Around the beginning the 20th century, Sexually Transmitted Diseases/Infections (STDs/STIs, then known as Venereal Disease or VD) were still among the most feared of diseases. The last stages of untreated syphillis were madness and death, and there was no effective treatment. Such treatments as there were involved mercury, and so were themselves highly toxic. The treatment for gonococcal salpingitis (inflammation of the urethra), involved a hard tube (bougie) inserted up the penis, which was painful.
Now, with 20/20 hindsight, it seems almost inevitable that circumcision would be wheeled in as a preventative measure, as it was for the almost equally feared "masturbation insanity" before it, and cancer and AIDS afterwards.
During and after the World Wars, when our boys were bringing home VD from the fleshpots of Europe and Asia Minor, circumcision rates of baby boys increased.
Yet there is no evidence that circumcision protects against STDs. On the contrary.
The Laumann study of 1511 men who answered the National Health and Social Life Survey is flawed (by relying on self-report to establish both circumcision status and disease history). However, it found no significant differences in STD rates between circumcised and intact men, except for one STD: 25.1/1000 (26/1033) circumcised men reported having suffered from the commonest STD, chlamydia, while no intact men (out of 353) did so. Conclusion:
Another study found similarly:
- Tsen HF, Morgenstern H, Mack T, Peters RK.
"Risk factors for penile cancer:
results of a population-based case-control study
in Los Angeles County (United States)"
Cancer Causes Control 2001 Apr;12(3):267-277.
And again chlamydia
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As with Castellsague's other study using the same data, this study pools data from five different countries, in only one of which circumcision is common, then claims it has corrected for this anomaly by removing the data for that country - which removes the vast majority of the circumcised men. Am J Epidemiol. 2005 Sep 21; [Epub ahead of print] Chlamydia trachomatis Infection in Female Partners of Circumcised and Uncircumcised Adult Men. Castellsague X, Peeling RW, Franceschi S, de Sanjose S, Smith JS, Albero G, Diaz M, Herrero R, Munoz N, Bosch FX. Abstract: Male circumcision has been shown to reduce the risk of acquiring and transmitting a number of venereal infections. [false] However, little is known about the association between male circumcision and the risk of Chlamydia trachomatis infection in the female partner. The authors pooled data on 305 adult couples enrolled as controls in one of five case-control studies of invasive cervical cancer conducted in Thailand, the Philippines, Brazil, Colombia, and Spain between 1985 and 1997. Women provided blood samples for C. trachomatis and Chlamydia pneumoniae antibody detection; a type-specific microfluorescence assay was used. Multivariate odds ratios were computed for the association between male circumcision status and chlamydial seropositivity in women. Compared with women with uncircumcised partners, those with circumcised partners had a 5.6-fold reduced risk of testing seropositive for C. trachomatis (82% reduction; odds ratio = 0.18, 95% confidence interval: 0.05, 0.58). The inverse association was also observed after restricting the analysis to monogamous women and their only male partners (odds ratio = 0.21, 95% confidence interval: 0.06, 0.72). In contrast, seropositivity to C. pneumoniae, a non-sexually-transmitted infection, was not significantly related to circumcision status of the male partner. [false] These findings suggest that male circumcision could reduce the risk of C. trachomatis infection in female sexual partners. [And therefore Carthage must be destroyed.] PMID: 16177149 [PubMed - as supplied by publisher] "Finally, our results may be driven by the large contribution of circumcised men from the study in the Philippines. It is possible that the observed associations were mediated by other practices or characteristics of the recruited couples in the Philippines that we were not able to identify or quantify. However, it is reassuring that the direction and statistical significance of the overall association remained virtually unchanged after we excluded the couples from the Philippines (OR ¼ 0.11, 95 percent CI: 0.01, 0.91)." In fact:
They only had 14 circumcised men outside the Philippines, and only 8 intact ones inside! It's just crazy to draw any conclusions from such a skewed sample, and to calculate odds ratios from such a tiny sample. How telling that "reassuring" is: how he WANTS circumcision to be protective! Look at the range of the percentages: in Thailand, being chlamydia+ with a cut partner is almost as likely as being chlamydia+ with an intact one in Brazil, for what it's worth - not much when we're looking at one case. In all five countries, the proportion of partners-of-cut-men who had sexually transmissible chlamydia was lower than that of partners-of-intact-men. However, the low numbers of intact men in the Philippines and the low numbers of cut men in the other four countries makes the probability that this could have occurred by chance high in all five countries. There was a 37% chance that none of the partners of cut men in Brazil would have tested +ve if the partners of cut men were equally likely as the partners of intact men to have chlamydia -- hardly an unusual outcome and scant evidence for an association. If just one more female partner of a cut man in Brazil, Thailand and Colombia and one fewer partner of an intact man in the Philippines had tested +ve, the weak evidence of an association would have disappeared altogether in all four countries. In Spain, there was only one cut man in the study. The probability that his partner would test negative if there was no association was more than two in three, so the fact that the partner did test negative provides scant evidence for an association (it was the expected result whether or not the man was cut and whether or not there was an association). "In contrast, seropositivity to C. pneumoniae, a non-sexually-transmitted infection, was not significantly related to circumcision status of the male partner." Actually, C. pneumoiae. is positively associated with having a CIRCUMCISED partner:
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Another flawed study
Males: An Analysis of a Longitudinal Birth Cohort David M. Fergusson, Joseph M. Boden and L. John Horwood Pediatrics 2006;118;1971-1977 DOI: 10.1542/peds.2006-1175 OBJECTIVES. Previous research suggests that male circumcision may be a protective factor against the acquisition of sexually transmitted infections; however, studies examining this question have produced mixed results. The aim of this study was to examine the association between circumcision status and sexually transmitted infection risk using a longitudinal birth cohort study. METHODS. Data were gathered as part of the Christchurch Health and Development Study, a 25-year longitudinal study of a birth cohort of New Zealand children. Information was obtained on: (1) the circumcision status of males in the cohort before 15 years old, (2) measures of self-reported sexually transmitted infection from ages 18 to 25 years, and (3) childhood, family, and related covariate factors. RESULTS. Being uncircumcised had a statistically significant bivariate association with self-reported sexually transmitted infection. Adjustment for potentially confounding factors, including number of sexual partners and unprotected sex, as well as background and family factors related to circumcision, did not reduce the association between circumcision status and reports of sexually transmitted infection. Estimates of the population-attributable risk suggested that universal neonatal circumcision would have reduced rates of sexually transmitted infection in this cohort by 48.2%. CONCLUSIONS. These findings suggest that uncircumcised males are at greater risk of acquiring sexually transmitted infection than circumcised males. Male circumcision may reduce the risk of sexually transmitted infection acquisition and transmission by up to one half, suggesting substantial benefits accruing from routine neonatal circumcision. ["And therefore Carthage must be destroyed"] ... Circumcision Status
Self-Reported STIs, Ages 18 to 21 and 21 to 25 Years
... Table 1 shows that, at both times, uncircumcised males were at increased risk of STI. [IT DOES NOT. Both 95% Confidence Interval ranges pass through 1.0 - no association.] ... ...
... These estimates suggest that had all members of this cohort been circumcised, the overall rate of STI within the cohort would have been reduced by 50%. [This ignores the low absolute rate of STIs. The proper figure to measure the effectiveness of circumcision is the Number Needed to Treat (NNT), i.e. the number of circumcisions required to prevent one STD. For the 18-21-year-olds this is 48.66, for the older men the NNT is 20.59. Multiply those figures by the cost of circumcision (with 21 or 25 years of interest since birth), and the total cost to prevent each STD is some thousands of dollars, compared with a few dollars to treat with antibiotic - and the benefits of leaving the men to enjoy their own foreskins.] ...a potential limitation of this research is that the assessment of STI was based on self-report, and this is likely to underestimate the true prevalence of these conditions. The prevalence estimates of STI reported in this article are, thus, likely to be lower-limit estimates of the true but nonobserved prevalence of STIs. However, whereas underreporting of STIs may bias estimates of the prevalence of STIs downward, it is unlikely to bias estimates of the association between STIs and circumcision, because there is no reason to believe that the reporting accuracy of STIs will vary with circumcision status. [...but the fact is, we have no idea. Maybe circumcised men are more defensive about the idea that there is anything wrong with their penises, for example. It has been suggested that people with an anti-sex mindset are more likely to have their sons circumcised, especially when they have to buck the trend because the incidence of circumcision is low (and declining), as it was in Christchurch in 1973, and people raised in that environment would be more ashamed of admitting to an STI. But the incidence of STIs is so low that random elements can have a strong effect.] ...The public health issues raised by these findings clearly involve weighing the longerterm benefits of routine neonatal circumcision in terms of reducing risks of infection within the population, against the perceived costs of the procedure. [Perceived by whom? Weigh in the risks, the pain, the ethical issues, and the value of the foreskin to its owner (and not to some present day man who can't remember having one) and it's a no-brainer: leave the babies alone.] This study generated headlines worldwide saying the likes of "Circumcision may reduce STD risk - study". One rebuttal appeared in the news. Others were published as Post-publication Peer Reviews (P3Rs). Prof Fergusson responded by admitting that his result was anomalous, and took on board the fact that it would take 20 circumcisions to prevent one minor STD. | ||||||||||||||||||||||||||||||||||||
This is in sharp contrast with a similar, but much larger British study:
Dave SS, Fenton KA, Mercer CH, Erens B, Wellings K, Johnson AM. Sex Transm Infect 2003;79:499-500
...We used data from the 2000 British National Survey of Sexual Attitudes and Lifestyles (Natsal 2000) - a large-scale, stratified, probability sample survey -- to estimate the prevalence of male circumcision in Britain and investigate its association with ... reported STI diagnosis.
[There were apparently 913 circumcised and 4833 intact subjects.] ...We did not find any significant differences in the proportion of circumcised and uncircumcised British men reporting ever being diagnosed with any STI (11.1% compared with 10.8%, p = 0.815), bacterial STIs (6.4% cf 5.9%, p = 0.628), or viral STIs (4.7% cf 4.5%, p = 0.786) (table 1Go). We also found no significant associations between circumcision and being diagnosed with any one of the seven specific STIs. | |||||||||||||||
J Richters, AM Smith, RO de Visser, AE Grulich, and CE Rissel Int J STD AIDS, August 1, 2006; 17(8): 547-54. The results from a telephone survey in 2001-02 of a probability sample of Australian households including 10,173 men aged 16-59 (response rate 69.4%) are used to assess the prevalence of circumcision across social groups in Australia and examine lifetime history of sexually transmissible infection (STI),... More than half (59%) of the men were circumcised. Circumcision was less common among younger men (32% aged <20)... After correction for age, circumcision was unrelated to reporting STI, but appeared to protect against penile candidiasis. [...or rather, negatively correlated with penile candidiasis.] |
And another, from the US military...
This abstract was submitted for The XV International AIDS Conference, 2004 (Poster Exhibition)
Prevalence of male circumcision and its association with HIV and sexually transmitted infections in a U.S. navy population
Background: Lack of male circumcision has been found to be a risk factor for HIV and sexually transmitted infection (STI) in several studies performed in developing countries. However, the few studies conducted in developed nations have yielded inconsistent results. Policy regarding circumcision of male infants as a prevention measure against HIV/STI remains a controversial topic. This study describes the prevalence of circumcision and its association with HIV and STI in a U.S. military population.
Methods: This is a case-control study of male HIV infected U.S. military personnel (n= 232) recruited from 7 military medical centers and male U.S. Navy controls (n=516) from a general aircraft carrier population. Cases and controls completed similar self-administered HIV behavioral risk surveys. Case circumcision status was abstracted from medical charts while control status was reported on the survey. Cases and controls were frequency matched on age. Multiple logistic regressions were constructed separately to evaluate the role of circumcision in the acquisition of HIV and STI.
Results: The proportion of circumcised men did not significantly differ between cases (84.9%) and controls (81.8%). Prevalence of circumcision among men born in the U.S. was higher (85.0%) than those born elsewhere (58.1%). After adjustment for demographic and behavioral risk factors lack of circumcision was not found to be a risk factor for HIV (OR = 0.9; 95% CI: 0.51, 1.7) or STI (OR = 1.08; 95% CI 0.52, 2.26). The odds of HIV infection were 2.6 higher for irregular condom users, 5 times as high for those reporting STI, 6.2 times higher for those reporting anal sex, 2.8-3.2 times higher for those with 2-7+ partners, nearly 3 times higher for Blacks, and 3.5 times as high for men who were single or divorced/separated.
Conclusions: Although there may be other medical or cultural reasons for male circumcision, it is not associated with HIV or STI prevention in this U.S. military population. |
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