1

Background, Methods, and Synthesis of Scientific Information

Used to Inform the “Recommendations for Providers 

Counseling Male Patients and Parents Regarding Male 

Circumcision and the Prevention of HIV infection, STIs, and 

other Health Outcomes.”

Division of HIV/AIDS Prevention

National Center for HIV/AIDS, Viral Hepatitis, STD, TB Prevention

Centers for Disease Control and Prevention
2

Table of Contents

Introduction..........................................................................................................................4

Methods to gather, synthesize and interpret information.....................................................6

Summary of evidence .........................................................................................................7

Effect of male circumcision on health outcomes ........................................................7

Biological plausibility .............................................................................................7

Male circumcision and the risk of HIV infection acquisition..................................8

Male acquisition of HIV infection from female partners ...........................8

HIV infection transmission from circumcised men to female partners.....12

Male acquisition of HIV infection and other STIs from male partners....13

HIV transmission in other populations at high risk for HIV acquisition...15

Male circumcision and other health conditions ....................................................16

Sexually transmitted infections (STIs).......................................................16

Genital Ulcer Disease (GUD) .......................................................17

GUD (multiple types).... ...................................................17

Herpes Simplex Virus (HSV-2)........................................17

Treponema pallidum .........................................................18

Haemophilus ducreyi ........................................................18

Other STIs .....................................................................................19

Human Papilloma Virus (HPV) ........................................19

Trichomonas vaginalis ......................................................19

Chlamydia trachomatis .....................................................20

Neisseria gonorrhoeae ......................................................20

Penile and prostate cancers .......................................................................20

Cervical cancer in female partners of circumcised men ...........................21

Urinary tract infections in male infants ....................................................21

Other health conditions .............................................................................21

Health conditions for which male circumcision is indicated ....................22

Safety and risks associated with male circumcision .................................23

Effect of male circumcision on sexual function and penile sensation ......26

Considerations related to male circumcision in the United States ............................26

HIV infection in the United States ........................................................................27

Rates of male circumcision in the United States ...................................................28
3

Acceptability..........................................................................................................29

Acceptability of adult male circumcision in the United States .................29

Acceptability of adult male circumcision in sub-Saharan Africa .............30

Acceptability of newborn male circumcision in the United States............31

Acceptability of newborn male circumcision in sub-Saharan Africa ........32

Provider attitudes and practices regarding male circumcision in the United States

................................................................................................................................33

Cost-effectiveness .................................................................................................34

Other considerations .............................................................................................36

Risk compensation ....................................................................................36

Policy considerations regarding reimbursement .......................................38

Ethical considerations ...............................................................................39

References..........................................................................................................................40

Apendix. Abbreviations Used in This Report....................................................................56

Tables.................................................................................................................................57

Table 1. Reduction in risk of male HIV acquisition and male circumcision in 

randomized controlled trials ......................................................................................57

Table 2. Sumary of evidence on the risk of STI associated with male circumcision 

status in heterosexual populations .............................................................................58
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[This information is distributed solely for the purpose of pre-dissemination peer review under 

applicable information quality guidelines. It has not been formally disseminated by the 

Centers for Disease Control and Prevention. It does not represent and should not be 

construed to represent any agency determination or policy.]

Introduction 

Male circumcision is the surgical removal of some or all of the foreskin (or prepuce) 

from the penis1. Medically attended circumcision performed by health care professsionals

are voluntary, elective procedures that are preceded by an informed consent process. 

Male circumcision may also be performed as part of religious or cultural rites.

Circumcision is a very common procedure; it has been estimated that approximately onesixth of the world’s male population is circumcised2

. In the United States, overall rates of 

newborn male circumcision rose through much of the twentieth century, largely due to 

changing cultural norms, increased rates of childbirths in hospitals, and a perception that 

male circumcision was more hygienic3. Personal decisions about circumcision are 

influenced by information about the preventive health benefits, safety and risk of the 

procedures as well as ethical, religious, cultural, familial, and economic considerations. 

Until recently, prevention of human immunodeficiency virus (HIV) infection was 

unlikely to factor in the decision to circumcise a male newborn or boy, although other 

preventive health benefits of male circumcision may have been considered.

However, data now indicate that male circumcision reduces the risk of male HIV 

acquisition through penile-vaginal sex. Although results from randomized controlled 

trials (RCTs) provide the strongest level of evidence, we describe data from both RCTs 

and observational studies. Observational studies are often conducted due to cost or other 

barriers to conducting RCTs, and may in some cases be the only feasible methodology 

for studying particular health outcomes, such as cancer. The results of three randomized 

controlled trials (RCTs) of voluntary male circumcision involving more than 10,000

HIV-negative men in settings in sub-Saharan Africa with predominantly heterosexual 

HIV transmission demonstrated 50-60% reductions in HIV incidence4-6in the study 

population. In the two trials for which data are available, reductions in the incidence of 

herpes simplex virus type 2 (HSV-2) and the prevalence of high-risk oncogenic human 

papillomavirus (HPV) were also demonstrated7-9. Observational studies indicate that male 

circumcision is likely to be associated with other health benefits as well, such as reduced 

rates of other sexually transmitted infections (STIs) in men and their female partners, 

reduced risk of penile and cervical cancer, and reduced rates of infant urinary tract 

infections (UTIs). Risks potentially associated with male circumcision include surgical 

adverse events, the possibility of adverse effects on sexual sensation and function, and 

possible behavioral risk compensation (increased risk behavior because of perception of 

decreased risk). In February 2007, the World Health Organization (WHO) and the Joint 

United Nations Programme on HIV/AIDS (UNAIDS) jointly recommended that male 

circumcision be recognized as an additional important intervention to reduce heterosexual 

acquisition of HIV infection among men in settings with high HIV prevalence and low 

male circumcision rates10.
5

There are both inherent limitations and strengths to be considered when describing the 

generalizability of the results of the African RCTs to the United States. In the United 

States, the prevalence of HIV and the lifetime risk of HIV infection are generally much 

lower than that in sub-Saharan Africa; 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. Despite these overall differences, the 

results of African trials are likely to have application to HIV prevention efforts in the 

United States. The United States differs epidemiologically from regions targeted by the 

WHO/UNAIDS recommendations and the sub-Saharan African areas in which the 

randomized trials were conducted in that the overall prevalence of HIV infection and the 

risk of HIV acquisition are considerably lower. However, there exist geographic areas 

and subpopulations in the United States with HIV incidence comparable to that of subSaharan African countries. Furthermore, studies have demonstrated efficacy in 

preventing male acquisition of HIV only for penile-vaginal sex, the predominant mode of 

sexual HIV acquisition among men in Africa. Although the predominant mode of sexual 

HIV acquisition among men in the United States is by penile-anal sex among men who 

engage in male-to-male sexual contact, one in every ten estimated new HIV infections in 

the United States are attributed to female-to-male sexual transmission11. In addition, 

although most American men are circumcised, African-American and Hispanic men, the 

men with the highest rates of HIV-infection are known to be significantly less likely to be 

circumcised compared to white, non-Hispanic men. Thus, 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. In light of recent decreases in neonatal male circumcision rates in the U.S., 

it remains to be seen whether men at higher risk for heterosexual acquisition of HIV 

would be willing to undergo circumcision, or whether parents would be willing to have 

their newborns circumcised to reduce possible future HIV and sexually transmitted 

infection (STI) risk.

This document presents a summary of data on the associated preventive health benefits, 

safety, and risks of the procedure and acceptability, provider attitudes, access and costeffectiveness of male circumcision, ethical considerations, and examines these data in the 

context of the United States. Data from other countries are included to inform the U.S. 

experience, particularly where data are lacking in the U.S. or for comparison purposes. 

This background document was used to inform the development of recommendations for 

providers counseling male patients and parents regarding the role of male circumcision as 

a prevention strategy1. CDC has developed recommendations to help ensure that persons 

considering undergoing male circumcision or parents of newborn boys considering male 

circumcision for their infants have the best possible public health information to guide 

those decisions. Factors such as social, cultural, religious, and ethical considerations also 

play an important role for some people.

 

1 The draft recommendations are available for public comment at www.regulations.gov. Locate document 

by placing docket no. “CDC-2014-0012” in search window.
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Methods to gather, synthesize and interpret information

A two-day symposium to discuss medically attended male circumcision in the United 

States was held on April 26-27, 2007. It included a face-to-face meeting of external 

partners and a broad range of subject matter experts, including clinicians, academicians, 

and public health practitioners to obtain input on the potential role of male circumcision 

in preventing transmission of human immunodeficiency virus in the U.S.12. A systematic 

Medline search was conducted and relevant literature describing male circumcision for 

the prevention of HIV and policy statements regarding male circumcision were

distributed to participants in advance of the meeting. Views on the benefits of male 

circumcision, as well as risks and adverse effects, were presented by meeting participants

to obtain input on the potential role of male circumcision in the United States. 

Participants examined scientific evidence to assess the relevance of male circumcision to 

the HIV epidemic in the United States and explored factors such as potential costeffectiveness, cultural, ethical and safety concerns, and integration with existing 

prevention methods. The questions posed to the participants, the resulting working group 

proposals, and names of participants in this symposium have been described12.

For this document, a systematic literature review was conducted in order to assess quality

of evidence to data on the association of male circumcision with medical benefits and 

adverse effects. Systematic reviews were conducted for the following outcomes related to 

medically attended male circumcision: HIV acquisition and transmission (female-tomale, male-to-female, and male-to-male); other STIs; penile cancer; cervical cancer; 

infant UTIs; risks and adverse events; sexual function and penile sensation. All studies of 

outcomes of male circumcision up to the end of November 2012 in Medline, Embase and 

Cochrane Library, as well as citation lists were included. More recent data through March 

2013 were included in updating data related to the HIV epidemic in the United Statates. 

Studies were restricted to those published in English after 1950, presenting original data, 

including RCTs, cohort studies, case-control studies, cross-sectional studies, case series 

and case reports. Study design was classified according to guidelines used for collecting 

scientific data in reports published in the Guide to Community Preventive Services (the 

Guide)

13

. The evidence was assessed according to strength of association, consistency of 

findings across studies and the methodologic rigor of study designs13-15. Because they 

eliminate spurious causality and bias, RCTs were considered the most rigorous method 

for determining whether a cause-effect relationship exists between a treatment and an 

outcome. Our literature review through November 2012 also included a broad, nonsystematic narrative review for the section Considerations related to male circumcision 

in the United States, because this section did not evaluate clinical outcomes. 

In formulating the recommendations, available evidence from the literature review was 

considered together with suggestions made at the 2007 symposium12 in addition to 

numerous comments from the public that were received and reviewed. A subcommittee 

of the CDC Public Health Ethics Committee (PHEC) reviewed the recommendations and 

provided guidance on ethical issues related to elective male circumcision. None of the 

primary authors of these recommendations reported a financial or other conflict of 
7

interest. These recommendations will be updated as needed based on availability of 

relevant significant new information.

Summary of evidence

Effect of male circumcision on health outcomes 

This section describes the evidence base about the biological plausibility; results of 

randomized clinical trials and observational studies, including meta-analyses; on the 

effect of male circumcision on acquisition of HIV and STIs. It also describes study 

results about the frequency of penile and prostate cancers among circumcised men, 

cervical cancer in female partners of circumcised men, urinary tract infections in 

circumcised infants, and other associated health risks, including effect on sexual function 

and penile sensation. 

Biological plausibility 

The foreskin can serve as a portal of entry for STIs (including HIV), lending biological 

credibility to the role of circumcision in preventing STI and HIV acquisition through 

insertive sexual intercourse16. The likely mechanism of increased susceptibility 

associated with an intact foreskin involves both histopathological and anatomic factors, 

as well as the interaction between HIV and other STIs. 

Compared to the dry external skin surface of the glans penis and the penile shaft, the 

inner surface of the foreskin is less keratinized. This may allow easier access to the 

epithelial cells of the epidermis and dermis (in which STIs such as HPV and HSV-2

replicate) as well as access to target cells for HIV infection16, 17. In some laboratory 

studies, foreskin tissue has been shown to be more susceptible to HIV infection than 

keratinized epithelium18,

19 although some studies have failed to show any difference in 

the ability of HIV to penetrate inner compared to outer foreskin surface20. Furthermore, 

the inner surface contains higher density of HIV target cells, such as Langerhans cells

close to the skin surface21-24, and in men with a history of recent STIs, the number of 

target cells in the prepuce is increased22. The fact that the size of foreskins excised from 

965 men enrolled in the Rakai Community Cohort Study25 significantly correlated with 

HIV incidence rates may be explained by the hypothesis that surface area would be 

associated with more resident HIV immune cells such as Langerhans cells, CD4+ T cells, 

CD8+ T cells, and macrophages and therefore greater rates of HIV transmission26.

However, the precise role of Langerhans cells is not fully understood27-29. 

Because the inner surface of the foreskin is lightly keratinized, it may be relatively 

susceptible to traumatic epithelial disruptions during intercourse, providing a portal of 

entry for pathogens16. Furthermore, the foreskin retracts away from the glans and over the 

shaft of the penis during intercourse, which exposes this surface to the body fluids of the 

sex partner21. It has been postulated that the foreskin may serve as a reservoir for sexually 

transmitted pathogens, since the micro-environment in the preputial sac between the 

unretracted foreskin and the glans penis may be conducive to viral survival, thereby 
8

increasing contact time of these infectious agents with penile tissues18. The anoxic 

microenvironment of the preputial sac may support pro-inflammatory anaerobes that can 

activate Langerhans cells to present HIV to CD4 cells in draining lymph nodes

30

. 

Investigators determined that uncircumcised compared to circumcised males had higher 

rates of ‘wetness’ around the glans or coronal sulcus and that higher degrees of ‘wetness’ 

were associated with higher rates of HIV infection31. Among male attendees at an STD 

clinic in Durban, South Africa, men with any level of penile wetness compared to men 

with no wetness had HIV seroprevalences of 66.3% and 45.9% , respectively. 

Langerhans cells and CD4+T cells in the inner foreskin are significantly more responsive 

to certain inflammatory cytokines than those in the outer foreskin. This may suggest that 

immune cells of the inner foreskin more easily respond to infectious and other exposures

resulting in increased viral susceptibility of the inner foreskin26, 32.

HIV infection and other STIs, which independently may be more likely in uncircumcised 

men, interact synergistically to increase acquisition risk33-37. Infection with ulcerative 

STIs such as HSV-2 has been associated with increased risk of HIV infection in 

observational studies35, 38, 39; this risk was 3-fold in a recent meta-analysis40. In the South 

African trial, the authors estimated that approximately 28% of incident HIV cases were 

attributable to HSV-2 seropositivity or acquisition7. Proposed mechanisms of increased 

susceptibility include breaches in the mucosal barrier and increased susceptibility of 

tissue due to inflammation, or increasing HIV target cells associated with inflammation

17

. 

Synergistically, HIV seropositivity may increase the risk for new STIs

35, 41, although 

some studies have failed to find such an association42. 

Male circumcision and the risk of HIV infection acquisition

Male acquisition of HIV infection from female partners

Three RCTs have been undertaken in sub-Saharan Africa to determine whether 

circumcision of adult males will reduce their risk for HIV infection (Table 1)4-6. The 

randomized, controlled follow-up in all three studies was stopped early when interim 

analyses demonstrated that circumcision by a clinician significantly reduced male 

participants’ risk of HIV infection. The control group was then offered circumcision, as it 

was determined to be unethical not to offer them circumcision. In intent-to-treat analyses, 

men who had been randomly assigned to the circumcision group had a 60% (South 

Africa), 53% (Kenya), and 51% (Uganda) lower incidence of HIV infection compared to 

men assigned to the group to be circumcised at the end of the study. In all three studies, 

some of the men who had been assigned to be circumcised did not undergo the procedure, 

and vice versa. Non-compliance with assigned study group may mean that the intentionto-treat analyses underestimated the potential benefit of circumcision. When the data 

were reanalyzed to account for these crossovers, men who had been circumcised had 76% 

(South Africa), 60% (Kenya), and 55% (Uganda) reductions in risk of HIV infection 

compared to those who were not circumcised4-6. However, it should be noted that astreated analyses may be considered biased. 
9

The Ugandan RCT included male participants 15 years of age or older6. Among all men 

15 – 49 years at 24 months of follow-up there was a 51% lower HIV incidence in 

circumcised compared to uncircumcised males. However, the reduction in HIV 

acquisition rate did not vary significantly by age group. 

The protective effect of male circumcision appears to be durable. In a rigorous metaanalysis of the three RCTs, the overall relative risk reduction of acquiring HIV using the 

intent-to-treat data was 50% at 12 months and 54% at 21 or 24 months following 

circumcision43. With 42 months of follow-up, a 64% reduction in HIV infection risk was 

seen in circumcised men compared to uncircumcised men. As of March 2010, results of 

longer-term follow-up of 54 months from the Kenya RCT indicate a 63% (46, 75) 

reduction in HIV infection risk in circumcised men compared to uncircumcised men44, 

similar to a 64% reduction at 42 months 45 and 60% reduction at 24 months5. Also, more 

recently, during 4.79 years of trial surveillance of participants in the Rakai randomized 

trial of male circumcision, investigators found that the overall HIV incidence was 

0.50/100 person-years and 1.93/100 person-years in circumcised men and uncircumcised 

men, respectively (adjusted effectiveness 73% [95% confidence interval (CI) 55–84%])46. 

The HIV prevention effectiveness in the post-trial observational study was not 

statistically significantly different to that of the as-treated effectiveness of circumcision 

observed during the randomized trial. 

International observational studies also indicate that male circumcision is associated with 

lower rates of HIV47, 48, although some cross-sectional studies conducted in general 

populations have failed to find an association between circumcision status and HIV-1

49-51

.

A systematic review and meta-analysis of 28 studies that focused on heterosexual 

transmission of HIV in Africa was published in 200047. It included 19 cross-sectional 

studies, five case-control studies, three cohort studies, and one partner study. In the 

overall pooled unadjusted analysis, a substantial protective effect of male circumcision on 

risk for HIV infection was noted, with a 48% reduction in risk for HIV infection among 

circumcised compared to uncircumcised men[pooled RR = 0.52, 95% confidence interval 

(CI) 0.40-0.68. P <0.001]. In addition, in three of four studies which were adjusted for 

other factors, including history of current or previous genital ulcer disease (GUD), an 

additional 1-6% risk for HIV infection was noted suggesting that a greater protection 

against HIV transmission is associated with male circumcision in populations with more 

prevalent GUD. After adjusting for confounding factors in the population-based studies, 

the relative risk for HIV infection was 44% lower in circumcised men compared with 

uncircumcised men. The strongest association was seen in men who were most likely to 

be exposed to HIV, such as patients at sexually transmitted disease (STD) clinics, for 

whom the adjusted relative risk was 71% lower for circumcised men. 

Prior to the completion of randomized clinical trials, another review was conducted that 

included stringent assessment of 10 potential confounding factors and was stratified by 

study type or study population48, 52 and included 37 studies48, including 18 studies (1 

cohort, 16 cross-sectional, and 1 case-control) conducted in the general population and 19 

studies (4 cohort, 12 cross-sectional, and 3 case-control) conducted in high risk 

populations. Most of the studies were from Africa. Of the 37 studies included in the 
10

review48, the 18 studies conducted in general populations had inconsistent results, 

whereas the 19 studies conducted in high-risk populations found a consistent, substantial 

protective effect, which increased with adjustment for confounding. Of the 18 studies in 

the general population, the single cohort study showed a benefit of male circumcision

(OR=0.58, 95% CI 0.36-0.96), the case-control study found no significant difference 

(OR=1.90; 95% CI 0.50-7.20), and the 16 cross-sectional studies had varying results 

including ten studies indicating a beneficial effect of male circumcision and six indicating 

a harmful effect (ORs ranging from 0.21-1.73). Of the eight cross-sectional studies with 

statistically significant findings, six indicated a benefit and two indicated harm. The one 

large prospective cohort study conducted in the general population, including 5,507 HIVnegative Ugandan men, and 187 HIV-negative men in discordant relationships, showed a 

significant protective effect, with 42% lower odds of acquisition of HIV infection among

circumcised men53. Among serodiscordant couples, in a substudy of this cohort, none of 

50 circumcised men with HIV-infected female partners seroconverted, whereas there 

were 40 incident cases among 137 uncircumcised men with HIV-infected female 

partners53, 54. The 19 studies conducted in high-risk populations in this review 48were in 

better agreement than the 18 studies in the general population, finding a consistent, 

substantial protective effect. All four cohort studies indicated a beneficial effect from 

male circumcision, including three with statistically significant results with point 

estimates from crude odds ratios (ORs) varying from 0.10 to 0.39. Eleven of the 12 

cross-sectional studies indicated a benefit of male circumcision, including eight which 

were statistically significant with ORs of 0.10 to 0.66. Of the five cross-sectional studies 

reporting adjusted ORs, these ranged from 0.20-0.59. Among the three case-control 

studies in high risk populations, all indicated a protective effect of circumcision on HIV 

status, including two which were statistically significant with ORs ranging from 0.37 to 

0.88.

A more recent meta-analysis of 13 studies, which included RCTs in addition to cohort

and case control studies, found a 58% reduced risk for HIV infection among circumcised 

men (overall risk ratio [RR], 0.42; 95% confidence interval [CI] 0.33-0.53) and 

determined that the studies met criteria for causality between lack of circumcision and 

HIV-1 infection55. 

At least one study has examined the association of male circumcision in reducing HIV 

acquisition in the context of other STI infections. In a randomized trial studying the role 

of genital ulcer disease (GUD) and HSV-2 in the protection against HIV associated with 

male circumcision in Rakai, Uganda, male circumcision significantly reduced the risk of 

HIV acquisition in HSV-2 seronegative men (incidence rate ratio [IRR] = 0.34, 95% CI 

0.15–0.81). There were 11.2% and 8.6% reductions in HIV acquisition mediated by 

reductions in symptomatic GUD (95% CI 5.0–38.0) and HSV-2 incidence, respectively. 

In Kenya, male medical circumcision did not affect HSV-2 incidence and GUD and 

HSV-2 did not impact the protective effect of male medical circumcision against HIV56.
11

Ecologic studies also demonstrate a strong association between lack of male circumcision 

and HIV infection at the population level. Although links between male circumcision, 

culture, religion, and risk behavior likely account for some of the differences in HIV 

infection prevalence, the countries in Africa and Asia with prevalence of male 

circumcision of less than 20% have HIV-infection prevalence several times as high

(seroprevalence range: 0.24 – 25.84) than countries in those regions where more than 

80% of men are circumcised (seroprevalence range: 0.03-11.64)57. 

The question of whether resumption of sexual intercourse soon after adult male 

circumcision affected HIV risk was examined in a combined analysis of data from the 

three RCTs, limited to HIV-negative men who were randomized to and underwent 

circumcision58. Early sex (intercourse <42 days after circumcision) was reported by 3.9% 

of participants in Kenya, 5.4% in Uganda, and 22.5% in South Africa. In all 3 trials, early 

resumption of sex was reported more often among men who were married or living as 

married. In pooled analyses, circumcised men reporting early sex did not have higher 

HIV infection rates at 3 or 6 months than circumcised men who did not have early sex. 

The RCTs in Africa and numerous observational studies have demonstrated that male 

circumcision reduces the risk for female-to-male transmission of HIV. Careful 

consideration is required to apply these findings to the U.S. context, given differences in 

HIV epidemics59, 60. In contrast to the sub-Saharan African countries where the clinical 

trials were conducted, the United States has a low population prevalence of HIV infection 

(0.4%)61, with ~50,000 new cases annually since the mid-1990s and an epidemic that has 

been concentrated among men who have male-to-male sexual contact (men who have sex

with men [MSM] and men who have sex with men and women) rather than men who 

have sex with women11, 62, 63. While no RCTs have been conducted in the United States, 

a similar magnitude of risk-reduction benefit of circumcision would likely apply to U.S. 

men engaged in penile-vaginal sex. However, the population effect would be less 

pronounced in the United States compared to sub-Sharan Africa due to the smaller

proportion of cases among men acquired through heterosexual sex in the United States. 

Few U.S. studies have evaluated the effect of male circumcision for preventing 

heterosexually acquired HIV infection. Two published observational studies have 

reported on the association between circumcision and the risk of HIV infection in the 

United States among male patients attending STD clinics37, 64. While the first study

suggests that being uncircumcised might be associated with increased HIV risk, the 

finding was limited by small sample size and not statistically significant. The more recent 

study was a cross-sectional evaluation conducted among heterosexual African American

men attending STD clinics in Baltimore, with an overall HIV seroprevalence of 3%64.

Among approximately 40,000 visits by patients with unknown HIV exposure, male 

circumcision was not associated with reduced HIV prevalence. However, among 394 

visits by men who had female sexual partners who were known to be infected with HIV, 

male circumcision was significantly associated with a 51% reduced relative prevalence of 

HIV infection (10.2% among circumcised men vs. 22.0% among uncircumcised men).
12

HIV infection transmissionfrom circumcised men to female partners

Studies on the effect of male circumcision on HIV transmission from male partners to 

female partners have shown mixed results. Some observational studies suggest a benefit,

while a randomized prospective study failed to demonstrate one. In a study of 

serodiscordant couples in Uganda in which the male partner was HIV infected and the 

female partner was initially HIV-negative, the infection rates of the female partners 

differed by the male circumcision status and viral load of their male partners. If the HIV 

viral load in the blood of the male partner was <50,000 copies/mL, there was no HIV 

transmission if the man was circumcised, compared to a rate of 9.6 per 100 person-years 

if the man was uncircumcised53. For all male partners, regardless of viral load, the maleto-female transmission rate from circumcised men was somewhat lower than that from 

uncircumcised men, but this was not statistically significant. Such an effect may be due to 

decreased viral shedding from circumcised men or to a reduction in ulcerative STIs 

acquired by female partners of circumcised men65. In a another study of heterosexual 

serodiscordant couples from 7 sites in eastern Africa and 7 sites in southern Africa, in 

which the HIV-infected partner was also infected with HSV, 1,096 couples had a male as 

the HIV-infected partner. Adjusting for male partner plasma HIV-1 concentrations, 

female partners of circumcised men compared to those with partners of uncircumcised 

men retained a non-statistically significant 40% reduced risk of HIV-1 acquisition (HR 

0.60, 95% CI 0.31-1.16, p=0.13, for genetically-linked events). After also excluding 

follow-up time occurring after male partners initiated antiretroviral therapy, the risk of 

HIV acquisition decreased by a non-statiscially significant 47% (HR 0.53, 95% CI 0.26-

1.07, p=0.07, for genetically-linked events)66. Other observational studies have evaluated 

the effect of male circumcision on HIV risk to women without limiting the participants to 

serodiscordant couples. In a prospective study among 2,471 HIV-uninfected women in 

Tanzania, having an uncircumcised husband was associated with a significantly increased 

risk of HIV acquisition (age-adjusted relative risk, 3.60; 95% CI, 1.12–11.59)67.

Similarly, in a cross-sectional case-control study of 4,404 women in Kenya, having a 

regular sex partner who was uncircumcised was associated with an odds ratio (OR) of 2.9 

(95% CI 2.0-4.2) of being HIV infected68. However, another observational study from 

Uganda found that after adjustment for other risk factors, male circumcision of the 

primary sex partner was not associated with women's risk for HIV infection69. 

Finally, an RCT in Rakai, Uganda among HIV-infected men failed to demonstrate benefit 

to female partners. In this trial, 922 uncircumcised, HIV-infected men were randomly 

assigned to immediate or delayed circumcision. HIV-negative female partners were 

concurrently enrolled70. Overall, 18% of women in the intervention group and 12% of 

women in the control group acquired HIV during follow-up (HR 1.58; 95% CI 0.68-

3.66). In a subanalysis not specified in the protocol, 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). These results suggest an increased risk for HIV acquisition with early 

resumption of sex after male circumcision. However, 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 1.2; 95% CI 0.39-3.73). 
13

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 populations71. The meta-analysis of data from 

the one RCT and six longitudinal analyses showed little evidence that male circumcision 

directly affects the risk of HIV in women (RR 0.80, 95% CI 0.53-1.36).

More recent estimates of the effect of male circumcision on male-to-female transmission 

were calculated using two mathematical models representing the HIV epidemics in 

Zimbabwe and Kisumu, Kenya, based on four trials of circumcision among adults and 

new observational data of HIV transmission in stable partnerships from men circumcised 

at younger ages. According to these models, it is estimated that male circumcision may 

confer a 46% reduction in the rate of male-to-female HIV transmission72. 

Whether or not circumcision of HIV-infected men directly reduces HIV risk for their 

female partners, male circumcision of HIV-negative men offers benefit to women to the 

extent that it contributes to a decline in the overall prevalence of HIV in the male 

population, and thus fewer HIV-infected sexual partners73. 

Male acquisition of of HIV and other STIs from male partners

HIV transmission. The RCTs demonstrating HIV risk reduction associated with male 

circumcision were conducted in settings in which most HIV transmission is through 

heterosexual sex and apply to men engaging mainly in insertive penile-vaginal sex74-76. 

Only 6 (0.2%) trial participants reported having had male-to-male sexual relations in the 

one RCT in which this history was collected 74. To date, the data on male circumcision 

and rates of HIV acquisition among men who have male-to-male sexual contact have 

been limited to observational studies. No prospective trial of male circumcision for 

reducing HIV risk among MSM has been conducted, although such studies have been 

proposed77. 

Some observational studies have shown higher rates of HIV acquisition among 

uncircumcised MSM compared with circumcised MSM. When controlling for the

number of male sex partners and having had unprotected sex with an HIV-positive 

partner, circumcision was associated with 2-fold decreased odds of prevalent HIV 

infection (adjusted odds ratio [aOR] 0.5; 95% CI 0.25-1.0) in a vaccine preparedness 

cohort followed from 1995 to 1997 78. Self-reported circumcised status was associated 

with a two-fold decreased odds of prevalent HIV infection (aOR 0.5; 95% CI 0.25-1.0) in 

a cross-sectional survey of MSM in Seattle in the early 1990s79, and the odds of being 

HIV infected were 5-fold lower among circumcised men in a cross-sectional survey of 

MSM in Soweto in 2008 (aOR 0.2; 95% CI 0.1-0.2)80. However, other observational 

studies have failed to show a benefit (or risk) of male circumcision. In a cross-sectional 

survey of black and Latino MSM in New York City, Los Angeles and Philadelphia, there 

was no evidence that being circumcised was protective against HIV infection, even 

among men who had reported engaging in unprotected insertive but not unprotected 
14

receptive anal sex81. Also, in a retrospective analysis of male circumcision status and risk 

for HIV among MSM participants in a vaccine trial, no association was found, even 

among primarily insertive partners82. Similarly, no association was found in a study of 

MSM in Seattle83, 84, or in an Australian study of MSM85. However, a subsequent 

prospective study of MSM in Australia did report a significantly reduced HIV infection 

risk in circumcised men who reported engaging primarily in insertive anal sex (HR 0.11;

95% CI 0.03–0.80)86. The authors noted that because more infections were associated 

with receptive intercourse, lack of male circumcision may have accounted for only 9% of 

the infections in the study overall. A study of Andean men reported similar results: 

circumcision was not protective overall, but was protective among men who reported 

mainly insertive intercourse87.

The presumed mechanism of decreased HIV acquisition among circumcised men

engaging in penile-vaginal sex is through decreased HIV entry and infection through 

target cells on the foreskin. Thus, if there is an HIV prevention benefit to circumcision 

for MSM, it is likely to accrue during insertive acts. Furthermore, the relative risk of HIV 

infection per sex act may be higher for insertive penile-anal sex than for penile-vaginal 

sex, due to higher HIV RNA concentrations in rectal secretions relative to vaginal or 

cervical secretions88, lending plausibility to a benefit of circumcision for MSM when 

engaged in insertive anal sex. However, the risk of HIV acquisition among MSM 

engaging in penile-anal sex is greater for the anal receptive partner, than for the insertive 

partner89, 90. Additionally, relatively few MSM are exclusively insertive. Although not 

well studied, in some settings many or most MSM practice both insertive and receptive 

sex. In the limited studies conducted in the United States, approximately half of men selfidentify as versatile partners (men who practice both insertive and receptive anal sex) and 

one quarter each identify as engaging either predominantly in insertive or predominantly 

receptive anal intercourse91. In another study, substantial proportions of partners who 

self-identified as predominantly insertive also report practicing receptive anal 

intercourse92. Engaging in unprotected receptive sex would dilute whatever risk-reduction 

benefit might be associated with being circumcised while engaging in insertive sex.

A recent Cochrane review of 21 observational studies including 71,693 participants

related to male circumcision in MSM indicated that there is a potential benefit of male 

circumcision in prevention of HIV transmission among MSM, however the evidence does 

not support making a recommendation for male circumcision in this population93. More 

specifically, the overall pooled effect estimate for HIV acquisition involving 20 studies 

and 65,784 participants was not statistically significant (OR 0.86, 95% CI 0.70 to 1.06) 

and showed significant heterogeneity (I2=53%). However, there were differing results in 

subpopulations based on having an insertive versus receptive role in MSM sexual 

relations. The results were statistically significant among 3,465 men in 7 studies 

reporting an insertive role (OR 0.27, 95% CI 0.17 to 0.44; I2=0%), but were not 

significant among 1,792 men in 3 studies reporting a receptive role (OR 1.20, 95% CI 

0.63 to 2.29; I2 = 0%). Male circumcision was not significantly associated with the 

following STIs: syphilis (34,999 men, 8 studies; OR 0.96, 95% CI 0.82 to 1.13, I2 = 0%),

herpes simplex virus 1 (2 studies, 2740 participants; OR 0.90, 95% CI 0.53 to 1.52; 

I2=0%), or herpes simplex virus 2 (5 studies; 10,285 participants; OR 0.86, 95% CI 0.62 
15

to 1.21; I2=0%). The overall quality of evidence based on the Grading of 

Recommendations Assessment, Development and Evaluation (GRADE) system was 

low94.Thus, while there is biological plausibility and evidence from some studies to 

suggest a reduced risk for HIV infection in circumcised men as compared with 

uncircumcised men engaging in insertive anal sex with an HIV-infected male partner, 

other well-conducted observational studies do not indicate a protective effect, either in 

predominately insertive MSM, or overall among MSM. And, because of the greater risk 

of receptive anal sex, the role of male circumcision as a public health intervention to 

prevent HIV transmission among MSM appears limited based on current data.

HIV or other STI. A meta-analysis of unpublished as well as published data from 15 

studies that quantitatively examined the association between male circumcision and HIV

and other STI among MSM found little overall effect95. Among a total of 53,567 MSM 

participants, 52% of whom were circumcised, the overall weighted odds of being HIVpositive was slightly less than one among circumcised versus uncircumcised MSM (OR 

0.95; 95% CI 0.81-1.11). There was also no significant association when stratified by 

study type (e.g., cross-sectional, prospective) or when limited to MSM who reported 

engaging exclusively in insertive anal sex. However, in three studies completed before 

the introduction of highly active antiretroviral therapy, male circumcision was protective 

against HIV (OR 0.47; 95% CI 0.32-0.69). No overall association was found between 

male circumcision and other STIs among MSM96. 

A subsequent U.S. Internet-based survey with 26,257 respondents also found that 

circumcision status did not significantly predict HIV serostatus or most STI diagnoses 

(syphilis, gonorrhea, chlamydia, HPV). Being uncircumcised was predictive of HSV-2 

diagnosis in this study; however, condom use mediated this relationship, as circumcision 

was associated with higher rates of condom use96.

STI. An observational study of MSM in Australia found that male circumcision was not 

associated with prevalent or incident HSV-1, HSV-2, self-reported genital warts, or 

incident urethral gonorrhea or chlamydial infection97. Being circumcised was associated 

with a significantly reduced risk of incident (HR 0.35 [95% CI, 0.15-0.84]) but not 

prevalent (OR 0.71 [95% CI, 0.35-1.44]) syphilis. 

HIV transmission in other populations at high risk for HIV acquisition

Presumably, the mechanism through which male circumcision affects the rates of HIV 

acquisition is through insertive sex. Thus, there is no plausible reason why male 

circumcision would directly affect the HIV risk from other exposures, such as injection 

drug use, transfusions, health-care related occupational exposure, or vertical (motherchild) transmission. 
16

Male circumcision and other health conditions

In addition to studies of male circumcision related to HIV acquisition, the following 

sections review other studies exploring the association between male circumcision and 

other health conditions including STIs (other than HIV), penile and prostate cancer, 

cervical cancer in female partners of circumcised men, urinary tract infections in infants, 

and other associated health risks, including effect on sexual function and penile sensation.

Sexually transmitted infections (STIs)

Male circumcision has been shown to reduce the risk for some other STIs in addition to 

HIV. The effect of male circumcision on susceptibility to other STIs has been assessed in 

a number of observational studies in men who have sex with women98, 99. Results from 

these studies have been mixed but suggest that male circumcision is associated with 

lower risk for some STIs. More recent data from the male circumcision RCTs show that 

circumcision is significantly associated with decreased incidence of herpes simplex virus

type 2 (HSV-2)7, 8, 100, and decreased prevalence of oncogenic types of HPV8, 9in 

circumcised men (Table 2). The trials provide evidence that male circumcision may 

reduce genital ulcer disease confirmed on physican exam

56

, self-reported GUD in men76,

as well as female genital ulceration and some vaginal infections (bacterial vaginosis [BV] 

and trichomoniasas) in female partners101. The trials did not show any association 

between male circumcision status and gonorrhea100, 102 and showed only weak evidence 

for protection against chlamydial infection100. In the one trial in which it was assessed, 

no association was found with syphilis8, although syphilis had been strongly associated 

with lack of male circumcision in observational studies99. 

Although rarely fatal, STIs other than HIV are among the most common communicable 

diseases in the United States, and interventions that prevent STIs would result in 

substantial reductions in morbidity and cost of health services. Most STIs are 

asymptomatic and the most prevalent STIs are not reportable in the United States; thus,

the incidence of these infections must be estimated. The most recent estimate is that 19.7

million new STIs were acquired in the United States in 2008, including infections with

Trichomonas vaginalis (1.1 million), HPV (14.1 million), Chlamydia trachomatis (2.9

million), HSV-2 (776,000), Neisseria gonorrhoeae (820,000), and Treponema pallidum

(55,400)103. Data on male circumcision and STIs in MSM are summarized above in the 

section “Male-to-male transmission.”

Rates of STIs differ in the United States compared to sub-Saharan Africa. Thus, it is 

important to assess the magnitude of the incremental benefit of male circumcision on 

HIV infection due to its protective effect against other STIs. In a dynamic stochastic 

model, Boily and authors concluded that the protection of male circumcision against STIs 

contributes little to the overall effect of circumcision on HIV104. Analyses of the RCTs 

confirmed this result7, 105, suggesting that differing rates of other STIs should not be a 

major concern in generalizing the HIV prevention results of the RCTs from one setting to 

another.
17

Genital Ulcer Disease (GUD). Male circumcision is associated with a reduction 

of HSV-2 and GUD in randomized controlled trials and a reduction of GUD due to 

syphilis or chancroid in observational studies. 

GUD (various types). There is evidence of an association of reduction in 

GUD with male circumcision in two RCTs. In the Kenyan RCT, male 

circumcision was associated with a reduction in GUD (risk ratio = 0.52; 95% CI 

0.37 – 0.73)56. This reduction occurred regardless of HSV-2 status. Male 

circumcision significantly reduced symptomatic GUD in HSV-2-seronegative 

men [Prevalence Rate Ratio (PRR) = 0.51,95% ] CI 0.43–0.74), HSV-2-

seropositive men (PRR = 0.66, 95% CI 0.51–0.69), and in HSV-2 seroconverters

(PRR = 0.48, 95% CI 0.30–0.79)56. In the Ugandan RCT, male circumcision was 

also associated with a reduction in GUD (PRR 0.53, 95% CI 0.43-0.64)

6

. 

Herpes Simplex Virus (HSV-2). HSV-2 infection is often asymptomatic 

but can cause genital ulcers. Compelling evidence of the protective effect of 

HSV-2 acquisition from male circumcision is available from two of three RCTs. 

In the South African trial, the incidence rate ratio (IRR) for acquisition of HSV-2 

was 0.66 (95% CI 0.39-1.12) for the intervention arm in the intent-to-treat 

analysis, and 0.55 (95% CI 0.32 – 0.94) for circumcised men in the as-treated 

analysis100. In the Uganda RCT among 1,684 intervention and 1,709 control 

participants who were HSV-negative at baseline, the adjusted HR in the 

intervention group for HSV-2 infection was 0.72 (95% CI 0.56-0.92) at 24 

months in the intent-to-treat analysis8. In these two clinical trials, circumcised 

men were approximately 30% to 45% less likely to become infected with HSV-2

over 21 to 24 months of observation. In addition, investigators estimated the 

HSV-2 per-sex-act female-to-male transmission probability in South Africa, and 

found that there was a positive correlation between HIV and HSV-2 infections 

and that male circumcision had a protective effect on HSV-2 acquisition by 

males106. From the RCT in Kisumu, Kenya, including 1,391 men assigned to the 

circumcision arm and 1,393 men assigned to the delayed circumcision arm, male 

circumcision was not associated with incident HSV-2 (circumcised: 

uncircumcised risk ratio = 0.94; 95% CI 0.70-1.25)56. Investigators hypothesized 

that the reason that results from the Kisumu RCT were inconsistent with South 

African and Ugandan RCTs may have been due to location of lesions or test 

performance. For example, 37% of clinically detected genital ulcers were detected 

on the penile shaft rather than the foreskin mucosa in Kisumu, however, similar 

data were not reported for the other two RCTs. Also the sensitivity and specificity 

of the Kalon test for detecting HSV-2 were higher in sub-Saharan Africa (95% 

and 91%, respectively) compared to Kisumu, Kenya (92% and 79%, 

respectively)107. Evidence from observational studies has provided mixed results. 

In an early review of six observational studies, two found male circumcision was 

protective against and four found no association with HSV-2

98. In a subsequent 

review of 10 observational studies related to HSV-2 serostatus, six studies found a 

reduced relative risk associated with male circumcision status, and the difference 
18

was statistically significant for two of the studies99. Compared to uncircumcised 

men, circumcised men had a summary estimated relative risk for HSV-2 infection 

of 0.88 (95% CI 0.77-1.01). In a cross-sectional observational study of men in 

rural Tanzania, those circumcised before sexual debut compared to uncircumsed 

men were less likely to be HIV seropositive compared with non-circumcised men 

(adjusted OR = 0.50, 95%CI:0.25–0.97), and were also less likely to be HSV-2 

infected (aOR = 0.67, 95%CI:0.57–0.80) or have genital ulcer syndrome in the 

past 12 months (aOR= 0.69, 95%CI:0.47–1.00)108. In a population-based 

observational survey in Kisumu, Kenya, conducted to estimate baseline male 

circumcision status and attitudes associated with male circumcision, circumcision 

status was not associated with HIV/HSV-2 infection109. Observational data from 

a cross-sectional study in the United States have not shown an association 

between male circumcision status and HSV-2 infection. In an evaluation 

conducted by the National Health and Nutrition Examination Survey of 3,850 

U.S. boys and men 14-49 years of age who reported having had sex, Xu et al. 

found no association between self-reported circumcision status and HSV-2 

infection, after controlling for potential confounders such as age, race/ethnicity 

and sexual behaviors110.

Treponema pallidum. Syphilis, caused by T. pallidum, classically presents as a 

painless genital ulcer. A review of 11 studies in which genital ulcers were due 

either to chancroid or syphilis found statistically significant decreases in risk of 

genital ulcer disease among circumcised men98. In addition, of 14 studies that 

have assessed the association between male circumcision and a serologic 

diagnosis of syphilis, 13 found a reduction in risk associated with male 

circumcision, and the difference was statistically significant in four studies99. A 

summary estimate of relative risk for syphilis was 0.69 (95% CI 0.50-0.94) for 

circumcised versus uncircumcised men. However, there was no prevention benefit 

from male circumcision against syphilis acquisition in the randomized trials. In 

the Uganda RCT, syphilis was detected in 50 of 2,083 subjects (2.4%) in the 

intervention group, compared with 45 of 2,143 subjects (2.1%) in the control 

group8. Circumcised men were less likely to report genital ulcers; however, nearly 

all genital ulcers with an identified etiology were attributed to herpes virus 

infection and not syphilis. 

Haemophilus ducreyi. H. ducreyi, the organism that causes chancroid, is now 

uncommon in the United States. Only one observational study was found that 

included serologic diagnosis, so a review included 6 other studies that were based 

on clinical diagnosis 99. Six studies found a reduced relative risk for circumcised 

versus uncircumcised subjects, which was statistically significant in four. Relative 

risks varied widely, and no summary relative risk was estimated due to variability 

in study design.
19

Other STIs. Male circumcision is associated with a reduction of high risk HPV 

infections in randomized controlled trials while there are mixed results for other STIs 

described in this section.

Human Papilloma Virus (HPV). HPV is generally an asymptomatic 

infection, but oncogenic HPV (principally genotypes 16, 18, 31, and 33) are 

believed to be responsible for 100% of squamous cervical cancers, 90% of anal 

cancers, and 40% of cancers of the penis, vulva and vagina111. Penile squamous 

carcinoma (caused by carcinogenic HPV subtypes) has been strongly and 

consistently associated with lack of male circumcision 98 (see section, Penile 

Cancers). Cervical cancer has been associated with lack of circumcision in male 

partners of women in several case-control studies112(see section, Cervical 

Cancer). Of three observational studies that looked at the prevalence of genital 

warts in men, one found male circumcision was protective, one found it increased 

risk, and one found no association98. In the Uganda RCT, a higher prevalence of 

high-risk HPV genotypes was observed among 287 men in the control group 

(27.9%) than among the 233 men in the intervention group (18.0%, adjusted risk 

ratio 0.65; 95% CI 0.46-0.90)8. Also in that trial, male circumcision reduced the 

incidence of multiple high-risk HPV infections, increased the clearance of highrisk HPV infections in HIV-uninfected men 113

, reduced the prevalence and 

incidence of multiple high-risk HPV infections in HIV-infected men 114, and 

decreased penile high-risk HPV shedding115. In the trial in Orange Farm, South 

Africa, high-risk HPV genotypes were detected among 140 (22.3%) of 627 men 

in the control group, compared to 94 (14.8%) of 637 men in the intervention 

group (adjusted prevalence rate ratio 0.68; 95% CI 0.52-0.89)9. 

T. vaginalis. Trichomoniasis, caused by the parasite T. vaginalis, is 

believed to be the most common curable STI in the United States. The infection is 

generally asymptomatic in men but can cause severe cervicitis, vaginal discharge 

and labial itching and irritation in women, and may increase susceptibility to 

HIV116. The association of T. vaginalis and male circumcision had not been 

previously studied in any major observational studies. In the South African RCT, 

the effect of male circumcision on T. vaginalis infections was measured by 

polymerase chain reaction (PCR) from urine specimens100. Circumcised men were 

less likely to have a prevalent trichomonas infection (1.7%) than were 

uncircumcised men (3.1%), with statistical significance in the as-treated analysis 

(aOR 0.47; 95% CI 0.25-0.92) and borderline statistical significance in the 

intention-to-treat group (aOR 0.53; 95% CI 0.32-1.02). However, in the Kenya 

trial, which measured T. vaginalis by culture in participants’ urine and urethral 

discharge, no significant association between male circumcision status and 

trichomonas infection was found102. The Uganda RCT assessed trichomonas 

infections in female partners. The prevalence of T. vaginalis was found to be 

about half as high among the HIV-negative wives of married participants who 

were circumcised (5.9%) compared to HIV-negative wives of men who were 

uncircumcised (11.2%)(adjusted PRR 0.52; 95% CI, 0.05-0.98)

101

. 
20

Chlamydia trachomatis. C. trachomatis causes urethritis in men and 

cervicitis and pelvic inflammatory disease in women. Before accurate tests were 

available, chlamydial infection in men was often diagnosed syndromically as 

“non-gonococcal urethritis,” after exclusion of gonorrhea by Gram stain. Of eight

observational studies of non-gonococcal urethritis, two found that male 

circumcision was protective, three found that it increased risk, and three found no 

association98. In women, one cross-sectional study found chlamydial infection

among female partners of circumcised men to be 5.6 fold lower than among 

partners of uncircumcised men (OR 0.18; 95% CI 0.05-0.58), as tested by the 

presence of antibodies to C. trachomatis

117. In another cross-sectional study, C. 

trachomatis infection was not associated with circumcision status of the partner 

(HR 1.25; 95% CI 0.96-1.63)118. In the Uganda trial, there was no association 

between male circumcision and self-reported urethritis or discharge in men or 

women76, and in the Kenya trial, no association was found between laboratoryconfirmed C. trachomatis infection and male circumcision status among trial 

participants102. However, the South African trial showed a borderline significant 

association in the intention-to-treat analysis (aOR 0.56; 95% CI 0.32-1.00) 

between C. trachomatis infection among male participants in the circumcision 

intervention arm (2.1%) and control arm (3.6%); this association was nonsignificant in the as-treated analysis (aOR 0.75; 95% CI 0.42-1.32)100

.

Neisseria gonorrhoeae. Gonorrhea is caused by the bacterium N. 

gonorrhoeae and can lead to urethritis in men and cervicitis and pelvic 

inflammatory disease in women. Of seven observational studies, five found 

statistically significant decreases in risk in circumcised men and two found no 

association with circumcision status 98. However, no association has been 

demonstrated in prospective trials. In the Uganda RCT, there was no association 

between male circumcision and self-reported urethritis or discharge in men or 

women76. In the South Africa trial, the prevalence of gonorrhea, tested by 

polymerase chain reaction in first void urine, was similar in the male circumcision

(10.0%) and the control (10.3%) groups100. Similarly, in the Kenya trial, no 

association between male circumcision status and gonorrhea was found102. 

Penile and prostate cancers

Penile cancer is rare in developed countries, accounting for <1% of malignancies among 

men119, but appears to be strongly associated with the lack of male circumcision. Aside 

from circumcision status, it is associated with a history of HPV infection and lifestyle 

choices such as smoking, poor hygiene and multiple sex partners. Invasive penile cancer 

is very rare in circumcised men. The lifetime risk for a U.S. male of ever being diagnosed 

with penile cancer is 1 in 1,437120. In a retrospective analysis of 89 cases of invasive 

penile cancer diagnosed from 1954 through 1997, 98% were in uncircumcised men; of 

118 cases of carcinoma in situ, 84% were in uncircumcised men121. Schoen published a 

retrospective review of 5 studies with 592 cases of invasive penile cancer in the United 

States; none of the cases were in men who had been circumcised in infancy122. Daling et 
21

al. have suggested that the protective effect of male circumcision may be by preventing 

phimosis 123. In a population-based case-control study, the authors found that men not 

circumcised during childhood were at increased risk of invasive (OR 2.3; 95% CI 1.3-

4.1) but not in situ (OR 1.1; 95% CI 0.6-1.8) penile carcinoma. Among uncircumcised 

men, phimosis was strongly associated with invasive penile cancer (OR 11.4, 95% CI 

5.0-25.9). Racial/ethnic distribution of penile cancer in the United States reflects the 

varying prevalence of male circumcision. In an analysis of penile cancer among 6539 

U.S. men identified through population-based registries during 1995-2003, Hispanic men 

had the highest age-adjusted incidence (6.58 per million), followed by blacks (4.02 per 

million) and whites (3.9 per million)124.

The lifetime risk of prostate cancer among men in the U.S. during 2008-1010 was about 

15%125. It was also one of the leading causes of cancer death among men, with 28,088 

men dying from prostate cancer in 2009126. Infection with STIs has been associated with 

the development of prostate cancer in some studies127-130 and not others131-133. In one 

meta-analysis, an increased risk of prostate cancer was associated with a history of any 

STI (OR, 1.5; 95% CI, 1.3-1.7)134. Risk factors for STIs have also been associated with 

prostate cancer, including earlier age of first sexual activity135 and a greater number of 

sexual partners131, 136. Circumcision before first sexual intercourse was associated with a 

15% reduction in risk of prostate cancer compared to that of uncircumcised men in a 

combined analysis using pooled data from 1754 cases and 1645 controls in two 

population-based case-control studies (95% confidence interval [CI], 0.73-0.99)137.

Cervical cancer in female partners of circumcised men

In a meta-analysis of male circumcision status and cervical cancer in female partners, 

data from 7 case-control studies were pooled112. Circumcision was associated with 

significantly less HPV infection in men. In an analysis restricted to monogamous 

women, there was a nonsignificant reduction in the odds of having cervical cancer risk 

among women with circumcised partners (OR 0.75; 95% CI 0.49-1.14). When the 

couples with men with five or fewer lifetime partners (40% of the study population) were 

excluded, there was a significantly reduced odds of cervical cancer in female partners of 

circumcised men compared with the female partners of uncircumcised men (OR 0.42; 

95% CI 0.23-0.79).

Urinary tract infections in male infants

Studies have consistently demonstrated decreased incidence of UTIs among circumcised 

compared to uncircumcised boys. A multicenter prospective study of 1025 febrile infants 

under 2 months of age found that 9.0% of the fevers were attributable to UTI. Of the 

uncircumcised male infants, 21.3% had UTIs compared with 2.3% of the circumcised 

male infants138. A large cohort study including all births (n=427,698) in U.S. Army 

hospitals worldwide between 1975 and 1984 demonstrated an increase in the total 

number of UTIs among male infants as the circumcision rate declined over time139.
22

A meta-analysis including 18 studies and 22,919 children, found a pooled UTI prevalence 

of 20.1% among febrile uncircumcised boys <3 months of age and a prevalence of 2.4% 

among febrile circumcised boys <3 months of age140. Another systematic review141

included 12 studies and over 400,000 children and concluded that male circumcision was 

associated with a significantly reduced risk of UTI (OR 0.13; 95% CI 0.08-0.20; 

p<0.001). 

Estimates of the net clinical benefit of the procedure have varied depending upon the 

assumptions made regarding complication rates of male circumcision itself. Using an 

estimate of 0.2% rate of complications (hemorrhage, surgical injury, infection) following 

male circumcision, one study found that 6 UTIs could be prevented for every 

complication142 (see section, Risks and adverse events associated with male 

circumcision). In another study, an assumption of 2% complication rate resulted in the 

conclusion that 20 complications would occur for every 9 UTIs prevented141. Overall, 

UTIs are not common among male infants, with estimates of the annual rate of UTI in 

uncircumcised infants being 0.70% versus 0.18% for circumcised infants143.

Other health conditions

The presence of a foreskin has been associated with various penile dermatoses, including 

psoriasis, infections (e.g., HPV, HSV, molluscum and candidiasis), lichen sclerosis and 

seborrheic dermatitis144. Balanitis, inflammation of the glans penis, or balanoposthitis, the 

inflammation of the glans and the prepuce, are painful conditions that occur more 

frequently in uncircumcised males145-147. In a retrospective cohort of boys, the total 

frequency of complications (balanitis, irritation, adhesions, phimosis, paraphimosis) was 

higher among uncircumcised than circumcised boys (14% vs 6%), but most conditions 

were minor147. A prospective longitudinal study of over 500 boys in New Zealand found 

rates of penile conditions after 1 year of age to be 5% in circumcised boys and 1% in 

uncircumcised boys. These conditions included phimosis, penile inflammation, 

inadequate circumcision, and post-circumcision infection. However, after 8 years of age, 

the collective rates in the boys in the study were 11% and 19%, respectively. The 

majority of these problems were for penile inflammation including balanitis, meatitis, and 

inflammation of the prepuce145. A separate study of penile hygiene in the United States 

found that subjects who retracted the foreskin when bathing were less likely to have 

smegma accumulation, inflammation, phimosis, or adhesions than those who did not. 

Significant correlations were also found between early instructions concerning hygiene 

and the type of hygiene practiced, suggesting that good hygiene can offer some of the 

advantages of circumcision148.

Health conditions for which male circumcision is indicated 

Specific medical indications for which male circumcision is indicated include phimosis, 

the narrowing of preputial orifice leading to an inability to retract the foreskin over the 

glans, and paraphimosis, the entrapment of a retracted foreskin behind the coronal sulcus. 

In the United States, phimosis is estimated to affect approximately 0.5 to 1% of 

uncircumcised males over 16 years of age. Phimosis may be confused with non-
23

retractable foreskins or preputial adherence to the glans, which occurs in babies and 

young boys149. This condition is a normal part of penile development, and foreskin 

separation from the glans occurs over time without intervention. Although male 

circumcision is the definitive treatment, phimosis may respond to topical steroids. Male 

circumcision may also be indicated for recurrent balanitis, also known as balanoposthitis, 

a swelling (inflammation) of the foreskin and head of the penis, if they do not respond to 

conservative medical treatment. 

A study of 25,718 admissions for male circumcision in Western Australia that excluded 

neonatal circumcisions at birth, found the rate of circumcision (per 1000 person-years) 

decreased from 5.51 at ages 0-4 years to 0.39 at >15 years150. Most male circumcisions 

were for phimosis, and some of the circumcisions may have been unnecessarily done for 

non-retractable foreskins or preputial adhesions. The rate of male circumcision for 

balanoposthitis was 0.44 at ages 0-4 years and decreased to 0.04 at >15 years. 

Safety and risks associated with male circumcision

Reported rates of complications in large studies of medically attended male circumcision

in the neonatal period in the United States are approximately 0.2%142, 151, 152, and vary by 

type of study, setting, operator and surgical technique. In a comprehensive risk-benefit 

analysis of infant male circumcision based on reviews of the literature and meta-analyses, 

it is estimated that over a lifetime, benefits exceed risks by a factor of 100:1153.

The most common complications reported have been bleeding and infection, and are 

usually minor and easily managed142, 151, 152, 154. Other reported complications, including

wound dehiscence, unsatisfactory cosmesis, skin bridges, urinary retention, meatal 

stenosis, chordee, retained or too-small Plastibell devices, “concealed” (or “buried”)

penis, major bleeding, injury to the urethra due to fistula, surgical mishap, and severe 

infection are rare155 and may occur after discharge from the hospital. In Christakis’ study 

of 130,475 circumcised neonates, 0.18% had hemorrhagic complications, 0.04% suffered 

injury to the penis, and 0.0008% had cellulitis; the overall complication rate was 

0.22%142. A similar adverse event rate of 0.19% was observed in a retrospective cohort of 

100,157 circumcised neonates, including local infection, bacteremia, hemorrhage, 

surgical trauma, and UTI151. In a smaller study, complications were associated with 4% 

of 361 neonatal male circumcisions (hemorrhage, infection, surgical revision) and 13% of 

230 circumcisions performed after the neonatal period (adhesions, poor hygiene, meatitis, 

surgical revisions)156. A recent meta-analysis of 16 prospective studies from diverse 

settings worldwide that evaluated complications following neonatal and infant male 

circumcision found that median frequency of severe adverse events was 0% (range 0-

2%). The median frequency of any complication was 1.5% (range 0-16%). Male 

circumcision by medical providers on children tended to be associated with more 

complications (median frequency 6%; range 2-14%) than for neonates and infants157.

In a study using data from a large longitudinal healthcare reimbursement dataset, 

investigators estimated the incidence of adverse events (AEs) between 2001-2010 

attributable to male circumcision, and assessed whether AE rates differed by the age 

range when male circumcision was performed (i.e., <1 year, 1-9 years, or ≥10 years of 
24

age)158. Among 1,400,920 circumcised males, circumcision was performed in 95.3% 

male infants age < 1 year, in 2.0% of males between one and nine years, and in 2.7% of 

males age 10 years and older. Among those males age 10 years of older, 22.9% were age 

10-18 years. The overall estimated crude and adjusted incidences of probable AEs were 

0.31% (95% CI 0.30-0.32) and 0.23% (95% CI 0.21 – 0.24). When estimated by age 

group, the incidence of probable AEs was 0.4%, 9.06%, and 5.31% for males age <1 

year, 1-9 years, and ≥ 10 years, respectively. This incidence of AEs was 10-20 fold 

higher for males in older age groups compared to infants. The hightest incidence rate 

differences (IRDs) AEs among circumcised newborn males compared to uncircumcised 

newborns included correctional procedures [1887 AE/million male circumcision 

(PMMC)]2, bleeding [998.24 AE/PMMC]3, and inflammation of the penis [168.36 

AE/PMMC]4. In comparing incidence rates of probable AEs between circumcised males

age 1-9 years and circumcised neonates younger than age 1 year, the highest IRDs

included correctional procedures [2947 AE/PMMC]5, bleeding [8,398 AE/PMMC]6, and

inflammation of the penis [6421 AE/PMMC]7. Finally, in comparing incidence rates of 

probable AEs between circumcised males older than 9 years compared and circumcised 

neonates younger than age 1 year, the highest IRDs included correctional procedures 

[29,460 AE/PMMC]8, inflammation [17,575 AE/PMMC]9, bleeding [7,346 

AE/PMMC]10, and wounds [2,944.7 AE/PMMC]11. 

Meatal stenosis may be a complication of surgery. In a prospective study, meatal stenosis 

was documented in 24 of 239 (7.3%) circumcised boys older than 3 years but no 

uncircumcised boys159. However, the study population was not clearly defined and the 

diagnosed cases were not independently confirmed. Other studies have found rates of 

 

2 Highest IRDs included repair incomplete circumcision [919 AE/PMMC], and lysis or excision of penile 

post-circumcision adhesions [757 AE/PMMC]

3 Highest IRDs included intraoperative bleeding [896.23 AE/PMMC], and hemorrhage control [107.21 

AE/PMMC]

4 Highest IRDs included edema of the penis [1,116.59 AE/PMMC], and other inflammatory disorders of 

the penis/ cellulites of the penis [68.0 AE/PMMC] 

5 Highest IRDS included division of penile adhesions [42,034 AE/PMMC], repair of incomplete 

circumcision [30,389 AE/PMMC], lysis or excision of penile adhesion [12,573 AE/PMMC], and other 

repair of penis [15,968 AE/PMMC within 365- day window post-circumcision and 15,795 AE/PMMC 

within 1200-day window post-circumcision]

6 Highest IRDs included intraoperative bleeding [7498.3 AE/PMMC], and hemorrhage control [807.76 

AE/PMMC].

7 Highest IRDs included edema of the penis [2605 AE/PMMC] and other inflammatory disorders of the 

penis/celluites of the penis [3816 AE/PMMC].

8 Highest IRDs included division of penile adhesions [12,395 AE/PMMC], other repair of penis [9, 864 

within the 356-day window post- circumcision and 9719 within the 1200-day window post-circumcision, 

repair of incomplete circumcision [3,388 AE/PMMC], and lysis or excision of penil post-circumcision 

adhesions [2,576.8 AE/PMMC].

9 Highest IRDs included edema of penis [4,163 AE/PMMC] and other inflammatory disorders of the 

penis/celluities of the penis [4,163 AE/PMMC].

10 Highest IRDs included intraoperative bleeing [6756.0 AE/PMMC] and hemorrhage control [569.38 

AE/PMMC].

11 Included open wound of penis without mention of complications [2944.7 AE/PMMC]
25

meatal stenosis as low as 0.9%160. Studies have implicated male circumcision in 

methicillin-resistant Staphylococcus aureus (MRSA) outbreaks. A case-control study of 

two outbreaks in 11 otherwise healthy male infants at one hospital identified circumcision 

as a potential risk factor. However, in no case did MRSA infections involve the 

circumcision site, anesthesia injection site, or the penis, and MRSA was not found on any 

of the circumcision equipment or anesthesia vials tested161. In a review of published 

MRSA outbreaks, Van Howe noted the male propensity for MRSA infection potentially 

related to circumcision162. 

Minimizing pain is an important consideration for the procedure. Appropriate use of 

analgesia is considered standard of care for male circumcision at all ages. As 

demonstrated by Banieghbal and colleagues, appropriate analgesia can substantially 

control pain163. In their study, 93.5% of neonates circumcised in the first week of life 

with appropriate analgesia gave no indication of pain on an objective, standardized 

neonatal pain rating system.

Because of their rarity, rates of severe complications are difficult to document. In a 

review article, Wiswell compiled data from a myriad of sources, including personal 

correspondence, to estimate the following rates of adverse events per circumcisions

performed: excessive bleeding requiring ligature, 1 per 4,000; bleeding requiring 

transfusion, 1 per 20,000; severe infection requiring parenteral antibiotics, 1 per 4000; 

subsequent surgery (e.g., for skin bridges), 1 per 1000; repair of traumatic injury, 1 per 

15,000; and loss of entire penis, less than 1 per 1,000,000146. He also noted three deaths 

due to male circumcision during the period 1954-1989. 

A study from a large longitudinal healthcare reimbursement dataset in the U.S. estimated 

the IRD (subtracting out the background rate of AEs in uncircumcised newborns) for 

potential serious probable AEs to range from a low of 0.76 persons (95% CI 0.10-5.43) 

with stricture of male genital organ per million male circumcisions (PMMC) to a high of 

703.23 persons (95% CI 153.92-245.66) with repair of incomplete circumcision 

PMMC164. Four amputations of the penis occurred in uncircumcised newborns and three 

partial amputations of the penis occurred in circumcised newborns [IRD = 1.58 95% CI -

6.16- 3.02]. 

In a study of 1,239 infant male circumcisions using the Mogen clamp in Western Kenya, 

the overall adverse events rate was 2.7%165. Most AEs were mild or moderate and 

treated conservatively. One severe AE involving excision of a small piece of the lateral 

aspect of the glans penis was documented. AEs were more common in babies who were 

one month of age or older, resulting in the conclusion that infant male circumcision is 

optimally conducted within the first month of life. 

Complication rates for medically attended adult male circumcisions were well 

documented in the three African clinical trials. They were of similar magnitude and 

severity, ranging from 2 to 4%, and most commonly were pain, bleeding, infection and 

unsatisfactory cosmesis166. Bailey et al. observed a 1.7% rate of complications in Kenya, 

the most common being bleeding and infection74. Auvert et al. reported complications in 
26

3.8% of South African participants; of these, the most common complications were pain 

(31.7%), bleeding (15.0%), swelling or hematoma (16.7%), and problems with 

appearance (15.0%)75. Gray et al. reported moderate to severe complications (those 

requiring any treatment) in 3.6% of procedures in Uganda, all of which resolved with 

treatment76. There were no reported deaths or long-term sequelae. 

In an observational follow-up study of males aged 12 years or older who underwent 

voluntary male medical circumcision (VMMC) between Nov 2008 and March 2010 in 16 

clinics in Nyanza Province, Kenya, the adverse event rate among clinic system 

participants during the intra-operative period was 0.1% and post-operative periods was 

2.15%. The rate increased to 7.5% among participants under active surveillance. 

Providers performing 100 or more procedures compared to those who performed fewer 

than 100 procedures were 63% and 39% less likely to perform a procedure resulting in an 

AE in the clinic and active surveillance systems, respectively, and had a shorter duration 

of male circumcision procedures (15.5 vs. 24.0 minutes, respectively). Those performing 

more than 100 procedures achieved an AE rate of 0.7% and 4.3% in the clinic and active 

surveillance systems, respectively167. 

In Uganda, it was determined that the mean time to complete male circumcision surgery 

was 40 minutes for the first 100 procedures and 25 minutes for the subsequent 100 

circumcisions168. The rate of moderate and severe AEs ranged from 8.8% for the first 19

unsupervised procedures after training, 4.0% for the next 20-99 procedures, and 2.0% for 

the last 100. All AEs were found to resolve with medical management. Investigators 

concluded that more than 100 circumcisions needed to be completed in order to achieve 

optimum duration of surgery and that the first 20 procedures after completing training 

should be supervised. 

Effect of male circumcision on sexual function and penile sensation 

The foreskin is a highly innervated structure169 and some authors have expressed concern 

that its removal may compromise sexual sensation or function170. However, in one survey 

of 123 men following medical circumcision in the United States, men reported no change 

in sexual activity and improved sexual satisfaction, despite decreased erectile function 

and penile sensation171. Furthermore, a small survey conducted among 15 men before and 

after circumcision found no statistically significant difference in sexual function or sexual 

satisfaction172. Other studies conducted among men after adult circumcision have found 

that relatively few men report that there is a decline in sexual functioning after 

circumcision; most report either improvement or no change173-176. 

Considerations related to male circumcision in the United States 

Policy decisions regarding male circumcision need to be considered in light of the 

domestic HIV epidemic, rates of male circumcision in the United States, acceptability of 

both adult male and newborn male circumcision in the United States and abroad, risk 

compensation, policy issues, and cost-effectiveness, while addressing ethical concerns. 
27

HIV infection in the United States 

The epidemiology of HIV in the United States differs considerably from that of regions 

targeted by the WHO/UNAIDS recommendations and the sub-Saharan African areas in 

which the RCTs were conducted10. The overall prevalence of HIV infection (0.4%)61 is 

considerably lower in the United States than in some other nations, e.g., Kenya (7.8%), 

Uganda (5.4%) and South Africa (18.1%), where the male circumcision clinical trials 

were conducted177. Further, most sexual transmission in the United States occurs among 

men who engage in male-to-male sexual contact, whereas in sub-Saharan Africa 

transmission is predominantly through heterosexual sex. It should be noted, however, that 

HIV prevalence is high in some U.S. communities (for example, 2.4% of all adults and 

adolescents in Washington, DC)178 and social networks179. In an analysis of surveillance 

data from 12 urban areas, overall prevalence was between 1-2% in four cities, between 2

-3% in four cities, and nearly 4% in one180. Prevalence was 1-4% among blacks in all 

areas and was 1-2.2% for Hispanics in five areas. Heterosexual contact accounted for 

about 20% of HIV infections among men in three areas, and 33.8% in Philadelphia.

New HIV cases in the United States and 6 dependent areas are predominantly in males;

adult and adolescent males who engage in male-to-male sex represent the largest risk 

group. Comparing 2008 to 2010, the number of new HIV infections in the general 

population of adults and adolescents remained stable, with 47,500 (95% CI: 42,000–

53,000) new infections in 2008 and 47,500 (95% CI: 42,000–53,000) in 201011. The rate 

of new HIV infections in 2010 was 18.8 per 100,000.

In 2011, it is estimated that approximately 50,199 new HIV diagnoses were made, of 

which 79% were in males; 10% new HIV diagnoses were in men or male adolescents 

who acquired HIV heterosexually, and 64% were in men or male adolescents who 

acquired HIV through male-to-male sex (61% MSM alone, 3% MSM and injecting drug 

use)63. In addition, it is estimated that among persons living with a diagnosis of HIV 

infection in the United States in 2010, 75% were men, 8% were among men who 

acquired HIV infection heterosexually, and 56% acquired HIV infection through male-tomale sexual relations (50% MSM alone, 6% MSM and IDU)

63

. As noted earlier, there 

are few data showing a benefit of male circumcision on the risk of HIV associated with 

penile-anal sex or oral sex between men, and thus the benefit of circumcision among 

MSM is uncertain. 

HIV transmission to heterosexual men reporting sexual relations with an HIV-infected 

female accounted for 1 of every 10 new HIV diagnoses in 2011 and 8 of every 100 

persons living with HIV in the United States in 201011. Circumcision is likely to play a 

role in preventing HIV among men who engage in unprotected heterosexual vaginal sex, 

especially in communities where prevalence of HIV infection among women is high or 

among men with multiple sex partners. The potential benefit of male circumcision as an 

intervention to prevent HIV infection among men who have sex with women depends 

upon the likelihood of HIV exposure among such men, and thus, upon the prevalence of 

HIV among their female sex partners. 

The applicability of newly proven HIV prevention technologies like male circumcision 

across racial/ethnic groups is a critical consideration. Of the new infections among 
28

whites, blacks, and Hispanics in the United States in 2011, the highest rates of new 

infections per 100,000 population occurred in black men (112.8) and black women 

(40.0)

63

. The overall rate of new HIV diagnoses among men in the United States and 6 

dependent areas is 30.9 per 100,000 population. The proportion of estimated new HIV 

diagnoses among men attributed to high-risk heterosexual contact was 10% overall; the 

proportions attributed to high-risk heterosexual contact was 14% among African

American males, 9% among Hispanics, and 4% among whites11. This reflects a similar 

racial/ethnic distribution of HIV incidence among females in the United States. The HIV 

rate of new diagnoses of HIV infection for black women (40.0 per 100,000) is five times 

that for Hispanic women (8 per 100,000) and 20 times the rate for white women (2.0 per 

100,000)63.

Rates of male circumcision in the United States

The United States differs from some regions of sub-Saharan Africa in that most 

American men are already circumcised. The practice of circumcising male newborns for 

reasons unrelated to religious beliefs was introduced to the United States in the late 

1800s3, and by the 1940s, an increasing proportion of male children in the United States 

were born in hospitals and circumcised shortly after birth181. The percentage of newborns 

that were circumcised annually reached 80% after World War II, peaked in the mid1960s, and has decreased somewhat in recent years. In 2002, approximately 1.2 million 

newborn boys were circumcised prior to discharge from the hospital182; in 1996, an 

estimated 142,000 male circumcision procedures were performed beyond the neonatal 

period; of these, 49,000 were in persons older than 15 years183.

Four nationally representative surveys have examined the prevalence of circumcision 

among U.S. males: two among newborns prior to discharge from the hospital, one among 

adult men, and one among adolescent males and adult men. According to the National 

Hospital Discharge Survey (NHDS), 65% of newborn boys born in hospitals were 

circumcised in 1999, and the overall proportion of newborns circumcised was stable from 

1979 to 1999184. The proportion of black newborns who were circumcised during this 

period rose from 58% to 64%, while the proportion of white newborns who were 

circumcised remained stable at 66%. Significant differences in rates of male circumcision

exist by region. While the proportion of newborns born in the Midwest who were 

circumcised increased over this 20-year period from 74% to 81%, the proportion of 

newborns born in the West who were circumcised decreased over the same period, from 

64% to 37%184. From 2000 to 2007, newborn male circumcision rates in the NHDS 

declined from 63% to 56% (CDC unpublished data). In another hospital discharge survey 

with different methodology (Healthcare Cost and Utilization Project National Inpatient 

Sample [NIS]), the rate of circumcision performed during newborn male delivery 

hospitalizations increased significantly from 48% in 1988–1991 to 61% in 1997–2000185

and declined from 2000 to 2008 from 61% to 56%186. Male circumcision was more 

common among newborns born to families of higher socioeconomic status, in patients 

with private insurance or belonging to a health maintenance organization, and among 

those born in the Northeast and Midwest. On multivariate analysis, black newborns were 
29

slightly more likely and newborns of other races much less likely to undergo male 

circumcision than whites185. These surveys document male circumcisions performed in 

hospitals and billed or coded in discharge diagnoses, but do not ascertain male 

circumcisions which were not billed or coded, were performed outside of hospitals (e.g., 

circumcision conducted in religious ceremonies), or were performed after the delivery 

hospitalization.

In a series of national probability samples of adults surveyed during 1999–2004 as part of 

the National Health and Nutrition Examination Surveys (NHANES), the overall 

prevalence of male circumcision among adult males in the United States was 79% and 

varied by race/ethnicity (88% in non-Hispanic white men, 73% in non-Hispanic black 

men, 42% in Mexican Americans, and 50% in men of other races/ethnicities)110.

Similarly, in a followup study, data from the National Health and Nutrition Examination 

Surveys 2005-2010 were used to estimate the prevalence of male circumcision among 

men and adolescents aged 14-59 years in the United States. The overall estimated 

prevalence of male circumcision in this population was 80.5% and also varied by 

race/ethnicity (90.8% in non-Hispanic whites, 75.7% in non-Hispanic blacks, and 44% in 

Mexican Americans)

187, 188

.

In a study of hospital discharge data (NHDS) which corrected for underreporting, the 

percentage of neonatal males in the U.S. who underwent circumcision decreased from 

83% in the 1960s to 77% by 2010153. This decrease was accompanied by an increase in 

the proportion of Hispanics, who are typically noncircumcising, in Western states, and 

withdrawal of Medicaid coverage in 18 states153.

Acceptability 

Acceptability of adult male circumcision in the United States

It is not well understood whether American men and male adolescents at higher risk for 

heterosexual acquisition of HIV would be willing to undergo circumcision for partial 

HIV prevention, nor whether parents would be willing to have their newborns

circumcised for the purpose of reducing risk of possible future HIV infection. A recent 

consumer survey was sent to a stratified, random sample selected from a panel of 

households across the country. Among 709 self-identified heterosexual uncircumcised 

men, when asked about the likelihood of getting circumcised if their healthcare provider 

told them that getting circumcised would reduce their risk of becoming infected with 

HIV, only 86 (12%) reported they would be likely or very likely to get circumcised, 

while 591 (83%) reported that they would be unlikely or very unlikely to get circumcised. 

Similarly, among the 52 homosexual or bisexual men who reported being uncircumcised

who were asked the same question, 42 (81%) reported being unlikely or very unlikely to 

get circumcised. In contrast, in an analysis of data collected from MSM interviewed at 

gay pride events in 2006, over half of uncircumcised MSM and 70% of uncircumcised 

black MSM indicated that they would be willing to be circumcised if the procedure were 

proven to reduce risk of HIV among MSM189. Willingness was associated with black race 
30

(OR 3.4; 95% CI 1.3–9.8), non-injection drug use (OR 6.1; 95% CI 1.8–23.7) and the 

perception that male circumcision reduces the risk of penile cancer (OR 4.7; 95% CI 2.0–

11.9). Post-surgical pain and wound infection were the most commonly reported 

concerns about male circumcision in that study.

In a more recent consumer survey assessing the acceptability of male circumcision as an 

HIV prevention intervention among adult males and the potential for risk compensation 

in the continental United States, investigators mailed surveys to a random sample of 

19,996 potential respondents of approximately 340,000 households. Among 10,108 male 

and female respondents (50.6% response rate), 4,892 were men (48.3%). In the analysis 

related to adult male circumcision190, of 4,265 men with responses to the question 

regarding their circumcision status, 846 (19.8%) reported being uncircumcised.

Completed survey responses to other questions critical to the analysis on acceptability of 

male circumcision were obtained for 789 of 846 uncircumcised men. Among the 789 

uncircumcised men with completed survey responses, 13.1% reported they would be 

likely or very likely to get circumcised if their health care provider told them it would 

reduce their risk of becoming HIV infected by having sex with an HIV-infected woman. 

In addition, 4,310 of 4,892 male respondents responded to the survey questions needed to 

conduct the risk compensation analysis. Among these 4,310 male respondents, 17.7% 

strongly agreed, agreed, or were neutral about this, meaning that men who are 

circumcised do not have to worry about risks like not using a condom during sex or 

having more sex partners.

Adult and adolescent male circumcision could potentially have the largest impact on HIV 

acquisition in populations in which a low percentage of males are circumcised and there 

is a high risk for HIV transmission through penile-vaginal sex. As noted above, among 

racial/ethnic groups, Hispanic men have the lowest rates of circumcision and higher rates 

of heterosexually acquired HIV than white men, while black men have the highest risk of 

heterosexually acquired HIV infection. Further research regarding acceptability of male 

circumcision in these populations is needed. 

Acceptability of adult male circumcision in sub-Saharan Africa 

More research on the acceptability of adult male circumcision has been conducted in subSaharan Africa in countries where HIV prevalence is high and male circumcision is 

practiced less frequently. The studies discussed below addressed facilitators and barriers 

to male circumcision. Many of the perceptions about benefits and risks of male 

circumcision that were identified are likely to be widespread. While some of the 

facilitators and barriers may be culturally-specific issues to sub-Saharan Africa, others 

are universal in nature and help inform the U.S. discussion.

A review of 13 articles concerning male circumcision in nine sub-Saharan African 

countries found that a median of 65% of uncircumcised men reported willingness to be 

circumcised, but there was a wide range of acceptability by country (from 29% in 

Uganda to 81% in Botswana)191, 192. A range of acceptability of male circumcision among 

uncircumcised men in four districts in Uganda was reported to be 40-62%192. Factors 
31

that increased acceptability of male circumcision in the studies from the review article 

and other studies include the perception of improved hygiene192-200, protection from HIV 

and other STIs

109, 192, 193, 196-200

, increased sexual pleasure192, 193, 196-200, acceptance of 

procedure by female partner201, and improved ease of condom use193, 194. 

Barriers to male circumcision include concerns about the pain associated with surgery193, 

194, 196, 197, 202

, religious and cultural beliefs194, 196-199, 203, the cost of surgery193, 196, 203, 

complications from surgery192, 193, 195, 197, lack of access to health care193, concerns about 

contracting HIV during the procedure192, need for financial assistance during the recovery 

period to help maintain family income192, and beliefs about resulting changes in penile 

size, sensation, or performance199. 

The beliefs of women also have an impact on the acceptability of male circumcision, and 

their beliefs differ by country191. There are several reasons why women report that they 

prefer that their male partners be circumcised. Some women reported that they believed 

that it is easier for men to maintain good hygiene if they are circumcised193, 196, 197, 199, 

some reported believing that male circumcision decreases their own risk of acquiring 

STIs

193, 197-199

, some reported preferring circumcised sex partners and some believed that 

men enjoy sex more if they are circumcised196, 198, 199. In the RCT in Uganda, of 455 

female partners of men circumcised as adults, 2.9% reported less sexual satisfaction after 

their partners were circumcised, 57.3% reported no change, and 39.8% reported an 

improvement204.

Acceptability of newborn male circumcision in the United States 

Newborn circumcision has generally been well accepted in the United States, as 

evidenced by the rates of parents choosing to circumcise their newborn sons. Parents 

have typically made the decision based more on social concerns or perceptions of 

improved hygiene rather than medical reasons156, 205. A 1999 survey among parents of 

young boys found that those whose sons were uncircumcised were generally less satisfied 

with the decision than those who had chosen to circumcise their sons, and felt that they 

had not received adequate information206. 

It is not clear whether more information on potential health benefits and risks of male 

circumcision would influence parents’ decisions, particularly among racial/ethnic groups 

that do not typically elect to have their sons circumcised. In a survey of new parents, 76% 

responded that they probably or definitely would want circumcision for their male 

children207 and few participants’ attitudes changed after reading an AAP policy summary 

or after reading about the results of the RCTs on HIV and HPV risk reduction.

However, in a more recent telephone survey of nearly 10,000 respondents across the 

continental United States, sampled through random digit dialing, 88% of respondents said 

that they would definitely or probably circumcise a newborn son, including 65% who 

“definitely would” and 23% who “probably would”; 53% of all respondents (including 

those who said they would definitely have their sons circumcised) stated that they would 

be more willing to consider circumcision for a male newborn child based on information 
32

provided about potential future HIV risk reduction190. Approximately one-third of those 

who probably would not circumcise a newborn son responded that they were more likely 

to circumcise as a result of the information of a partial HIV protective effect later in life.

Greater odds of not being inclined to circumcise a newborn son were associated with 

individuals of Hispanic ethnicity and other race/ethnicity compared with non-Hispanic 

whites, uncircumcised men and men with unknown circumcision status compared with 

females, individuals with postgraduate versus high school education, individuals living in 

the South and West compared to the Midwest, and those who were not or only somewhat 

confident in the safety of routine childhood vaccines versus those who were confident or 

very confident.

In a study about attitudes and decision making about infant male circumcision in a 

predominantly Hispanic population in New York City, the parental decision in favor of 

circumcising a male infant was associated with parents who came from a culture and 

family that believed in circumcision and who believed that it was not too risky208. 

Investigators studying whether presence of state Medicaid coverage for infant male 

circumcision was associated with male circumcision rates in the United States, found that 

the average rate of male circumcision was 55.9% and states with Medicaid coverage for 

routine male circumcision had, on average, male circumcision rates that were 24% higher 

percentage points than states without such coverage. Hospitals with higher percentages of 

Hispanic patients also had lower circumcision rates209. As of 2012, coverage for male 

circumcision through the Medicaid program is denied in 18 states210.

Acceptability of newborn male circumcision in sub-Saharan Africa

Although, some of the issues related to acceptability of newborn male circumcision in 

sub-Saharan Africa may be culturally-specific to this region, others are universal in 

nature and help inform the discussion of male circumcision in the U.S. In addition, some 

of the culturally-specific issues of sub-Saharan Africans may continue to influence their 

decision making around male circumcision even after migrating to the U.S. In Uganda, 

willingness of men to have their sons circumcised ranged from 60%-86% , depending on 

geographic region192. A higher proportion of circumcised (96%-100%) compared to 

uncircumcised men (59-79%) were likely to have their sons circumcised. Women’s 

support of a son’s circumcision ranged from 49%-95%, based on geographic region. To 

prevent HIV/AIDS or provide for a ‘‘healthier future’’ was the most common reason for 

willingness to support a son’s circumcision. Concerns about male circumcision included 

cost, pain associated with surgery, perception that circumcision would signify a religious 

conversion, or that it would encourage their children to engage in risky sexual activity,

and lack of information about male circumcision. Household survey participants and 

healthcare workers preferred male circumcision during infancy or childhood (0-9 years) 

compared to adolescence (10-17 years) or adulthood (≥ 18 years)192. In Zimbabwe, 

acceptability of early infant male circumcision was high among most ethnic groups; 

concerns included issues related to safety, questionable motivations behind free service 

provision by health care providers, handling of the discarded foreskin, separation of 

traditional circumcision from the adolescent initiation process, and female nursing of an 
33

infant’s wound which would be considered taboo211. In Botswana, among mothers who 

were interested in circumcision, protecting the infant from future infections such as HIV 

and hygiene were the main reasons expressed for circumcising their infants, while the 

child’s comfort or safety during the procedure and timing of the procedure at too young 

an age were concerns voiced by those not interested in the procedure212. Among 129 

grandparents and parents participating in focus group discussions in Lusaka, Zambia 

most participants felt there were benefits for HIV prevention associated with 

circumcision, as well as advantages conducting circumcisions at a young age213. Among 

these same focus group participants, barriers to neonatal circumcision included concerns 

about pain and cultural identity. Factors associated with allowing infant males to be 

circumcised among parents participating in a case-control study at five government 

hospitals in Nyanza Province, Kenya differed by gender214. Among mothers, having a 

husband (infant’s father) who was circumcised or agreeing with the husband (infant’s 

father) about the infant male circumcision facilitated infant male circumcision. Among 

fathers, being circumcised and agreeing with the mother about infant male circumcision 

were factors associated with conducting infant male circumcision. The primary decision 

makers were found to be fathers in 66% of instances.

Provider attitudes and practices regarding male circumcision in the United States

Although many medical societies have addressed neonatal male circumcision215-218, few

systematic data are available regarding provider attitudes and practices. In a nationally 

representative self-administered cross-sectional electronic survey of 1500 physicians (510 

family practitioners, 490 internists, 250 pediatricians, and 250 obstetricians/

gynecologists) conducted in 2008, 29% of respondents thought that the medical benefits 

outweighed the risks of newborn male circumcision, while 41% thought the benefits and 

risks were equal, and 20% believed that the benefits did not justify the risks219. Overall, 

39% of physicians reported being somewhat or very familiar with data from the male 

circumcision RCTs including 34% of family physicians, 33% of internists, 51% of 

pediatricians, and 48% of obstetricians. Most family physicians, pediatricians, and 

obstetricians (53%, 59%, and 58% respectively) reported that data from the RCTs in 

Africa made no difference in their likelihood of recommending male circumcision for 

neonates. Among internists and family physicians, 57% and 58% respectively reported 

that these data made them more likely to recommend circumcision for uncircumcised 

male patients who engage in high-risk heterosexual sex, and 61% and 60% respectively 

also reported that these data made them more likely to recommend elective circumcision 

to MSM. In addition, 22% (n = 327/1,500) of physicians in this study reported not 

understanding the risks and benefits of newborn male circumcision well enough to 

counsel parents and 40% (n = 504/1,250) reported not understanding the risks and 

benefits well enough to counsel adult men, suggesting the need for more education of 

physicians regarding the latest male circumcision research in order to feel comfortable 

counseling adult men or parents of newborn male infants220.

Study results from interviews of a nonrandom sample of key informants and health care 

practitioners serving the Hispanic community in Miami, including physicians, nurses, and 

other allied health professionals illustrated differing attitudes based on gender and 
34

highlighted the importance of supporting healthcare workers in any efforts to counsel 

clients around male circumcision and its role as an HIV prevention strategy221. The 

acceptability of male circumcision among male healthcare providers was associated with 

acceptability of American Pediatric Association guidelines, and personal circumcision. 

Some male healthcare providers expressed skepticism regarding health benefits for 

sexually transmitted disease/HIV risk reduction. Female providers expressed the 

importance of parental financial burden, lack of information, and low acceptability 

among Hispanic men.

Cost-effectiveness 

The medical costs of male circumcision must also be accounted for in considering the 

role of circumcision for HIV prevention in any setting. While male circumcision has been 

shown to be a cost-saving HIV prevention intervention in sub-Saharan Africa222, 223, the 

calculus is different in the United States, where the costs of performing male 

circumcision as well as HIV treatment costs are higher, and the risk of HIV infection is 

lower. Another important factor driving the cost-effectiveness is the length of time 

between the intervention and when the benefits are experienced. The value of these 

benefits is discounted over decades for newborn male circumcision, but over a shorter 

time period for adult male circumcision.

One cost-effectiveness analysis of male circumcision in the United States showed a net 

negative impact of circumcision. However, like most other cost-effectiveness analyses of 

male circumcision in the United States, it was conducted prior to publication of the RCTs 

and focused on costs and benefits of related conditions other than HIV224; costeffectiveness increases when these additional benefits are factored in. One evaluation of a 

large health maintenance organization database found the expected lifetime cost of male 

circumcision was small, compared with larger expected benefits225. Much of the benefit 

of neonatal male circumcision in that analysis derived from pre-empting the need for 

post-neonatal circumcision, which is substantially more costly. Two other studies 

published in 1991, which did not include an HIV prevention benefit, estimated that both 

costs and benefits were too small to play a substantial role in the decision whether to 

perform the procedure226, 227.

A model estimating the impact of newborn circumcision on a U.S. male’s lifetime risk of 

HIV from heterosexual contact showed that circumcision reduced the 1.9% absolute 

lifetime risk by 15.7% overall, by 20.9% for black males, 12.3% for Hispanic males and 

7.9% for white males228. The number of circumcisions needed to prevent one HIV 

infection was 298 for all males, and ranged from 65 for black males to 1,231 for white 

males. Newborn male circumcision was a cost-saving HIV prevention intervention 

overall, as well as for black and Hispanic males. The net cost of newborn male 

circumcision per QALY saved was $87,792 for white males. Results were most sensitive 

to the discount rate, male circumcision efficacy, and cost. The main analysis did not take 

into account secondary prevention (i.e., HIV cases prevented among partners of 

circumcised males), the benefits of male circumcision in preventing other STIs, adverse 

events, and possible reduction in HIV risk from male-to-male sexual contact. 
35

A population-based model of the effect of adult male circumcision in MSM indicated that 

over 20 years, circumcision could very slightly reduce (<1%) the number of new HIV 

cases among MSM (CDC, unpublished data). Although there are no conclusive data 

demonstrating a protective effect for MSM, the model assumed 50-60% protection from 

HIV for circumcised men engaging in insertive sex. The net costs of the procedure were 

less than $50,000 per QALY saved, which is considered a conservative threshold for 

cost-effectiveness. The model included the prevention of secondary cases of HIV. The 

reduction in new cases of HIV was small because the chief source of HIV infection 

among MSM is receptive anal sex and the model assumed no circumcision-related 

protection for receptive acts.

Investigators evaluated the reduction in infections associated with male circumcision and 

resulting health care costs associated with continued decreases in male circumcision

rates. They estimated that if male circumcision rates continue to decrease in the United 

States, such decreases would likely be associated with increased infection prevalence and 

resulting increased medical expenditures for men and women. For example, a reduction 

in the male circumcision rate to 10%, a rate similar to that in Europe, would result in an 

increase in lifetime health care costs by $407 per male and $43 per female, and an in 

increase in net expenditure per annual birth cohort $505 million. The projected increase 

in HIV infections would be responsible for 78.9% of increased costs229.

Investigators conducting a cost-effectiveness analysis for MSM in Australia similarly 

found that male circumcision could be cost effective or cost saving in some scenarios, 

although a relatively small percentage of HIV infections would be prevented by 

circumcision of MSM and the associated cost was high relative to other HIV prevention 

programs230. They estimated that 2-5% of HIV infections per year would be averted and 

that 118-338 male circumcisions would be required to prevent one HIV infection. Either 

circumcising 100% of all MSM or MSM aged 35-44 years were both cost-effective 

strategies. 

A number of cost-effectiveness studies and modeling exercises have found that male 

circumcision would be a cost-effective HIV prevention tool in subSaharan Africa. 

Using mathematical modeling, The Joint United Nations Programme on HIV/AIDS 

(UNAIDS), the World Health Organization (WHO), and the South African Centre for 

Epidemiological Modelling and Analysis (SACEMA) estimated that male circumcision 

among heterosexual men in areas with a low prevalence of male circumcision and a high 

HIV prevalence would be very beneficial; five to 15 male circumcisions would need to be 

performed in order to avert one HIV infection231. The estimated costs to avert one HIV 

infection would range from US$150 to US$900 using a 10-year time span. Investigators 

conducting a cost-effectiveness study in Botswana estimated that US$689 per HIV 

infection and 70,000 HIV infections through 2025 could be averted by scaling-up adult 

and neonatal circumcision to reach 80% coverage by 2012 , at a total net cost of US$47 

million between 2012 and 2025232.
36

In a cost-effectiveness study of male circumcision at different ages in Rwanda, an 

African country with an adult HIV prevalence of 3%, infant male circumcision was found 

to be less expensive than adolescent and adult male circumcision (US$15 instead of 

US$59 per procedure) and cost-saving despite a delay in realization of savings from 

infant circumcision. Adult male circumcision was neither cost-saving nor highly costeffective when considering only the direct benefit for the circumcised man233

. A 

compartmental epidemic model simulating the population-level impact of various male 

circumcision programs on heterosexual transmission in Soweto, South Africa, 

incorporated both gender-specific negotiation strategies related to condom use with the 

male circumcision program. Investigators determined that even modest programs 

offering circumcision would result in significant benefits and estimated that a five-year 

prevention program in which an additional ten percent of uncircumcised males undergo 

circumcision annually, would prevent 13% of expected new HIV infections over a 20-

year period234.

Other considerations

Risk compensation

The possibility that men may alter their risk behavior and engage in riskier sex practices 

following circumcision may undermine the preventive health benefits of male 

circumcision235, 236. In addition, it is possible that generalized dissemination of public 

health information regarding male circumcision may introduce complacency and greater 

risk behavior among men circumcised early in life, such as the period during infancy 

through young adulthood.

In general, however, risk compensation was not observed among circumcised participants 

in the majority of RCTs. A meta-analysis of secondary outcomes measuring sexual 

behavior for the Kenyan and the Ugandan trials found no significant differences between 

circumcised and uncircumcised men43, and in a sub-sample of men in the Kenyan trial, a 

detailed longitudinal sexual risk assessment indicated no statistically significant 

differences in sexual risk propensity scores or in incident infections of gonorrhea, 

chlamydial infection, or trichomoniasis by male circumcision status

237

. A similar result 

for the RCT conducted in Kenya found no significant difference in risk behavior between 

circumcised and uncircumcised men over 12 months of follow-up5. More recently, during 

4.79 years of trial surveillance of participants in the Rakai randomized trial of male 

circumcision, there was no evidence of significant self-selection or behavioral risk 

compensation based on male circumcision status46. However, in the South African RCT,

during 2002-2005, the mean number of sexual contacts was statistically significantly 

greater for circumcised men compared to uncircumcised men at the visits during months 

4 – 12 (5.9 vs. 5.0, p<0.001) and at the visits during months 13 - 21 (7.5 vs. 6.4, p= 

0.0015), although the number of partners did not increase.

46

In observational studies, the results appear to be mixed. In a population-based 

observational survey conducted to estimate baseline male circumcision status and 

attitudes associated with male circumcision in Kisumu, Kenya, some respondents 
37

expressed a concern that circumcised men might engage in riskier sex or might become 

more promiscuous due to misperceptions about the degree of protection provided by male

circumcision109. However, in this same study, circumcision status was not associated 

with increased high-risk sexual behavior or lifetime number of sexual partners109.

Similarly, in Uganda, in a mixed-method study using survey and focus group

methodology, some respondents also expressed a concern that circumcised men might 

engage in riskier sex or might become more promiscuous due to misperceptions about the 

degree of protection provided by male circumcision, however, the RCT failed to find 

evidence of this192. A cross-sectional survey of 1,257 sexually active men aged 15 years 

or older in Botswana found that circumcision was not significantly associated with 

condom use; 15% of circumcised men compared to 12% of uncircumcised men did not 

use condoms. Lack of condom use was significantly associated with religious beliefs, 

low level of education, marriage, drunkenness, and misconceptions regarding 

antiretroviral therapy238. Between 2007-2008, in a cross-sectional survey of 7,300 young 

men age 15-34 years in 20 rural communities in Tanzania, the prevalence of male 

circumcision was 40.6%. Circumcised compared to uncircumcised men were more likely 

to report having ever used a condom (adjusted OR = 2.62, 95% CI:2.32–2.95)108. Among 

304 HIV-uninfected circumcised men surveyed in Cape Town, South Africa, men who 

were aware that circumcision offers protection against HIV compared to those who were 

not aware were more likely to agree that risk compensation might occur in association 

with male circumcision ([RR 1.19, 95% confidence interval [CI]1.06–1.32, P, 0.01), 

perceived lower risk of HIV infection when circumcised (RR 1.15, 95% CI 1.11–1.12, P, 

0.01) and were more likely to report unprotected vaginal sex acts (RR 1.08, 95% CI 

1.04–1.12, P, 0.01). Those who were more likely to agree that risk compensation might 

occur in relation to male circumcision were also more likely to be diagnosed with a 

chronic STI (odds ratio [OR] 1.64, 95% CI 1.06–2.53, P, 0.05)239. Another study in Cape 

Town, South Africa, found risk compensation among women, but not men, who were 

informed of the HIV-protective effects of male circumcision240. 

To date, there are few data to predict possible patterns of risk compensation in U.S. 

males. In one national survey of 4,892 U.S. men, 82% of circumcised and uncircumcised 

men agreed that even if being circumcised does reduce a man’s risk of HIV infection 

from heterosexual sex, circumcised men still needed to concern themselves with safe sex 

practices190. Xu found few differences in sexual behaviors among U.S. men according to 

their circumcision status. In a more recent consumer survey assessing the acceptability of 

male circumcision for both adult men and newborn males as an HIV prevention 

intervention and the potential for risk compensation in the continental United States, 

investigators mailed surveys to a random sample of 19,996 potential respondents of 

approximately 340,000 households. Among 10,108 male and female respondents (50.6% 

response rate), 4,892 were men (48.3%) and 4,310 male respondents responded to the 

survey questions needed to conduct the risk compensation analysis. Among these 4,310 

male respondents, 17.7% strongly agreed, agreed, or were neutral about the idea that men 

who are circumcised do not have to worry about the risks associated with not using a 

condom during sex or having more sex partners190. Among high-risk heterosexual men, 

defined as those who reported having had more than one sexual partner or a new 

sexually transmitted infection in the past 12 months, the odds of potential risk 

compensation were higher among 1) non-Hispanic blacks and men of other race/ 
38

ethnicity compared to non-Hispanic whites, 2) men reporting an annual household 

income < $60,000 compared to >$60,000, 3) men who were never married or 

widowed/divorced/separated compared to married men, 4) men who agreed versus 

disagreed that they have little control over the things that happen to them, and 5) men 

who were 45 years and older compared to 18–34 years of age.

Policy considerations regarding reimbursement 

Until recently, most U.S. medical societies have adopted relatively neutral stances 

regarding the practice of routine neonatal male circumcision. In 1999, the American 

Medical Association stated: "Virtually all current policy statements from specialty 

societies and medical organizations do not recommend routine neonatal circumcision, 

and support the provision of accurate and unbiased information to parents to inform their 

choice,”215. The American Academy of Pediatrics (AAP) statement on neonatal male 

circumcision from that year, reaffirmed in 2005, concluded that “[data demonstrate] 

potential medical benefits...however, these data are not sufficient to recommend routine 

neonatal circumcision”241. Similar neutral statements were issued by the American 

Academy of Family Physicians242 and the American Urological Association (AUA)243. 

The AUA states that “when circumcision is being discussed with parents and informed 

consent obtained, medical benefits and risks, and ethnic, cultural, religious, and 

individual preferences should be considered. The risks and disadvantages of 

circumcision are encountered early whereas the advantages and benefits are prospective.” 

However, in the wake of the male circumcision clinical trial results from Africa, the AUA 

has modified their recommendation to say that, “While the results of studies in African 

nations may not necessarily be extrapolated to men in the United States at risk for HIV 

infection, the American Urological Association recommends that circumcision should be 

presented as an option for health benefits (but)... should not be offered as the only 

strategy for risk reduction244. In addition, in 2012, after the AAP’s Taskforce on 

Circumcision reviewed the latest evidence, the AAP updated its stance concluding that 

the new evidence indicates that the preventive 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 it245.

In two studies, reimbursement by Medicaid or private insurance for the costs of neonatal 

male circumcision, were associated with higher circumcision rates in hospitals compared 

to states which disallow Medicaid reimbursement or where patients did not have private 

insurance coverage246, 185. In one retrospective study of rates of neonatal and early 

childhood male circumcision conducted from 1977-2001 limited to two hospitals in the 

Midwest, insurance coverage was not correlated with rates of neonatal male 

circumcision247. 

Ethical considerations

Recommendations related to male circumcision must consider ethical issues in addition 

to medical benefits and risk. A subcommittee of the CDC Public Health Ethics
39

Committee (PHEC) composed of CDC staff and external non-governmental consultants 

from academia and a center for ethics was consulted in October 2009 to review the 

ethical considerations related to elective male circumcision in the United States. The 

ethical principles of beneficence (maximizing benefit and minimizing harm, both at the 

individual and societal level); autonomy (respect for individual values and choices); and 

justice (the obligation to fairly distribute risks, burdens and benefits, to minimize 

stigmatization, and to make decisions in a transparent fashion) were considered. Of 

particular importance were ethical questions related to parental decision-making on 

behalf of a newborn boy, targeting populations at high risk for HIV, and medical 

reimbursement for the procedure. 

The subcommittee concluded that newborns cannot provide informed consent and so 

must rely on their parents or caretakers to determine and act in their best interests, raising

the issue of autonomy in discussions of circumcision of male newborns. They took into 

account varying opinions about the decision-making process including that the decision 

about whether to be circumcised should be made by individuals when they are old 

enough to make their own informed decisions. It has been pointed out that a man with a 

foreskin can elect to be circumcised but if circumcised as a newborn, cannot easily 

reverse the decision248, 249. Others argue that it is a choice that parents should be able to 

make on behalf of their male children because of the strong evidence showing that the 

procedure is beneficial and the risks are minimal if performed competently250-252. Parents 

are generally given the authority to make decisions, such as vaccination, for their minor 

children based on their evaluative consideration of the child’s best interests. 

Appropriately, this consideration takes into account social, cultural, and religious 

perspectives, as well as objective, scientific information about preventive health benefits

and risks. Thus, in the opinion of the PHEC subcommittee, both a decision to circumcise 

and a decision to not circumcise are legitimate decisions, and either decision is an 

appropriate exercise of parental authority on behalf of a minor child.

There are advantages and disadvantages to performing male circumcision at various 

stages of life. The procedure is simpler, safer, and less expensive for neonates and infants 

than for adolescents and adults. However, the newborn has no ability to participate in the 

decision. Furthermore, although there is evidence of reduced urinary tract infections 

among male infants who have been circumcised, the benefit of the protective effect 

against STIs, including HIV, is delayed for many years, not accruing until the child 

becomes sexually active. It is possible that new, less invasive interventions (e.g., 

effective topical microbicides or vaccines) may be developed in the intervening years251. 

Delaying male circumcision until adolescence or adulthood obviates concerns about 

violation of autonomy. However, performing the procedure after sexual debut would

result in missed opportunities for prevention of HIV infection251, 253. In the United States, 

previous sexual intercourse was reported among 32% of males age 15 to 17 years and 

65% of males age 18 to 19 years254. Uptake of the procedure after the neonatal period is 

also likely to be lower due to the increased cost, greater likelihood of complications, and 

other barriers to male circumcision at a later age. The PHEC subcommittee concluded 

that the disadvantages associated with delaying male circumcision would be ethically 
40

compensated to some extent by the respect for the integrity and autonomy of the 

individual.

The prevalence of HIV infection in the United States is not as high as in sub-Saharan 

Africa, and most men do not acquire HIV through penile-vaginal sex. Targeting 

recommendations for adult male circumcision to men at elevated risk for heterosexually 

acquired HIV infection would be more cost effective than offering routine adult male 

circumcision. Men may be targeted according to sexual practices or an elevated 

prevalence of HIV within a geographic region or race/ethnicity group. However, some 

groups at high risk for HIV infection may also be more likely to be members of certain

racial or ethnic groups, thus leading to the perception that men are being targeted because 

of their ethnic/racial status rather than their risk for HIV infection. Furthermore, 

recommendations to increase rates of male circumcision in the U.S. to reduce male 

acquisition of heterosexually acquired HIV infection may result in stigmatization of 

uncircumcised men or groups of men who are not routinely circumcised should they 

choose to not undergo circumcision. Conversely, targeting populations at high risk may 

raise questions about distributive justice, if persons in groups that are not targeted do not 

have equal access to the procedure251. The PHEC subcommittee concluded that programs 

incorporating male circumcision should be undertaken with sensitivity to the beliefs and 

practices of communities affected, and potential participants must be provided with an 

accurate explanation of potential risks and benefits, as well as assurances of protection of 

their best interests and informed choice250, 251, 255. 

The PHEC subcommittee also noted that lack of health care insurance for some groups

and lack of coverage for male circumcision by Medicaid in some states raises issues of 

distributive justice, and because data demonstrate that male circumcision has the potential 

to reduce the risk of HIV infection and other adverse health conditions, the procedure 

should be made available to all who want it.

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Appendix. Abbreviations Used in This Report

AIDS acquired human immunodeficiency syndrome

AAFP American Academy of Family Physicians

AAP American Academy of Pediatrics

ACOG American College of Obstetrics and Gynecology

AE adverse event

AMA American Medical Association

aOR adjusted odds ratio

AUA American Urological Association

BV bacterial vaginosis

CDC Centers for Disease Control and Prevention

CI confidence interval

GRADE Grading of Recommendations Assessment, Development and Evaluation

GUD genital ulcerative disease

HIV human immunodeficiency virus

HPV human papillomavirus 

HR hazard ratio

HSV herpes simplex virus

IDU injection drug user

IRR incidence rate ratio

MMWR Morbidity and Mortality Weekly Report

MRSA methicillin-resistant Staphlococcus aureus

MSM men who have sex with men

NIS National Inpatient Sample

NHANES National Health and Nutrition Examination Surveys

PHEC Public Health Ethics Committee

OR odds ratio

PMMC per million male circumcisions

PRR prevalence rate ratio

QALY quality-adjusted life-year

RCT randomized controlled trial

RR risk ratio

STD sexually transmitted disease

STI sexually transmitted infection

UNAIDS Joint United Nations Programme on HIV/AIDS

US United States

UTI urinary tract infection

VMMC voluntary male medical circumcision

WHO World Health Organization
57

Tables

Table 1. Reduction in risk of male HIV acquisition and male circumcision in randomized controlled trials

IRR = incidence rate ratio

* Reduction in HIV incidence

† Source: 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 Med 2005;2(11):e298. 

§ Source: Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomized 

trial. Lancet 2007;369:657-66. 

¶ Source: Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a 

randomized controlled trial. Lancet 2007;369:643-65.

Reference Setting Number 

and age 

range of 

HIVnegative 

participants 

enrolled

Adverse 

events related 

to surgery 

(%), among 

HIV-negative 

participants

Cumulative HIV infection 

events / cumulative personyears of follow-up (incidence 

per 100 person-years)

Modified intention- to-treat 

analysis 

Per protocol (as-treated) 

analysis

Intervention Control IRR (95% CI) Efficacy* IRR (95% CI) Efficacy*

Auvert† Orange Farm, 

South Africa

3,128 men 

aged 18-24 

years

54 / 1495 

(3.6%)

20 / 2354 

(0.85)

49 / 2339 

(2.11)

0.40 (0.24-0.68) 60% 0.24 (0.14-

0.44)

76%

Gray§ Rakai, Uganda 4,996 men 

aged 15-49 

years

178 / 2328 

(8%) (3.6% 

moderate or 

severe)

22 / 3352

(0.66)

45 / 3392 

(1.33)

0.49 (0.28-0.84) 51% 0.45 (0.25-

0.78)

55%

Bailey¶ Kisumu, 

Kenya

2,784 men 

aged 18-24 

years

24 (in 23 

persons) / 

1334 (1.7%)

22 / 

1391(2.1)

47 / 1393 (4.2) 0.47 (0.28-0.78) 53% 0.40 (0.23-

0.68)

60%
58

Table 2. Summary of evidence on the risk of STI associated with male circumcision status in heterosexual populations

STI Summary of data 

Etiology Population, type of study, location, result Measure of association

HSV-2 In men:

In RCTs: 

- In Uganda, significant association 

- In South Africa, no significant association in 

intention to treat analysis; 

significant association in as-treated analysis 

- In Kenya, no significant association In 

observational studies: no significant association 

in meta-analysis 

adjusted HR 0.72, 95% CI 

0.56-0.92* 

IRR 0.66, 95% CI 0.39-1.12 

IRR 0.55, 95% CI 0.32-

0.94†

RR 0.94, 95% CI 0.70-1.25&

summary RR 0.88, 95% CI 

0.77-1.01§

High-risk HPV In men, significant association in RCTs: 

- Uganda 

- South Africa

adjusted RR 0.65, 95% CI 

0.46-0.90*

PRR 0.68, 95% CI 0.52-

0.89¶ 

Trichomoniasis In men:

In RCTs: 

- In Kenya, no significant association 

- In South Africa, no significant association in 

intention-to-treat analysis; 

significant association in as-treated analysis 

I

n female partners significant association in RCT: 

-In Uganda

IRR 0.77, 95% CI 0.44-

1.36** 

aOR 0.53, 95% CI 0.32-1.02

aOR 0. 47, 95% CI 0.25-

0.92 ††

adjusted PRR 0.55; 95% CI, 

0.34-0.89

§§
59

Syphilis In men:

No significant association in RCT: 

- In Uganda 

In observational studies: significant association 

adjusted HR 1.10, 95% CI 

0.75-1.65*

summary RR 0.69, 95% CI 

0.50-0.94) § 

Chlamydial infection In men: 

No significant association in RCTs:

- In Kenya 

- In South Africa, intention-to-treat analysis; 

as-treated analysis

In female partners: 

Not assessed in RCTs, mixed results in crosssectional studies:

- Significant association in one study 

- No significant association in another study 

IRR 0.87, 95% CI 0.65-

1.16** 

aOR 0.56, 95% CI 0.32-1.00

aOR 0.75, 95% CI 0.42-

1.32††

OR 0.18, 95% CI 0.05-0.58 

¶¶

HR 1.25; 95% CI 0.96-1.63

Gonorrhea In men:

No significant association in RCT

- In Kenya (IRR 0.95, 95% CI 0.68-1.34) **

- In South Africa, intention-to-treat analysis

IRR 0.95, 95% CI 0.68-1.34 

**

aOR 0.94, 95% CI 0.69-1.29

aOR 1.02, 95% CI 0.74-1.32 

††

Chancroid In men:

- Not assessed in RCTs. 

- In observational studies, lower risk of chancroid

in six out of seven studies (mostly assessed by 

clinical exam) 

no summary RR due to 

heterogeneity, individual 

study RRs: 0.12 to 1.11 §
60

aOR = adjusted odds ratio; BV = bacterial vaginosis; CI = confidence interval; GUD = genital ulcerative disease; HPV = human 

papillomavirus; HR = hazard ratio; HSV = herpes simplex virus; IRR = incidence rate ratio; OR = odds ratio; PRR = prevalence rate 

ratio; RCT = randomized controlled trial; RR = risk ratio; STI = sexually transmitted infection

* Source: Tobian AAR, Serwadda D, Quinn TC, et al. Male circumcision for the prevention of HSV-2 and HPV infections and 

syphilis. N Eng J Med 2009;360;1298-309.

BV In female partners: 

- In Uganda, significant association with 

Any BV 

severe BV 

adjusted PRR 0.60, 95% CI 

0.38-0.94

PRR 0.39, 95% CI 0.24-0.64 

§§

Syndromes

GUD In men: 

- In Uganda RCT, significant association 

- In Kenya RCT, significant association

In female partners:

- In Uganda RCT, significant association 

PRR 0.53, 95% CI 0.43-

0.64***

RR 0.52; 95% CI 0.37-0.73&

adjusted PRR 0.78, 0.61-

0.99

§§

 

Genital discharge In men: 

- In Uganda RCT, no significant association 

In female partners: 

- In Uganda RCT, no significant association 

PRR 0.84, 95% CI 0.63-1.11 

***

PRR 0.99, 95% CI 0.89-1.12

§§

Dysuria In men: 

- In Uganda RCT, no significant association

In female partners: 

- In Uganda RCT, no significant association 

PRR 0.97, 95% CI 0.77-1.21 

***

PRR 0.97, 95% CI 0.75-1.21

§§
61

† Source: Sobngwi-Tambekou J, Taljaard D, Lissouba P, Zarca K, Puren A, Lagarde E, et al. Effect of HSV-2 serostatus on 

acquisition of HIV by young men: results of a longitudinal study in Orange Farm, South Africa. J Infect Dis 2009;199(7):958-64.

&

Source: Mehta SD, Moses S, Parker CB, et al. Circumcision status and incident herpes simplex virus type 2 infection, genital ulcer 

diseae, and HIV infection. AIDS 2012; 26(9):1141-1149.

§ Source: Weiss HA, Thomas SL, Munabi SK, Hayes RJ. Male circumcision and risk of syphilis, chancroid, and genital herpes: A 

systematic review and meta-analysis. Sex Transm Infect 2006;82(2):101-10. 

¶ Source: 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. J Infect Dis

2009;199(1):14-9.

** Source: Mehta SD, Moses S, Agot K, et al. Adult Male Circumcision Does Not Reduce the Risk of Incident Neisseria 

gonorrhoeae, Chlamydia trachomatis, or Trichomonas vaginalis Infection: Results from a Randomized, Controlled Trial in Kenya. J 

Infect Dis 2009;200(3):370-8.

†† Source: Sobngwi-Tambekou J, Taljaard D, et al. Male circumcision and Neisseria gonorrhoeae, Chlamydia trachomatis and 

Trichomonas vaginalis: observations after a randomised controlled trial for HIV prevention. Sex Transm Infect 2009;85(2):116-20.

§§ Source: Gray RH, Kigozi G, Serwadda D, et al. The effects of male circumcision on female partners' genital tract symptoms and 

vaginal infections in a randomized trial in Rakai, Uganda. Am J Obstet Gynecol 2009;200(1):42 e1-7

¶¶ Source: Castellsague X, Peeling RW, Franceschi S, et al. Chlamydia trachomatis infection in female partners of circumcised and 

uncircumcised adult men. Am J Epidemiol 2005;162(9):907-16.

*** Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomized trial. 

Lancet 2007;369:657-66. 

††† Source: Turner AN, Morrison CS, Padian NS, et al. Male circumcision and women's risk of incident chlamydial, gonococcal, and 

trichomonal infections. 2008 Sex Transm Dis;35:689-95.