GARDIAN - PENTRU PROTECTIA GENITALA A BAIETILOR





Studiu: Functiile de aparare imunologica ale preputului uman

Revista Infectiilor cu Transmitere Sexuala, vol. 74, nr. 5 (Oct. 1998), p. 364 - 367

P M Fleiss, F M Hodges, R S Van Howe



Demonizarea preputului a fost un proces nestiintific, chiar daca putine cerecetari, la suprafata, par sa sprijine acest lucru. La sfarsitul sec. 19, cand circumcizia masculina a inceput sa fie practicata in medicina americana, a existat aproape un consens printre medicii americani ca circumcizia este un mijloc de tratament eficient pentru "boli" precum masturbarea, migrenele, nebunia, epilepsia, paralizia, strabism, prolaps rectal, cefalee si malformatii congenitale ale picioarelor. (1).



Jurnale medicale de varf au publicat mii de studii de caz care demonstrau aceste, si alte beneficii terapeutice miraculoase, date de amputarea preputului. Ideea ca circumcizia imbunatateste igiena si previne bolile cu transmitere sexuala (STDs) a aparut tot atunci, in contextul predicilor despre igiena morala si rasiala. Fenomenul delapidator al circumciziilor fortate, involuntare, in masa, in SUA, este insa produsul epocii de imediat de dupa cel de al doilea razboi mondial. Medicii din SUA au imbratisat repede conceptul circumciziei in masa, obligatorie, la fel cum tot atunci imbratisau usor conceptele de sterilizare involuntara (vasectomie), si alte masuri ale medicinei - "productie de masa", comerciala, orientata spre profit - practici respinse de majoritatea tarilor dezvoltate. Circumcizia in masa a atins maximul in anii 70, cand aproape 90 la suta din baietii nascuti in SUA au fost circumcisi. De atunci, rata a scazut, dar purtatorii de cuvant ai afacerii numite circumcizie au mai adaugat cate ceva, la lista de boli pe care se pretinde ca le-ar vindeca si previne circumcizia.



Din punct de vedere istoric, cea mai frecventa indicatie a circumciziei a fost pentru prevenirea masturbarii. Astazi, cea mai frecventa indicatie este ca ar inhiba raspandirea bolilor cu transmitere sexuala, chiar daca studii riguros controlate au demonstrat in mod constant ca de fapt barbatii circumcisi sint la risc mai mare de infectare cu oricare din principalele maladii cu transmitere sexuala, comparativ cu barbatii cu penis intact, natural. (2,3,4,5,6). Avocatii circumciziei pretind acum ca circumcizia previne SIDA.



O scurta trecere in revista, insa, a literaturii stiintifice, scoate la iveala ca, de fapt, efectul circumciziei este distrugerea proprietatilor de aparare imunologica si igienice, clinic demonstrate, pe care le are preputul si penisul intact, natural.



Actiunea de sfincter a orificiului preputial functioneaza ca o valva cu deschidere numai intr-o directie, blocand intrarea de agenti contaminanti din mediu, permitand in acelasi timp trecerea urinei. (7,8). Glandele sebacee ectopice concentrate langa frenul produc smegma. (9,10,11,12). Acest emolient natural contine si secretii seminale si prostatice, celule de piele si continut mucin din glanda uretrala. (13, 14). Protejeaza si lubrifiaza glandul si lamela interioara a preputului, facilitand erectia, retractia preputului si penetrarea in timpul actului sexual.



Preputul interior contine glande apocrine, (15) care secreta catepsin B, lisozome, cimotripsin, elastaza de neutrofil, (16), citokina (o proteina nonanticorp care genereaza un raspuns imunologic la contactul cu antigeni specifici), (17) si feromoni cum este androsteronul. (18). Lisozomele, care se gasesc si in lacrimi, laptele de mama si alte secretii ale corpului, distrug peretii celulelor bacterie.



Continutul natural al florei bacteriene preputiale este in functie de varsta si asemanatoare cu ceea ce se afla in gura, ochi, piele si genitalele femeilor. (19). Spalarea sacului preputial este suficienta pentru a facilia igiena. Spalarea cu sapun favorizeaza dezvoltarea organismelor patogene. (20). Spalarea preputului uman cu sapun este principala cauza a infectiei balanopostita. (21).Fussell et al au pretins ca preputul ar fi predispus, prin natura sa, la acumulare de bacterii patologice, insa ei nu au masurat flora bacteriala naturala in cohorte vii formate din micromedii preputiale nederanjate. (22). Ei au masurat ratele bacteriilor la preputuri moarte, amputate, tratate chimic, inoculate cu bacterii patologice - conditie care nu reprezinta vreo realitate biologica sau comportamentala cunoscuta.



Experimentele pe animale au relevat ca in prezenta peroxidului de hidrogen si a halidelor sau pseudohalidelor, solutia de peroxid solubila are o actiune antimicrobiala in preput. (23). Celulele plasma din mucusul preputial la bovine secreta imunoglobina sub epiderma care se difuzeaza peste epiderma in cavitatea preputiala. Ca raspuns la infectia patogenica bacteriala, celulele plasma preputiale se inmultesc. (24). Anticorpii din laptele de mama suplimenteaza imunitatea genitala a mucoasei preputului la nou nascuti. Oligosacaridele din laptele de mama sint ingerate, apoi eliminate prin urina, de unde impiedica ca E coli sa patrunda in tractul urinar si interiorul preputului. (25). Un studiu prospectiv condus timp de 8 ani care a urmarit anormalitatile genitourinare nu a gasit nici o diferenta in rata infectiilor urinare la baietii circumcisi, comparativ cu cei intacti. (26).



Nu exista nici un studiu histologic care sa valideze pretentia ca epiteliul sclerotic keratinizat al glandului externalizat chirurgical, deshidratat, ca meatul ori cicatricea penisului circumcis creaza vreo bariera de protectie impotriva infectiilor. Rata mai mare a infectiilor cauzatoare de maladii cu transmitere sexuala, prezenta la barbatii circumcisi, poate fi foarte usor cauzata de pierderea structurilor imunoprotective preputiale. Pierderea preputului, organ in doua straturi, auto-lubricant, mobil si protectiv, expune glandul si meatul la frictiune, abraziune directa si trauma. Ochii fara pleoape nu vor fi mai curati. Nici glandul fara preputul sau. Glandul neprotejat si meatul, externalizate chirurgical, sint expuse in mod constant la actiunea de abraziune si la murdarie, astfel ca un penis circumcis este mai putin igienic decat unul intact. (27). Un penis circumcis este mai predispus la infectii in primii ani de viata decat unul intact. (28, 29, 30).



Preputul este o zona erogena specializata. (31). Contine o retea nervoasa complexa, bogata, si o abundenta de endorgane mucocutanate sensibile la miscare, atingere, temperatura si stimulare erotica. (32, 33, 34, 35, 36, 37). Atat foldurile interior cat si exterior al preputului au o distributie mai densa de retele nervoase decat restul tesutului penil. (38). Bogata inervare a preputului interior contrasteaza puternic cu dotarea senzoriala limitata a glandului penisului, care poate detecta numai presiunea puternica si durerea. (39). Preputul, organ in doua straturi, furnizeaza tesutul suficient pentru a face fata organului in erectie si permite tesutului penil sa alunece liber, usor si placut peste trunchiul penisului si gland. Una din functiile preputului este de a facilita miscarea usoara, gentila, intre suprafetele mucus ale celor doi parteneri in timpul actului sexual. Preputul permite penisului sa alunece in si din vagin intr-un mod neabraziv, si in interiorul sau, intr-un mod auto-lubrifiant, flexibil. Astfel, femeia este stimulata de o presiune a miscarii si nu prin frictiune numai, cum se intampla atunci cand preputul barbatului lipseste.



Circumcizia desensibilizeaza in mod radical penisul si imobilizeaza restul de tesut penil, din trunchiul penisului, ce a mai ramas. (40). Pierderea mobilitatii preputiale, a structurilor senzoriale primare, a terminatiilor nervoase cu rol de declansare a orgasmului, si desensibilizarea inevitabila a glandului poate necesita o penetrare mai viguroasa si mai prelungita pana la declansarea orgasmului. Din acest motiv un penis circumcis este mai predispus la crapaturi, micro-fisuri, abraziuni si laceratii in vagin (sau rect), prin care virusul HIV din sperma intra in sistemul sanguin al partenerului.



Preputul este si bogat vascularizat. (37, 41, 42). Cele mai vascularizate parti ale corpului sint si cele mai putin vulnerabile la infectii.



Acesti factori explica de ce barbatii circumcisi americani sint mai predispusi, comparativ cu cei intacti genital, sa se angajeze in comportamente sexuale riscante (cum este sexul anal si sexul oral homosexual activ sau pasiv) ceea ce conduce la infectii HIV si alte infectii conducatoare la maladii cu transmitere sexuala. (43).



Celulele epiteliu Langerhans (ELCs), componente ale sistemului imunitar, ajuta organismul sa recunoasca si proceseze antigenii, directionandu-i spre limfocite ori macrofagi. Weiss et al au remarcat abundenta de celule Langerhans in exteriorul preputului la nou nascuti, comparativ cu densitatea generala a acestor celule la adult. (44). Ei sugereaza ca densitatea relativa mai mica a acestor celule in mucoasa interioara a preputului la copii ar conduce la imunitate mai redusa si recomanda circumcizia universala, obligatorie, pentru a preveni SIDA. Acesta recomandare este irationala si nefondata, pentru ca preputul este la toti copiii lipit de gland, sigiland preputul interior si glandul nematurizate de contactul cu exteriorul. (45, 46). Mai departe, un baiat nou nascut tocmai a iesit dintr-un mediu steril, unde celulele Langerhans nu sint necesare. Nu exista nici vreo documentare ca ar exista celule Langerhans de aceeasi densitate in membrana mucus externalizata chirurgical a glandului penisului, meat sau cicatricei lasate de circumcizie, la barbatul adult activ sexual. (47).



Desi un studiu pe primate a gasit celule asemanatoare cu Langerhans in lamina propria, nu in epiteliu, ce pareau infectate cu virusul simian al imunodeficientei, (48) nu este clar daca acesta observatie poate fi extrapolata la celulele Langerhans din epiteliul preputului uman. Daca totusi celulele Langerhans ar constitui un factor, raspunsul etic este promovarea utilizarii prezervativelor, si nu excizia de tesut normal cu celule imunoprotective.



In 1986 un circumcizer american a ipotetizat pentru prima data ca circumcizia previne infectia HIV. (49). Intr-o tentativa de a-i verifica teoria, altii au publicat numeroase sondaje epidemiologice, conduse in principal in Africa. La o analiza a acestor sondaje, nu se verifica teoria. Din 36 studii publicate cautand relatia dintre un penis circumcis si infectia cu HIV, 15 au gasit o corelatie negativa, (50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64), 4 au gasit o corelatie pozitiva, (65, 66, 67, 68), si 16 nu au gasit nici o diferenta semnificativa statistic. (2, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83).



Studiile care gasesc o corelatie pozitiva sint toate bazate pe populatie. Majoritatea celor ce gasesc o asociere negativa sint bazate pe date furnizate de clinicile de tratament a bolilor cu transmitere sexuala, au un viciu de populatie serios, si de aceea trebuie privite cu precautie. De exemplu, conform criteriului nediscluderii, Pepin et al au numarat 11% din cohorta de studiu circumcisa ca intacti. (70). Kode-Lule et al merg pe premiza ca toti musulmanii sint circumcisi, (77) o presupunere care Urassa et al au gasit-o adevarata numai in 68% din 92% din cazuri. (64).



Desi avocatii circumciziei citeaza aceste studii cand discuta despre necesitatea circumciziei la baieti, (84, 85), datele din Africa nu sint aplicabile la tarile dezvoltate. (86). Statutul de circumcis in Africa are o semnificatie culturala importanta dar prost inteleasa, pe care avocatii circumciziei o ignora. Barbatii circumcisi si cei intacti traiesc vieti total diferite in regiunile africane investigate. Marck a aratat ca barbatii intacti in zonele circumcise intampina discriminari severe la locul de munca, acasa, in casnicie si relatiile sexuale. Un procent semnificativ din ei se refuleaza la prostituate, marind riscul de expunere la boli cu transmitere sexuala. (87). Ignorand aceste realitati, unii cercetatori SIDA au recomandat a se interveni in culturile africane si promova circumcizia in zonele libere de circumcizie. (88). Implementarea unei astfel de recomandari ar conduce la un dezastru. In multe parti din Africa circumcizia este cauza principala a infectiilor cu tetanus. (89). Infectarea cu tuberculoza in tarile dezvoltate, prin circumcizie, este bine documentatata. (90). Riscul de complicatii severe si deces datorita circumciziei rituale in Africa este inalt. (91, 92). Utilizarea de instrumente murdare in circumciziile in grup mareste riscul de imprastiere a virusului HIV. (93). Desi riscul de complicatii datorita circumciziei este mai mare in Africa decat in SUA, nici un nivel de risc nu este acceptabil cand un "pacient" sanatos - si de regula impotrivindu-se operatiei de amputare, nu si-a dat consimtamantul pe deplin informat.



Pe langa handicapul imunologic pe care il cauzeaza circumcizia, acesta mai compromite imediat si sistemul imunitar, facand baiatul / barbatul proaspat circumcis vulnerabil la infectii, adesea cu consecinte tragice. (94, 95). Chiar daca "studiile" circumcizerilor ar fi valide, riscurile reale si inevitabile al circumciziei depasesc, atat cantitativ cat si etic, orice presupus risc pe care l-ar avea organele genitale intacte. Amputarea preputului nici nu inhiba comportamentul sexual riscant, nici nu confera imunitate la expunerea la patogeni. Acest lucru e demonstrat de faptul ca SUA are atat cel mai mare numar de barbati circumcisi activi sexual, si in acelasi timp cea mai mare rata de cancer genital, boli cu transmitere sexuala, si SIDA. (96, 97).



Circumcizia obligatorie in masa din SUA a esuat in a furniza orice beneficiu pentru sanatatea publica pe care avocatii ei au pretins ca ar aduce; dar chiar daca si-ar fi atins toate scopurile, nu exista nici o justificare stiintifica ori etica pentru a priva pe nimeni de suveranitatea individuala pe care o are asupra propriilor sale organe genitale. Circumcizia baietilor violeaza dreptul la integritate corporala si impune la un individ neconsensual un penis redus pentru tot restul vietii. In zorii proceselor de la Nuremberg, este nepotrivit si inetic pentru medici sa persiste in a efectua sau promova interventii chirurgicale penile reductive involuntare la indivizi sanatosi, normali. Conceptul totalitar al chirurgiei profilactice inventat de avocatii circumciziei nu are ce cauta in medicina moderna a lumii civilizate. Cheia reducerii ratei bolilor cu transmitere sexuala este educatia, informarea, si nu amputarea penila.



University of Southern California Medical Center, Los Angeles, California, USA P M Fleiss

Wellcome Unit for the History of Medicine, University of Oxford, Oxford OX2 6PE F M Hodges

Medical College of Wisconsin, Milwaukee, Wisconsin, USA R S Van Howe Correspondence to: Dr. Fleiss, 1824 North Hillhurst Avenue, Los Angeles, CA 90027, USA.

Referinte


1. Hodges F. A short history of the institutionalization of involuntary sexual mutilation in the United States. In: Denniston GC, Milos MF, eds. Sexual mutilations: a human tragedy. New York. Plenum, 1997:17-40.
2. Laumann EO, Masi CM, Zuckerman EW. Circumcision in the United States: prevalence, prophylactic effects, and sexual practice. JAMA 1997;277:1052-7.
3. Donovan E. Bassett I, Bodsworth NJ. Male circumcision and common sexually transmitted diseases in a developed nation setting. Genitourin Med 1994;70:317-320.
4. Smith GL, Greenup R, Takafuji ET. Circumcision as a risk factor for urethritis in racial groups. Am J Public Health 1987;77:452-454.
5. Cook LS, Koutsky A, Holmes KK. Clinical presentation of genital warts among circumcised and uncircumcised heterosexual men attending an urban STD clinic. Genitourin Med 1993;69:62-64.
6. Bassett I, Donovan B, Bodsworth NJ, et al. Herpes simplex virus type 2 infection of heterosexual men attending a sexual health center. Med J Aust 1994;160:697-600.
7. Jefferson G. The peripenic muscle; some observations on the anatomy of phimosis. Surg Gynecol Obstet 1916;23:177-81.
8. Lakshmanan S, Parkash S. Human prepuce--some aspects of structure and function. Indian J Surg 1980; 42:134-7.
9. Delbanco E. Über das geh&auwl;ufte Aufreten von Talgdrusen an der Innerflähe des Präputium. Monatshefte für praktishe Dermatologie 1904; 38:536-8.
10. Hyman AB, Brownstein MD. Tyson's "glands" sebaceous glands and papillomatosis penis. Arch Dermatol 1969;99:31-7.
11. Piccinno R, Carrel C-F, Menni S. et al. sebacous glands mimicking molluscum contagiosum Acta Derm Venerol1990;70:344-5.
12. Krompecher St. Die Histologie der Absonderung fur Smegma Praeputi. Anatomischer Anzeiger 1932; 75:170-176.
13. Koning M, Streekferk JG. Kleine Kwalen in de Husiartsgeneenkunde; Smegma en Fysiologische Fimose. Ned Tijdschr Groeskd 1995; 139: 1632-4.
14. Parkash S, Rao R, Venkatesan K. et al. Sub-preputial wetness--its nature. Ann Nat Med Sci 1982;18:109-112.
15. Ahmed A, Jones AW. Apocrine cystodenoma: a report of two cases occurring on the prepuce. Br J Derm 1969;81:899-901.
16. Frolich E, Shaumberg-Lever F, Kissen C. Immunelectron microscopic localization of cathepsin B in human apocrine glands. J Cutan Pathol 1993; 20: 54-60.
17. Ahmed AA, Nerdlind K, Schulzberg M.et al. Immunoelectrochemical localization of IL-1 alpha-, IL-1 beta, IL-6 and TNF-alpha-like immunoreactivities in human prepuce apocrine glands. Arch Dermatol Res 1995; 287:764-6.
18. Cohn BA. In search of human skin pheromones. Arch Derm 1994;130:1048-51.
19. Neubert U, Lantze. Die Bakterielle Flora des Präeputial raumes. Hautarzt 1979; 30: 41-5.
20. Bowen JM, Tobin N, Simpson RB, et al. Effects of washing on the bacterial flora of the stallion's penis. J Reprod Sci (Suppl) 1982;32:41-45.
21. Birl ey HDL, Walker MM, Luzzie GA, et al. Clinical features and management of recurrent balanitis, association with atopy and genital washing. Genitourin Med 1993;69:400-3.
22. Fussell EN, Kaack MB, Cherry R, et al. Adherence of bacteria to human foreskins. J Urol 1988;140:997-1001.
23. Prabir K. Tissue distribution of constitutive and induced soluble peroxidase in rat: purification and characterization from lacrimal gland. Eur J Biochem 1992;206:59-67.
24. Flower PJ. Ladd PW, Thomas AD, et al. An immunopathologic study of the bovine prepuce. Vet Pathol 1983; 30:199-202.
25. Coppa GV, Gabriella O, Giorgi P, et al. Preliminary study of breastfeeding and bacterial adhesion to uroepithelial cells. Lancet 1990; 358:568-571.
26. Mueller ER, Steinhardt G, Naseer S. The incidence of genitourinary tract abnormalities in circumcised and uncircumcised boys presenting with an initial urinary tract infection by 6 months of age. Pediatrics (Suppl) 1997;100:580.
27. Van Howe RS. Variability in penile appearance and penile findings: a prospective study. Br J Urol 1997; 80: 776-782.
28. Fe rgusson DM, Lawton JM, Shannon FT. Neonatal circumcision and penile problems: an 8 year longitudinal study. Pediatrics 1988; 81:537-541.[Link to www.pediatrics.org]
29. Enze nauer RW, Dotson CR, Leonard T. et al. Increased incidence of neonatal staphylococcal pyoderma in males. Mil Med 1984;149:408-410.
30. Enze nauer RW, Dotson CR, Leonard T. et al.. Male predominance in persistent staphylococcal colonization and infection of the newborn. Hawaii Med J 1985;44:389-90, 392, 394-6.
31. Winkelmann RK. The erogenous zones: their nerve supply and its significance. Proc Staff Meet Mayo Clin 1959;34:39-47.
32. Dogiel AS. Die Nervenendigungen in der Haut der Genitalorganen in der Äusseren Menschen. Archiv für Microskopische der Anatomia 1893;41:585-612.
33. Winkelman n RK. The cutaneous innervation of the newborn prepuce. J Invest Dermat 1956;26:53-67.
34. De Girolamo A, Cecio A. Contributo alla conoscensza dell'innervazione sensitiva del prepuzio nell'uomo. Boll Ital Biol Sperimentale1968;44:1521-2.
35. Ohmori D. &Uml;ber die Entwicklung der Innervation der Genitalapparate als peripheren Aufnameapparat der Genitalen Reflex. Zeitschift für Anatomie und Entwicklungeschichte 1924; 70:347-50.
36. Bazett HC, Mcglane B, Williams RG, et al. Depth, distribution and probable identification in the prepuce of sensory end-organs concerned in sensations of temperature and touch; thermometric conductivity. Arch Neurol Psychiat 1932;27:489-507.
37. Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996;77:591-595.
38. Bourlond A, Winkelmann RK. L'innervation du prépuce chez le nouveau-né. Arch Belg Derm Syph 1965;21:139-56.
39. Halata Z, Munger BL. The neuroanatomical basis for the protopathic sensibility of the human glans penis. Brain Research 1986;371-205-230.
40. Lander MM. The human prepuce. In: Denniston GC, Milos MF, eds. Sexual mutilation: a human tragedy: Plenum 1997:79-81.
41. Justkiewenski S, Vaysse Ph, Moscovici J. et al. A study of the arterial blood supply to the penis. Anat Clin 1982;4:101.
42. Hinman F. Jr. The blood supply to preputial island flaps. Urol 1991;145:232-5.
43. Van Howe RS, Cold CJ. Advantages and disadvantages of neonatal circumcision. JAMA 1997;278:203.
44. Weiss GN, Sanders SM, Westbrook KC. The distribution and density of Langerhans cells in the human prepuce. cause of a diminished immune response? Israel J. Med Sci 1993;29-42-3.
45. Kayaba H, Tamura H, Kitajima S, . Analysis and retractability of the prepuce in 603 Japanese boys. Urol 1996;156:813-5.
46. Gairdner D. The fate of the foreskin: a study of circumcision. BMJ 1949; 2:1433-7.
47. Berman B, Chen VL, France DS, et al. Anatomical mapping of epidermal Langerhans cell densities in adults. Br J Derm 1983; 109:553-8.
48. Spira IA, Marx PA, Patterson BK. et al. Cellular targets of infection and route of viral disssemination after introvaginal inoculation of simian immunodeficiency virus into rhesus macaques. J Exp Med 1996;183:215-25.
49. Fink AJ. A possible explanation for heterosexual male infections with AIDS. N Engl J Med 1986;315:1167.
50. Bwaya JJ, Omari AM. utere AN. et al. Long distance truck-drivers: I. Prevalence of sexually transmitted diseases (STDs). East Africa Med J 1991;68:425-9.
51. Bwayo J, Plummer F, Omari M. et al. Human immunodeficiency virus infection in long distance truck drivers in East Africa. Arch Intern Med 1994;154:1291-6.
52. Kreiss JK, Hopkins SG. The association between circumcision status and human immunodeficiency virus infection among homosexual men. J Infect Dis 1993; 168:1404-8.
53. Cameron DW, Simonsen, JN, D'Costa LJ, et al.Female to male transmission of human immunodeficiency virus type 1 risk factors for seroconversion in men. Lancet 1989; 2: 403-7.
54. Greenblatt RM, Lukeha SA, Plummer FA, et al. Genital ulceration as a risk factor for human immunodeficiency virus infection. AIDS 1988;2:47-50.
55. Diallo MO, Ackash AN, LaFontaine M-F, et al. HIV-1 and HIV-2 infections in men attending sexually transmitted disease clinics in Abidijan, Cote d'Ivoire. AIDS 1992;6:581-5.
56. Simonsen JN, Cameron DW, Gakinya MN, et al. Human immunodeficiency virus infection among men with sexually transmitted diseases. N Engl J Med 1988; 319:274-8.
57. Tyndall MW, Ronald AR, Agoki E, et al. Increased risk of infection with genital ulcer disease in Kenya. Clin Infect Dis 1996;23:449-453.
58. Nasio JM, Nagelkerke NO, Mwatha A, et al. Genital ulcer disease amongst STD clinic attenders in Nairobi; association with HIV-1 and circumcision status. Int J STD AIDS 1996;7:410-414.
59. Mehendale SM, Shepherd ME, Divekar AD,et al. Evidence for high prevelance and rapid transmission of HIV among individuals attending STD clinics in Pune, India. Indian J Med Res 1996; 104: 327-35.
60. Sassan-Morokro M, Greenberg AE, Coulibaly IM. et al. High rates of sexual contact with female sex workers, sexually transmitted disease and condom neglect among HIV infected and uninfected men with tuberculosis in Abijan, Cote d'Ivoire. J Acquired Immune Defic Syndr Hum Retrovirol 1996;11:183-7.
61. Hunter DJ, Maggwa BN, Mati JKG, et al. Sexual behavior, sexually transmitted diseases, male circumcision and risk of HIV infection among women in Nairobi, Kenya. AIDS 1994;8:93-9.
62. Seed J, Allen S, Theiry M, et al. Male circumcision, sexually transmitted disease and risk of HIV. J Acquired Immune Defic Syndr Hum Retrovirol 1995;8:83-90.
63. Malamba SS, Wagner HJ, Maude G, et al. Risk factors for HIV-1 Infection in adults in a rural Ugandan community: a case control study. AIDS 1994; 8: 253-257.
64. Urassa M, Todd J, Boerra JT, et al. Male circumcsion and susceptibility to HIV infection among men in Tanzania. AIDS 1997;11,73-80. [study 4]
65. Barongo LR, Borgdorff W, Mosha FF, et al. The epidemiology of HIV-1 infection in rural areas, roadside settlements and rural villages in Mwanza Region, Tanzania. AIDS 1992;6:1521-8.
66. Grossk urth H, Mosha F, Todd J, et al. A community trial of the impact of improved sexually transmitted disease treatment on the HIV epidemic in rural Tanzania: 2. Baseline survey results. AIDS 1995;9:927-34.
67. Chao A, Bulterys M, Musanganire F, et al.Risk factors associated with prevalent HIV-1 infection among pregnant women in Rwanda. National University of Rwanda-Johns Hopkins University AIDS Research Team. Int J Epidemiol 1994;23:371-380.
68. Urassa M, Todd J, Boerra JT, et al. Male circumcision and susceptibility to HIV infection among men in Tanzania. AIDS 1997;11:73-80. [study 1]
69. Hira SK, Kamanga J< Mcuacua R, et al. Genital ulcers nad male circumcision as risk factors for acquiring HIV-1 in Zambia. J Infect Dis 1990;161:584-5.
70. Pépin J, Quigley M, Todd J, et al. Association between HIV-2 Infection and genital ulcer diseases among male sexually transmitted disease patients in The Gambia. AIDS 1992;6:489-93.
71. Bollinger RC, Brookmeyer RS, Mehendale SM,l et al. Risk factors and clinical presentation of acute primary HIV infection in India. JAMA 1997; 278:2085-9.
72. Chiasson M, Stoneburner RL, Hildebrandt DS, et al. Heterosexual transmission of HIV-1 associated with use of smokable freebase cocaine (crack). AIDS 1991;5:1121. 73. Carael M, Van De Perre, PH, Lepage PH, et al. Human immunodeficiency virus transmission among heterosexual couples in Africa. AIDS 1988;2:201-5.
74. Moss GB, Clemerson D, D'Costa L, et al. Association of cervical ectopy with heterosexual transmission of human immunodeficency virus: results of a study of couples in Nairobi, Kenya. J Infect Dis 1991;164:588-91.
75. Allen S, Lindan C, Serufilira A, et al. Human immunodeficiency virus infection in urban Rwanda: demographic and behavioral correlate in a representative sample of childbearing women. JAMA 1991; 266:1657-63.
76. Seidlin M, Vogler M, Lee E, et al. Heterosexual transmission of HIV in a cohort of couples in New York City. AIDS 1993;7:1247-54.
77. Konde-Lule JK. Bergley SF, Downing R. Knowledge attitudes and practices concerning AIDS in Ugandans. AIDS 1989;3:513-18.
78. Van de Perre P, Clumeck N, Steens M, et al. Seroepidemiological study on sexully transmitted diseases and hepatitis B in African promiscuous heterosexuals in relation to HTLV-III infection. Eur J Epidemiol 1987;3:14-8.
79. Quigley M, Munguti K, Grosskurth H, et al. Sexual behavior patterns and other risk factors for HIV infection in rural Tanzania: a case control study. AIDS 1997;11:237-48.
80. Urassa M, Todd J, Boerma JT, et al. Male circumcision and susceptibility to HIV infection among men in Tanzania. AIDS 1997;11:73-80.[study 2]
81. Urassa M, Todd J, Boerma JT, et al. Male circumcision and susceptibility to HIV infection among men in Tanzania. AIDS 1997;11:73-80.[study 3]
82. Urassa M, Todd J, Boerma JT, et al. Male circumcision and susceptibility to HIV infection among men in Tanzania. AIDS 1997;11:73-80. [study 5]
83. Hudson CP, Hennis AJM, Kataaha P, et al. Risk factors for the spead of AIDS in rural Africa, hepatitis B and syphilis in southwestern Uganda AIDS 1988; 2: 255-60.
84. Schoen EJ. Benefits of newborn circumcision: is Europe ignoring medical evidence? Arch Dis Child 1997; 77: 258-60.
85. Weiss GN, Prophylactic neonatal surgery and infectious diseases. Pediatr Infect Dis J 1997;16:727-34.
86. Storms, MR. AAFP fact sheet on neonatal circumcision. a need for updating. Am Fam Physician 1996;54:1216,1218.
87. Marck J. Aspects of male circumcision in sub-equatorial African cultural history. Health Transition Review 1997; 7:357-59.
88. Moses S, Bradley JE, Nagelkerke NJD, et al. Geographical patterns of male circumcision practice in Africa: association with HIV seroprevalence. Int J Epidemiol 1990;19:693-7.
89. Sow PS, Diop BM, Barry HL, et al. Tétanus et practique traditionnelle à Dakar (à propos de 141 cas). Dakar Med 1993; 38:55-9.
90. Hardy DB. Cultural practices contributing to the transmission of human immunodeficiency virus in Africa. Rev Infect Dis 1987;9:1109-19.
91. Annobil SH, Al-Hilf A, Kazie T. Primary tuberulosis of the penis in an infant. Tubercle 1990; 71:229-30.
92. Crowley IP, Kesner KM. Ritual circumcision (umkhwetha) among the Xhosa of the Ciskei. Br J Urol 1990;66:318-321.
93. Phillips K, Ruttman T, Viljoen J. Flying doctors, saving costs. S Afr Med J 1996; 86:1557-8.
94. Blass DP, Jr. Healey JJ, Waldhausen JHT. Necrotizing fasciitis after Plastibell circumcision. J Pediatr 1997;131;459-62.
95. Williams N, Kapila L. Complications of circumcision, Br J Surg 1993;80:1231-6.
96. Hitchcock R. Commentary on: Benefits of newborn circumcision: is Europe ignoring medical evidence? Arch Dis Child 1997:77:250.
97. Wise J. HIV epidemic is far worse than thought. BMJ 1997;3:5:1486. Br>


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