AIDS PATIENT CARE and STDs

Volume 24, Number 8, 2010

ª Mary Ann Liebert, Inc.
DOI: 10.1089/apc.2010.0082

Relations Between Circumcision Status,

Sexually Transmitted Infection History,
and HIV Serostatus Among a National Sample
of Men Who Have Sex with Men in the United States

Kristen Jozkowski, M.S.,1,2 Joshua G. Rosenberger, M.P.H.,1–3 Vanessa Schick, Ph.D.,1,2

Debby Herbenick, Ph.D.,1,2 David S. Novak, M.S.W.,4 and Michael Reece, Ph.D., M.P.H.1,2

Abstract

Circumcision’s potential link to HIV/sexually transmitted infections (STI) has been at the center of recent global
public health debates. However, data related to circumcision and sexual health remain limited, with most
research focused on heterosexual men. This study sought to assess behavioral differences among a large sample
of circumcised and noncircumcised men who have sex with men (MSM) in the United States. Data were
collected from 26,257 U.S. MSM through an online survey. Measures included circumcision status, health in-
dicators, HIV/STI screening and diagnosis, sexual behaviors, and condom use. Bivariate and regression analyses
were conducted to determine differences between HIV/STI status, sexual behaviors, and condom use among
circumcised and noncircumcised men. Circumcision status did not significantly predict HIV testing ( p > 0.05), or
HIV serostatus ( p > 0.05), and there were no significant differences based on circumcision status for most STI
diagnosis [syphilis, gonorrhea, chlamydia, human papilloma virus (HPV)]. Being noncircumcised was predictive
of herpes-2 diagnosis, however, condom use mediated this relationship. These data provide one of the first large
national assessments of circumcision among MSM. While being noncircumcised did not increase the likelihood
of HIV and most STI infections, results indicated that circumcision was associated with higher rates of condom
use, suggesting that those who promote condoms among MSM may need to better understand condom-related
behaviors and attitudes among noncircumcised men to enhance the extent to which they are willing to use
condoms consistently.

Introduction searchers have found that circumcision acts as a protective

C ircumcision’s potential link to HIV and sexually
transmitted infection (STI) prevention has been at the
center of recent global public health debates. Approximately
one quarter of men worldwide have been circumcised for
various reasons including religion, culture, medical reasons
and/or parental/nonmedical preference,1 yet researchers are
divided in terms of gauging the potential benefits and risks
of recommending the procedure as a mechanism to prevent
HIV and STIs.2-4
Data from several studies have identified a higher preva-
lence of HIV among men who were not circumcised
compared to those who were circumcised.3–6 In addition, re-
factor against some STIs including syphilis and gonorrhea.1,2
Halperin and Baily5 found that men who were circumcised
were two to eight times less likely to become infected with
HIV, while Weiss et al.6 found that among men in sub-
Saharan Africa, circumcision was associated with a reduction
in risk of risk of HIV infection.
However, although some researchers recommend circum-
cision as an HIV prevention strategy,6 others have been less
confident. According to a meta-analysis conducted by Van
Howe,4 of the 29 articles examined, circumcised men were at
increased risk for both HIV acquisition and transmission
compared to uncircumcised men, leading the author to sug-
gest that routine circumcision as a means to prevent HIV

1
Center for Sexual Health Promotion, 2Department of Applied Health Science, Indiana University, Bloomington, Indiana.
3
Division of Adolescent Medicine, Indiana University, Indianapolis, Indiana.
4
Online Buddies, Inc., Cambridge, Massachusetts.

465
466
infection would be unfounded. Similarly, Baily et al.3 reported
no difference among circumcised and uncircumcised men
with regard to STI histories and Cook and colleagues2 re-
ported mixed findings; in their study uncircumcised men had
an increased likelihood of syphilis and gonorrhea infection yet
had a decreased likelihood of genital warts, and no associa-
tions existed between circumcision status and genital herpes,
chlamydia, or nongonococcal urethritis.
Among studies that have discussed the efficacy of cir-
cumcision in protecting against HIV transmission among
men, most tend to focus on transmission via heterosexual
sex.7 Vaginal intercourse may present differences with regard
to disease transmission and circumcision status compared to
anal intercourse due to the differences between vaginal and
anal mucosa ( J. Sanchez, unpublished data). Limited research
exists highlighting circumcision as an HIV prevention tech-
nique among MSM. According to Millett and colleagues,8
there was no relationship among circumcision status and
self-reports of STIs among a sample of 1,154 black and 1,091
Latino MSM nor did a meta-analysis of 15 studies, examining
circumcision and HIV/STI rates, find any sufficient evidence
to support findings that circumcision provides a protective
effect against HIV/STI infection.9
While there seems to be inconclusive findings regarding the
risks and benefits of circumcision, previous research tends
to focus on STI status and/or diagnosis. Little research has
examined the differences among circumcised and uncir-
cumcised men with respect to sexual behavior. One study
indicated that some behavioral characteristics such as en-
gaging in sexual activity the last time they spent a night away
from home, ever having used a condom, or having used a
condom during last intercourse did not differ among cir-
cumcised and uncircumcised men.3 Furthermore, Buchbinder
and colleagues10 found no relationship between unprotected
insertive anal intercourse and circumcision, nor was circum-
cision associated with a reduction in HIV infection in men
who engaged in protective receptive anal sex and unprotected
insertive anal sex.
While MSM in the United States continue to be dis-
proportionally impacted by HIV and STIs, data from large
populations of men related to circumcision status and sexual
health behaviors remains limited, inconclusive,1,2,4 and most
research available tends to be heterosexually focused.7 The
current study sought to assess behavioral differences among
a large, fairly representative sample of circumcised and
noncircumcised MSM in the United States.
Methods
Participant recruitment and data collection
This study was conducted via a participatory effort with an
Internet-based networking site for men who seek sexual or
social interactions with other men. An electronic recruitment
message was sent via e-mail to all individuals residing in the
United States who had an account with the website at the time
of the study ( July 2009). The recruitment e-mail provided
a brief description of the study, its incentives, and included a
link to the study website. Previous research has found that
Internet-based convenience samples are useful tools to better
understand understudied issues and/or for collecting data
from hard-to-reach populations, such as gay men who seek
sex partners via the Internet.11 Interested individuals pro-
JOZKOWSKI ET AL.
ceeded to the study questionnaire; most participants took
approximately 20 min to complete the questionnaire. Com-
pensation for participation included the opportunity to re-
ceive an electronic coupon valued at $10 that could be
redeemed for merchandise from an affiliate of the site from
which men were recruited.
The recruitment message remained in each individual’s
electronic mailbox for a period of 7 days, after which time any
unopened e-mails were automatically removed. A total of
127,489 individuals opened the recruitment email and 43,477
(34.1%) of these men clicked on the link to the study website.
Of those viewing the study information and consent form,
26,257 (60.4%) consented to and subsequently participated in
the study. All study protocols were reviewed and approved
by Institutional Review Board at the academic institution of
the authors.
Main outcome measures
Participants completed items related to sociodemographics,
circumcision status, health status, health-related behaviors,
and sexual behaviors.
Sociodemographics. Measures included those related to
a participant’s age, sexual orientation, race/ethnicity, and
level of education completed. Participants also responded to
items related to their relationship and current sexual rela-
tionship status.
Circumcision status. Measures included a single item,
asking men to respond to the question, ‘‘Are you circum-
cised?’’ with one of the following response options: no, yes, or
no response.
Health status. Measures included those related to physi-
cal and mental quality of life using the four-item Healthy Days
Core Module from the Centers for Disease Control and Pre-
vention (CDC) health-related quality of life measure (HRQOL-
4),12 a widely validated set of survey measures used to assess
a person’s sense of well-being.13–18 In addition, we assessed
history of participation in testicular self-examinations, pro-
vider-administered (general physical examination) examina-
tions, and HIV and other STI screenings and diagnoses
(including HIV, chlamydia, gonorrhea, syphilis, HPV, or her-
pes within the past 2 years).
Sexual behaviors. Participants were asked to indicate
whether or not they had engaged in specific sexual behaviors
with men within the past month, past 3 months, past year,
more than a year ago, or never. Behaviors included receptive
and insertive anal intercourse, and performing and receiving
oral sex. Sexual behaviors were summed across participants.
Condom behaviors. Participants were asked to indicate
the number of times they used a condom during the past ten
times they engaged in insertive anal intercourse, and the
number of times their partner used a condom during the past
ten times they engaged in receptive anal intercourse.19 Con-
dom use variables were created for insertive behaviors, (top,
when the participant used a condom during insertive sex) and
receptive behaviors (bottom, when the participants’ partner
wore a condom during receptive anal intercourse). These
items were treated as a continuous variables from using a
CIRCUMCISION STATUS, STI HISTORY, AND HIV SEROSTATUS
condom 0 of 10 times to using a condom 10 of the 10 times
during the past 10 sexual acts.
Data analyses
The overall sample was narrowed further to include (1)
only men who indicated that they currently have at least one
male sexual partner (eliminating 334, 1.3%, participants from
the sample) and (2) men who responded to the item related to
circumcision status (removing an additional 764, 2.9%, men
from the sample) . The final sample utilized for these analyses
included 25,159 men. All analyses were conducted using
PAWS version 17.0 (SPSS Inc., Chicago, IL). Descriptive ana-
lyses were conducted to present participant characteristics
including demographics, health behaviors, and sexual be-
haviors. Bivariate analyses including independent sample
t-tests, and a series of w2 and Mann-Whitney U tests were
calculated to compare demographic differences between men
who had been circumcised and men who had not. In addition,
logistic regression analyses with adjusted odds ratios (ad-
justed for age, race, education, and relationship status) were
conducted to determine if circumcision was a predictor of
HIV/STI testing behaviors and HIV/STI serostatus. Multiple
regression analyses were conducted to determine if circum-
cision status was a predictor of condom use behaviors. Baron
and Kenny’s20 suggested methods were used for testing me-
diators between circumcision and herpes diagnosis. Sobel’s
test was also used to test for partial mediation.
Results
Participant characteristics
Of the 25,159 men who had participated in the current
study, 21,312 (82.1%) indicated that they were circumcised
whereas 3,847 (14.8%) indicated that they were not circum-
cised.
Table 1 provides a summary of the main demographics
from the entire sample and a comparison of men based on
circumcision status. For the entire sample, age was diverse,
although most participants tended to be 30 years of age or
older (n ¼ 16,905; 69.0%), and circumcision rates were highest
among Caucasian participants (n ¼ 18472; 86.9%), followed
by African Americans (n ¼ 815; 77.5%) and Latinos (n ¼ 896;
46.2%). Most participants had received some college educa-
tion or higher (87.4%), identified as white (n ¼ 21,295, 81.9%),
and self-identified as homosexual/gay (n ¼ 21,162; 81.4%). In
terms of relationship status, a majority of men indicated that
they were not currently dating anyone (n ¼ 14,625; 56.2%),
although most (n ¼ 20, 900; 83.7%) were currently sexually
active. Comparison of circumcised and noncircumcised men
based on demographic characteristics, indicated that differ-
ences existed with regard to age, race, education, and rela-
tionship status.
Circumcision status and general health
The sample was healthy overall, with the majority of men
indicating their general health to be very good to excellent
(71.2%). Overall, based upon the CDC (CDC, 2003) guide-
lines19 which designate ‘‘good’’ health as under 14 unhealthy
days per month, participants reported a relatively low num-
ber of physically, mentally or activity limited days (M ¼ 1.73–
4.46, SD ¼ 4.55–7.35). Using the HRQOL health outcomes
467
including general health, physically unhealthy days (t(24,260) ¼
0.75), mentally unhealthy days (t(24,374) ¼
0.098) and activity
limited days (t(24,238) ¼ 0.65) there were no significant differ-
ences based on quality of life on any of the measures for those
individuals who were circumcised compared to those who were
not ( p > 0.05).
When looking at general assessments of non-disease related
health issues, there were no differences based on circumcision
status for getting a physical exam (w2(25,113) ¼ 0.175, p > 0.05),
however, groups were significantly different based on cir-
cumcision status for conducting a testicular self-examination
(w2(25,103) ¼ 41.345, p < 0.001), with noncircumcised men
having been more likely to conduct a testicular self-examination
in the last month.
Sexual behaviors and condom use
Circumcision status was predictive of men’s engagement in
sexual behavior in the past month ( p < 0.001) with circum-
cised men being more likely to have engaged in sexual be-
havior (oral and anal sex) within the past month, compared to
uncircumcised men (odds ratio [OR] ¼ 0.882, p < 0.001).
At the bivariate level, there were no differences based on
circumcision status for condom use during insertive anal sex
(t(17,554) ¼
0.897, p > 0.05) and partner’s use of a condom
during receptive anal sex (t(16,299) ¼
1.908, p > 0.05).
However, when circumcision was entered into a multivariate
model, controlling for age, race, relationship status, and ed-
ucation level, circumcision status was predictive of men’s
condom use behaviors during both insertive and receptive
anal sex ( p < 0.05).
Upon further exploration of condom use behaviors, results
indicate that about one fifth of men used a condom 10 of 10
times they engaged in anal sex (insertive, 23.3%; receptive,
23.9%), %), while one third reported using a condom zero 0 of
10 times or never using a condom (32.2%; receptive, 33.9%) for
both insertive and receptive sexual behaviors. Nearly one half
of the men in this sample fell into the range of using a condom
1 of 10 times to 9 of 10 times out of the past 10 acts of anal sex
(insertive, 44.5%; receptive, 42.2%).
STI testing and diagnosis
Participant’s history of getting tested for HIV did not sig-
nificantly differ based on circumcision status, however, group
differences did exist for STI testing ( p < 0.01) in the last year,
with men who were circumcised reporting higher rates of STI
testing. Among those participants who reported having pre-
viously been diagnosed with any STI or HIV, no differences
existed with the exception of herpes, which was more likely in
men who were not circumcised (Table 2).
Logistic regressions were conducted to determine if cir-
cumcision status was predictive of having been diagnosed
with an STI or HIV in the past 2 years (Table 3), when con-
trolling for age, racial status, education level, and relationship
status. Results indicate that circumcision status was not pre-
dictive of HIV/STI diagnoses, exclusive of herpes. Because
group differences at the bivariate level existed for STI testing
and at the multivariate level for condom use, these variables
were entered in the logistic regression model as potential
mediators using Baron and Kenny’s four-step test of media-
tion.21 Both STI testing and condom use met Baron and
Kenny’s first three criteria. When STI testing was entered into
468 JOZKOWSKI ET AL.

Table 1. Participant Characteristics and Circumcision Status (n ¼ 25,159)

Circumcision status

Total sample Yes No

Characteristics n % 21,097 3803 p

Age (n ¼ 24,900) <0.001

18–23 3560 14.2 2851 80.1 709 19.9
24–29 4435 17.6 3666 82.7 769 17.3
30–39 5762 22.9 4935 85.6 827 14.4
40–49 6970 27.7 6122 87.8 848 12.2
50–59 3318 13.2 2868 86.4 450 13.6
60 þ 855 3.4 655 76.6 200 23.4
Education (n ¼ 25,104) 0.02
High school or less 2817 11.3 2316 82.2 501 17.8
Some college or associates degree 8485 33.7 7157 84.3 1328 15.7
Bachelors degree 8112 32.2 6976 86.0 1136 14.0
Masters degree 3826 15.2 3245 84.8 581 15.2
Professional 1625 6.5 1374 84.6 251 15.4
Other 239 0.9 199 83.3 40 16.7
Race/ethnicity (n ¼ 25,028) <0.001
Black 1014 4.0 815 80.4 199 19.6
White 20650 82.1 18472 89.5 2178 10.5
Hispanic/Latino 1857 7.4 896 48.2 961 51.8
Asian/pacific islander 729 2.9 426 58.4 303 41.6
Other 777 3.1 599 77.1 178 22.9
Sexual orientation (n ¼ 25,112) 0.087
Homosexual/gay 20542 81.6 17435 84.9 3107 15.1
Bisexual 3927 15.6 3317 84.5 610 15.5
Heterosexual/straight 126 0.5 115 91.3 11 8.7
Relationship status (n ¼ 25,099) <0.001
In a relationship: 5 years 4767 18.9 4153 87.1 614 12.7
In a relationship: 1–5 years 2658 10.6 2252 84.7 406 15.3
In a relationship: 1 year or less 2044 8.1 1672 81.8 352 18.2
Currently dating more than one person 1439 5.7 1209 84.0 230 16.0
Not currently dating anyone 14105 56.1 11892 84.3 2213 15.7
Current sexual relationship (n ¼ 24,999) 0.08
In a monogamous sexual relationship 4643 18.5 3923 84.5 720 15.5
Sexual relationships with more than one person 6025 23.9 5120 85.0 905 15.0
Sexually active but not in a sexual relationship 10232 40.7 8757 85.6 1475 14.4
Not sexually active with another person 4099 16.3 3381 82.5 718 17.5

the model, the relationship from circumcision to herpes
was significantly reduced, indicating partial mediation
( p < 0.01).
Additionally, when condom use was entered into the
model, it emerged as a significant predictor of herpes diag-
nosis ( p < 0.05) while circumcision status dropped out of the
model ( p > 0.05), indicating full mediation.
Discussion
This study provides data of one of the first, large national
assessments of associations between circumcision status,
sexual behaviors, and STI screening and diagnosis among
MSM in the United States. Study participants were fairly
representative of national rates of the MSM population which
are weighted toward metropolitan areas. Consistent with
previous studies,3,4 results from this study suggest that cir-
cumcision status (being circumcised) shows no protective
factors for most STIs (chlamydia, HPV, syphilis) or HIV, as
diagnoses are not significantly different across groups. Such
findings support claims made by the American Pediatric
Association and other organizations, that there is not enough
substantial evidence to indicate the necessity of recommend-
ing neonatal circumcision as a preventive procedure to protect
against future STI or HIV infection.18
Unlike previous research, the current study examined
sexual and condom-use behaviors among MSM based on
circumcision status. Most of the men in this sample, regardless
of circumcision status were currently sexually active with a
partner, however, circumcised men were more likely to en-
gage in a higher frequency of sexual behavior (any oral or anal
sex) in the past month or three months. Furthermore, 65.1% of
circumcised men indicated they were currently having sex
with more than one person, potentially increasing their like-
lihood for STI exposure.
In addition, being circumcised was associated with higher
rates of never using a condom whereas not being circumcised
was associated with higher rates of always using a condom.
These findings suggest that those who promote condoms
among MSM may need to better understand condom-related
CIRCUMCISION STATUS, STI HISTORY, AND HIV SEROSTATUS 469

Table 2. w2 and Mann-Whitney U

Circumcision status

Yes No

Health variable n % n % w2

21,312 84.7 3847 15.3

Physical examination in last year 15,531 73.0 2784 72.7 0.175
Testicular examination in last month 9412 44.2 1909 49.9 41.345a
STD test in last year 9224 43.5 1575 41.2 7.127b
Positive syphilis diagnosis (2 year) 936 4.4 170 4.5 0.028
Positive gonorrhea diagnosis (2 year) 1009 4.8 193 5.1 0.713
Chlamydia diagnosis (2 year) 886 4.2 165 4.4 0.220
HPV (2 year) 911 4.4 153 4.1 0.555
Herpes (2 year) 878 4.2 187 5.0 4.987a
HIV test 18697 88.3 3330 87.2 3.348
HIV positive 3012 14.3 543 14.3 0.009
Sexual behavior (any oral, or anal sex) in past month 12300 59.1 2094 56.3 10.983b

Circumcision status

Yes No

Condom Use & Health Variables n % n % Mann-Whitney U

Health status
1.081 (ns)

Excellent 5990 28.1 1125 29.2
Very good 9653 45.3 1706 44.3
Good 4830 22.7 873 22.7
Fair 745 3.5 127 3.3
Poor 79 0.4 13 0.3

STD, sexually transmitted disease; HPV, human papilloma virus; ns, not significant.
a
p < 0.01 level; bp < 0.05 level.

behaviors and attitudes among both circumcised and non-
circumcised men to enhance the extent to which all MSM are
willing to use condoms consistently. Future research should
potentially explore better understanding this discrepancy in
condom use behavior based on circumcision status.
Similar to findings of condom use among heterosexual
men,19 for both circumcised and uncircumcised men, condom
use behaviors were inconsistent as just over 20% (23.6%) re-
ported always using a condom for insertive and receptive
behaviors and approximately one third (33.1%) reported
never using a condom. In addition, 43.4% of men reported
using a condom between 1 and 9 times out of the past 10
instances of intercourse, indicating a range of inconsistency in
condom use behaviors. While this measure of condom use
may not be optimal, as it is quantified in such a wide range, it
does provide an important insight for researchers studying
condom use. Previous research regarding condom use often
asks participants about condom use in terms of a dichoto-
mous (yes/no) variable. Given that nearly half the sample
reported condom use somewhere within the range of 1 to 9 of

Table 3. Logistic Regression (Control for Race/Ethnicity, Age, and Education)

Outcome variable B SE ExpB Wald statistic

Positive syphilis diagnosis (2 year) 0.001 0.087 1.001 0.000

Positive gonorrhea diagnosis (2 year)
0.077 0.082 0.926 0.868
Chlamydia diagnosis (2 year)
0.05 0.088 0.951 0.325
HPV (2 year) 0.086 0.091 1.090 0.893
Herpes (2 year)
0.186 0.084 0.831 4.875b
HIV test 0.062 0.055 1.064 1.292
HIV positive
0.041 0.052 0.959 0.640
Herpes with condom use mediator
0.168 0.086 0.845 3.791
Condom use (top)
0.196 0.053 0.822 13.485a
Condom use (bottom)
0.133 0.054 0.876 5.974b
Sexual behavior (any oral or anal sex) in past month
0.126 0.037 0.882 12.272a
a
p < 0.01 level.
b
p < 0.05 level.
HPV, human papilloma virus.
470
the previous 10 sexual encounters, measuring condom use
with a dichotomous (yes/no) variable may not be appropriate
in all situations especially if the intent is to asses individual
HIV/STI risk on a longer term basis (e.g., to assess condom
use in the last week). In addition, a ‘‘yes’’ response to a
question about whether or not a condom was used in a sexual
encounter may include individuals who used a condom for
part of the time, but did not use it the entire time penetration
was occurring. Researchers and clinicians should make efforts
to be more accurate in terms of the realization and concep-
tualization of the variation in this behavior. More clearly
worded questions, taking into account contextual and situa-
tional factors, regarding condom use should be considered in
order to gain the most accurate information from research
participants or patients about their condom use behaviors.
While this study represents an exploration of health be-
haviors and STI diagnoses based on circumcision status
among a large sample of MSM from all states in the United
States, it remains limited by the extent to which the sample is
one of convenience, as challenges remain with establishing
true nationally representative samples of MSM for research.
Furthermore, data were collected on the Internet and only
from members of a single Internet-based site, yet this method
of recruitment was purposive and closely resembles national
representations of MSM in the United States.
In addition, because this study was not specifically de-
signed to examine circumcision, future large scale research
should take a more in-depth approach to understanding im-
portant issues associated with circumcision and condom use,
including pleasure and satisfaction.
Author Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Joshua G. Rosenberger, M.P.H.
Center for Sexual Health Promotion
Indiana University
1025 East Seventh Street, HPER 116
Bloomington, IN 47405
E-mail: jorosenb@iupui.edu
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