"An article in the 20 September issue of the Journal that suggested circumcision of infant boys could be considered a “surgical vaccine” against future heterosexually transmitted HIV has attracted strong criticism from many of our readers."
In a recent editorial, Cooper and colleagues recommend increasing infant circumcision to combat increasing rates of heterosexual transmission of HIV infection, and contend that the major obstacle to increasing male circumcision in Australia is a Royal Australasian College of Physicians (RACP) policy. [1]
In September, after a literature review and analysis, the RACP released a revised policy on infant male circumcision, concluding that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand. [2] While evidence of HIV prevention by circumcision is strong in high-prevalence settings with predominantly heterosexual transmission, [3] this is not so in low-prevalence environments where homosexual transmission is more important. [4] Evidence of the protective effect of circumcision against other sexually transmitted infections in Australia is limited. [5]
Cooper et al’s comparison of circumcision with vaccines is misleading. Protection against HIV by circumcision is predominantly for males, and the risk for females may increase. [6] There is minimal protection against homosexual acquisition of HIV. [4]
The RACP acknowledges the strong and differing opinions on this topic, ranging from the strong pro-circumcision views of Cooper et al to the equally strong diametrically opposed views of the Royal Dutch Medical Association, which believes that (for reasons of ethics and medical risks) legal prohibition of infant circumcision is warranted. [7]
The RACP recognises the important role of parents in decision making, and recommends that parents contemplating circumcision of their newborn sons be carefully apprised of the risks and benefits. If they elect to proceed with circumcision, the procedure should be undertaken in a safe child-friendly environment, with appropriate analgesia, and by an appropriately trained, competent practitioner who is capable of dealing with complications. We believe that this approach safeguards the social and community interests of children, and offers protection from unnecessary surgical risks. [2]
The RACP does not accept that its policy on circumcision of infant males represents an obstacle to effective public health policy — it believes that, at present, the evidence does not allow a recommendation for widespread infant male circumcision and that Cooper et al have misrepresented this evidence. In the interests of children, and of public health more generally, it is important that this evidence be kept under review and decisions that could lead to increased morbidity and mortality of children only be made when it is clear that the benefits very clearly outweigh any risks.
David A Forbes, Chair, Policy and Advocacy Committee Paediatrics and Child Health Division, Royal Australasian College of Physicians, Sydney.
1. Cooper DA, Wodak AD, Morris BJ. The case for boosting infant male circumcision in the face of rising heterosexual transmission of HIV [editorial]. Med J Aust 2010; 193: 318-319.
2. Royal Australasian College of Physicians. Circumcision of infant males. Sydney: RACP, 2010.
3. Siegfried N, Muller M, Deeks JJ, Volmink J. Male circumcision for prevention of heterosexual acquisition of HIV in men. Cochrane Database Syst Rev 2009; (2): CD003362.
4. Templeton DJ, Jin F, Mao L, et al. Circumcision and risk of HIV infection in Australian homosexual men. AIDS 2009; 23: 2347-2351.
5. Templeton DJ, Jin F, Prestage GP, et al. Circumcision and risk of sexually transmissible infections in a community-based cohort of HIV-negative homosexual men in Sydney, Australia. J Infect Dis 2009; 200: 1813-1819.
6. Wawer MJ, Makumbi F, Kigozi G, et al. Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial. Lancet 2009; 374: 229-237.
7. Royal Dutch Medical Association. Non-therapeutic circumcision of male minors. Utrecht: KNMG, 2010.
In their recent editorial, Cooper and colleagues propose newborn circumcision as primary prevention for heterosexual HIV transmission in Australia. [1] However, they cite no evidence for its effectiveness as a primary prevention measure, and their editorial references few high-quality studies, offering instead opinions from like-minded individuals.
Experience in the United States suggests that circumcision is unlikely to be effective in preventing heterosexual HIV transmission. While having a high infant circumcision rate for the past 60 years, the US has had one of the highest rates of heterosexually transmitted HIV infection among developed nations. African Americans have the highest rates of both circumcision [2] and heterosexually transmitted HIV infection. [3] Circumcision removes the most sensitive tissue of the penis [4] and serious complications include death (about 0.9 deaths per 10 000 circumcisions). [5] If two-thirds of Australian newborn boys were circumcised at birth, around nine would die every year from complications.
Cooper et al sidestep the ethical issues raised by non-therapeutic circumcision. Infants and children lack the legal capacity to grant consent but have human rights. The High Court of Australia holds that parents may grant consent only when surgery to the genital organs is therapeutic, [6] which does not include neonatal circumcision. Without valid consent, circumcision constitutes legal battery. It is far preferable legally and ethically for circumcision decisions to be deferred until the child is competent to make a fully informed decision for himself. Cooper et al state that infant circumcision is cost-effective, but the cost analysis that they reference does not directly assess cost effectiveness. [7] In fact, the data suggest that infant circumcision costs more than it saves. Another cost analysis showed that a circumcision program would be five times more costly in preventing HIV than providing free condoms, and that condoms are 95 times more effective than circumcision. [8]
In summary, newborn circumcision for primary prevention of HIV remains unsupported by evidence of efficacy or cost-effectiveness, introduces potentially serious risks, and raises complex ethical and medico-legal issues. New 2010 Royal Australasian College of Physicians guidelines [9] continue to not recommend circumcision, despite pressure from a well funded, international, pro-circumcision lobby group. [10] Instead of adopting a circumcision experiment that has failed in the US, Australia should take its lead from the Royal Dutch Medical Association and condemn non-therapeutic circumcision in boys. [11]
John W Travis, Adjunct Professor, School of Health Sciences, RMIT, Melbourne; Sarah J Buckley, General Practitioner, Brisbane; Paul Mason, Former Commissioner for Children, Tasmania; Ken McGrath, Senior Lecturer in Pathology, Auckland University of Technology; Robert S Van Howe, Clinical Professor, Department of Pediatrics and Human Development, Michigan State University; George Williams, Former Director, Newborn Intensive Care Unit, Sydney Children’s Hospital.
1. Cooper DA, Wodak AD, Morris BJ. The case for boosting infant male circumcision in the face of rising heterosexual transmission of HIV [editorial]. Med J Aust 2010; 193: 318-319.
2. Mor Z, Kent CK, Kohn RP, Klausner JD. Declining rates in male circumcision amidst increasing evidence of its public health benefit. PLoS ONE 2007; 2: e861.
3. Centers for Disease Control and Prevention. Racial/ ethnic disparities in diagnoses of HIV/AIDS — 33 states, 2001–2005. MMWR Morb Mortal Wkly Rep 2007; 56: 189-193.
4. Sorrells ML, Snyder JL, Reiss MD, et al. Fine-touch pressure thresholds in the adult penis. BJU Int 2007; 99: 864-869.
5. Bollinger D. Lost boys: an estimate of US circumcision-related infant deaths. Thymos 2010; 4: 78-90.
6. Secretary, Department of Health and Community Services v JWB and SMB (Marion’s case) (1992) 175 CLR 218, FC 92/010.
7. Schoen EJ, Colby CJ, To TT. Cost analysis of neonatal circumcision in a large health maintenance organization. J Urol 2006; 175: 1111-1115.
8. McAllister RG, Travis JW, Bollinger D, et al. The cost to circumcise Africa. Int J Men’s Health 2008; 7: 307- 316.
9. Royal Australasian College of Physicians. Circumcision of infant males. Sydney: RACP, 2010.
10. Llewellyn DJ. The circumcision lobby. The 11th International Symposium on Circumcision, Genital Integrity, and Human Rights. Genital Autonomy. Program and Syllabus of Abstracts; 2010 Jul 29–31; University of California, Berkeley.
11. Royal Dutch Medical Association. Non-therapeutic circumcision of male minors. Utrecht: KNMG, 2010.
We refer to a recent editorial in which Cooper and colleagues made a case for boosting infant male circumcision in Australia to reduce female-to-male HIV transmission. [1] The case is strong for hyperendemic countries, such as those in sub-Saharan Africa, given the evidence for circumcision reducing the prevalence of HIV when infections are primarily from heterosexual contact. [2] However, the epidemiology of the HIV epidemic in Australia paints a radically different picture from these countries. Most striking is that men who have sex with men (MSM) still comprise the largest group — around 83% — of people living with HIV. [3] Prevalence of HIV among men and women who report a history of heterosexual contact only remains at less than 0.5%4 while MSM continue to have the majority of new infections. [4] In short, efforts to reduce Australia’s HIV epidemic still require a primary focus on MSM.
With this in mind, a recent meta-analysis of 18 international studies and a combined pool of 53 567 MSM5 showed only a small, statistically non-significant trend toward a protective benefit from circumcision with regard to HIV and other sexually transmitted infections. Hypothesised benefits are limited to the insertive partner; however, circumcised MSM who engaged primarily in insertive anal intercourse (IAI) were not significantly less likely to be HIV-positive than other MSM.
The sexual repertoire of many MSM suggests that interventions designed specifically to protect those who engage in IAI are unlikely to be successful at a population level. Data from a national survey of 856 homosexual men, conducted recently by the Australian Research Centre in Sex, Health and Society, show that only 9% of those who had anal intercourse in the past 12 months reported taking an exclusively insertive role. Of the remainder, 8% were exclusively receptive and 83% were versatile, adopting each role at least once over the preceding 12 months. Uncircumcised men who engaged exclusively in IAI were just as likely to be HIV-negative as their circumcised counterparts (P=0.90).
As infant male circumcision programs are rolled out in some hyperendemic countries, we encourage policymakers to tread carefully when considering such a move in Australia. Boosting education campaigns that promote HIV awareness and safer sex may prove to be more cost-effective and successful than largescale infant male circumcision programs which seem likely to offer, at most, a marginal benefit to the extremely small proportion of the Australian male population who are exclusively insertive partners in homosexual anal intercourse.
Anthony N Lyons, Research Fellow; Marian Pitts, Director; Anthony Smith; Professor Jeffrey Grierson, Senior Research Fellow, Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne.
1. Cooper DA, Wodak AD, Morris BJ. The case for boosting infant male circumcision in the face of rising heterosexual transmission of HIV. Med J Aust 2010; 193: 318-319.
2. Doyle SM, Kahn JG, Hosang N, et al. The impact of male circumcision on HIV transmission. J Urol 2010; 183: 21-26.
3. Grierson J, Power J, Croy S, et al. HIV futures six: making positive lives count. Melbourne: La Trobe University, 2009.
4. National Centre in HIV Epidemiology and Clinical Research. HIV/AIDS, viral hepatitis and sexually transmissible infections in Australia: annual surveillance report 2009.
5. Millett GA, Flores SA, Marks G, et al. Circumcision status and risk of HIV and sexually transmitted infections among men who have sex with men: a meta-analysis. J Am Med Assoc 2008; 300: 1674- 1684.
In their recent editorial, Cooper and colleagues argue for a shift in Australian policy to boost neonatal male circumcision levels, in an effort to prevent future heterosexual acquisition of HIV. [1] There is very strong evidence for a protective effect of male circumcision against HIV acquisition in high-prevalence settings, where heterosexual intercourse is the most common mode of transmission and access to antiretroviral therapy is poor. However, Australia is a low-prevalence setting with an HIV epidemic that largely affects the homosexual population and excellent access to condoms and antiretroviral therapy.
There have been very few studies on the protective effect of male circumcision in settings similar to Australia, and those that have been reported have produced variable results. [2] The publications cited by Cooper et al do not strongly support the notion that male circumcision confers similar protection in both high- and low-prevalence settings — the conclusions are based on expert opinion or other inconclusive, low-quality evidence. [2-4] There are also other issues to consider when discussing a population-based intervention strategy for a low-prevalence disease. Given that rates of male circumcision in Australia are currently low,1 compliance could be an issue, as parents may be unwilling to accept a surgical procedure for their newborns on the basis of predictions about future HIV protection.
Is circumcision cost-effective compared with other modalities used to prevent or treat heterosexually transmitted HIV? Cost effectiveness studies have been carried out in the United States, where health care costs are likely to be significantly different to those in Australia. The Centers for Disease Control and Prevention consultation report cited by the authors acknowledges that the available cost and cost-effectiveness research on male circumcision is subject to a variety of “methodological limitations and data insufficiencies”. [3] Further, the case needs to be made that neonatal male circumcision is a more cost-effective option in preventing heterosexual HIV transmission than the current response — targeted education campaigns, antiretroviral therapy, and medical advice regarding safe sex practices.
In conclusion, the jury is still out with regard to the role of male circumcision in HIV prevention in Australia on two counts: efficacy and cost-effectiveness. To justify a shift in policy towards actively encouraging routine neonatal circumcision at a national level, we should have access to high-quality, relevant data. Until such information is available, the environment doesn’t exist for parents or policymakers to make a truly informed decision about this issue.
Niall Conroy, Public Health Registrar, Sir Albert Sakzewski Virus Research Centre, Queensland Paediatric Infectious Diseases Laboratory, Brisbane.
1. Cooper DA, Wodak AD, Morris BJ. The case for boosting infant male circumcision in the face of rising heterosexual transmission of HIV [editorial]. Med J Aust 2010; 193: 318-319.
2. Smith DK, Taylor A, Kilmarx PH, et al. Male circumcision in the United States for the prevention of HIV infection and other adverse health outcomes: a report from a CDC consultation. Public Health Rep 2010; 125 Suppl 1: 72-82.
3. Centers for Disease Control and Prevention. Male circumcision and risk for HIV transmission and other health conditions: implications for the United States [CDC HIV/AIDS science facts]. Atlanta: CDC, 2008.
4. Morris BJ. Why circumcision is a biomedical imperative for the 21st century. Bioessays 2007; 29: 1147- 1158.
In a recent editorial, Cooper and colleagues asserted that infant male circumcision reduces heterosexual (female-to-male) transmission of HIV. [1] However, they failed to acknowledge the serious methodological flaws of the three African randomised controlled trials (RCTs) on which the claim is based, including early termination and loss of participants to follow-up. These RCTs reported on circumcision of adults in Africa and, therefore, are not relevant to children in Australia. In a major oversight, the editorial did not cite contradictory RCT evidence that male circumcision increases heterosexual (male-to-female) HIV transmission by 61.4%. [2] Therefore increased male-to-female transmission of HIV would negate any reduction in female-to-male HIV transmission.
Common law recognises the right of bodily integrity. International human rights law enshrines the right to security of the person. The High Court of Australia opines that parents may grant surrogate consent only when a surgical intervention is therapeutic. As male circumcision amputates healthy, functional, protective, erogenous tissue, imposing male circumcision on unconsenting minors violates these rights. It has been strongly argued that non-therapeutic infant circumcision is tantamount to criminal assault. [3]
Unlike America, which has a high incidence of male circumcision and a high prevalence of HIV infection (0.6%),4 in the Australian context there is a low incidence of male circumcision among men aged under 35 years combined with a very low prevalence of HIV (0.1%). [4, 5] HIV infection in Australia occurs mostly among homosexual men. [6] It has been reported that any prophylactic value of male circumcision in preventing homosexual transmission of HIV is not statistically significant, [7] so male circumcision would be of little value in reducing future Australian HIV infection rates.
Despite calling for increased non-therapeutic infant male circumcision, Cooper et al unequivocally stated “Condom use remains essential”. Since this is the case, what is the purpose of inflicting lifelong bodily and psychosexual harm [8] on defenceless children, contrary to ethical or moral principles? Furthermore, circumcision of unconsenting minors may amount to criminal assault.
Gregory J Boyle, Professor of Psychology, Bond University, Queensland; George Hill, Independent Consultant, Port Allen, La, USA.
1. Cooper DA, Wodak AD, Morris BJ. The case for boosting infant male circumcision in the face of rising heterosexual transmission of HIV. Med J Aust 2010; 193: 318-319.
2. Wawer MJ, Makumbi F, Kigozi G, et al. Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial. Lancet 2009; 374: 229-237.
3. Boyle GJ, Svoboda JS, Price CP, Turner JN. Circumcision of healthy boys: criminal assault? J Law Med 2000; 7: 301-310.
4. UNAIDS. Country factsheets. Geneva: UNAIDS, 2010. http://cfs.unaids.org/ (accessed Dec 2010).
5. National Centre in HIV Epidemiology and Clinical Research. HIV/AIDS, viral hepatitis and sexually transmissible infections in Australia: annual surveillance report 2009. Sydney: NCHECR, 2009.
6. Richters J, Smith AMA, de Visser RO, et al. Circumcision in Australia: prevalence and effects on sexual health. Int J STD AIDS 2006; 17: 547-554.
7. Millett GA, Flores SA, Marks G, et al. Circumcision status and risk of HIV and sexually transmitted infections among men who have sex with men: a meta-analysis. JAMA 2008; 300: 1674-1684.
8. Boyle GJ, Goldman R, Svoboda JS, Fernandez E. Male circumcision: pain, trauma and psychosexual sequelae. J Health Psych 2002; 7: 329-343.
Cooper and colleagues propose circumcision of male infants in Australia as a strategy for reducing the incidence of heterosexually transmitted HIV infection. [1] They base this suggestion on evidence, from three clinical trials in Africa, that circumcision of adult men can reduce the risk of men acquiring HIV during unprotected sexual intercourse with an infected female partner. The proposal must be rejected because it is irrelevant to the Australian situation and departs from the principles of evidence-based medicine.
The proposal is irrelevant because it targets infants, who are not at risk of infection by sexual contact and will not be at risk until they become sexually active in 16–20 years time, by which time treatment and prevention options, and the virus itself, may have altered beyond recognition. Evidence-based medicine requires that recommendations for treatment or prophylaxis follow logically and directly from the evidence. In this case, there is a radical disconnect between the evidence and the recommendation. Even assuming the African evidence is reliable and applicable (and ignoring the many critiques), [2, 3] the logical prescription arising from these data is that sexually active adult men who have regular intercourse with numerous different female partners and who do not always use condoms should consider circumcision for themselves as a means of lowering their risk of infection.
This is not what Cooper et al propose. What they prescribe is that parents be advised to circumcise their boys in infancy as a precaution against a risk they will not face until they are adults, and against a disease that is very rare among heterosexually active adult men in Australia. Even if circumcised, they would still have to use a condom to be sure of avoiding infection, as the risk reduction promised by the African data is only partial — between 38 and 66 per cent. [4] We have no data at all on what the risk reduction in Australia might be. If it is still necessary to wear a condom there seems little point in getting circumcised.
As others point out, [5] moreover, the African trials on which Cooper et al rely involved sexually active adult men, not infants, and there is no hard evidence that neonatal circumcision has any protective effect against acquiring HIV. Arguments concerning other possible, non-HIV-related benefits of circumcision (all contested in the literature and rejected in the policy statement on circumcision recently issued by the Royal Australasian College of Physicians [6]) are irrelevant to HIV infection itself. In sum, the prescription offered has so little connection with the evidence on which it relies that it cannot be taken seriously.
Robert J L Darby, Independent Researcher, Canberra, ACT.
1. Cooper DA, Wodak AD, Morris BJ. The case for boosting infant male circumcision in the face of rising heterosexual transmission of HIV [editorial]. Med J Aust 2010; 193: 318-319.
2. Green LW, McAlister RG, Peterson KW, Travis JW. Male circumcision is not the surgical vaccine we have been waiting for. Futur HIV Ther 2008; 2: 193- 199.
3. Myers A, Myers JE. Rolling out male circumcision as a mass HIV/AIDS intervention seems neither justified nor practicable [editorial]. S Afr Med J 2008; 98: 781-782.
4. Siegfried N, Muller M, Deeks JJ, Volmink J. Male circumcision for prevention of heterosexual acquisition of HIV in men. Cochrane Database Syst Rev 2009; (2): CD003362.
5. Perera CL, Bridgewater FHG, Thavaneswaran P, Maddern GJ. Safety and efficacy of nontherapeutic male circumcision: a systematic review. Ann Fam Med 2010; 8: 64-72.
6. Royal Australasian College of Physicians. Circumcision of infant males. Sydney: RACP, 2010.
I write in response to the editorial by Cooper and colleagues, which advocates an increase in male infant circumcision as an anti-HIV strategy. [1] The authors claim that male circumcision is effectively a surgical vaccine for preventing female-to-male HIV transmission and, while the authors do present evidence in favour of this, they fail to canvass the serious and inevitable long-term adverse effects of the procedure. Far from being an inconsequential snip, male circumcision is a highly mutilating operation which seriously impairs penile function.
Glibly quoting four articles which “prove” that circumcised and uncircumcised males are equally satisfied sexually, the authors totally ignore a large and expanding body of evidence to the contrary, [2-4] and indeed growing popular movements against circumcision and for restoration of the foreskin. Circumcision typically removes nearly half the skin of the penis [3] — including its most sensitive areas — and, by exposing the glans to the elements, induces keratinisation of its formerly moist mucosal surface — making it rougher, dryer and less sensitive. It also destroys the “sliding” or “rolling” action of the shaft in the skin tube and most certainly impairs both male and female sexual satisfaction. [4,5]
It is totally inappropriate to suggest that circumcision is akin to vaccination: needle vaccination generally confers high-level immunity to the majority of its recipients with few, if any, long-term sequelae. In contrast, circumcision confers moderate immunity at best, and does so at the cost of mutilating and de-functioning every penis so treated. I strongly urge my colleagues who still believe that male circumcision is a trivial operation to type “foreskin restoration” into a search engine and see what they find. Finally, I implore us all to refrain from removing body parts from our unconsenting children without immediate and direct surgical need.
Bruce R Paix, Anaesthetist, Department of Anaesthesia, Flinders Medical Centre, Adelaide.
1. Cooper DA, Wodak AD, Morris BJ. The case for boosting infant male circumcision in the face of rising heterosexual transmission of HIV [editorial]. Med J Aust 2010; 193: 318-319.
2. Zoossmann-Diskin A, Blustein R. Challenges to circumcision in Israel. In: Denniston GC, Mansfield Hodges F, Milos MF, editors. Male and female circumcision: medical, legal and ethical considerations in pediatric practice. New York: Kluwer Academic/ Plenum Publishers, 1999: 343-350.
3. Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996; 77: 291-295.
4. Fleiss PM, Hodges FM, Van Howe RS. Immunological functions of the human prepuce. Sex Transm Infect 1998; 74: 364-367.
5. Cold CJ, Taylor JR. The prepuce. Br J Urol 1999; 83 Suppl 1: 41.
I read with interest the editorial by Cooper and colleagues in which the authors argue for infant male circumcision as a population-wide strategy to reduce HIV transmission. Circumcision is an irreversible body-altering procedure and, therefore, as far as possible, individuals should participate in the decision of whether or not to be circumcised. Male circumcision in infancy removes an individual’s ability to participate in the decision-making process. Further, the protective benefits of infant circumcision with regard to reduction of HIV transmission are not conferred until an individual becomes sexually active and is capable of understanding the risks and benefits. Deferment of circumcision to a later age would allow individuals to fully appreciate the magnitude of the procedure and participate in the decision-making process, and it would not necessarily negate the protective benefits. This should be considered by anyone who advocates infant male circumcision as a strategy to reduce HIV transmission.
Jeremy J Chin, Intern, Northern Health, Melbourne.
Source: Medical Journal of Australia, Vol. 194 (2), 17 January 2011, 97-101. Headings to the letters have been added by Circumcision Information Australia.
Click here for Cooper et al's reply to their critics and our response to their reply