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Sexually-Transmitted Infections
by Professor Brian J. Morris, University of Sydney (Australia)

Ulcerative STIs (particularly chancroid and syphilis) are associated with lack of circumcision, as seen in over 11 studies (for review see [234]). There are no studies to the contrary [234]. For other STIs the overall picture indicates greater prevalence in uncircumcised men, but more recent studies do exist that show no difference (reviewed in [234]). For genital herpes this 1998 review noted there were 2 studies showing association with lack of circumcision [266, 352] and 4 that found no association [37, 75, 92, 207]. For gonorrhoea 5 reported significant association [75, 151, 160, 266, 388] and 2 no association [207, 333]. For chlamydial, non-gonococcal or other types of urethritis 2 studies reported association with lack of circumcision [151, 363], 3 with circumcision [160, 207, 243] and 3 no association [75, 92, 333]. Similarly, no association was found in a 2005 report [87].

The possible protection afforded by circumcision against syphilis, genital herpes and urethritis was recognized over a century ago [290]. Subsequently, in 1947, a study involving 1,300 consecutive patients in a Canadian Army unit, showed that being uncircumcised was associated with a 9-fold higher risk of syphilis and 3-times higher gonorrhea [388]. Then, in the mid-70s work by the London Hospital showed higher chancroid (an infectious venereal ulcer), syphilis, papillomavirus and herpes in uncircumcised men [352]. Subsequent to this, a study in 1983 at the University of Western Australia, showed twice as much herpes and gonorrhea, 5-times more candidiasis and 5-fold greater incidence of syphilis [266]. In South Australia, a study in 1992 showed that uncircumcised men had more chlamydia (odds ratio 1.3) and gonoccocal infections (odds ratio 2.1) [151]. Others have reported higher rates of non-gonococcal urethritis in uncircumcised men [333].

In 1988 a study in Seattle of 2,776 heterosexual men reported higher syphilis and gonorrhoea in uncircumcised men, but no difference in herpes, chlamydia and non-specific urethritis (NSU) [75]. Like this report, a study in 1994 in the USA, found higher gonorrhoea and syphilis, but no difference in other common STIs. An earlier (1987) study of 9,514 sexually transmitted infection patients from a US military base found higher non-gonococcal, but not gonococcal, urethritis in those who were circumcised [333]. In 1994, Dr Basil Donovan and associates reported the results of a study of 300 consecutive heterosexual male patients attending Sydney STI Centre at Sydney Hospital [92]. They found no difference in NSU, genital herpes (24% having a history of this [37]) or seropositivity for HSV-2 (65% [37]) and genital warts (i.e., the benign, so-called 'low-risk' human papillomavirus types 6 and 11, which are visible on physical examination, unlike the 'high-risk' types 16 and 18, which are not). As mentioned earlier, 62% were circumcised and the two groups had a similar age, number of partners and education. Gonorrhoea, syphilis and hepatitis B were too uncommon in this Sydney study for them to conclude anything about these other STIs. Similar findings were obtained in the National Health and Social Life Survey in the USA, which asked about gonorrhoea, syphilis, chlamydia, non-gonococcal urethritis, herpes and HIV (a virus more often acquired intravenously in heterosexual i.v. drug-using men in the USA) [206], although some under-reporting by uncircumcised men was likely as they tended to be less educated. Also, circumcision at birth was assumed, so that the number who sought circumcision later in life for problems, such as STIs and/or other infections, and therefore had switched group, was not taken into account. In a cross-sectional and cohort study from a multicenter controlled trial involving 2021 men in the USA from 1993 to 1996, and using multiple logistic regression to compare STI risk among circumcised and uncircumcised men adjusted for potential confounding factors, uncircumcised men were significantly more likely to have gonorrhoea in the multivariate analysis adjusted for age, race and site (odds ratio 1.3 and 1.6 for each respective study) [90]. This was also the case for syphilis (odds ratios 1.4 and 1.5), but not chlamydia. Another study found no difference in frequency of serum antibodies to HSV2 (7%) between New Zealand men aged 26 who had been circumcised prior to age 3 versus those who were uncircumcised [87].

Design aspects of a number of the studies have been criticized. As a result there is still no overwhelming agreement. Nevertheless, on the bulk of evidence, it would seem that at least some STIs could be more common in the uncircumcised. This conclusion is, however, by no means absolute in Western settings, and the incidence may be influenced by factors such as the degree of genital hygiene, availability of running water and socioeconomic group being studied. In some more recent studies in developed nations, in which hygiene is good, little difference was apparent in several of the more common STIs. In a global society risk of contracting an STI cannot be ascribed parochially. Travellers are particularly vulnerable to the different risk in a new country they may visit, particularly when holiday-making is associated with consumption of alcohol and other drugs, as well as an attitude of having a good time, which can lead to sexual relations with the locals, often with no condom [220].
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