Cervical Cancer

It is now known that the primary risk factor for cancer of the cervix is infection with human papilloma virus (HPV).[144] Only a handful of the hundred or so types of HPV are carcinogenic, with HPV 16 and HPV 18 associated with 70% of cervical cancers.[145] Behavioral risks such as age at sexual debut, the number of partners, and partners’ sexual behavior are associated with an increased risk of HPV infection.[146,147] Smoking is an important co-factor.[148]

The HIM (HPV Infection in Men) study showed that HPV is just as prevalent in circumcised as in intact males.[149] In this study, intact males showed faster clearance of the oncogenic (cancer-causing) HPV strains than did circumcised males, which could correlate to decreased transmission of oncogenic HPV from intact males to females.

There is no clear evidence that male circumcision decreases the risk of HPV infection in female partners, as studies have produced conflicting results. In a study of female university students in Washington State, circumcision status of the male partner was not associated with incident HPV infection over a mean follow-up time of 41 months.[150] A subsequent study, carried out in Uganda in conjunction with the HIV RCTs, found a lower rate of “high-risk” HPV strains, at 24 months, in women whose partners were circumcised at the beginning of the trial versus those whose partners had not been circumcised.[151] Although cervical cancer was not tracked as an outcome, this study has been used to support the claims of circumcision as a preventative for cervical cancer. The Ugandan HPV study suffers from numerous methodological flaws.[152] As with the HIV trials, these include lead-time bias and a high rate of loss to follow-up. The vaginal swabs analyzed were self-collected, a sub-standard technique potentially increasing rates of false positives and false negatives. Most tellingly, the study found no association between the male partner’s circumcision status and the presence of HPV types 16 and 18, the ones most likely to cause cervical cancer.

Sixteen studies have attempted to demonstrate a connection between cervical cancer in women and the circumcision status of their male sexual partners; all of them have failed.[153-168] One of these, by Castellsagué et al.,[153] has been repeatedly cited as proof of the connection between circumcision status and cervical cancer. Yet, in fact, the study was unable to show a significant association, except in a small subset of women who had partners with high-risk sexual behaviors. Again, serious methodological problems were present, with inappropriate design elements and analysis (described elsewhere [78,152]), further undermining the results.

Given all of the above, it is safe to say that cervical cancer has no appreciable link to male circumcision status. Furthermore, safe and effective vaccines are now available for adolescent and young adult females and males to help protect against HPV and, subsequently, cervical cancer in women, and various other cancers in men.[169] But even if the claims about the presence of the foreskin causing cervical cancer were true, it would be ethically and legally impermissible to circumcise non-consenting minors on this account, because the person bearing the risk would not be the person receiving the benefit.[170,171]

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