Varieties of male circumcision: a study from Kenya

Does Voluntary Medical Male Circumcision Reduce HIV Risk in Men Who Have Sex with Men?

PURPOSE OF REVIEW

To review the evidence on the effect of voluntary medical male circumcision (VMMC) on reducing HIV risk among men who have sex with men (MSM) and assess the limitations of available evidence.

RECENT FINDINGS

Individual studies have shown conflicting results, but recent meta-analyses have consistently suggested that VMMC was associated with 7 to 23% reductions in HIV prevalence or incidence in MSM, particularly among a subgroup of men who predominantly practice insertive role in anal sex. Mathematical models have also suggested a moderate population-level impact of VMMC intervention. All original studies have been observational and are subject to confounding and bias. Randomized clinical trials (RCTs) are needed to provide strong evidence of assessing the efficacy of VMMC on HIV risk among MSM. VMMC is a promising HIV risk reduction tool for MSM. RCTs are needed to evaluate the efficacy of VMMC intervention.

Accessory fold of skin on the ventral surface of the penis: Is it a redundant prepuce?

Variations in the skin of the prepuce are very rare. We report here a variation of the penile skin as observed in an adult male cadaver aged approximately 65 years. The penis was covered by thin nonhairy skin. The glans was not covered with prepuce. There was no evidence of circumcision. The ventral surface of the penis, adjacent to the glans, had a huge fold of skin. This fold resembled the prepuce and had a hole in it. The glans penis had a normal urethral meatus. There was no evidence of hypospadias as the entire ventral surface of the penis was covered completely by the skin. We discuss the clinical importance of this accessory fold of skin.

Towards a gender perspective in qualitative research on voluntary medical male circumcision in east and southern Africa

The World Health Organization endorsed voluntary medical male circumcision (VMMC) in 2007 as an effective method to provide partial protection against heterosexual female-to-male transmission of HIV in regions with high rates of such transmission, and where uptake of VMMC is low. Qualitative research conducted in east and southern Africa has focused on assessing acceptability, barriers to uptake of VMMC and the likelihood of VMMC increasing men's adoption of risky sexual behaviours. Less researched, however, have been the perceptions of women and sexual minorities towards VMMC, even though they are more vulnerable to HIV/AIDS transmission than are heterosexual men. The purpose of this paper is to identify core areas in which a gendered perspective in qualitative research might improve the understanding and framing of VMMC in east and southern Africa. Issues explored in this analysis are risk compensation, the post-circumcision appearance of the penis, inclusion of men who have sex with men as study respondents and the antagonistic relation between VMMC and female genital cutting. If biomedical and social science researchers explore these issues in future qualitative inquiry utilising a gendered perspective, a more thorough understanding of VMMC can be achieved, which could ultimately inform policy and implementation.

Risk factors for HIV infection among circumcised men in Uganda: a case-control study

INTRODUCTION

Male circumcision (MC) reduces the risk of HIV infection. However, the risk reduction effect of MC can be modified by type of circumcision (medical, traditional and religious) and sexual risk behaviours post-circumcision. Understanding the risk behaviours associated with HIV infection among circumcised men (regardless of form of circumcision) is critical to the design of comprehensive risk reduction interventions. This study assessed risk factors for HIV infection among men circumcised through various circumcision approaches.

METHODS

This was a case-control study which enrolled 155 cases (HIV-infected) and 155 controls (HIV-uninfected), all of whom were men aged 18-35 years presenting at the AIDS Information Center for HIV testing and care. The outcome variable was HIV sero-status. Using SPSS version 17, multivariable logistic regression was performed to identify factors independently associated with HIV infection.

RESULTS

Overall, 83.9% among cases and 56.8% among controls were traditionally circumcised; 7.7% of cases and 21.3% of controls were religiously circumcised while 8.4% of cases and 21.9% of controls were medically circumcised. A higher proportion of cases than controls reported resuming sexual intercourse before complete wound healing (36.9% vs. 14.1%; p<0.01). Risk factors for HIV infection prior to circumcision were:being in a polygamous marriage (AOR: 6.6, CI: 2.3-18.8) and belonging to the Bagisu ethnic group (AOR: 6.1, CI: 2.6-14.0). After circumcision, HIV infection was associated with: being circumcised at >18 years (AOR: 5.0, CI: 2.4-10.2); resuming sexual intercourse before wound healing (AOR: 3.4, CI: 1.6-7.3); inconsistent use of condoms (AOR: 2.7, CI: 1.5-5.1); and having sexual intercourse under the influence of peers (AOR: 2.9, CI: 1.5-5.5). Men who had religious circumcision were less likely to have HIV infection (AOR: 0.4, 95% CI: 0.2-0.9) than the traditionally circumcised but there was no statistically significant difference between those who were traditionally circumcised and those who were medically circumcised (AOR: 0.40, 95% CI: 0.1-1.1).

CONCLUSIONS

Being circumcised at adulthood, resumption of sexual intercourse before wound healing, inconsistent condom use and having sex under the influence of peers were significant risk factors for HIV infection. Risk reduction messages should address these risk factors, especially among traditionally circumcised men.

Impact of male circumcision on the HIV epidemic in Papua New Guinea: a country with extensive foreskin cutting practices

The degree to which adult medical male circumcision (MC) programs can reduce new HIV infections in a moderate HIV prevalence country like Papua New Guinea (PNG) are uncertain especially given the widespread prevalence of longitudinal foreskin cuts among adult males. We estimated the likely impact of a medical MC intervention in PNG using a mathematical model of HIV transmission. The model was age-structured and incorporated separate components for sex, rural/urban, men who have sex with men and female sex workers. Country-specific data of the prevalence of foreskin cuts, sexually transmitted infections, condom usage, and the acceptability of MC were obtained by our group through related studies. If longitudinal foreskin cutting has a protective efficacy of 20% compared to 60% for MC, then providing MC to 20% of uncut males from 2012 would require 376,000 procedures, avert 7,900 HIV infections by 2032, and require 143 MC per averted infection. Targeting uncut urban youths would achieve the most cost effective returns of 54 MC per HIV infection averted. These numbers of MC required to avert an HIV infection change little even with coverage up to 80% of men. The greater the protective efficacy of longitudinal foreskin cuts against HIV acquisition, the less impact MC interventions will have. Dependent on this efficacy, increasing condom use could have a much greater impact with a 10 percentage point increase averting 18,400 infections over this same period. MC programs could be effective in reducing HIV infections in PNG, particularly in high prevalence populations. However the overall impact is highly dependent on the protective efficacy of existing longitudinal foreskin cutting in preventing HIV.

Circumcision and prostate cancer: a population-based case-control study in Montréal, Canada

Objectives

To investigate the possible association between circumcision and prostate cancer risk, to examine whether age at circumcision influences prostate cancer risk, and to determine whether race modifies the circumcision–prostate cancer relationship.

Subjects and Methods

PROtEuS (Prostate Cancer and Environment Study), a population-based case-control study set amongst the mainly French-speaking population in Montréal, Canada, was used to address study objectives. The study included 1590 pathologically confirmed prostate cancer cases diagnosed in a Montréal French hospital between 2005 and 2009, and 1618 population controls ascertained from the French electoral list, frequency-matched to cases by age. In-person interviews elicited information on sociodemographic, lifestyle and environmental factors. Unconditional logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) between circumcision, age at circumcision and prostate cancer risk, adjusting for age, ancestry, family history of prostate cancer, prostate cancer screening history, education, and history of sexually transmitted infections.

Results

Circumcised men had a slightly lower risk, albeit not statistically significant, of developing prostate cancer than uncircumcised men (OR 0.89, 95% CI 0.76–1.04). Circumcision was found to be protective in men circumcised aged ≥36 years (OR 0.55, 95% CI 0.30–0.98). A weaker protective effect was seen among men circumcised within 1 year of birth (OR 0.86, 95% CI 0.72–1.04). The strongest protective effect of circumcision was recorded in Black men (OR 0.40, 95% CI 0.19–0.86, P-value for interaction 0.02) but no association was found with other ancestral groups.

Conclusion

Our findings provide novel evidence for a protective effect of circumcision against prostate cancer development, especially in those circumcised aged ≥36 years; although circumcision before the age of 1 year may also confer protection. Circumcision appeared to be protective only among Black men, a group that has the highest rate of disease. Further research into the differences in effect of circumcision on prostate cancer risk by ancestry is warranted, as is the influence of age at circumcision.

Building social currency with foreskin cuts: a coping mechanism of Papua New Guinea health workers and the implications for new programmes

BACKGROUND

Recent research as part of a multi-disciplinary investigation on the acceptability and impact of male circumcision for HIV prevention in Papua New Guinea (PNG) has shown that health workers (HWs) undertake unauthorized forms of penile cutting practices in public health facilities or in community settings, at times within a traditional context. Participation in these activities shares common features with coping mechanisms, strategies used by HWs to alleviate the burden of unsatisfactory living and working conditions. Coping mechanisms, however, are typically described as motivated by economic advantage, but in PNG evidence exists that the behaviours of HWs are also influenced by opportunities for social capital.

METHODS

Twenty-five in-depth interviews (IDIs) were completed with a variety of HWs from 2009 until 2011 and were triangulated with findings from 45 focus group discussions and 82 IDIs completed with community members as part of a wider qualitative study. Thematic analysis examined HW participation in unauthorized penile cutting services.

RESULTS

The emergence of unauthorized practices as a coping mechanism in PNG is compelled by mutual obligations and social capital arising from community recognition and satisfaction of moral, professional and cultural obligations. Using the example of unauthorized penile cutting practices amongst HWs in PNG, the research shows that although economic gains are not explicitly derived, evidence exists that they meet other community and socio cultural responsibilities forming a social currency within local traditional economies.

CONCLUSIONS

Coping mechanisms create an opportunity to extend the boundaries of a health system at the discretion of the HW. Fragile health systems create opportunities for coping mechanisms to become institutionalized, pre-empting appropriate policy development or regulation in the introduction of new programmes. In order to ensure the success of new programmes, the existence of such practices and their potential implications must be addressed within programme design, and in implementation and regulation.

Foreskin cutting beliefs and practices and the acceptability of male circumcision for HIV prevention in Papua New Guinea

BACKGROUND

Male circumcision (MC) reduces HIV acquisition and is a key public health intervention in settings with high HIV prevalence, heterosexual transmission and low MC rates. In Papua New Guinea (PNG), where HIV prevalence is 0.8%, there is no medical MC program for HIV prevention. There are however many different foreskin cutting practices across the country's 800 language groups. The major form exposes the glans but does not remove the foreskin. This study aimed to describe and quantify foreskin cutting styles, practices and beliefs. It also aimed to assess the acceptability of MC for HIV prevention in PNG.

METHODS

Cross-sectional multicentre study, at two university campuses (Madang Province and National Capital District) and at two 'rural development' sites (mining site Enga Province; palm-oil plantation in Oro Province). Structured questionnaires were completed by participants originating from all regions of PNG who were resident at each site for study or work.

RESULTS

Questionnaires were completed by 861 men and 519 women. Of men, 47% reported a longitudinal foreskin cut (cut through the dorsal surface to expose the glans but foreskin not removed); 43% reported no foreskin cut; and 10% a circumferential foreskin cut (complete removal). Frequency and type of cut varied significantly by region of origin (p < .001). Most men (72-82%) were cut between the ages of 10-20 years. Longitudinal cuts were most often done in a village by a friend, with circumferential cuts most often done in a clinic by a health professional. Most uncut men (71%) and longitudinal cut men (84%) stated they would remove their foreskin if it reduced the risk of HIV infection. More than 95% of uncut men and 97% of longitudinal cut men would prefer the procedure in a clinic or hospital. Most men (90%) and women (74%) stated they would remove the foreskin of their son if it reduced the risk of HIV infection.

CONCLUSION

Although 57% of men reported some form of foreskin cut only 10% reported the complete removal of the foreskin, the procedure on which international HIV prevention strategies are based. The acceptability of MC (complete foreskin removal) is high among men (for themselves and their sons) and women (for their sons). Potential MC services need to be responsive to the diversity of beliefs and practices and consider health system constraints. A concerted research effort to investigate the potential protective effects of longitudinal cuts for HIV acquisition is essential given the scale of longitudinal cuts in PNG.

Listening to diverse community voices: the tensions of responding to community expectations in developing a male circumcision program for HIV prevention in Papua New Guinea

BACKGROUND

The success of health programs is influenced not only by their acceptability but also their ability to meet and respond to community expectations of service delivery. The World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) have recommended medical male circumcision (MC) as an essential component of comprehensive HIV prevention programs in high burden settings. This study investigated community-level perceptions of MC for HIV prevention in Papua New Guinea (PNG), a setting where diverse traditional and contemporary forms of penile foreskin cutting practices have been described.

METHODS

A multi-method qualitative study was undertaken in four provinces in two stages from 2009 to 2011. A total of 82 in-depth interviews, and 45 focus group discussions were completed during Stage 1. Stage 2 incorporated eight participatory workshops that were an integral part of the research dissemination process to communities. The workshops also provided opportunity to review key themes and consolidate earlier findings as part of the research process. Qualitative data analysis used a grounded theory approach and was facilitated using qualitative data management software.

RESULTS

A number of diverse considerations for the delivery of MC for HIV prevention in PNG were described, with conflicting views both between and within communities. Key issues included: location of the service, service provider, age eligibility, type of cut, community awareness and potential shame amongst youth. Key to developing appropriate health service delivery models was an appreciation of the differences in expectations and traditions of unique cultural groups in PNG. Establishing strong community coalitions, raising awareness and building trust were seen as integral to success.

CONCLUSIONS

Difficulties exist in the implementation of new programs in a pluralistic society such as PNG, particularly if tensions arise between biomedical knowledge and medico-legal requirements, compared to existing socio-cultural interests. Community participatory approaches offer important opportunities to explore and design culturally safe, specific and accessible programs.

Traditional male circumcision in Uganda: a qualitative focus group discussion analysis

Background

The growing body of evidence attesting to the effectiveness of clinical male circumcision in the prevention of HIV/AIDS transmission is prompting the majority of sub-Saharan African governments to move towards the adoption of voluntary medical male circumcision (VMMC). Even though it is recommended to consider collaboration with traditional male circumcision (TMC) providers when planning for VMMC, there is limited knowledge available about the TMC landscape and traditional beliefs.

Methodology and Main Findings

During 2010–11 over 25 focus group discussions (FGDs) were held with clan leaders, traditional cutters, and their assistants to understand the practice of TMC in four ethnic groups in Uganda. Cultural significance and cost were among the primary reasons cited for preferring TMC over VMMC. Ethnic groups in western Uganda circumcised boys at younger ages and encountered lower rates of TMC related adverse events compared to ethnic groups in eastern Uganda. Cutting styles and post-cut care also differed among the four groups. The use of a single razor blade per candidate instead of the traditional knife was identified as an important and recent change. Participants in the focus groups expressed interest in learning about methods to reduce adverse events.

Conclusion

This work reaffirmed the strong cultural significance of TMC within Ugandan ethnic groups. Outcomes suggest that there is an opportunity to evaluate the involvement of local communities that still perform TMC in the national VMMC roll-out plan by devising safer, more effective procedures through innovative approaches.

Acceptability of medical male circumcision and improved instrument sanitation among a traditionally circumcising group in East Africa

By removing the foreskin, medical male circumcision (MMC) reduces female to male heterosexual HIV transmission by approximately 60 %. Traditional circumcision has higher rates of complications than MMC, and reports indicate unsanitized instruments are sometimes shared across groups of circumcision initiates. A geographically stratified, cluster survey of acceptability of MMC and improved instrument sanitation was conducted among 368 eligible Maasai participants in two Northern Districts of Tanzania. Most respondents had been circumcised in groups, with 56 % circumcised with a shared knife rinsed in water between initiates and 16 % circumcised with a knife not cleaned between initiates. Contrasting practice, 88 % preferred use of medical supplies for their sons' circumcisions. Willingness to provide MMC to sons was 28 %; however, provided the contingency of traditional leadership support for MMC, this rose to 84 %. Future interventions to address circumcision safety, including traditional circumciser training and expansion of access to MMC, are discussed.

The (mis)reporting of male circumcision status among men and women in Zambia and Swaziland: a randomized evaluation of interview methods

BACKGROUND

To date, male circumcision prevalence has been estimated using surveys of men self-reporting their circumcision status. HIV prevention trials and observational studies involving female participants also collect data on partners' circumcision status as a risk factor for HIV/STIs. A number of studies indicate that reports of circumcision status may be inaccurate. This study assessed different methods for improving self- and partner reporting of circumcision status.

METHODS/FINDINGS

The study was conducted in urban and rural Zambia and urban Swaziland. Men (N = 1264) aged 18-50 and their female partners (N = 1264), and boys (N = 840) aged 13-17 were enrolled. Participants were recruited from HIV counseling and testing sites, health centers, and surrounding communities. The study experimentally assessed methods for improving the reporting of circumcision status, including: a) a simple description of circumcision, b) a detailed description of circumcision, c) an illustration of a circumcised and uncircumcised penis, and d) computerized self-interviewing. Self-reports were compared to visual examination. For men, the error in reporting was largely unidirectional: uncircumcised men more often reported they were circumcised (2-7%), depending on setting. Fewer circumcised men misrepresented their status (0.05-5%). Misreporting by women was significantly higher (11-15%), with the error in both directions. A sizable number of women reported that they did not know their partner's circumcision status (3-8%). Computerized interviewing did not improve accuracy. Providing an illustration, particularly for illiterate participants, significantly improved reporting of circumcision status, decreasing misreporting among illiterate participants from 13% to 10%, although misreporting was not eliminated.

CONCLUSIONS

Study results suggest that the prevalence of circumcision may be overestimated in Zambia and Swaziland; the error in reporting is higher among women than among men. Improved reporting when a description or illustration is provided suggests that the source of the error is a lack of understanding of male circumcision.

Determinants of circumcision and willingness to be circumcised by Rwandan men, 2010

BACKGROUND

Male Circumcision (MC) has been recommended as one of the preventive measures against sexual HIV transmission by the World Health Organization (WHO). Rwanda has adopted MC as recommended but the country is a non-traditionally circumcising society. The objective was to explore knowledge and perception of Rwandan men on Male Circumcision (MC) and to determine the factors associated with the willingness to be circumcised and to circumcise their sons.

METHODS

This cross sectional study was conducted in 29 districts of Rwanda between January and March 2010. Data were collected using a structured questionnaire among men aged 15-59 years. The rate of MC was measured and its perception from respondents, and then the factors associated with the willingness to go for MC were analysed using multiple logistic regressions.

RESULTS

A total of 1098 men were interviewed. Among respondents 17% (95% CI 14-19%) reported being circumcised. About three-quarter (72%) could define MC, but 37% of adolescent could not. Half of the participants were willing to get circumcised and 79% of men would accept circumcision for their sons. The main motivators for MC were its benefits in HIV/STI prevention (69%) and improving hygiene (49%). Being too old was the main reason (32%) reported by men reluctant to undergo MC and younger men were afraid of pain in particular those less than 19 years old (42%). The willingness to circumcise was significantly associated with younger age, living in the Eastern Province, marital status, and the knowledge of the preventive role of circumcision.

CONCLUSIONS

Adolescents and young adults were more willing to be circumcised. It is critical to ensure the availability of pain free services in order to satisfy the increasing demand for the scale up of MC in Rwanda.

Acceptability of male circumcision for prevention of HIV infection among men and women in Uganda

In the last decade, three randomized controlled trials in Kenya, South Africa, and Uganda have shown that medical male circumcision (MMC) reduces the sexual transmission of HIV from women to men. Objectives of this assessment were to measure acceptability of adult MMC and circumcision of children to inform policies regarding whether and how to promote MMC as an HIV prevention strategy. This mixed-method study, conducted across four Ugandan districts, included a two-stage household survey of 833 adult males and 842 adult females, focus group discussions, and a health provider survey. Respondents' acceptability of MMC was positive and substantial after being informed about the results of recent randomized trials. In uncircumcised men, between 40% and 62% across the districts would consider getting circumcised. Across the four districts between 60% and 86% of fathers and 49% and 95% of mothers were supportive of MMC for sons. Widespread support exists among men and women in this study for promoting MMC as part of Uganda's current 'ABC + ' HIV prevention strategy.

Traditional male circumcision in eastern and southern Africa: a systematic review of prevalence and complications

OBJECTIVE

to systematically review studies on the prevalence and complications of traditional male circumcision (i.e. circumcision by a traditional provider with no formal medical training), whose coverage and safety are unclear.

METHODS

we systematically searched databases and reports for studies on the prevalence and complications of traditional male circumcision in youth 10-24 years of age in eastern and southern Africa, and also determined the ages at which traditional circumcision is most frequently performed.

FINDINGS

six studies reported the prevalence of traditional male circumcision, which had been practised in 25-90% of all circumcised male study participants. Most circumcisions were performed in boys 13-20 years of age. Only two of the six studies on complications reported overall complication rates (35% and 48%) following traditional male circumcision. The most common complications were infection, incomplete circumcision requiring re-circumcision and delayed wound healing. Infection was the most frequent cause of hospitalization. Mortality related to traditional male circumcision was 0.2%.

CONCLUSION

published studies on traditional male circumcision in eastern and southern Africa are limited; thus, it is not possible to accurately assess the prevalence of complications following the procedure or the impact of different traditional practices on subsequent adverse events. Also, differences in research methods and the absence of a standard reporting format for complications make it difficult to compare studies. Research into traditional male circumcision procedures, practices and complication rates using standardized reporting formats is needed.

Male circumcision and HIV prevention: looking to the future

Now that male circumcision has been shown to have a protective effect for men against HIV infection when engaging in vaginal intercourse with HIV-infected women, the research focus needs to shift towards the operational studies that can pave the way for effective implementation of circumcision programs. Behavioral research is needed to find out how people perceive the procedure and the barriers to and facilitators of uptake. It should also assess the risk of an increase in unsafe sex after circumcision. Social research must examine cultural perceptions of the practice, in Africa and beyond, including how likely uncircumcised communities are to access surgery and what messages are needed to persuade them. Advocates of male circumcision would benefit from research on how to influence health policy-makers, how best to communicate the benefits to the public, and how to design effective delivery models.

Foreskin length in uncircumcised men is associated with subpreputial wetness

This study was performed to identify possible factors associated with penile wetness, defined as the observation of a diffuse homogenous film of moisture on the surface of the glans and coronal sulcus, in men attending a sexually transmitted infection clinic. Genital examination was undertaken in 422 uncircumcised men and any degree of subpreputial wetness observed was recorded. The degree of visibility of the urinary meatus on direct inspection was also assessed. Subjects were asked whether they retracted the foreskin while urinating and how long since they had last passed urine. Penile wetness was observed in 13.0% of the men and was more common in those whose foreskin covered the urinary meatus on direct inspection (17.4% vs. 4.9%) and those with balanitis (33.3%). On multivariate analysis, penile wetness was independently associated with balanitis, non-specific urethritis/chlamydia, reporting sex with another man and having a visible urinary meatus on direct inspection. Penile wetness was not associated with retracting the foreskin while passing urine or duration since last passed urine. Men with a foreskin covering the urinary meatus on direct observation should be advised about the benefits of good genital hygiene if penile wetness was observed.

Traditional circumcision during manhood initiation rituals in the Eastern Cape, South Africa: a pre-post intervention evaluation

Background

Circumcisions undertaken in non-clinical settings can have significant risks of serious adverse events, including death. The aim of this study was to test an intervention for safe traditional circumcision in the context of initiation into manhood among the Xhosa, Eastern Cape, South Africa.

Methods

Traditional surgeons and nurses registered with the health department were trained over five days on ten modules including safe circumcision, infection control, anatomy, post-operative care, detection and early management of complications and sexual health education. Initiates from initiation schools of the trained surgeons and nurses were examined and interviewed on 2^nd, 4^th, 7^th and 14^th day after circumcision.

Results

From 192 initiates physically examined at the 14th day after circumcision by a trained clinical nurse high rates of complications were found: 40 (20.8%) had mild delayed wound healing, 31 (16.2%) had a mild wound infection, 22 (10.5%) mild pain and 20 (10.4%) had insufficient skin removed. Most traditional surgeons and nurses wore gloves during operation and care but did not use the recommended circumcision instrument. Only 12% of the initiates were circumcised before their sexual debut and they reported a great deal of sexual risk behaviour.

Conclusion

Findings show weak support for scaling up traditional male circumcision.

Adult male circumcision outcomes: experience in a developing country setting

INTRODUCTION

We examined male circumcision outcomes among young adults in an African setting.

MATERIALS AND METHODS

Participants were healthy, sexually active, uncircumcised, HIV-seronegative males aged 18-24 years. The main outcomes measured included complications, healing, satisfaction and resumption of activities.

RESULTS

Of 1,475 procedures, 26 (1.8%) were associated with 27 adverse events, most commonly wound disruption/delayed healing (0.6%), wound infection (0.4%), and bleeding (0.3%). Adverse events per clinician averaged 3.8 and 2.1% for procedures 1-100 and 101-200, respectively, and <1% for procedures 201-300, 301-400 and >400, respectively (p < 0.001). Participants resumed normal general activities after a median of 1 postoperative day and 93% with regular employment resumed working within 1 week. After 30 days, 99% of participants reported being very satisfied. After 90 days, 65% reported having had sex, 45% reported that their partners had expressed an opinion, 92% of whom were very satisfied with the outcome.

CONCLUSIONS

Safe and acceptable adult male circumcision services can be delivered in developing country settings.

Adult male circumcision: results of a standardized procedure in Kisumu District, Kenya

OBJECTIVE

To develop a standard procedure for male circumcision in a resource-poor medical setting and prospectively evaluate the outcome in a randomized, controlled trial with the incidence of human immunodeficiency virus (HIV) as the main outcome, as studies suggest that circumcision is associated with a lower incidence of HIV and other sexually transmitted infections in high-risk populations.

SUBJECTS AND METHODS

Healthy, uncircumcised, HIV-seronegative men aged 18-24 years from Kisumu District, Kenya, were offered participation in a clinical trial using a standard circumcision procedure based on "usual" medical procedures in Western Kenya. The follow-up included visits at 3, 8 and 30 days after circumcision, with additional visits if necessary. Healing, satisfaction and resumption of activities were assessed at these visits and 3 months from randomization.

RESULTS

Overall, 17 (3.5%) of the 479 circumcisions were associated with adverse events judged definitely, probably or possibly related to the procedure. The most common adverse events were wound infections (1.3%), bleeding (0.8%), and delayed wound healing or suture line disruption (0.8%). After 30 days, 99% of participants reported being very satisfied with the procedure; approximately 23% reported having had sex and 15% reported that their partners had expressed an opinion, all of whom were very satisfied with the outcome. About 96% of the men resumed normal general activities within the first week after the procedure.

CONCLUSION

Safe and acceptable adult male circumcision services can be delivered in developing countries should male circumcision ultimately be advocated as a public-health measure.

Anthropology and Circumcision

This chapter reviews the anthropology of male and female circumcision over the past century. After surveying classic sociocultural and psychodynamic interpretations of male circumcision, I shift to the biblical and Jewish rite, focusing on gender symbolism and counter-hegemonic practice within European-Christian society. The chapter then reviews the relationship between male circumcision in sub-Saharan Africa and reduced rates of HIV. Next, I address female circumcision, focusing again on symbolism but especially on highly impassioned debates over cultural relativism and human rights, medical complications, criticism and imperialism, and female agency versus brute patriarchy. What are the moral, political, and scientific obligations of anthropology to a cultural practice that is increasingly vilified in Western popular culture and jurisprudence? Should anthropology advocate eradication, contextualize Western opposition, or critique one's own bodily practices? Finally, I critically analyze the growing movement to ban the medical and ritual circumcision of infant boys in the West.

Neonatal Circumcision: A Review of the World’s Oldest and Most Controversial Operation

Untimely old, circumcision has elicited more controversy and war of words than any surgical procedure in history. Although previous claims of benefits like curing masturbation, gout, epilepsy, and even insanity were no doubt absurd, important research has shed light on real medical benefits of circumcision. In particular, the procedure has consistently shown to result in the decreased risk of debilitating and costly diseases such as HIV, cervical cancer, and infantile urinary tract infection. Because of advances in the understanding of the anatomy of the foreskin and pain conditioning in infants, prevailing attitudes have changed about anesthesia and analgesia during the procedure. This article objectively summarizes the bulk of significant medical literature over the last century to provide an accurate statement about what we know and what we do not know about neonatal circumcision, including its history, epidemiology, medical benefits, complications, contraindications, techniques, management for pain, and current controversies.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to describe the evolution of circumcision, to list the potential benefits of circumcision, to outline the various neonatal circumcision techniques, and to summarize the data on the use of analgesia for circumcision.