NOTE: Self-evident statements were not rated(see statements below) Statement 1: "MSM may choose to be circumcised despite i.e. the lack of definitive evidence of circumcision decreasing the risk for the insertive anal sex partner of acquiring HIV infection, but male circumcision involves potential risks (see Adverse Events section of Box 1) and costs." Statement 2: "However, current risks for either HIV or other non-HIV STIs may not remain constant in the future and the future risk for any individual neonate child, or adolescent cannot be definitively defined at the time that a circumcision decision is made." Statement 3: "Those who enjoy the sensation of the foreskin during sexual relations will no longer experience that sensation." (after circumcision)#
Health benefits and risks of elective neonatal, adolescent, or adult medically performed male circumcision should be considered in consultation with medical providers while taking into account factors associated with decision-making around male circumcision, including religion, societal norms and social customs, hygiene, aesthetic preference, and ethical considerations. See below acquiring HIV and some STIs during penile-vaginal sex. In clinical trials, medically performed male circumcision reduced the incidence of genital ulcer disease (GUD) by 48% and the prevalence by 47%, reduced the prevalence of HR-HPV by 23 -47%, and reduced the incidence of syphilis by 42% among circumcised men. . Siegfried N, Muller M, Deeks J, Volmink J. Male circumcision for Meta-analysis of 3 RCTs HIV incidence (acquisition) Decrease Uganda, South Africa, Kenya AIa The overall relative risk reduction of acquiring HIV was 50% at 12 months and 54% at 21 or 24 months following circumcision prevention of heterosexual acquisition of HIV in men (review).
Heterosexual adult males Cochrane database of systematic reviews. 2009;15(2):CD003362. . Byakika-Tusiime J. Circumcision and HIV Infection: Assessment of Meta-analysis of 13 studies HIV incidence (acquisition) Decrease Observational studies: United States, BIIa 61% reduced risk of HIV infection among circumcised men (aRR 0.39, 95% CI 0.27-0.56) Causality. AIDS Behav. 2008;12(6):835-841.
Analysis limited to 10 India, Kenya, Malawi, Cote d'Ivoire, observations studies (6 cohort Sengal, Tanzania studies, 1 nested case-control
Heterosexual adult males study, 3 case control studies) .
Lei JH, Liu LR, Wei Q, et al. Circumcision status and risk of HIV Meta-analysis of 9 studies related HIV incidence (acquisition) Decrease Prospective Cohort Studies: Kenya, BIIa Male circumcision was associated with 70% reduction in the risk for HIV acquisition (pooled adjusted risk ratio  0.40, 95% CI 0.31-0.53) acquisition during heterosexual intercourse for both males and to female-to-male transmission (3 Uganda, India Heterosexual adult females: a meta-analysis. PLOS ONE. 2015;10(5) is biologically plausible Male circumcision has not been shown to reduce the risk of HIV transmission to female partners. However, in clinical trials, medically performed male circumcision reduced the incidence of syphilis by 59%, and reduced the prevalence of GUD by 22%, HR-HPV by 22%, T. vaginalis by 45%, and bacterial vaginosis by 40% among female partners.
Weiss HA, Hankins CA, Dickson K. Male circumcision and risk of HIV infection in women: a systematic review and meta-analysis. Lancet Infect Dis. 2009;9:669-677. Systematic review and random effects meta-analysis (1 RCT and 6 longitudinal analyses)

# HIV acquisition
No difference RCT: Uganda Longitudinal studies: 14 sites and southern Africa; Uganda; Zimbabwe, Tanzania in east AIb A systematic review and meta-analysis of the evidence for a direct effect of male circumcision on the risk of women becoming infected with HIV identified 19 epidemiological analyses from 11 study populations. The meta-analysis of data from the 1 RCT and 6 longitudinal analyses showed little evidence that male circumcision directly affects the risk of HIV acquisition in women (RR 0. lower BV prevalence compared to female partners of uncircumcised men (aPRR Male circumcision has also been shown to reduce the risk of urinary tract infections in males aged 0-1 years by 90%, males aged 1-16 years by 85%., and males aged >16 years by 71%.
Morris BJ, Wiswell TE. Circumcision and lifetime risk of urinary tract infection: a systematic review and meta-analysis. J Urol. 2013;189( 6

# BIIb
Early resumption of sexual relations following male circumcision was significantly associated with higher risk for HIV acquisition among female participants, with a rate ratio versus control of 3.50 (95% CI = 1.14-10.76). Among couples in the immediate male circumcision arm who delayed resumption of sex until after wound healing, there was no significant difference in HIV incidence relative to uncircumcised controls (rate ratio 1. In a vaccine preparedness cohort of MSM followed from 1995 to 1997, circumcision was significantly associated with a decreased risk for HIV seroconversion (aOR = 0.5; 95% CI 0.3-0.9), controlling for number of male sex partners and unprotected sex with an HIV-positive partner . In a crosssectional survey of gay men in Seattle in the early 1990s, circumcision was associated with decreased odds of prevalent HIV infection (aOR = 0.5; 95% CI 0.25-1.0) . While falling short of the quality of data from a randomized intervention trial, these limited data suggest that circumcised MSM in the US may have decreased risk of HIV infection. However, it is possible that the noted associations in these two observational studies were related to uncontrolled bias. A small cross-sectional study of Australian MSM found no association between circumcision status and risk of HIV infection, when stratifying by insertive and receptive roles .
Row no. CIIIb . When providing information to parents about male circumcision for an adolescent minor, the adolescent should be included in the decision-making process about undergoing elective male circumcision. When counseling an adolescent inquiring about male circumcision, parents should be engaged in the discussion, unless the adolescent is legally emancipated. Minors may be deemed emancipated, giving them sole authority to make health care decisions on their own behalf under certain circumstances, which vary by state law; for example, if the minor 1) lives independently and is self-supporting, 2) is married, 3) is pregnant or a parent, 4) is in the military, or 5) is declared emancipated by a court as defined in the mature minor section.

# BIIb
When estimated by age group, the incidence of probable AEs was 0.40%, 9.06%, and 5.31% for males aged < respectively. The incidence of AEs was 10-20-fold higher for males in older age groups compared with infants.

# BIIa
In a meta-analysis of 18 studies and 22,919 children mainly from the United States, the pooled prevalence of UTI in infants presenting with fever in outpatient clinics and emergency departments was 7.0% (95% CI = 5.5-8.4), but was as high as 20.1% (95% CI = 16.8-23.4) among febrile uncircumcised males aged < 3 months compared with 2.4% (95% CI = 1.4-3.5) among febrile circumcised males aged < 3 months and with 7.8% (95% CI = 6.6-8.9) among both febrile and afebrile older children aged < 19 years 95 o Complications of medically performed male circumcision in the United States are typically uncommon and easily managed. Severe complications are rare in all age groups and occur in 0.23% of all circumcised males overall.

# BIIb
Approximately 0.4% of male newborns in the first year of life experienced an adverse event associated with circumcision. Severe complications are rare in all age groups and rates of potentially serious male circumcision adverse events range from 0.8 per million male circumcisions for stricture of male genital organs to 703.2 per million male circumcision for repair of incomplete circumcision.

# CIIIb
In a review article, data from a myriad of sources were compiled, including personal correspondence, to estimate the following rates of AEs per circumcisions performed in the United States: excessive bleeding requiring ligature, 1 per 4,000; bleeding requiring transfusion, 1 per 20,000; severe infection requiring parenteral antibiotics, 1 per 4,000; subsequent surgery (e.g., for skin bridges), 1 per 1,000; repair of traumatic injury, 1 per 15,000; and loss of entire penis, less than 1 per 1,000,000. There were 3 deaths due to male circumcision during 1954-1989. BIIb "Nine AEs were significantly less likely to occur in circumcised infants compared with uncircumcised infants at P < .05. Circumcised newborn males had a higher risk for wounds, correctional procedures, inflammation, and bleeding compared with uncircumcised newborn males but had a lower risk for surgical procedures, penile disorders and gangrene, pneumothorax, and infections. Among the extremely rare but serious AEs occurring only among circumcised newborns (but once or none among uncircumcised newborns), we found 0 cases of complete amputation of penis, 1 case of stricture of male genital organs, 3 cases of partial amputation of penis, 4 cases of replantation of penis, and 16 cases of suture of artery." o On average, adult men who undergo circumcision generally report minimal or no change in sexual satisfaction or function. Grade-consensus Comments o Some men enjoy the sensation of the foreskin during sexual relations, and such a sensation will not be experienced after circumcision; however, the bulk of scientific evidence states that men on average, do not experience a loss of sexual pleasure or function because of circumcision.

# AIb
In another systematic review and meta-analysis including 10 studies and 9,317 circumcised men and 9,423 uncircumcised men, there were no significant associations between male circumcision and sexual desire, dyspareunia, premature ejaculation, ejaculation latency time, erectile dysfunction, or orgasm difficulties.
AIb IRR 0.55, 95% CI 0.32-0.949 (AT analysis) Note: When men who crossed over from control arm to intervention arm were included in the case arm analysis, the circumcision effect changed from "no difference" (in the intention-to-treat analysis, to "decrease" (as treated analysis) See below. Grade-consensus Comments During adulthood, the prevalence of invasive penile cancer is lower in males circumcised prior to 10 years of age (6%) compared with males not circumcised prior to 10 years of age (12%)