Intended for healthcare professionals


Male circumcision and HIV prevention

BMJ 2000; 321 doi: (Published 09 December 2000) Cite this as: BMJ 2000;321:1467

Some science would not have gone amiss

  1. Robert S Van Howe, doctor, department of pediatrics (,
  2. Christopher J Cold, doctor, department of pathology,
  3. Michelle R Storms, family practitioner
  1. Marshfield Clinic, Lakeland Center, Minocqua, WI 54548-1390, USA
  2. Marshfield Clinic, Marshfield, Wisconsin, USA
  3. Hazelhurst, Wisconsin, USA
  4. International Coalition for Genital Integrity, Box 8462, Santa Cruz, CA 95061, USA
  5. Howgate Farm, Linglabank, Frizington, Cumbria CA26 3SU
  6. St Bartholomew's Hospital, London EC1A 7BE
  7. University of Birmingham medical School, Birmingham B15 2TT
  8. National Reference Centre for Sexually Transmitted Diseases, South African Institute for Medical Research, Johannesburg, South Africa
  9. Mildura Base Hospital, Mildura, Victoria, Australia
  10. Department of Obstetrics and Gynaecology, University of Melbourne, Royal Women's Hospital, Carlton, Victoria 3053, Australia

    EDITOR—While a number of studies suggest an association between the foreskin and HIV infection, a simple tallying of studies, such as performed by Szabo and Short,1 is unscientific and misleading. Meta-analysis suggests that men engaging in high risk behaviours may be placed at further risk by having a foreskin, but in the general population circumcision status is not a significant factor. It also showed an important degree of heterogeneity between studies, calling into question the validity of the summary results.2 The multiple confounding factors influencing sexual behaviour and HIV susceptibility make it irresponsible to place blame on normal anatomy.

    Langerhans' cells in the preputial mucosa are nothing new: all mucosal tissues have Langerhans' cells. Szabo and Short did not report Langerhans' cell concentrations in comparison with other mucosal tissues, their concentration in the glans, foreskin remnant, and circumcision scar in circumcised men, the presence of associated T cell infiltration (which may be necessary for viral transmission), or how findings in elderly cadavers correlate to sexually active young men. Szabo and Short state that the inner surface of the foreskin and the frenulum must be regarded as the most probable sites for viral entry of primary HIV infections in men; but without quantitative comparative data their statements are pure speculation.

    The only reports of preputial Langerhans' cells have been in specimens from neonates3 and elderly cadavers. If normal genital mucosa is at risk, we need to know the concentration of Langerhans' cells in healthy men, men with multiple sexual partners, men with genital infections, men with HIV, and men of differing races and ages before any recommendations can be made.

    Szabo and Short dismiss the complications of circumcision as having a low incidence; but the rate of immediate complications in the United States is between 3.1% and 9%, …

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