Effect of male circumcision on risk of sexually transmitted infections and cervical cancer in women
Authors: Brian J Morris, Catherine A Hankins
Journal: The Lancet Global Health (2017)

Current scientific evidence demonstrates compellingly that male circumcision confers a lifetime of medical and health benefits to men.1Tobian AA Kacker S Quinn TC Male circumcision: a globally relevant but under-utilized method for the prevention of HIV and other sexually transmitted infections.Ann Rev Med. 2014; 65: 293-306Crossref PubMed Scopus (59) Google Scholar Are there also any benefits for women who have a male sexual partner who is circumcised? In The Lancet Global Health, researchers from the US Centers for Disease Control and Prevention and Johns Hopkins University report results of a systematic review2Grund JM Bryant TS Jackson I et al.Association between male circumcision and women's biomedical health outcomes: a systematic review.Lancet Glob Health. 2017; 5: e1113-e1122Summary Full Text Full Text PDF PubMed Scopus (38) Google Scholar that directly addresses the question of whether male circumcision reduces acquisition of sexually transmitted infections (STIs) and cervical cancer in women. Clearly, reduced population prevalence of STIs in men will translate into lower risk of STI exposure in women. But will circumcised men with STIs be less infective? Jonathan Grund and colleagues' extensive search of nine literature databases generated 112 eligible publications, of which 60 reported quantitative biomedical health outcomes and 57 were included. Of these, most studies were observational and nine were randomised controlled trials (RCTs). Women were from populations in Africa, North America, South America, Asia, and Europe. Their ages spanned from either 15 or 18 years through to either 49 or 65 years. Strong, consistent evidence was found for protection against cervical cancer (eight of nine studies involving women in multiple non-African settings), cervical dysplasia (four of five studies involving women in Africa and other continents), herpes simplex virus type 2 infection (six of six studies, including one RCT, involving women in Africa, Asia, and the USA), chlamydia (four of five studies, involving women in five continents), and syphilis (six of six studies, involving women in Africa and Asia). Persistent human papillomavirus (HPV) infection is the cause of almost all cervical cancers. Women with circumcised partners were protected against any HPV (five of five studies including three RCTs, involving women from multiple settings in Africa and Europe) and low-risk HPV types (three of three studies, two being RCTs, involving women in Africa and Europe). These HPV findings stemmed from medium-consistency evidence. For six outcomes—protection against any STI, candidiasis, dysuria, genital warts, gonorrhoea, high-risk HPV viral load, and Mycoplasma genitalium—evidence was regarded as intermediate consistency because there were fewer than the minimum of three studies required for medium consistency. Seven other outcomes—bacterial vaginosis, gonorrhoea, HIV infection, high-risk HPV infection, non-specific genital ulcers, trichomonas, and vaginal discharge—had discrepant values, which rendered the evidence as low-consistency. Over her lifetime, a woman might have sexual partners of either male circumcision status, potentially confounding associations between male partner's circumcision status and a woman's HPV risk. A noteworthy global multinational study of HPV and cervical cancer obtained data for women who had had only one male partner.3Castellsague X Bosch FX Munoz N et al.International Agency for Research on Cancer Multicenter Cervical Cancer Study G. Male circumcision, penile human papillomavirus infection, and cervical cancer in female partners.N Engl J Med. 2002; 346: 1105-1112Crossref PubMed Scopus (597) Google Scholar Sampling of urethra and glans or coronal sulcus revealed HPV infection in 5·5% of circumcised versus 19·6% of uncircumcised men.3Castellsague X Bosch FX Munoz N et al.International Agency for Research on Cancer Multicenter Cervical Cancer Study G. Male circumcision, penile human papillomavirus infection, and cervical cancer in female partners.N Engl J Med. 2002; 346: 1105-1112Crossref PubMed Scopus (597) Google Scholar Among women who had a high-risk sexual partner (defined as one who had had ≥6 sexual partners and first intercourse before the age of 17 years), cervical cancer was 82% less prevalent if that partner was circumcised than if he was uncircumcised. Reduction of cervical cancer risk from circumcision was 50% for women whose male partner had an intermediate risk index. Analysis of this multinational dataset4Castellsagué X Peeling RW Franceschi S et al.Chlamydia trachomatis infection in female partners of circumcised and uncircumcised adult men.Am J Epidemiol. 2005; 162: 907-916Crossref PubMed Scopus (67) Google Scholar demonstrated that male circumcision conferred a 79% reduction in the risk of Chlamydia trachomatis infection for single-partnered women whose lifetime partner tested positive for this STI. The authors speculated that infected cervicovaginal secretions might be retained under the foreskin of an uncircumcised penis for longer, so increasing risk of urethral infection and transmission to a subsequent female partner.4Castellsagué X Peeling RW Franceschi S et al.Chlamydia trachomatis infection in female partners of circumcised and uncircumcised adult men.Am J Epidemiol. 2005; 162: 907-916Crossref PubMed Scopus (67) Google Scholar A study5Pintye J Baeten JM Manhart LE et al.Association between male circumcision and incidence of syphilis in men and women: a prospective study in HIV-1 serodiscordant heterosexual African couples.Lancet Glob Health. 2014; 2: e664-e671Summary Full Text Full Text PDF PubMed Scopus (30) Google Scholar of women in Kenya and Uganda enrolled in an RCT and followed up for 3 years found circumcision of their male partners was associated with a 59% reduction in incident syphilis among the women. A prospective study6Pintye J Drake AL Unger JA et al.Male partner circumcision associated with lower Trichomonas vaginalis incidence among pregnant and postpartum Kenyan women: a prospective cohort study.Sex Transm Infect. 2017; 93: 137-143Crossref PubMed Scopus (10) Google Scholar in Kenya by the same authors found that those with circumcised male partners had a 58% lower risk of incident Trachomatis vaginalis than did women with uncircumcised partners.6Pintye J Drake AL Unger JA et al.Male partner circumcision associated with lower Trichomonas vaginalis incidence among pregnant and postpartum Kenyan women: a prospective cohort study.Sex Transm Infect. 2017; 93: 137-143Crossref PubMed Scopus (10) Google Scholar The systematic review2Grund JM Bryant TS Jackson I et al.Association between male circumcision and women's biomedical health outcomes: a systematic review.Lancet Glob Health. 2017; 5: e1113-e1122Summary Full Text Full Text PDF PubMed Scopus (38) Google Scholar emphasises that male circumcision confers an STI risk reduction to women. Prophylactic vaccines against HIV and most other STIs have remained elusive. HPV vaccination against a subset of HPV types in early adolescence can help to partly mitigate cervical cancer risk, but uptake is not widespread in all settings. The emerging switch from Papanicolaou smears to primary screening for HPV7Morris BJ Flanagan JL McKinnon KJ Nightingale BN Papillomavirus screening of cervical lavages by polymerase chain reaction.Lancet. 1988; 2: 1368Abstract PubMed Scopus (36) Google Scholar in high-income countries will improve risk detection, but is not practicable in resource-constrained settings. Thus, although the diagnosis and treatment of STIs continue to improve in effectiveness, prevention has to remain a priority for many reasons, not the least of which is cost. The benefits of male circumcision for men are well established, with the science driving affirmative policy recommendations by WHO, UNAIDS, the World Bank, the American Academy of Pediatrics, and the US Centers for Disease Control and Prevention. The findings of this systematic review support affirmative policy recommendations for women. Women can have considerable power in regard to male circumcision. They can and do influence the choice of male circumcision for their sons ideally soon after birth,8Morris BJ Waskett JH Banerjee J et al.A ‘snip’ in time: what is the best age to circumcise?.BMC Pediatr. 2012; 12: 1-15Crossref PubMed Scopus (88) Google Scholar and later, as well as for their brothers and other male family members. Women can choose a circumcised sexual partner or encourage an uncircumcised partner to get circumcised. Most studies, including an RCT,9Kigozi G Lukabwe I Kagaayi J et al.Sexual satisfaction of women partners of circumcised men in a randomized trial of male circumcision in Rakai, Uganda.BJU Int. 2009; 104: 1698-1701Crossref PubMed Scopus (45) Google Scholar have noted that women generally favour male circumcision for aesthetic reasons, sexual pleasure, vaginal penetration, hygiene, and reduced infection risk. BJM holds US Patents 5,783,412 and 6,218,104, European Patent 88902077.2-2107 (British, 0357611; German, P 3853678.1; Swiss, 3853678.1; Swedish, 0357611), Japanese patent 3096704 and Australian Patent 611135, with Priority date 26 Feb 1987, for use of PCR technology for HPV detection in cervical screening; he is a member of the Circumcision Academy of Australia, a not-for-profit, government-registered, medical association that provides evidence-based information on male circumcision and a list of doctors who perform male circumcision in Australia and New Zealand on its website. CAH declares no competing interests. Association between male circumcision and women's biomedical health outcomes: a systematic reviewScale-up of male circumcision in sub-Saharan Africa has public health implications for several outcomes in women. Evidence that female partners are at decreased risk of several diseases is highly consistent. Synergies between male circumcision and women's health programmes should be explored. Full-Text PDF Open Access