1

Recommendations for Providers Counseling 

Male Patients and Parents Regarding Male Circumcision and the 

Prevention of HIV 

Infection, STIs, and other Health Outcomes

Introduction:

These recommendations are intended to assist health care providers in the United States who are 

counseling men and parents of male infants in decision making about male circumcision

conducted by health care providers (i.e. medically performed) as it relates to the prevention of 

human immunodeficiency virus (HIV) infection, sexually transmitted infections (STIs), and 

other health outcomes. Such decision making is made in the context of not only health 

considerations, but also other social, cultural, ethical, and religious factors. Although data have

been accumulating about infant male circumcision for many years, clinical trials conducted in 

Africa between 2005-2010 have demonstrated safety and significant efficacy of voluntary adult 

male circumcision performed by clinicians for reducing the risk of acquisition of human 

immunodeficiency virus (HIV) by a male during penile-vaginal sex (“heterosexual sex”). Three 

randomized clinical trials showed that adult male circumcision reduced HIV infection risk by 50-

60% over time1-4. These trials also found that medically performed adult circumcision reduced 

the risk of men acquiring two common sexually transmitted infections (STIs), herpes simplex 

virus type-2 (HSV-2)

5,6

and types of human papilloma virus (HPV)

6,7

that can cause penile and 

other anogenital cancers, by 30%. Since the release of these trial data, various organizations 

have updated their recommendations about adult male8and infant male circumcision9,10.

Much of the data related to HIV and STI prevention are from randomized clinical trials (RCTs)

conducted among men in sub-Saharan Africa in regions with high rates of heterosexually 

acquired HIV infection. In the United States, the prevalence of HIV and lifetime risk of HIV 

infection are generally much lower than that in sub-Saharan Africa. Also, most new HIV 

infections in the United States are attributed to male-male sex, a population for whom male 

circumcision has not been proven to reduce the risk of HIV acquisition. While such factors limit 

the impact of medically performed male circumcision in reducing the overall HIV epidemic in 

the U.S., there is epidemiologic data to suggest that some subpopulations in the U.S. are likely to 

benefit. One in every ten estimated new HIV infections in the United States are attributed to 

female-to-male sexual transmission11. In addition, African-American and Hispanic men have 

higher risk of HIV infection and lower male circumcision rates than men of other 

race/ethnicities. Although similar randomized clinical trials have not been conducted in the 

United States, based on evidence from the African trials, uncircumcised heterosexual men living 

in areas with high HIV prevalence are likely to experience the most public health risk-reduction 

benefit from elective male circumcision. 

Methods:

A CDC consultation was held in April 2007 to obtain input on the potential role of male 

circumcision in preventing transmission of HIV in the United States. A summary of the 
2

consultation, including a list of the participants has been previously published12 and helped 

define key issues for inclusion in this document. 

These recommendations are based on an evaluation of available information on the health risks 

and benefits associated with high-quality, medically performed male circumcision and were 

developed to pertain to men and male newborns in the United States13. In these 

recommendations, the preventive benefits of male circumcision are generally expressed as 

relative-risk reductions (e.g., a 50% reduction from a 2% risk of an STI to a 1% risk), whereas 

any associated harm is expressed as an absolute risk (e.g., a 2-4% risk of adverse events). 

Appropriate denominators are not available in many cases to establish an absolute risk for HIV 

and other STIs in higher-risk populations, e.g., heterosexual males at increased risk for infection.

Recommendations:

1. Consideration of factors associated with decision making

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.

2. Counseling sexually active adolescent and adult males regardless of circumcision status

All sexually active adolescent and adult males should continue to use other proven HIV and STI 

risk-reduction strategies such as reducing the number of partners, and correct and consistent use 

of male latex condoms, and HIV preexposure or postexposure prophylaxis among others1.

3. Counseling uncircumcised sexually active adolescent and adult males

Prior to counseling uncircumcised sexually active adolescent and adult males about medically 

performed male circumcision, their HIV risk behaviors, HIV infection status, and the gender of 

their sexual partner should be assessed14. The results of these assessments will inform the 

discussion with men about the risks and benefits of male circumcision.

3A. Counseling uncircumcised heterosexually and bisexually active adolescent and adult 

males (i.e., men who have sex with women)

3A-1. An assessment of the patient’s risk of acquiring HIV through heterosexual sex should be 

conducted:

o Providers should review the patient’s HIV risk behavior. 

o Providers should assess condom use practices, consistency of use, and barriers to 

use.

 

1

Information about HIV and STD prevention strategies other than medically performed male circumcision can be 

found at http://wwwdev.cdc.gov/hiv/basics/prevention.html and 

http://www.cdc.gov/std/prevention/default.htm.
3

o Heterosexually and bisexually active adolescent and adult males should be informed 

that men at high risk of HIV exposure during heterosexual sex include HIV-uninfected 

men in sexual relationships with:

 An HIV-infected woman (i.e., in an HIV discordant couple);

 One or more women who are at high risk for HIV (this includes commercial sex 

workers, injection drug users, and women in defined geographic locations with a 

prevalence of HIV >1.0%);

 Multiple female partners.

3A-2. All uncircumcised adolescent and adult males who engage in heterosexual sex should be 

informed about the significant, but partial, efficacy of male circumcision in reducing the risk of 

acquiring HIV and some STIs through heterosexual sex, as well as the potential harms of male 

circumcision. 

o Men and male adolescents being counseled about male circumcision should be told 

that (see Box 1): 

 Male circumcision reduces, but does not eliminate, the risk of acquiring HIV 

and some STIs during penile-vaginal sex. In clinical trials, medically 

performed male circumcision was associated with reduced number of new 

herpes simplex virus type 2 (HSV-2) infections and reduced number of

oncogenic types of human papilloma virus (HPV) among circumcised men.

 Male circumcision has not been shown to reduce the risk of HIV or STIs

during oral or anal sex.

 Male circumcision has not been shown to reduce the risk of HIV transmission 

to female partners.

 After circumcision, men should not have sex until their health care provider 

has documented wound healing. 

o Uncircumcised, HIV-uninfected men and male adolescents at increased risk for HIV 

acquisition through heterosexual sex should be counseled about the risk and benefits 

of male circumcision (See Box 1). When a decision is made to undergo male 

circumcision, a referral for surgical consultation and access to high-quality male 

circumcision surgical services should be provided.

3B. Counseling men who have sex with men (exclusively)

Although it is biologically plausible that male circumcision could benefit MSM during insertive 

sex, no definitive data exist. Currently, there are no study results from RCTs including large 

enough numbers of MSM and results from observational studies are not conclusive among MSM 

overall or among MSM who practice exclusively insertive anal sex. For example, some 

epidemiologic data suggest that male circumcision provides partial protection for the insertive 

partner during penile-anal sex while other studies do not. In contrast, male circumcision provides 

no biologically plausible HIV risk-reduction benefit for the anal-receptive partner and receptive 

anal intercourse carries a substantially higher risk for acquisition of HIV than insertive anal sex. 
4

3B-1. Men who have sex with men should be informed that:

o The demonstrated benefits of male circumcision for HIV risk reduction apply to 

heterosexual (penile-vaginal) sex only.

o Male circumcision has not been proven to reduce the risk of acquiring HIV or other 

STIs during anal sex among men. 

o While some MSM may choose to be circumcised because of the potential to decrease 

risk for the insertive anal sex partner, male circumcision involves potential risks (see 

Adverse Events section of Box 1) and costs.

4. Counseling parents of male newborns, children, or adolescents

Health benefits and risks of elective neonatal, pediatric, or adolescent male circumcision should 

be considered in consultation with medical providers. In the case of discussion about neonatal 

circumcision, ideally such discussion should occur prior to the birth of the child. Ultimately, 

whether to circumcise a male neonate or child is a decision made by parents or guardians on 

behalf of their newborn son or dependent child. 

When counseling 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.

4-A. Parents and guardians should be informed about the medical benefits and risks of neonatal, 

pediatric, or adolescent medically performed male circumcision (see Box):

o During infancy, circumcised infants are less likely than uncircumcised infants to 

experience urinary tract infections (UTIs), although UTIs are uncommon during 

infancy. 

o Circumcised boys are less likely than uncircumcised males to experience balanitis

and balanoposthitis. 

o During adulthood, circumcised males are less likely than uncircumcised males to 

experience penile or possibly prostate cancer. 

o Other anticipated health benefits derive in part from future prevention of HIV and 

some STIs acquired through heterosexual sex. The risk for any individual neonate, 

child, or adolescent cannot be definitively defined at the time that a circumcision 

decision is made; for example, current risks for HIV and STIs, such as those for a 

particular individual’s racial/ethnic group or gender, may not remain constant in the 

future. 

o Considerations for the timing of male circumcision:

 Neonatal male circumcision is, safer, and heals more rapidly than circumcision 

performed on older boys, adolescent males, and men, and is less expensive.

 Most of the health benefits of male circumcision accrue after sexual debut.

 Male circumcision can also be conducted in adulthood when the individual can 

make the decision for himself. However, male circumcision after sexual debut 

could result in missed opportunities for:
5

 HIV and STI prevention during the window period between sexual 

debut and circumcision 

 Prevention of UTIs during infancy.

o The most commonly described complications of medically performed male 

circumcision in the United States are typically uncommon and easily managed. 

Severe complications are rare in all age groups.

 Among newborns and children age 1 to 9 years, most frequently reported 

complications include bleeding and inflammation of the penis or the need for

corrective procedures2.Complications occur in less than 1⁄2 % of infants, and in 

approximately 9% of children age 1 to 9 years15. 

 Among persons 10 years of age and older, the most frequently reported 

complications include those complications reported in younger children as well 

as wounds of the penis3. Complications occur in approximately 5% of persons in 

this age group

15

. There are not specific data about the frequency of complications 

in the adolescent age group (13-18).

o The American Academy of Pediatrics Taskforce on Circumcision states that the 

health benefits of newborn male circumcision outweigh the risks and that the benefits 

of newborn male circumcision justify access to this procedure for families who 

choose it9.

4-B. Medically performed neonatal, pediatric, or adolescent male circumcision should be done

by trained clinicians according to accepted standards of clinical care, with appropriate use of 

anesthesia.

Contributors: Division of HIV/AIDS Prevention, NCHHSTP, CDC

 

2

Corrective procedures Include repair of incomplete circumcision or removal of any attachments which may form 

after circumcision between the remaining foreskin and the head of the penis.

3

Any open wound of the penis without additional complications
6

References

1. Bailey RC, Moses, S., Parker, C. B., Agot, K., MacLean, I., Krieger, J. N., Williams, C. 

F. M., Ndinya-Achola, J. O. The protective effect of adult male circumcision against HIV 

acquisition is sustained for at least 54 months: results from the Kisumu, Kenya trial. 

XVIII International AIDS Conference; 2010; Vienna, Austria.

2. Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young 

men in Kisumu, Kenya: a randomised controlled trial. Lancet. Feb 24 

2007;369(9562):643-656.

3. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, 

controlled intervention trial of male circumcision for reduction of HIV infection risk: the 

ANRS 1265 Trial. PLoS medicine. Nov 2005;2(11):e298.

4. Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in 

Rakai, Uganda: a randomised trial. Lancet. Feb 24 2007;369(9562):657-666.

5. Sobngwi-Tambekou J, Taljaard D, Lissouba P, et al. Effect of HSV-2 serostatus on 

acquisition of HIV by young men: results of a longitudinal study in Orange Farm, South 

Africa. The Journal of infectious diseases. Apr 1 2009;199(7):958-964.

6. Tobian AA, Serwadda D, Quinn TC, et al. Male circumcision for the prevention of HSV2 and HPV infections and syphilis. The New England journal of medicine. Mar 26 

2009;360(13):1298-1309.

7. Auvert B, Sobngwi-Tambekou J, Cutler E, et al. Effect of male circumcision on the 

prevalence of high-risk human papillomavirus in young men: results of a randomized 

controlled trial conducted in Orange Farm, South Africa. The Journal of infectious 

diseases. Jan 1 2009;199(1):14-19.

8. American Urological Association. Circumcision. 2012; 

http://www.auanet.org/about/policy-statements/circumcision.cfm. Accessed 1/24/2013.

9. American Academy of Pediatrics Task Force on Circumcision. Circumcision Policy 

Statement. Pediatrics. Sep 2012;130(3):e756-785.

10. American Academy of Family Physicians. Position paper on neonatal circumcision. 

2007; 

http://www.aafp.org/online/en/home/clinical/clinicalrecs/guidelines/Circumcison.html. 

Accessed 1/25/2013.

11. Centers for Disease Control and Prevention. Estimated HIV incidence in the United 

States, 2007-2010. HIV Surveillance Supplementatl Report. 2012;17(4). 

http://www.cdc.gov/hiv/surveillance/resources/reports/2010supp_vol17no4/index.htm. 

Accessed 20 April 2013.

12. Smith DK, Taylor A, Kilmarx PH, et al. Male circumcision in the United States for the 

prevention of HIV infection and other adverse health outcomes: report from a CDC 

consultation. Public health reports. Jan-Feb 2010;125 Suppl 1:72-82.

13. Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention. 

Background, Methods, and Synthesis of Scientific Information Used to Inform the Draft: 

Recommendations for Providers Counseling Male Patients and Parents Regarding 

Elective Male Circumcision and the Prevention of HIV Infection and Other Adverse 

Health Outcomes. 2013.
7

14. Adimora AA, Schoenbach VJ, Martinson FE, et al. Heterosexually transmitted HIV 

infection among African Americans in North Carolina. JAIDS Journal of Acquired

Immune Deficiency Syndromes. 2006;41(5):616-623.

15. El Bcheraoui CZ, X.; Cooper, C. S.; Rose, C. E.; Kilmarx, P.H.; Chen, R. T. Rates of 

Adverse Events Associated with Male Circumcision in U.S. Medical Settings, 2001 –

2010. Pediatrics. 2013.

Box:

Health Benefits and Risks of Elective Medically Performed Male Circumcision

 Health benefits of elective male circumcision in adults and adolescents: 

o Male circumcision reduces the risk of acquiring HIV infection through penile-vaginal 

sex by 50-60%, as demonstrated in three well-conducted clinical trials among adult 

men living in sub-Saharan Africa.

o In clinical trials involving heterosexual males living in sub-Saharan Africa, male 

circumcision reduces the risk of some sexually transmitted infections. 

 HSV-2

4

: circumcised men were approximately 30%-45% less likely to acquire 

HSV-2 infection than were uncircumcised men. 

 HPV5: circumcised men were approximately 30% less likely to be infected with 

high-risk strains of HPV associated with cancers than were uncircumcised men. 

 Adverse events and risks associated with elective male circumcision of adults:

o For adult male circumcision performed by clinicians, the rate of adverse events is 

between 2% and 4%, with pain, bleeding, infection and unsatisfactory post-surgical 

appearance most commonly reported. While severe and/or long-term complications 

have been reported, they are so rare that they have not been precisely established. 

o Adult men who undergo circumcision generally report minimal or no change in 

sexual satisfaction or function.

 Health benefits of neonatal male circumcision:

o The estimated annual rate of urinary tract infections (UTIs) in uncircumcised male 

infants is 0.70%. Male circumcision reduces the risk for infant UTIs by about 80%.

o In the U.S., the estimated lifetime risk of penile cancer for males is about 1 in 1,400

(0.07%) and that of prostate cancer is about 15%. Neonatal male circumcision 

reduces the risk of penile carcinoma by about 90% and may reduce the risk of 

prostate cancer by 15% compared to men who are uncircumcised. 

 Adverse events and risks associated with neonatal male circumcision:

o Adverse events: For male circumcision performed by clinicians, 

 the rate of reported adverse events is as follows

 0.4% in infants (age through 12 mo.)

 9.1% in children (age 1-9 years)

 

4

HSV-2 = herpes simplex virus type 2

5

HPV = human papillomavirus
8

 5.3% in persons (age 10 years and older)

 Most commonly reported complications in all age groups include bleeding and 

inflammation of the penis, and correctional procedures6.

 The incidence of severe adverse events associated with male circumcision 

performed by clinicians, such as permanent disabilities, disfigurements, and 

death, is so low that rates have not been precisely established; these events 

have occurred, but are rare. Other major complications requiring intervention

including major bleeding, and severe infection are uncommon.

 

6

Frequently reported corrective procedures include repair of incomplete circumcision, lysis or excision of penile 

post-circumcision adhesions, and division of penile adhesions.