Location, political and cultural history
The Commonwealth of Puerto Rico is an island nation located in that part of the Caribbean known as the The Greater Antilles. Other islands in the same geographical group are Cuba, the Cayman Islands, Hispaniola (containing the Dominican Republic and Haiti) and Jamaica.
Originally populated for centuries by indigenous aboriginal peoples known as Taínos, the island was claimed by Christopher Columbus for Spain, during his second voyage to the Americas, on 19 November 1493. Under Spanish rule, the island was colonised and the indigenous population was forced into slavery. Spain possessed Puerto Rico for over 400 years, despite attempts at capture of the island by the French, Dutch, and British.
As one of the terms of the Treaty of Paris at the conclusion of the Spanish-American War of 1898, Spain ceded Puerto Rico, along with the Philippines, to the United States. In 1917, Puerto Ricans were granted US citizenship and since 1948 they have elected their own governor. In 1952 the Constitution of Puerto Rico was adopted and ratified by the electorate.
A democratically elected bicameral legislature is currently in place (2013), but the United States Congress legislates many fundamental aspects of Puerto Rican life. The island’s current political status, including the possibility of statehood or independence, is widely debated in Puerto Rico. In November 2012, a non-binding referendum resulted in 54% of respondents voting to reject the current status. Among respondents to a second question about alternatives, 61% voted for statehood as the preferred alternative to the current territorial status. Statehood in this context means becoming a fully-fledged State of the USA, following in the footsteps of Alaska (03.January.1959) and Hawaii (21.August.1959).
The left-hand map shows Puerto Rico in relation to other islands of the Caribbean.
The right-hand map shows the principal islands. Please use your browser magnifier to enlarge.
Circumcision in Puerto Rico
Whilst the census of Puerto Rico might have you believe that 75%+ of the country’s residents self-classify as “white”, it is also the case that the vast majority – 99% – are Hispanic or Latino by culture. Given the absence of religious motivations arising from Judaism or Islam, the rate of male circumcision in Puerto Rico is credibly reported as being low. Some estimates put it below 20%, a marked difference from the North American norm.
The subject of circumcision in Puerto Rico came to prominence in 2012 in consequence of the publication of a research paper suggesting that the procedure had no major effect on rates of transmission of the HIV virus in a Caribbean context. (Rodriguez-Diaz CE et al
, More than Foreskin: Circumcision Status, History of HIV/STI, and Sexual Risk in a Clinic-Based Sample of Men in Puerto Rico. In: J Sex Med. 2012 Aug 15. (PMID: 22897699)
The Abstract reported "These analyses represent the first assessment of the association between circumcision and STI/HIV among men in the Caribbean. While preliminary, the data indicate that in and of itself, circumcision did not confer significant protective benefit against STI/HIV infection."
Even taking into account the high proportion of HIV infections in Puerto Rico arising from needle-sharing by drug addicts, this conclusion didn't ring true with those supporting male circumcision as a form of prophylaxis against HIV acquired through heterosexual intercourse.
In fairly short order, a rebuttal was published in the form of a Letter to the Editor. The text below reproduces that letter in full:
Faulty Analysis Leads to Erroneous Conclusions
I read with some concern the report by Rodriguez-Diaz CE et al. in “More than Foreskin: Circumcision Status, History of HIV/STI, and Sexual Risk in a Clinic-Based Sample of Men in Puerto Rico” . The authors conducted a large random survey of men in an STI/HIV clinic waiting room in San Juan, Puerto Rico, and measured self-reported circumcision status, various demographic and sexual risk behaviors and history of STI/HIV infection. While the intent and survey methods of the authors’ study were laudable the methods of analysis and interpretation of the results left a lot to be desired. Nearly a quarter of the sample were men who have sex with men and an unknown proportion had a history of injection drug use, two well-known routes of acquisition of HIV infection that would not be expected to be associated with protection of HIV infection by circumcision. Furthermore, the authors found that twice as many circumcised men (43.8%) reported receptive anal intercourse as uncircumcised men (20.4%), yet in their multivariable model they failed to control for that critical sexual risk behavior – the authors only controlled for place of birth and education level. Based on the authors’ analytic model, they report that male circumcision increased the likelihood of having HIV infection (P=0.027) with no reported measure showing the strength of that association. Given the increased risk behaviors in circumcised men (receptive anal intercourse in particular) it is no surprise that men who had increased sexual risk for HIV infection had increased odds of infection. The finding of increased odds of infection among circumcised men is likely erroneous due to confounding. The authors should have controlled for confounding by stratifying – separating those who reported receptive anal intercourse (or same-sex male sexual behavior) from those who did not. At the minimum they should have included same-sex behavior status in their multivariable model.
The failure to address confounding leads the authors to false conclusions. The authors state the findings from their study suggest that circumcision may not confer sufficient protective benefit in their setting. While perhaps an accurate statement, based on the biological understanding that foreskin removal reduces HIV entry into the penis, no reader would expect male circumcision to protect all those at risk of HIV infection including women, injection drug users, and those who engage in receptive anal intercourse . The authors do a disservice to the epidemiologic study of the role of circumcision in the prevention of HIV infection and STIs by performing an incomplete and faulty analysis of their data. The recent endorsement of newborn circumcision by the American Academy of Pediatrics is an evidence-based policy recognizing the clear benefits of medical male circumcision for male sexual and reproductive health . Strong consideration should be given toward the implementation of newborn circumcision as a sexual and reproductive health promotion strategy in the Caribbean.
Jeffrey D. Klausner
UCLA–Medicine, Los Angeles, CA, USA
Conflict of Interest: None.
 Rodriguez-Diaz CE, Clatts MC, Jovet-Toledo GG, Vargas-Molina RL, Goldsamt LA, García H. More than foreskin: Circumcision
status, history of HIV/STI, and sexual risk in a clinic based sample of men in Puerto Rico. J Sex Med 2012 Aug 15
[Epub ahead of print] doi: 10.1111/j.1743-6109.2012.02871.x.
 Tobian AA, Gray RH. The medical benefits of male circumcision. JAMA 2011;306:1479-80. PubMed PMID: 21972310.
 Task Force on Circumcision. Circumcision policy statement. Pediatrics 2012;130:585-6.
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