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|accessdate=2020-05-28
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de Vincenzi & Mertens (1994) reviewed the literature regarding the alleged role of the [[foreskin]] in HIV transmission. They concluded:
<blockquote>
The potential public-health benefits of male circumcision have been greatly discussed in the past 50 years, often in a passionate and emotional manner. However, relatively few studies have been carried out and those that have, present conflicting results. The major criticism of most of the studies preformed to date is the lack of attention given to potential confounding factors, which could be related to both circumcision status and risk of sexually transmitted infections, such as sexual behaviour or differences in hygienic practices, or differential use of specific health facilities. As Poland [48] noted, "We must remember that circumcision is not performed randomly."
Therefore, further efforts are still required to quantify the relative risk associated with the lack of male circumcision. Some of this can be achieved by using observational designs which better address the limitations discussed above. Laboratory and primate research might also continue to provide useful information.
As the safety, expected benefits, feasibility and acceptability of mass circumcision are all questionable, neither public-health interventions nor intervention studies appear to be defensible options before there is stronger evidence from observational studies in different settings that show lack of male circumcision may be a genuinely independent risk factor for the transmission of HIV.<ref>{REFjournal
|last=Mertens
|first=Isabelle
|author-link=
|last2=Mertens
|first2=Thierry
|author2-link=
|etal=so
|title=Male circumcision: a role in HIV prevention?
|trans-title=
|language=
|journal=AIDS
|location=
|date=1994
|volume=8
|issue=2
|pages=153-60
|url=http://www.cirp.org/library/disease/HIV/vincenzi/
|archived=
|quote=
|pubmedID=8043224
|pubmedCID=
|DOI=
|accessdate=
}}</ref>
</blockquote>
== Confounding factors ==