenya: a randomised controlled trial', Lancet; 369: 643-56.

7. The incidence in circumcised men was 0.7-1.0 per hundred person years. 'Male circumcision for HIV prevention: Research implications for policy and programming WHO/UNAIDS technical consultation 6-8 March, conclusions and recommendations' (excerpts). (2007) Reproductive Health Matters, 15 (29): 11-14:12.

8. 'New data on male circumcision and HIV prevention: policy and programme implications', (2007) WHO/UNAIDS. http://data.unaids.org/pub/Report/2007/mc_recommendations_en.pdf

9. Grulich, A,, Hendry, O., Clarke, E., Kippax, S., Kaldor, J. (2001), 'Circumcision and male-to-male transmission of HIV', [Research letter] AIDS; 15 (9):1188-89.

10. Of the estimated 665 million men worldwide who are circumcised, 13% are men living in the USA who are neither Muslim nor Jewish, see Hankins, C. (2007) 'Male circumcision: Implications for women as sexual partners and parents', Reproductive Heath Matters; 15 (29): 62-67.

11. O'Farrell, N., Morison, L., Moodley, P., Pillay, K., Vanmali, T., Quigley, M., et al. (2006) 'Association Between HIV and Subpreputial Penile Wetness in Uncircumcised Men in South Africa', JAIDS Journal of Acquired Immune Deficiency Syndromes, September; 43(1): 69-77. HIV prevalence among uncircumcised men without penile wetness was close to that of circumcised men (42.9%).

12. Hankins, Op Cit: 62.

A pdf of this document may be downloaded from AFAO website.

African health crisis is not an argument for circumcision in developed countries

"Ex Africa semper aliquid novi", said the ancient Romans, "always something new out of Africa". So it is today, when we hear nothing but bad news from the dark continent – drought, disease, war, famine and now circumcision.

After many years of fruitless endeavour and an expenditure running into hundreds of millions of dollars, evidence has finally come to light that in Africa men who have unprotected intercourse with HIV positive partners are less likely, or will take longer, to become infected with HIV if they have been circumcised. The protective effect is estimated at 50 per cent, meaning that if it takes an uncircumcised man eight sessions of unsafe sex to get infected, it will take a circumcised man twelve sessions. How this rather limited protection justifies talk of a "vaccine", or authorises circumcision of sexually inactive – and thus not at risk – infants and boys, is not at all clear. The media hype surrounding the results of the clinical trials [1] on which these conclusions are based have been out of all proportion to their real significance.

The point to remember is that the developed world is not Africa, which faces such a crisis situation (poverty, poor levels of health and education services, very high levels of HIV infection and of prostitution etc) that resort to desperate measures is understandable. There is no such crisis in developed countries, where HIV has been successfully managed and is confined to specific sub-cultures (homosexual men, especially those who take the passive role in anal intercourse, to whom being circumcised will be no help at all), intravenous drug users (ditto) and immigrants from ... well, Africa.

You would not know it from the media coverage, but the World Health Organisation/UNAIDS are not recommending indiscriminate circumcision, but only that circumcision be offered as a preventive option to high risk groups in Third World countries where other (more effective) means of protection (such as safe sex education, fidelity, abstinence and condom use) seem to be impossible to achieve).

Who is at risk?

Infants and children, especially in the developed world, are not an at-risk population because they are not sexually active. You might argue that it is better to take away a boy's foreskin now than to see him contract AIDS at some unknown date in the future – and who would disagree? But the argument is valid only if circumcision were the only way to avoid AIDS and if it were pretty certain that he would get AIDS if he were not circumcised. In fact, the main risk factor for AIDS is not the foreskin, but unsafe sex; the best, cheapest and most certain way to avoid this easily avoidable disease is not to engage in unsafe sex practices and to avoid sex with partners likely to be HIV positive, such as prostitutes, casual sex workers and the generally promiscuous. There is plenty of time to get this message across to boys before they become sexually active.

Prostitution a bigger problem than anatomy

The prevalence of prostitution is a major factor in the spread of heterosexually transmitted AIDS, yet government agencies have been extremely reluctant to regulate the sex industry or restrict the activities of the prostitutes in any way because such action might infringe their civil or human rights. At the same time, they have recommended widespread circumcision of male infants and boys, whose own civil and human rights are thus treated as non-existent or of no account. It is of interest that in Senegal, one of the few African countries where the AIDS threat was faced early on and efforts were made to regulate the sex industry and ensure that prostitutes received regular health checks, the incidence of HIV infection is only around 2 per cent, compared with 30 or 40 per cent in places such as Tanzania or Botswana. (For Senegal, see Martin Meredith, The State of Africa: A History of Fifty Years of Independence (London: Free Press, 2005), p. 367.) The sad fact is that little boys are an easier target.

Further information on prostitution

As Philip Setel has shown in A Plague of Paradoxes: AIDS, Culture and Demography in Northern Tanzania (University of Chicago Press, 1999), there is a very high incidence of prostitution, of various kinds, throughout sub-Saharan Africa, and a very high incidence of HIV infection among the prostitutes. (See review in Archives of Sexual Behaviour, Vol. 34, December 2005).

Africa is not Australia

In Africa the problem that circumcision is meant to address is heterosexually acquired HIV through Female to Male transmission via unprotected intercourse. in the West there is negligible F to M infection, and most workers in the sex industry are insistent on safe sex and condoms.

In the West, the at risk populations are promiscuous male homosexuals [1] and intravenous drug users. Circumcision will not affect HIV transmission in these groups.

Western countries such as Australia have low rates of HIV infection because our policies of safe sex education have been successful. What children need to be taught is how to avoid this easily avoidable disease; they do not need, and they do not deserve, to have their natural anatomy forcibly altered.

The data from the Africa trials [2] say nothing about the effectiveness of infant or child circumcision, since the trials were confined to sexually active adult men who consented to the procedure.

Circumcision does not confer immunity to HIV infection. The level of risk reduction shown (50 per cent) is not sufficient to warrant talk of a vaccine. The protection is not lifelong, and it is far less than the 90 per cent protection given by regular condom use and observation of other forms of safe sex. A study of Nigerian prostitutes in 1988 found that, after counselling sessions, condom use increased markedly and that even occasional condom use had a significant protective effect: of 28 women who never used a condom, only eight escaped infection with HIV; but of 50 women who used them in approximately one third of sexual encounters, 27 (54 per cent) avoided infection. [3] It is interesting to compare this with the results of the recent clinical trials of circumcision, which reported a risk reduction of between 50 and 60 per cent: almost exactly the same as the risk reduction achieved by condom use 30 per cent of the time.

Despite what enthusiasts for cutting babies say, there is no evidence that circumcision later in life is more risky or harmful than in infancy. On the contrary, all the evidence is that the younger it is done the more harmful, risky and painful it is, and the greater the effects on sexual function and sensation. This is because of the tiny size of the organ, ignorance as to the eventual size of the penis and length of foreskin at puberty,  the impossibility of safe and effective anaesthetic, and the fact that the neural pathways that learn to transmit pleasurable sensation have not fully developed. If those urging compulsory circumcision of children in preference to optional circumcision of sexually active adult men believe that circumcision in adulthood is so risky, why did they not raise concerns about the dangers of the African circumcision trials, conducted as they were on adults? (Is it the presence of consent that upsets them?)

History urges scepticism

In the days of the Roman Empire many African peoples already practised circumcision (both male and female) as a cultural ritual. The arrival of imperialism in the form of Roman soldiers and administrators meant that such practices were discouraged as abhorrent to civilized people. Today western medical imperialism is having the opposite effect, spreading circumcision from circumcising to non-circumcising cultures, with the excuse that it is the only measure that can stop the AIDS pandemic. Desperate fears produce desperate reactions, but one wonders how much emotional baggage is bound up in this massive effort. It is interesting to recall that in nineteenth century United States respectable doctors demanded compulsory (legally mandated) circumcision of American Negroes to control syphilis (the AIDS of that era), and even to protect white women from sexual assault.

Further details on "Solving the Negro rape problem"

Further information on ethical aspects of prophylactic surgery as a disease control strategy on low income countries

References

1. Because AIDS is not a really serious public health issue in the developed world, there is not much research on the difference in rates of HIV infection between circumcised and uncircumcised men in developed countries, but two significant studies (in Britain and the USA) both found a higher incidence of HIV among circumcised men:

David Reid, Peter Weatherburn, Ford Hickson, Michael Stephens, Know the score: Findings from the National Gay Men's Sex Survey (London 2001)

Laumann, EO, Masi CM, Zuckerman EW. Circumcision in the United States: Prevalence, Prophylactic Effects, and Sexual Practice. Journal of the American Medical Association 1997;277(13):1052-7

2. The clinical trials are, in any case, a bit fishy for several reasons. (1) They were not blind (as they should have been). (2) They were not random, in that the men chose whether to be or not to be circumcised, thus allowing the likelihood that the former group were more cautious than the latter. (3) There is no reason to suppose that the two groups men then had similar sexual experiences: more of the circumcised men might have had more sex with negative partners than the other group, or they might have engaged in less risky sexual practices, meaning that they were less exposed to risk; in these cases you could not know whether it was the differing behaviour or the altered anatomy that conferred the protection. (4) The trials were terminated prematurely, allowing suspicions that the most favourable moment for statistical purposes was chosen. (5) It is common for the early results of clinical trials to be highly and misleadingly positive, inspiring premature optimism. For an analysis of why this is so, see John P.A. Ioannidis, "Why Most Published Research Findings Are False", Plos Medicine, Vol. 8, 2005, online at

[3].  E.N. Ngugi et al, "Prevention of transmission of human immunodeficiency virus in Africa: Effectiveness of condom promotion and health education among prostitutes", Lancet, Vol. 332, No. 8616, 15 October 1988, 887-890. In case it is suspected that the foreskin might have been a factor here, it should be remembered that the vast majority of Nigerian men are circumcised, and that female genital cutting is also common. Abstract of Lancet article available here.

Further reading

Lawrence Green et al, Male circumcision is not the HIV vaccine we have been waiting for, Future HIV Therapy, Vol. 2, 2008

Robert Van Howe and J. Steven Svoboda, Neonatal circumcision is neither medically necessary nor ethically permissible: A reply to Clark et al, Medical Science Monitor, Vol. 14, 2008