Circumcision of sexually active adult men has been in the news lately as the latest tactic against the AIDS epidemic in Africa. Many people are wondering if this means that boys in Australia and other developed countries should also be circumcised as a precaution. The answer is No. Africa has unique problems, arising from the fact that AIDS there is a heterosexual epidemic caused by social and political breakdown, poor health services, failure to take action when the disease first appeared, widespread sexual promiscuity, often involving prostitution, and refusal to use condoms.
In Australia and the rest of the developed countries, AIDS is not an epidemic at all, but a disease that remains confined to specific sub-cultures – homosexual men and intravenous drug users. Unlike in Africa, there is little or no female-to-male transmission, meaning that the average male is not at risk of the disease. In Australia, nearly all cases of HIV have arisen from anal intercourse among men, intravenous drug-taking (using needles), blood transfusions and surgical procedures. In none of these cases would circumcision have made the slightest difference. Studies in developed countries (such as the British Gay Men’s Health Survey) show that the incidence of AIDS is actually higher among circumcised men. [1] In Australia, recent studies have found no difference in the incidence of HIV between cut and uncut men. [2]
There is evidence from Africa that men who have unprotected intercourse with an infected female partner have a reduced risk (estimated at 50 to 60 per cent) of HIV if they are circumcised, but this only means that they will take longer to get infected. It certainly does not mean that they have any kind of immunity. Assuming the reduction of risk is 50 per cent, it only means that if an uncircumcised man needs eight sessions of unsafe sex with an infected partner to catch HIV, it will take a circumcised man twelve sessions. Studies in developed countries show that condoms provide a risk reduction of 90 to 95 per cent – without the dangers of surgery, and without losing a valuable body part.
The real problem is reckless behaviour, not normal human anatomy. You would think that any sensible and ethical health strategy would take anatomy as a given and seek to change behaviour, not attempt to do it the other way around.
Protection against HIV could never be a justification for circumcising infants or children, since they are not sexually active and thus not at any risk of contracting the disease – unless through surgery itself (always risky, and a frequent vector for all kinds of infection.) When the boy is old enough to become sexually active, he will also be old enough to learn about safe sex and how to act responsibly in sexual matters.
The Australian Federation of AIDS organization has stated that circumcision has no role in the management of HIV in Australia. (Australian Federation of AIDS Organisations, Briefing Paper, 23 July 2007, Male circumcision has no role in the Australian AIDS epidemic.
Despite the conclusions of the experts and Australia's great success in minimising HIV infections at the very time when the incidence of circumcision was steadily falling, the familiar names among the circumcision promoters continue ti try to use the fear of AIDS to scare parents into demanding that their baby boys be circumcised. The latest example of this trick is the much-publicised opinion piece by Messrs Cooper, Wodak and Morris, The case for boosting infant male circumcision in the face of rising heterosexual transmission of HIV, published in the Medical Journal of Australia in September 2010. This document rehearses all their familiar themes, offers no new evidence or ideas, and even tries to get away with the old furphy of circumcision as a "surgical vaccine" - a completely invalid comparison, and piece of pure rhetoric that has no place in a paper with scientific pretensions.
Cooper, Wodak and Morris propose the introduction of near universal circumcision of male infants in Australia as a strategy for reducing the incidence of heterosexually transmitted HIV infection. They base this suggestion on evidence from three clinical trials in Africa that circumcision of adult men can significantly reduce the risk of a male’s acquiring HIV during unprotected sexual intercourse with an infected female partner.
There are, in fact, many objections to such a proposal. The most important of these are that it is marred by unscientific thinking; is irrelevant to the Australian situation; departs from the tenets of evidence-based medicine; and is contrary to established principles of bioethics and human rights.
Read full reply here: Australia is not Africa: Neonatal circumcision plan unscientific, irrelevant and unethical.
References
1. The British Gay Men’s Health Survey 2001 found that 5 per cent uncircumcised men were HIV positive, compared with of 6.1 per cent of circumcised men. The report comments: “If circumcised men are less likely to acquire HIV than men with foreskins, then we should expect fewer of the circumcised men to have tested positive than the men with a foreskin. However, more of the circumcised men had tested positive for HIV (6.1%) than had those with a foreskin (5.0%). This small but significant difference is in the opposite direction than predicted if foreskins are contributing to transmission, and was observed in all ethnic groups and across the age range.”
David Reid, Peter Weatherburn, Ford Hickson, Michael Stephens, Know the score: Findings from the National Gay Men’s Sex Survey 2001 (Sigma Research: University of Portsmouth, 2002), p. 38 Full text available here.
2. For example, Richters J, Smith AMA, de Visser RO, et al. Circumcision in Australia: prevalence and effects on sexual health. Int J STD AIDS 2006;17:547–54
Further articles available at CIRP HIV page.
The full text of the AFAO statement is printed below
Australian Federation of AIDS Organisations Inc
P.O. Box 51
Newtown NSW 2042 Australia
Phone: 61 2 9557 9399
Fax 61 2 9557 9867
Email afao@afao.org.au
Briefing paper, 23 July 2007
Male circumcision has no role in the Australian HIV epidemic
Key points
There is no demonstrated benefit of circumcision in men who have sex with men.
Correct and consistent condom use, not circumcision, is the most effective means of reducing female-to-male transmission, and vice-versa.
African data on circumcision is context-specific and cannot be extrapolated to the Australian epidemic in any way.
Background
Male circumcision is a surgical procedure that involves the removal of all or part of the foreskin from the head of the penis. It is an ancient practice that has been performed in some cultures for millennia – well before the advent of sterile surgery. [1] It has ritual significance in some cultures, and so its practice may be ceremonial, performed with non-surgical instruments by elders rather than doctors, and without anaesthesia. [2] It is an irreversible procedure. Different cultures have performed the rite at different stages of life: commonly in preadolescence as part of a ritual of becoming a man; sometimes for older adult men as a sign of status; and in more recent history, in infancy. Cultural identity may also be entwined with non-circumcision. [3]
In the twentieth century in industrialized countries such as Australia and the United States, circumcision became very popular for reasons that are not clear but do not appear to be directly related to religious or specific ethno-cultural affiliation. This trend was reversed in Australia in the 1980s and 90s due to increased acceptance that circumcision provided no medical benefit.
Recent data from three major trials in Africa challenges the notion that it is of no benefit. Adult male circumcision has been found to reduce the risk of acquiring HIV in men by around 55-60% in three randomized controlled studies. [4, 5, 6] These trials were conducted in African countries where HIV is endemic – Uganda, South Africa and Kenya. Heterosexual vaginal intercourse is the predominant mode of HIV transmission in these countries. Circumcision did not provide complete protection against HIV, but researchers concluded that circumcision reduced the risk of HIV acquisition in the study groups. While there were high rates of HIV acquisition in both arms of these studies – the circumcised and the uncircumcised – rates were lower in the former group. [7]
Following the release of these trial results UNAIDS and the World Health Organisation held an international consultation to analyse the data and consider policy implications. Mass circumcision programs are being proposed throughout the sub-Saharan region. [8] While consideration is being given to making such programs culturally sensitive, the proposed implementation of male circumcision raises complex moral problems relating to cultural practice, gender equity, informed consent, and the just allocation of limited resources.
The Australian epidemic
In Australia, receptive anal intercourse is the predominant mode of HIV transmission. There has been some research into whether circumcision status makes a difference in terms of HIV acquired through insertive anal sex, but this research has shown no difference between the two groups. [9] Therefore, circumcision is NOT an HIV risk-reduction strategy for men who have sex with men. (Further research from the Health in Men Study will be reported at the IAS conference in Sydney in July 2007.)
Circumcision to reduce HIV risk for heterosexual men in Australia?
The USA has a growing heterosexual epidemic and very high rates of circumcision. [10] Circumcision does not prevent HIV – in high prevalence areas it reduced the risk of female-to-male transmission. HIV acquisition rates were nevertheless high in both the circumcised and the non-circumcised groups involved in the trials.
The African epidemic
There is some division of opinion as to whether circumcision programs should be implemented in Africa. UNAIDS and the World Health Organisation have accepted that the data show a population-level benefit of circumcision. However, there are social and ethical arguments against such programs, such as:
A partially effective technology may adversely affect condom use and negotiation.
Partial efficacy is a difficult concept to communicate to obtain informed consent.
Risk behaviour may increase as a result of perceived invulnerability to infection.
Women aged 15-24 are at the greatest risk of HIV acquisition and circumcision and circumcision.
programs will not reduce infections in women directly for at least 10-20 years.
Circumcision may reduce women’s ability to negotiate condom use.
Circumcision is a complex cultural practice.
Circumcision status may become a marker of HIV status, as circumcision of HIV positive men is not being proposed.
Ritual circumcision itself may be a route of HIV transmission.
Good penile hygiene (washing under the foreskin) may be as effective in reducing the risk of acquiring HIV and STIs as circumcision in uncircumcised men. [11, 12]
Circumcision has a 2-10% incidence of complications.
If circumcised men have sex before wound-healing their vulnerability to HIV infection increases.
References
1. Aggleton P. (2007) ‘“Just a snip”?: A social history of male circumcision’, Reproductive Health Matters.;15 (29): 15-21
2. Niang, CI. & Boiro, H. (2007) ‘“You can also cut my finger”: Social construction of male circumcision in West Africa, a case study of Senegal and Guinea-Bissau’. Reproductive Health Matters. 15 (29): 22-32.
3. Ibid.
4. Auvert B., Taljaard D., Lagarde E., Sobngwi-Tambekou J., Sitta R., et al (2005) ‘Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: The ANRS 1265 Trial. PLoS Medicine, 2 (11) e298 doi:10.1371/journal.pmed.0020298.
5. Gray H., Kigali G., Estrada D., et al. (2007) ‘Male circumcision for HIV prevention in young men in Racial, Uganda: a randomised trial’, Lancet, 369:657-66.
6. Bailey C., Moses S., Parker CB., et al. (2007) ‘Male circumcision for HIV prevention in young men in Kyushu, Kenya: a randomised controlled trial’, Lancet; 369: 643-56.
7. The incidence in circumcised men was 0.7-1.0 per hundred person years. ‘Male circumcision for HIV prevention: Research implications for policy and programming WHO/UNAIDS technical consultation 6-8 March, conclusions and recommendations’ (excerpts). (2007) Reproductive Health Matters, 15 (29): 11-14:12.
8. ‘New data on male circumcision and HIV prevention: policy and programme implications’, (2007) WHO/UNAIDS. http://data.unaids.org/pub/Report/2007/mc_recommendations_en.pdf
9. Grulich, A,, Hendry, O., Clarke, E., Kippax, S., Kaldor, J. (2001), ‘Circumcision and male-to-male transmission of HIV’, [Research letter] AIDS; 15 (9):1188-89.
10. Of the estimated 665 million men worldwide who are circumcised, 13% are men living in the USA who are neither Muslim nor Jewish, see Hankins, C. (2007) ‘Male circumcision: Implications for women as sexual partners and parents’, Reproductive Heath Matters; 15 (29): 62-67.
11. O’Farrell, N., Morison, L., Moodley, P., Pillay, K., Vanmali, T., Quigley, M., et al. (2006) ‘Association Between HIV and Subpreputial Penile Wetness in Uncircumcised Men in South Africa’, JAIDS Journal of Acquired Immune Deficiency Syndromes, September; 43(1): 69-77. HIV prevalence among uncircumcised men without penile wetness was close to that of circumcised men (42.9%).
12. Hankins, Op Cit: 62.
A pdf of this document may be downloaded from www.afao.org.au
If circumcised men are less likely to acquire HIV than men with foreskins, then we should expect fewer of the circumcised men to have tested positive than the men with a foreskin. However, more of the circumcised men had tested positive for HIV (6.1%) than had those with a foreskin (5.0%). This small but significant difference is in the opposite direction than predicted if foreskins are contributing to transmission, and was observed in all ethnic groups and across the age range.
Source: Know the score. Findings from the National Gay Men’s Sex Survey 2001
The full report can be downloaded from http://www.sigmaresearch.org.uk/downloads/report02d.pdf
“Ex Africa semper aliquid novi”, said the ancient Romans, “always something new out of Africa”. So it is today, when we hear nothing but bad news from the dark continent – drought, disease, war, famine and now circumcision.
After many years of fruitless endeavour and an expenditure running into hundreds of millions of dollars, evidence has finally come to light that in Africa men who have unprotected intercourse with HIV positive partners are less likely, or will take longer, to become infected with HIV if they have been circumcised. The protective effect is estimated at 50 per cent, meaning that if it takes an uncircumcised man eight sessions of unsafe sex to get infected, it will take a circumcised man twelve sessions. How this rather limited protection justifies talk of a “vaccine”, or authorises circumcision of sexually inactive – and thus not at risk – infants and boys, is not at all clear. The media hype surrounding the results of the clinical trials [1] on which these conclusions are based have been out of all proportion to their real significance.
The point to remember is that the developed world is not Africa, which faces such a crisis situation (poverty, poor levels of health and education services, very high levels of HIV infection and of prostitution etc) that resort to desperate measures is understandable. There is no such crisis in developed countries, where HIV has been successfully managed and is confined to specific sub-cultures (homosexual men, especially those who take the passive role in anal intercourse, to whom being circumcised will be no help at all), intravenous drug users (ditto) and immigrants from … well, Africa.
You would not know it from the media coverage, but the World Health Organisation/UNAIDS are not recommending indiscriminate circumcision, but only that circumcision be offered as a preventive option to high risk groups in Third World countries where other (more effective) means of protection (such as safe sex education, fidelity, abstinence and condom use) seem to be impossible to achieve).
Who is at risk?
Infants and children, especially in the developed world, are not an at-risk population because they are not sexually active. You might argue that it is better to take away a boy’s foreskin now than to see him contract AIDS at some unknown date in the future – and who would disagree? But the argument is valid only if circumcision were the only way to avoid AIDS and if it were pretty certain that he would get AIDS if he were not circumcised. In fact, the main risk factor for AIDS is not the foreskin, but unsafe sex; the best, cheapest and most certain way to avoid this easily avoidable disease is not to engage in unsafe sex practices and to avoid sex with partners likely to be HIV positive, such as prostitutes, casual sex workers and the generally promiscuous. There is plenty of time to get this message across to boys before they become sexually active.
Prostitution a bigger problem than anatomy
The prevalence of prostitution is a major factor in the spread of heterosexually transmitted AIDS, yet government agencies have been extremely reluctant to regulate the sex industry or restrict the activities of the prostitutes in any way because such action might infringe their civil or human rights. At the same time, they have recommended widespread circumcision of male infants and boys, whose own civil and human rights are thus treated as non-existent or of no account. It is of interest that in Senegal, one of the few African countries where the AIDS threat was faced early on and efforts were made to regulate the sex industry and ensure that prostitutes received regular health checks, the incidence of HIV infection is only around 2 per cent, compared with 30 or 40 per cent in places such as Tanzania or Botswana. (For Senegal, see Martin Meredith, The State of Africa: A History of Fifty Years of Independence (London: Free Press, 2005), p. 367.) The sad fact is that little boys are an easier target.
As Philip Setel has shown in A Plague of Paradoxes: AIDS, Culture and Demography in Northern Tanzania (University of Chicago Press, 1999), there is a very high incidence of prostitution, of various kinds, throughout sub-Saharan Africa, and a very high incidence of HIV infection among the prostitutes. (See review in Archives of Sexual Behaviour, Vol. 34, December 2005).
In Africa the problem that circumcision is meant to address is heterosexually acquired HIV through Female to Male transmission via unprotected intercourse. in the West there is negligible F to M infection, and most workers in the sex industry are insistent on safe sex and condoms. In the West, the at risk populations are promiscuous male homosexuals [1] and intravenous drug users. Circumcision will not affect HIV transmission in these groups.
Western countries such as Australia have low rates of HIV infection because our policies of safe sex education have been successful. What children need to be taught is how to avoid this easily avoidable disease; they do not need, and they do not deserve, to have their natural anatomy forcibly altered.
The data from the Africa trials [2] say nothing about the effectiveness of infant or child circumcision, since the trials were confined to sexually active adult men who consented to the procedure. Circumcision does not confer immunity to HIV infection. The level of risk reduction shown (50 per cent) is not sufficient to warrant talk of a vaccine. The protection is not lifelong, and it is far less than the 90 per cent protection given by regular condom use and observation of other forms of safe sex.
There is no evidence that circumcision later in life is more risky or harmful than in infancy. On the contrary, all the evidence is that the younger it is done the more harmful, risky and painful it is, because of the tiny size of the organ, ignorance as to the eventual size of the penis and length of foreskin at puberty, and the impossibility of safe and effective anaesthetic. If those urging compulsory circumcision of children in preference to optional circumcision of sexually active adult men believe that circumcision in adulthood is so risky, why did they not raise concerns about the dangers of the African circumcision trials, conducted as they were on adults? (Is it the presence of consent that upsets them?)
History urges scepticism
In the days of the Roman Empire many African peoples already practised circumcision (both male and female) as a cultural ritual. The arrival of imperialism in the form of Roman soldiers and administrators meant that such practices were discouraged as abhorrent to civilized people. Today western medical imperialism is having the opposite effect, spreading circumcision from circumcising to non-circumcising cultures, with the excuse that it is the only measure that can stop the AIDS pandemic. Desperate fears produce desperate reactions, but one wonders how much emotional baggage is bound up in this massive effort. It is interesting to recall that in nineteenth century United States respectable doctors demanded compulsory (legally mandated) circumcision of American Negroes to control syphilis (the AIDS of that era), and even to protect white women from sexual assault.
In a paper published in the recent collection of essays on circumcision, Genital Autonomy, the French demographer and reproductive health expert Michel Garenne examines the contradiction between the results of the African clinical trials (apparently showing that circumcision can have a protective effect against heterosexually acquired HIV) and the realities of many African societies, where HIV infection is found to be more common among circumcised men. He shows why circumcision as an HIV preventive is unlikely to be as effective in real world situations as it appears to be in the artificial conditions of those famous clinical trials.
Abstract: This paper reviews the demographic evidence for the relationship between male circumcision and HIV infection in national or sub-national African populations. A meta-analysis based on 18 countries, representing more than half of the population of sub-Saharan Africa, shows no relationship [standardized odds ratio=1.00; 95% CI: 0.96–1.05]. There were even more countries in which HIV prevalence was higher among circumcised persons than countries where it was lower. In only five countries, the odds ratio of HIV prevalence (circumcised/intact) was significantly different from 1.0; three countries where it was higher, and two countries where it was lower. The contrast between lack of demographic impact and results from clinical trial is striking, and can probably be explained by the low clinical efficacy in situations of intense and repeated exposure, and by the interactions with the many other determinants of HIV spread. This paper also addresses some ethical and political issues, and in particular raises the question of power abuse, which may lie in the practice of genital mutilations and relevant international recommendations.
Further details on “Solving the Negro rape problem”
NOTES
1. Because AIDS is not a really serious public health issue in the developed world, there is not much research on the difference in rates of HIV infection between circumcised and uncircumcised men in developed countries, but two significant studies (in Britain and the USA) both found a higher incidence of HIV among circumcised men: David Reid, Peter Weatherburn, Ford Hickson, Michael Stephens, Know the score: Findings from the National Gay Men’s Sex Survey (London 2001); Laumann, EO, Masi CM, Zuckerman EW. Circumcision in the United States: Prevalence, Prophylactic Effects, and Sexual Practice. Journal of the American Medical Association 1997;277(13):1052-7
2. The clinical trials are, in any case, a bit fishy for several reasons. (1) They were not blind (as they should have been). (2) They were not random, in that the men chose whether to be or not to be circumcised, thus allowing the likelihood that the former group were more cautious than the latter. (3) There is no reason to suppose that the two groups men then had similar sexual experiences: more of the circumcised men might have had more sex with negative partners than the other group, or they might have engaged in less risky sexual practices, meaning that they were less exposed to risk; in these cases you could not know whether it was the differing behaviour or the altered anatomy that conferred the protection. (4) The trials were terminated prematurely, allowing suspicions that the most favourable moment for statistical purposes was chosen. (5) It is common for the early results of clinical trials to be highly and misleadingly positive, inspiring premature optimism. For an analysis of why this is so, see John P.A. Ioannidis, “Why Most Published Research Findings Are False”, Plos Medicine, Vol. 8, 2005.
It is sexual behaviour, not anatomy, which is the main factor determining whether a person will become infected with STDs. This fact seems to elude those naive but brutal researchers who think they have found a miracle solution to the AIDS crisis in penile surgery. They might as well advocate the pre-emptive excision of a lung so as to reduce the danger of SARS, or cauterisation of the nasal and throat passages so as to block the many common infections which get in that way. To say nothing of what might be done to women to reduce the area of their susceptible (“treacherous”) genital mucosa.
It’s interesting that arguments about cultural autonomy does not seem to carry much weight here. It seems to work only one way. According to many defenders of traditional tribal practices, who tend to be romantically anti-western and anti-modern in their tenderness for the exotic and the primitive, we are not allowed to discourage circumcising cultures from dropping the practice. But it’s fine and commendable for American medical bodies to try to foist circumcision on non-circumcising cultures in Africa, and even India, as a supposedly valuable tactic in the fight against AIDS. One would have thought that such a blatant example of medico-cultural imperialism, and from the USA at that, would have sent those who value the specificity of other cultures up in arms. Isn’t it an example of racist stereotyping for Americans to assume that sex-crazed black men will never be able to direct their sex drive into safe channels, but must be forced to have their penises surgically altered?
The idea that pre-emptive surgery is the miracle-working answer to the AIDS crisis should be treated very sceptically. The evidence for it is on a par with the abundant evidence in nineteenth century medical journals that masturbation caused tuberculosis, madness, pimples and premature decay (et tutti quanti), and the equally promoted delusion that circumcision provided immunity to syphilis. Whenever an incurable illness turns up, desperate people try to find scapegoats: in the Black Death it was witches and Jews. In the nineteenth century, when sexuality was seen as the root of most evil, doctors blamed “sexual excess” for many diseases, the foreskin for premature sexual arousal, masturbation, epilepsy and a host of other illnesses, and the clitoris for hysteria, catalepsy and other nervous complaints. American medicine has a particularly fine record in this area. In 1896 the Medical Record listed the following indications for male circumcision:
Hygienic indications: phimosis, paraphimosis, redundancy (where the prepuce more than covers the glans), adhesions, papillomata, eczema, oedema, chancre, chancroid, cicatrices, inflammatory thickening, elephantiasis, naevus, epithelioma, gangrene, tuberculosis, preputial calculi, hip-joint disease, hernia. Systemic indications: onanism, seminal emissions, enuresis (Bed wetting), dysuria, retention [of urine], general nervousness, impotence, convulsions, hystero-epilepsy. (Medical Record, Vol. 49, 1896, p. 430).
The danger of newspaper headlines about circumcision providing immunity to AIDS is that circumcised men start to think they are safe and stop using condoms. AIDS educators are concerned that the enormous publicity this theory has attracted is the main reason why cases of HIV in Australia are rising at the moment, as circumcised men drop safe sex and stop using condoms, saying, “Oh well, apparently if you’re cut you can’t get infected.” They can and do get infected.
The following comment was from a Canadian AIDS educator on the H-Hist-Sex discussion list.
The literature from which the report on circumcision and HIV transmission was based came from 27 studies in Africa. Science is not my field, but from what I remember, for a scientific study to support a hypothesis such as foreskins affect the rate of HIV transmission, then the study needs to be replicated elsewhere, or are African foreskins different than other foreskins? Considering all the research done on gay men in North America, isn’t it strange that, after 20 years, no one has found that, say, more gay Muslims and gay Jews don’t/do contract the virus than, say, gay Catholics? (Maybe the transmission has nothing to do with the foreskin, but that the HIV virus has a strong religious bias.)
Does this type of research truly stop the transmission of HIV, or is it just a means to start/stop circumcisions? You cannot transmit the virus, with or without a foreskin, unless you have the virus. You can not get the virus, with or without a foreskin, unless you are involved in unsafe practices with someone who has the virus. More skin, whether penile or vaginal, creates a higher probability, but the salient word in the study was “unprotected” sex. You have a higher probability to be bit by playing with two rabid pit-bulls than with one, but you won’t get bit at all if you put muzzles on them beforehand.
How will information such as the one on foreskins and HIV be perceived by the general public? Anyone who has been involved in the HIV community since the beginning will remember all the crazy beliefs people had to protect themselves from the virus, many based on “scientific research”, instead of just not sharing blood or sperm. Why won’t this study be used the same way, as the author of the study by the US Agency for International Development worries? When I was a teenager, I heard guys saying that they couldn’t get VD because they had a hood. I heard men saying their wives couldn’t get ovarian cancer because they were Jewish (read: circumcised). I can see straight teenagers (the group with the largest increase of HIV transmission) now having sex without condoms because they are circumcised. (And let’s not forget about all those who share uncircumcised needles.)
It is easier to find something/someone to blame (“Patient Zero”, gays, loss of religious beliefs, the media’s constant promotion of sex, the West, Democrats, foreskins) than to work hard at changing one’s activities, regardless of countries or traditions. Education has been shown to be the best way to prevent HIV transmission. With such a small amount of money going into HIV/AIDS research - particularly on women and HIV- and money for medication for people living with HIV/AIDS, isn’t focusing on the [uncondomed] penis (the favorite activity for all men) side-stepping the real issues of HIV transmission?
Full discussion available here: http://www.h-net.org/~histsex/
Quite apart from its irrelevance to the developed world, there are numerous problems with the reliability of the African data on which the circumcision proponents depend. For a start, numerous observational and cohort studies have failed to find any correlation between circumcision and HIV. In at least six African countries, HIV is more common among circumcised men than among the uncut – a puzzling fact that circumcision enthusiasts are anxious to ignore. [1]
The most telling studies of the effect of circumcision in limiting HIV infection are three clinical trials held in Uganda and Kenya. [2] The researchers in charge refer to these as randomized and controlled when in fact they were neither. A randomized trial is one in which the subjects who are given the treatment being tested and those who are not given it are chosen at random, thus minimizing the effect of selection bias. In these trials the men treated with circumcision all volunteered for the operation, thus introducing an imponderable distorting factor. The so called control group was merely a similar number of men who did not want to get circumcised. There were probably cultural and psychological differences between the two groups that affected their subsequent behaviour and thus the rate at which they got infected.
This violates the fundamental rule about controlled experiments: that the only difference between the group taking the treatment and the group not taking it (the control group) is the fact that one group is taking the treatment and the other is not.
In the event, a total of 5,411 men were circumcised and a comparable number left intact. The trials were meant to last two years, but they were terminated after only twenty months, by which time 64 of the circumcised men had contracted HIV and 137 of the not-circumcised. That is the total evidence for the much trumpeted proposition that “circumcision gives protection from HIV”.
Further problems are that testimony from the cut men that they had not had sex or had engaged only in protected or safe sex was ignored, and no account was taken of male-to-male, intravenous drug or iatrogenic infection (i.e. during medical procedures, a problem suspected to be very common in African conditions ). To top it all off, 673 of the original men, 327 of them circumcised, were lost from study, and their HIV status remains unknown. In the end there is really no way of knowing whether the lower incidence of HIV among the cut men was the result of their changed anatomy, or of patterns of sexual behaviour that were different from the uncut group.
Even on the basis of these figures, the protective effect of circumcision is not that great – a risk reduction of between 50 and 60 per cent. What this means in practical terms, assuming a 50 per cent reduction in risk, is that if a an uncircumcised man takes eight sessions of unprotected intercourse with a HIV-positive partner to get infected, it will take a circumcised man twelve sessions. Such a modest level of protection would hardly seem great enough to justify the risks and losses of circumcision.
None of these problems have deterred the promoters of these studies from proclaiming circumcision as the magic bullet the world has been waiting for, and the billions of yankee dollars duly poured in from President Bush and Bill Gates. The researchers go so far as to call the results of their experiments “compelling”, meaning that can they market them as striking enough to justify “compelling” children to undergo circumcision. At least the World Health Organisation can now say it is “doing something” about the problem. Cynics might call it bribery.
A more recent study from Uganda has found that circumcising men has no effect in preventing transmission of HIV to women, and may in fact increase the risk to them. [4] Perhaps women should also be offered the benefits of surgery to reduce their vulnerable genital mucosa, and that girls should also be included in the scope of all those “compelling” recommendations.
References
1. The countries are Cameroon, Ghana, Lesotho, Malawi, Rwanda, Swaziland and Tanzania: see National Health and Demographic Surveys, and further information at Circumstitions.
2. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, et al. 2005. Randomized, controlled intervention trial of male Circumcision for reduction of HIV infection risk: The ANRS 1265 Trial. PLoS Med 2(10 pages):e298; Bailey RC, Moses S, Parker CB, Agot K, Maclean I, et al. 2007. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet 369:643–656; Gray RH, Kigozi G, Serwadda D, Makumbi F, Watya S, et al. 2007. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet 369:657–666.
3. One group of HIV researchers believes that iatrogenic transmission (through non-sterile medical procedures) is responsible for as much as one third of African HIV cases. Further details.
4. Wawer M J et al. Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial The Lancet, Volume 374, Issue 9685, Pages 229 - 237, 18 July 2009
Read more about African circumcision sceptics on this site
A recent comparative study in Kenya and Uganda found that in Uganda, where efforts were put into safe sex education, the rate of HIV infection was falling far more significantly than in neighbouring Kenya, where such efforts were much weaker. Circumcision was found not to be a significant influence.
Moore D, and Hogg R, Trends in antenatal human immunodeficiency virus prevalence in western Kenya and eastern Uganda: Evidence of differences in health policies?, International Journal of Epidemiology, Vol. 33, 2004, pp. 542-8
There are many dangers in introducing routine circumcision of infants or children in societies where it has been unknown merely as a response to a temporary problem. What is likely to happen is that when the problem disappears (when AIDS becomes curable or preventable by a vaccine) circumcision will have become a habit and will be very difficult to eradicate, even though the rationale for its original introduction has disappeared. The experience of Australia and the U.S.A. show that once circumcision gets into the medical repertoire of a country it is very difficult to get it out again. For those who wish to read further than hysterical and misleading media beat-ups (the main source of the delusion that forcible mass circumcision is the answer to the AIDS crisis), the following thoughts by Professor Greg Boyle may be of interest.
G.J. Boyle,
Issues associated with the introduction of circumcision into a non-circumcising society
Sexually Transmitted Infections, Vol. 79, 2003, pp. 427-428
A team lead by Kebaabetswe propose the introduction of infant circumcision in Botswana, based on:
a survey of its acceptability to Batswana (people of Botswana);
its practice in certain Western nations;
its alleged value in preventing HIV infection.
There are several medical, psychological, sexual, social, ethical, and legal problems with this proposal.
Full article here: http://www.cirp.org/library/disease/HIV/boyle-sti/
Over the last ten years or so a small band of mostly American researchers have been trying to convince the world that the male foreskin is the most important risk factor for HIV infection and therefore that circumcision is the most effective strategy against AIDS. There is nothing new in this sort of argument. Whenever a horrible and incurable disease appears, people look for scapegoats, and if it is a sexually transmitted disease they focus on the genitals. In the nineteenth century it was claimed that circumcision gave immunity to syphilis, and the claim that it will do the same for HIV is pretty much a rerun of the same sad delusion.
The approaches which have been proven to be successful in reducing the incidence of HIV infection are those that have worked in Australia and most European countries, where HIV levels are much lower than in underdeveloped countries, and indeed the United State, despite its high level of circumcision. The most important of these is safe sex education, since nobody is at risk of sexually-transmitted infection with AIDS unless he or she engages in unsafe sex (usually unprotected intercourse) with an infected person.
On top of this, recent research has shown that up to a third of African HIV cases may not be transmitted sexually at all, but by unsafe medical practices – such as non-sterile instruments and needles. If this is true, circumcision could even be be spreading AIDS, not stopping it. Other studies suggest that the epidemic level of HIV in Africa is due to genetic factors – that Africans lack a resistance gene found in Europeans. This would explain a major puzzle: why HIV infection is at a low level in Europe, where hardly anybody is circumcised, but rages at pandemic levels in Africa, where about a third of the population is traditionally circumcised as part of religious or tribal customs. Logically, you would think that if circumcision made such a big difference, AIDS would be a bigger problem in Europe than in Africa.
Although the claim that circumcision provides significant protection against HIV infection has received a lot of publicity, it would not be relevant in a developed country like Australia even if it was true.
In third world countries like Africa, AIDS is a disease affecting heterosexual people, and now more women than men. In Australia AIDS is a significant problem only within small communities, such as male homosexuals and intravenous drug users.
In Australia, people do not live in poverty without access to medical care or running water. Men do not commonly practise polygamy or have frequent unprotected intercourse with prostitutes. African women are likely to be under the patriarchal thumb; women in Australia can say, “If it’s not on, it’s not on”.
Australian children do not engage in the sort of sexual practices which put them at risk of HIV. Circumcision will not protect them from infection from dirty needles or contaminated blood should they need a transfusion. When a boy grows up and if he wants to engage in casual sex, he is old enough to know about safe sex and condoms.
Safe sex education in Australia has kept the level of HIV infection at a low level. If they are going to be sexually promiscuous, people know that they should use condoms, and they can buy them cheaply at any supermarket.
Sexual behaviour, possibly abetted by genes, not anatomy, is the explanation for the spread of AIDS. It is irrational and unscientific to blame normal body parts for the action of micro-organisms.
Circumcision of sexually active adult men may or may not be useful in controlling the spread of AIDS in African countries of high prevalence - only time will tell. Circumcision of adult men for this purpose in developed countries is neither appropriate nor necessary. Circumcision of sexually-inactive children as an AIDS control tactic is neither necessary nor ethically permissible anywhere.
On this site
Rising incidence of AIDS infection among circumcised men
Neonatal circumcision neither necessary nor ethically permissible
African doctors question question Bush/Gates/WHO circumcision push
HIV-AIDS control: Growing doubts on the circumcision solution
Condoms: The real magic bullet against HIV-AIDS
HIV-AIDS control: Growing doubts on the circumcision solution
Circumcision as AIDS control strategy: Random clinical trials and the real world
On other sites
Circumcision Information and Resource Pages
International Coalition for Genital Integrity
Male circumcision and HIV: A Public Heath Policy Weblog
Norm-UK: Circumcision an inappropriate strategy in AIDS control
Circumcision not a silver bullet: South Africa Medical Journal
F M Hodges, J S Svoboda and R S Van Howe, Prophylactic interventions on children: balancing human rights with public health, Journal of Medical Ethics, Vol. 28, No. 1, February 2002
Lawrence Green et al, Male circumcision is not the HIV vaccine we have been waiting for, Future HIV Therapy, Vol. 2, 2008
Marie Fox and Michael Thomson, Short Changed? The Law and Ethics of Male Circumcision, International Journal of Children's Rights, Vol. 13, 2006
J. Steven Svoboda, Robert Van Howe and James G. Dwyer, Informed Consent for Neonatal Circumcision: An Ethical and Legal Conundrum, Journal Of Contemporary Health Law and Policy, Vol. 17, Fall 2000
Michel Garenne, Male circumcision and HIV control in Africa, PLoS Medicine, Vol. 3, No. 1, 31
January 2006