11 10 240 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h1>Is circumcision the solution to the African HIV-AIDS epidemic?</h1> <h2>Leading public health journal has doubts and seeks wider debate</h2> Controversy surrounding the African circumcision programs has been reignited by a special issue of the journal Global Public Health, which subjects the current policies of UNAIDS and WHO to a searching critique. From the very start, the proposition that mass circumcision of African men was the best tactic against heterosexually transmitted HIV in sub-Saharan Africa attracted <a href="http://www.circumstitions.com/HIV-SA.html" rel="noopener" target="_blank">strong criticism</a> on <a href="https://www.circinfo.org/hiv.html" rel="noopener" target="_blank">numerous grounds</a>: that it ignored history, ethics and the functions of the foreskin; that it threatened human rights; that it was likely to be ineffective; that it was expensive; that it overlooked the needs of those at greater risk of HIV infection (women and homosexual men); and that it reflected a Western view of African sexuality, as well as a specifically American faith in the power of bio-medicine, to the exclusion of social, demographic, sexual and personal factors. Nonetheless, the critics were marginalised, and the circumcision lobby was able to attract massive funding for a series of supposedly voluntary circumcision programs that have continued with varying degrees of uptake. What makes this special issue of Global Public Health remarkable is that it represents the first sustained critique of the “circumcision solution” from a major international journal at the heart of the public health policy community. Up until this time, critics of the circumcision programs have mostly been marginal and isolated figures whose views have been ridiculed by the biomedical experts and ignored by the media. This time it is different, and the circumcision lobby has reacted with some annoyance – not merely at the specific criticisms raised, but at the very idea that there was anything controversial about the “circumcision solution”. As far as they are concerned, the issue was settled by the three clinical trials and a subsequent “consultation” in Montreux, and they are furious at the suggestion that there is anything left to debate: the only issues they want to discuss are the most efficient circumcision instruments and the best ways to persuade men to submit. But as the analysis by Giami et al shows, there never was any real debate about the implementation of the circumcision programs, which were forced upon the reluctant officials of the WHO by a well-organised United States faction, backed by abundant cash. As they write, “the time devoted to the presentations did not allow for a genuine, open debate, in particular about how to extrapolate from the findings in the narrow context of the RCTs to the general population. This question was thought to be settled, given the results from previous observational and epidemiological studies. There was no mention of the contradictory findings that had been published, nor of a scientific controversy. According to Dowsett during our interview, Hankins’ speech on the second day barely mentioned the recommendation’s social and cultural consequences.” Catherine Hankins was the chief medical adviser to UNAIDS, and reportedly instrumental in having the papers based on the three clinical trials published in leading journals. The only firm sceptic of the circumcision solution at the Montreux meeting was Professor Gary Dowsett, an Australian sociologist with extensive experience in social science research on AIDS who had served as consultant for WHO and other international organisations. As Giami writes: “As one of a group of self-identified gay researchers, his activities in this field reached back to the mid-1980s. Nonetheless, the possibility for him to present his critique was limited by both the agenda and the perceived hostility towards him during discussions by, in particular, a major US epidemiologist, one of the recommendation’s principal advocates. During our interview, Dowsett cited this person’s name, which we have replaced with the pronoun HE in the transcripts: “I’m standing in the hotel, with a glass of champagne and HE … comes charging over to me, immediately … and just started to attack me, immediately, and … ‘How wrong I was! Why I was doing this? I got the argument wrong – Did I not understand how important all this was’ … and HE attacked me … every time I spoke in the meeting at Montreux. Every time!” That should give you an idea of how consultative the Montreux consultations were. In this context, it is clear that the special issue of Global public Health is not asking for the debate to be reopened, but asking that a genuine debate take place. To that end, anthropologist Kirsten Bell criticises the narrow focus of the biomedical approach and seeks to expand the debate to include issues of culture and sexuality. Historian Robert Darby compares the response to HIV-AIDS in Africa with the response to syphilis in nineteenth century Britain, and notes that many of the same kneejerk responses and human rights violations are found in each. He also shows that in each case the circumcision solution was as much a product of culture as of “science”. Giami et al explore the limitations of the Montreux “consultation” and show how a well-organised pressure group was able to get the decision it wanted. Robert Van Howe performs a detailed statistical analysis which shows that there is no consistent relationship between circumcision status and susceptibility to HIV, concluding that circumcision is not an effective preventive tactic. Adams et al show that in Swaziland the ambitious program to circumcise 80 per cent of the male population failed because men learned from their friends that circumcision had an adverse impact on sexual experience and body image. Perez et al criticise the circumcision programs for paying insufficient attention to the needs of women and homosexual men and call for a gender-aware approach to HIV control. Finally, an article from an earlier issue of GPH shows that the “circumcision solution” is not a settled matter, as the circumcision lobby would like us to believe, but a controversial and unsettled question that requires far more genuine debate than it has received hitherto. <h2>Abstracts of selected papers appear below.</h2> Kirsten Bell. HIV prevention: Making male circumcision the ‘right’ tool for the job In recent years, HIV/AIDS programming has been transformed by an ostensibly ‘new’ procedure: male circumcision. This article examines the rise of male circumcision as the ‘right’ HIV prevention tool. Treating this controversial topic as a ‘matter of concern’ rather than a ‘matter of fact’, I examine the reasons why male circumcision came to be seen as a partial solution to the problem of HIV transmission in the twenty-first century and to what effect. Grounded in a close reading of the primary literature, I suggest that the embrace of male circumcision in HIV prevention must be understood in relation to three factors: (1) the rise of evidence-based medicine as the dominant paradigm for conceptualising medical knowledge, (2) the fraught politics of HIV/AIDS research and funding, which made the possibility of a biomedical intervention attractive and (3) underlying assumptions about the nature of African ‘culture’ and ‘sexuality’. I conclude by stressing the need to expand the parameters of the debate beyond the current polarised landscape, which presents us with a problematic either/or scenario regarding the efficacy of male circumcision. Robert Darby. Syphilis 1855 and HIV-AIDS 2007: Historical reflections on the tendency to blame human anatomy for the action of micro-organisms In this paper, I discuss the parallels between responses to syphilis in nineteenth century Britain and HIV/AIDS in contemporary Africa. In each case, an incurable disease connected with sexual behaviour aroused fear, stigmatisation and moralistic responses, as well as a desperate scramble to find an effective means of control. In both cases, circumcision of adult males, and then of children or infants, was proposed as the key tactic. In the ensuing debates over the effectiveness and propriety of this approach, three questions occupied health authorities in both Victorian Britain and the contemporary world: (1) Were circumcised men at significantly lower risk of these diseases? (2) If there was evidence pointing to an affirmative answer, was it altered anatomy or different behaviour that explained the difference? (3) Given that circumcision was a surgical procedure with attendant risks of infection, was it possible that circumcision spread syphilis or HIV? I show that in both situations the answers to these questions were inconclusive, argue that circumcision played little or no role in the eventual control of syphilis and suggest that attention to nineteenth century debates may assist contemporary policy-makers to avoid the treatment dead-ends and ethical transgressions that marked the war on syphilis. The full paper is available at Academia.edu Alain Giami, Christophe Perrey, André Luiz de Oliveira Mendonça & Kenneth Rochel de Camargo. Hybrid forum or network? The social and political construction of an international ‘technical consultation’: Male circumcision and HIV prevention The technical consultation in Montreux, organised by World Health Organization and UNAIDS in 2007, recommended male circumcision as a method for preventing HIV transmission. This consultation came out of a long process of releasing reports and holding international and regional conferences, a process steered by an informal network. This network's relations with other parties is analysed along with its way of working and the exchanges during the technical consultation that led up to the formal adoption of a recommendation. Conducted in relation to the concepts of a ‘hybrid forum’ and ‘network’, this article shows that the decision was based on the formation and consolidation of a network of persons. They were active in all phases of this process, ranging from studies of the recommendation's efficacy, feasibility and acceptability to its adoption and implementation. In this sense, this consultation cannot be described as the constitution of a ‘hybrid forum’, which is characterised by its openness to a debate as well as a plurality of issues formulated by the actors and of resources used by them. On the contrary, little room was allowed for contradictory discussions, as if the decision had already been made before the Montreux consultation. Robert Van Howe. Circumcision as a primary HIV preventive: Extrapolating from the available data Billions of dollars to circumcise millions of African males as an HIV infection prevention have been sought, yet the effectiveness of circumcision has not been demonstrated. Data from 109 populations comparing HIV prevalence and incidence in men based on circumcision status were evaluated using meta-regression. The impact on the association between circumcision and HIV incidence/prevalence of the HIV risk profile of the population, the circumcision rates within the population and whether the population was in Africa were assessed. No significant difference in the risk of HIV infection based on the circumcision status was seen in general populations. Studies of high-risk populations and populations with a higher prevalence of male circumcision reported significantly greater odds ratios (odds of intact man having HIV) (p < .0001). When adjusted for the impact of a high-risk population and the circumcision rate of the population, the baseline odds ratio was 0.78 (95% CI = 0.56–1.09). No consistent association between presence of HIV infection and circumcision status of adult males in general populations was found. When adjusted for other factors, having a foreskin was not a significant risk factor. This undermines the justification for using circumcision as a primary preventive for HIV infection. Alfred Adams and Eileen Moyer. Sex is never the same: Men’s perspectives on refusing circumcision Faced with an HIV prevalence of 31% among 18- to 49-year-olds, Swaziland developed a male circumcision policy in 2009, following compelling scientific evidence from three randomised controlled trials. Utilising United States Agency for International Development funds, the state set out to circumcise 80% of adult men in 2011. Only 8667 of the targeted 150,000 men were circumcised during the campaign. This paper presents findings from a 2012 to 2013 in-depth qualitative study among Swazi men. Methods included 13 focus group discussions, 20 in-depth interviews, 16 informal interviews and participant observation. We argue that the campaign's failure can be partly explained by the fact that circumcision was perceived as a threat to Swazi masculinities, a factor hardly considered in the planning of the intervention. Results show that men believed circumcision resulted in reduced penis sensitivity, reduced sexual pleasure and adverse events such as possible mistakes during surgery and post-operative complications that could have negative effects on their sexual lives. Given the conflicting state of scientific data about the effects of circumcision on sexuality or sexual pleasure, this study addresses important lacunae, while also demonstrating the need for more research into the relationship between sexuality, masculinity and health interventions seeking to involve men. Guillermo Martínez Pérez, Laura Triviño Durána, Angel Gasch. Towards a gender perspective in qualitative research on voluntary medical male circumcision in east and southern Africa The World Health Organization endorsed voluntary medical male circumcision (VMMC) in 2007 as an effective method to provide partial protection against heterosexual female-to-male transmission of HIV in regions with high rates of such transmission, and where uptake of VMMC is low. Qualitative research conducted in east and southern Africa has focused on assessing acceptability, barriers to uptake of VMMC and the likelihood of VMMC increasing men's adoption of risky sexual behaviours. Less researched, however, have been the perceptions of women and sexual minorities towards VMMC, even though they are more vulnerable to HIV/AIDS transmission than are heterosexual men. The purpose of this paper is to identify core areas in which a gendered perspective in qualitative research might improve the understanding and framing of VMMC in east and southern Africa. Issues explored in this analysis are risk compensation, the post-circumcision appearance of the penis, inclusion of men who have sex with men as study respondents and the antagonistic relation between VMMC and female genital cutting. If biomedical and social science researchers explore these issues in future qualitative inquiry utilising a gendered perspective, a more thorough understanding of VMMC can be achieved, which could ultimately inform policy and implementation. Global Public Health: An International Journal for Research, Policy and Practice. Volume 10, Issue 5-6, 2015: <a href="http://www.tandfonline.com/toc/rgph20/10/5-6" rel="noopener" target="_blank">Special Issue: Circumcision and HIV prevention: Emerging debates in science, policies and programs</a> Kenneth Rochel de Camargo, Jr., Andre Luiz de Oliveira Mendonca, Christophe Perrey and Alain Giami. Male circumcision and HIV: A controversy study on facts and values We present a controversy study on the association between male circumcision (MC) and HIV. Our general goal is to shed light on the issue, unravelling and comparing different conceptions of scientific evidence and their respective world views. We seek to reconstruct, based on an analysis of the literature on the topic, key moments in the history of the controversy about the association between MC and HIV prevention, analysing more closely three recent randomised studies, given their relevance to the argumentative strategy employed by those who defend circumcision as a prevention method. Following this, we present a synthesis of the main arguments against the three referred studies. In conclusion, it seems that reasonable arguments for a more cautious approach are not being adequately considered. <a href="https://dx.doi.org/10.1080/17441692.2013.817599" rel="noopener" target="_blank">Global Public Health</a>, Vol. 8 ( 7) 2013: 769-783 </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource HIV/AIDS: global health journal questions African circumcision campaign darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> “When millions in aid money flood into the country, nobody asks questions.” Weltgeschehen: Ein Einschnitt fürs Leben? Millionen afrikanischer Männer sollen sich beschneiden lassen, als Schutz vor HIV. Sinnvolle Hilfe oder gefährlicher Irrglaube? WORLD AFFAIRS From handouts to the TV spot: Hardly any man in Zambia escapes the propaganda of the circumcision lobby. Those who do not undergo the surgery are stigmatized as irresponsible – and are shunned by women. The execution of the operation is taken on by so-called providers, trained for a couple of hours on a practice penis made of plastic. A Cut for Life? Millions of African men are supposed to get themselves circumcised as a protection against HIV. Wise assistance, or dangerous superstition? by Michael Obert (text) and Matthias Ziegler (photos) THE WORLD HEALTH ORGANIZATION (WHO) wants to have 20 million men in southern and eastern Africa circumcised. The officials claim to thereby prevent HIV-infections. To induce the men to undergo the surgery, they are being promised that, without foreskin, they were “vaccinated against AIDS”. This is an unheard-of event: Never before have aid agencies tried to surgically alter so many people. It could end in an unprecedented disaster. Ernest Chisha hangs his pants on the doorknob of the operating room and lies down on his back on the table, his head embedded on a dirty foam pad. His breathing accelerates. Down to his dusty socks the 30-year-old accountant is naked. “Why do you want to have your foreskin removed?”, he is asked by a lean man who calls himself a “provider” who, with white rubber gloves, opens a syringe package. Eight times he stabs directly below the glans. “I want to protect myself from the virus,” groans Chisha. “I just do not want to get AIDS, I want to live”. The numbing of Ernest Chisha’s penis in the circumcision room at Chilenje Clinic in the Zambian capital Lusaka is the beginning of a medical procedure that currently occurs a million times in southern and eastern Africa. In the fight against HIV, the WHO and the United Nations appeal to the public to get on board their unprecedented prevention campaign. Their goal: In 14 African countries more than 20 million men between age 15 and 49 should be circumcised by 2016. Two billion dollars is the level of the costs to be covered by international funders, with PEPFAR (President´s Emergency Plan for AIDS Relief) and The Bill & Melinda Gates Foundation leading the way. A single cut. As if it were a wonder weapon against AIDS For if African men have their foreskin removed they reduce the risk of infection by the HIV virus during vaginal intercourse by 60%. Thus claims the WHO. If the campaign is successful, 3.4 million new infections will have been prevented by 2025. Yet critics warn that these mass-circumcisions are based on controversial studies and could, in the end, have the opposite of the desired effect: more HIV-infections. Zambia, the landlocked country in Southern Africa, is one of the model countries of the campaign. More than 840,000 Zambians have already let their foreskins be removed. WHO’s representative in the country, Olusegun Babaniyi, praises the figures as “significant success”. Zambia has a 12.5 per cent HIV-infection rate among 15- to 49-year-olds, one of the highest HIV rates in the world. Every seven minutes a Zambian gets infected with HIV. There are well over a half a million AIDS orphans in a country that barely has 15 million inhabitants. Photo caption It’s like Chinese Whispers: Researchers have found correlations between foreskin and infection. The WHO tells the aid organizations. They tell their employees. These in turn convince patients in the country. On its way the message gets simpler ... and wrong. At the market in Lusaka, men tell each other that after the visit to the circumcision clinic they’ll never need condoms again. A seven hour car ride south of Lusaka, in a village called Sichiyasa, a few kilometers from the famous Victoria Falls, Margret Nkunika stalks in her city shoes through a harvested cornfield. Thatched mud huts glimmer in the savannah. Dust clouds swirl in the hot wind. The woman in her fifties with the wild Afro wig and her four companions are so called mobilizers, who swarm out by the thousands to the most remote parts of the country to convince men. “We are circumcision agents”, says Margret Nkunika to some corn farmers who, under an awning, are carving animal figures for tourists. “Circumcision protects you to 60 per cent against HIV! 60 per cent people! 60 per cent!” It sounds like a silver bullet. AIDS has claimed more than one million deaths in Africa south of the Sahara in 2013 alone. 25 million people live with the HIV virus that causes acquired immunodeficiency syndrome. Almost three-quarters of all new infections worldwide occur in this region. “My two sisters and my husband died of AIDS” says Margret Nkunika who, as a mobilizer, goes several times a week and without payment from village to village, and from hut to hut. “If they had known then that they could protect themselves through circumcision, they would still be alive.” The persuasion work of the “field staff” is flanked by a multi-million dollar marketing campaign. In the streets of Lusaka huge posters show a male silhouette, confidently thumbs hooked under his belt. The caption reads: “Circumcision – be a responsible man!” Famous musicians announce on television that they have undergone the procedure. “Hello, I’m Chief Mumena!” says the tribal chief of the Kaonde people in a commercial In his hand he holds a scepter of ivory. “Let yourself be circumcised today! For more information dial 990.” Photo caption Margret Nkunika is one of thousands of circumcision agents who, on behalf of Western aid organisations, are traveling to the most remote parts of Zambia. She lost her husband to the deadly HIV-virus. Ever more confident is she of the message she is preaching to the corn farmers: “Your foreskin is a deadly threat”. In Zambia’s neighboring country Zimbabwe, MPs let their foreskin be removed in order to lead by example. In Uganda, men can win bicycles or power generators at folk festivals if they get circumcised. In the mountainous area of the small country of Swaziland, booming sound systems on trucks can be heard, DJs voices call out by microphone: “Circumcision does not hurt! Go into the tent and be registered!” In neighboring South Africa, there are veritable circumcision factories where doctors go from bed to bed to remove foreskins without a break. Up to ten per hour. “A single harmless cut, which never needs to be repeated, can save your life” explains Margret Nkunika in southern Zambia to corn farmers who squat in front of her on the floor. She splays out her little finger, the last link of which represents the glans. “Your foreskin is a mortal danger” says the circumcision agent and cuts it off with an imaginary knife. “Clean! Healthy! Safe!” IN MANY PARTS OF THE WORLD circumcision is performed, involving the full or partial removal of the male foreskin, mainly for religious reasons. The ancient Egyptians circumcised their men, and cultural historians suspect they wanted to symbolically re-enact the moulting of a snake. A process that would render the snake immortal due to its ability to shed its old skin and repeatedly renew it. In Judaism and in Islam male circumcision applies as a sign of religious affiliation. Many evangelical Christians, especially in the USA, let the foreskin be removed, because they want to follow the example of Jesus, of whom they assume he was circumcised as a Jew. For decades, circumcision of newborns for medical or aesthetic reasons had become routine in the United States, funded by health insurance, but is, however, in a declining trend. In Western Europe, the circumcision of boys at preschool age became fashionable in the 1970s – to prevent a constricted foreskin, and because of the belief that a circumcised penis is more hygienic than an intact one – as some suppose still today. First suggestions of a correlation between foreskin and HIV were made in the mid-1980s by scientists when they observed that circumcised men were less infected, and interpreted the foreskin as potential target for the virus. In the area of the inner foreskin, lymphocytes and so-called Langerhans cells can be found in increased numbers. Actually, these are specialized cells of the immune system to protect against infections. But while the Langerhans cells normally intercept HIV and destroy it, they can, under certain conditions like parallel infections, pass the virus to the target cells of HIV and thus increase the infection rate. “60 per cent protection” – this is the formulaic number from the WHO campaign Then, in October 2005 the message was “Male circumcision protects against HIV infection like a vaccine.” A sensation! Everywhere hope flared up. Triggering the euphoria was the French physician Bertran Auvert. In his study in Orange Farm township near Johannesburg, South Africa, 1,339 men had been voluntarily circumcised. Auvert compared their infection rate after the intervention with a control group of 1,309 non-circumcised men in the same region. His conjecture: Together with the foreskin, HIV target cells can also be eliminated and thus also the risk of infection. After one and a half years he seemed to confirm this. Among the control group of non-circumcised men, Auvert found 49 cases of HIV, however, only 20 cases among the circumcised. He extrapolated the famous 60 per cent reduction in risk of HIV infection, which soon would become the mantra of the WHO campaign in Africa. Two other studies of international researchers in Kenya and Uganda produced similar results. The WHO declared the results a milestone – and recommended in 2007 to promote voluntary male circumcision in 14 countries with high HIV rates, including Zambia, South Africa, Zimbabwe, Botswana, Uganda, Tanzania and Kenya. There are around six million Africans who have since then had their foreskins removed. “THAT’S ALL UTTER NONSENSE” says German circumcision expert Wolfgang Bühmann. “Condoms provide almost complete protection against HIV. Why then a surgical intervention?” Bühmann is spokesman for the Professional Association of German Urologists. He has performed more than 1,000 circumcisions – but for therapeutic medical reasons to relieve boys of painful foreskin constriction and inflammation. In the treatment room of his practice on the North Sea island of Sylt are a cot, sonography unit, and white walls. “These circumcisions in Africa are not only useless, but potentially fatal”, Bühmann warns. “To help the people in areas of high HIV rates, one has to make clear to them: sex without a condom is dangerous, Sex with a condom, however, is safe whether with or without foreskin. With everything that is being said, nuances only create confusion”. “ARE YOU CUTTING YET?” asks Ernest Chisha at Chilenje Clinic in Lusaka. The provider – formerly a taxi driver, trained in a two-week course for circumcisers – has Chishas numbed penis divided like the face of a clock. With a pair of pliers he pinches on three and nine clock. Other than one dull plucking between the legs, Chisha does not feel the cutting, as the provider cuts the foreskin at twelve o’clock parallel to the urethra, then unfolds it beneath the corona of the glans and amputates it with circular cuts. “Done!” the provider exclaims after five minutes and lets the bloody skin pieces drop in a bucket. “Now you are on the safe side.” The WHO says: not quite. It explicitly points out that condoms are to be used after being circumcised. The USAID, the authority responsible for US government development coordination, also emphasizes this in their training for local staff. “We do not simply cut off foreskins,” says George Sinyangwe, senior health advisor of USAID in Lusaka. The local doctor – grey suit, pink shirt, tie – has worked for the US authority since 2006. In front of him on the polished table of the conference room are circumcision brochures. An American-educated female consultant with a strong handshake and a penetrating gaze watches over every word Sinyangwe says: “All men receive information that certainly dispels any misconceptions about the benefits of the procedure. Before, during and after their circumcision.” But does the message get received? Certainly not by the corn farmers in southern Zambia. “If you have unprotected sex, your penis gets fine fissures, into which the virus can penetrate”, mobilizer Margret Nkunika tells the men under the awning. “But circumcision makes your glans hard and resistant.” Not a word of condoms. All men let their names be placed on a list. Once the list is full, the management in Livingstone, the nearest major city, sends a provider to perform the surgeries. “I know the protection is only 60 per cent” says Innocent, 28, a corn farmer. “Better than nothing.” But condoms offer a much higher protection! Up to 95 per cent! The men laugh. Condom use during vaginal intercourse is like eating candy in its plastic wrap: “You can’t taste the sweet!” EVERYWHERE IN ZAMBIA – on fields and rivers, in bars, market stalls, even on the campus of the University of Lusaka – men proclaim circumcision delivers them from the annoying condom. Photo caption Counter enlightenment: Musician Danny Kaya points out in the “Sunday Post” that unprotected sex after circumcision remains dangerous. Prostitutes like Mariam Kaoma ignore this message: Sex “live”, without a condom, the most common customer request, is what they prefer to grant to circumcised suitors. “Men without foreskin are healthier. Every woman in our country knows this.” It’s just like the children’s game Chinese Whispers: Scientists whispered their findings to the WHO – which in turn retold them to USAID, to African governments and to hundreds of NGOs. They provide the information to their local helpers, foot soldiers like Margret Nkunika, who roam the country as mobilizers. Once the message arrives where it should – with the corn farmers of Sichiyasa – crucial parts of the message have been lost. “If I had not let myself be circumcised, I would have continued to use condoms - and would now not suffer from AIDS” says Kito, 44, on the river bank Chongwe, an hour’s drive west of Lusaka. The man with the sunken cheeks and shiny, thin skin sits in the shade of a flame tree overlooking the water. Birds chirp and reed walls rustle in the wind. A peaceful oasis that stands in stark contrast to Kito’s history. At the beginning of the circumcision campaign in Zambia in 2009 Kito was working as office assistant in the Ministry of Health. Round the clock he was exposed to the “propaganda from America”: “Once you are circumcised, you cannot get HIV any more” his mobilizer and his circumcision counsellor assured him. Both had been trained by an American-funded NGO. Kito got circumcised in Lusaka. Then he renounced condoms. Sometime later he got a headache, diarrhoea, fever. A test showed that Kito was HIV-positive. “The world collapsed for me” he says at the river bank. Soon he visibly lost weight and was laughed at by neighbors on the street. His friends no longer shook his hand. After 15 years in the Ministry of Health, he was let go because of HIV infection. In a support group he gradually got back on its feet. “Thousands share my fate” Kito learned there. “The circumcision campaign is a deadly deception.” In fact, a number of recent studies warn of mixed messages from unclear campaign information. In Uganda, for instance, scientists at Makarere University established that circumcised men take many more risks in sexual practices than intact men. Photo caption Millions of US dollars in aid are poured into the region for the circumcision campaign. “Since then, no one questions its sense and nonsense”, says the MP Elias Chipimo. And thus the message of the saving cut takes on a life of its own. Non-circumcised men make it more and more rarely to wedding photos taken in front of the High Court, because they are considered disease propagators – victims of misinformation who are left alone, just like office assistant Kito (below). He considered himself on the safe side, contracted HIV and lost his job at the Ministry of Health. [HIV incidence higher in circumcised men] In Zambia’s neighboring country Zimbabwe, the government has already announced that more circumcised than uncircumcised men are HIV-positive. In Malawi, which also participates in the WHO campaign, the latest national health report is devastating: Among circumcised men the HIV rate is about 30 per cent higher than among uncircumcised men. “We use every means to avoid misconceptions about the benefits of the procedure” says Albert Kaonga from the Zambian Health Ministry. “Our motto is: Circumcision and condom – Two are better than one.” But does the number of infections in Zambia really decrease thanks to the mass circumcisions? Circumcision, says Kaonga, was part of a “security package” of various measures, including education, HIV testing and condoms. “How only circumcision by itself affects the outcome we cannot calculate in isolation.” In the Chilenje Clinic in Lusaka, at the door of the circumcision room, in which the provider is just stitching the wound on Ernest Chisha’s penis, eleven men sit on low wooden benches around a young woman with pigtails and red earrings. In her hand she is holding a brown model penis. In one day six months ago, Barbara Luchembe completed a two hour circumcision consultant training. She correctly points out to the men that they must continue using condoms after the procedure. But a young man in fashionable ripped jeans and silver embroidered shirt whispers to his neighbor: “I only let them cut at my thing so that afterwards I no longer need any condoms.” DISTRESS. Health experts find the campaign’s risks for women also worrisome because male circumcision – according to the WHO – is supposed to reduce the risk of HIV being passed from female to male, but not in the opposite direction. It does not offer protection for women. This information does not seem to have arrived in Zambia. To the contrary. A Saturday night in Motero, a neighborhood of Lusaka. The headlights of cars refract the dust from the road. In it, the shadowy silhouettes of women appear. “You want a nice time?” They open their coats or wraparound garments. They are naked underneath. Mariam Kaoma, 40, wears high heels and around her hips colorful chainlets of plastic beads. During a good night, she makes 25 Kwacha – about 4 Euro – having quick sex with 12 men. With the last one she stays until morning for 20 Euro. “They see my pussy and want it live.” “Live” means without condom. And “live” is the most frequent customer request. “That’s why I’d rather do it with circumcised men” says Mariam Kaoma later in her tiny room, which only holds a pink mattress and clothes stacked in front of damp walls. “Circumcised men are healthier. Every woman in Zambia knows that.” The pressure that men experience to have their foreskin cut is often enormous in southern Africa. Posters in the streets show a horrified African woman, tearing her hair out and screaming. “What? You’re not cut?” Men with an intact penis are generally labelled as disease agents. Non-circumcised men hardly have any chance of finding a female partner. “I’ve left my boyfriend. He didn’t want to be circumcised.” She loved him very much. Without foreskin the two of them could have become a happy couple. A STUDY IN UGANDA shows how fatal this tendency really is: Among wives of circumcised men, the HIV rate has drastically increased within six months after the circumcision – by 61%. In the science magazine Nature, the “father of the circumcision solution”, the French physician Bertran Auvert, admits “Most certainly some women will get infected because their partners are circumcised and have allowed themselves to be lulled into a false sense of security.” Yet, Auvert believes that women too will benefit long-term from male circumcision after the general HIV rate has been lowered. As well, homosexuals, who belong to the groups at-risk of HIV infection worldwide, are hardly protected from HIV by circumcision. The danger of infection during anal intercourse without a condom is many times greater than in unprotected contact between vagina and penis. Even the WHO explicitly recommends circumcision only for heterosexual men. Yet in Zambia hardly anybody knows this, where homosexuality warrants imprisonment and is accordingly taboo. “Most Zambian gays believe that circumcision protects them from HIV as well” says a gay human rights activist in Lusaka who wants to remain anonymous. “We don’t use condoms and we die like flies.” CONFUSING, FALSE, missing information? More HIV because of risky behavior by circumcised men? “We do not have any indication that confirms such assumptions” says George Sinyangwe at USAID at the conference table in Lusaka. His advisor nods. But how can this be? How can the facts stated in the health report of the country of Malawi, where circumcised men already show a higher infection rate than intact men, be ignored? And all the other alarming studies? Sinyangwe is unimpressed: “We are on the right path.” Maybe Zambia’s national health report could provide clearer data on the effects of the thousand-fold foreskin removals, but the complete statistics have not been published since 2007. Why do African governments get involved in such a thing? WHY DOES A GOVERNMENT AGREE to such a “flight in the dark”? In Zambia, more than three quarters of the rural population live below the poverty threshold. The supporting industry that sprung up around the AIDS epidemic is, after the government, the second largest employer. “When millions in aid money flood into the country, nobody asks questions” says MP Elias Chipimo. “All moneys are accepted with open hands – regardless of whether the measures financed through them are effective or not.” Critics attest that the WHO campaign has a colonialistic attitude, generally assuming Africans are unable to alter their sexual behavior and to use condoms. Even newborns nowadays are circumcised − mainly to polish up the quotas the campaign aims for − believes Edith Nawakwi, President of the Forum for Democracy and Development in Lusaka. Naturally, the baby boys cannot consent to the irreversible procedure. But even UNICEF, the children’s aid program of the UN, jumped onto the circumcision wagon. “With this quick cut”, according to Edith Nawakwi, “the bodies of Africans become the playground of Western development aid.” In the high security WHO compound in Lusaka the CEO crosses his arms in front of his chest. “You won’t get a single word from us” says the American in blue and white striped shirt. “Nobody wants to say the wrong thing.” WALLS. SILENCE. Ploughing ahead. Buy why? Why do USAID, the WHO and the UN risk a catastrophe? Why don’t they use their mighty budgets to promote the use of condoms? Zambian politicians like Nawakwi and Chipimo view the mass circumcisions as an expression of deep frustration from Western development aid. Changing complex human behavior − the most important parameter in fighting sexually transmitted diseases − has been given up as a goal, in favor of the benefit of technocratic solutions like circumcision. “Here, the measures and successes can more easily be reported, especially to funders” according to Chipimo. “Changing human behavior is a vague business. Circumcision, on the other hand, produces impressive numbers of removed foreskins, and well-made photos of clinics, helpers and medical equipment that let the dollars to continue to flow.” The WHO remains non-transparent. Their headquarters in Geneva does not answer written inquiries. In his doctor’s office on the island of Sylt, urologist Wolfgang Bühmann shakes his head. “The worst of it is that the WHO’s core reference studies are full of mistakes.” Australian circumcision expert Gregory Boyle of Bond University in Queensland shares this opinion. He holds a whole list of scientific errors against the WHO studies; especially “inadequate balance, distorted selection of study participants, suppression of important details”. Photo caption Like a dull plucking between the legs – that is how the surgery felt to Ernest Chisha. Then the procedure was over. With a gauze bandage, pain killers and a strict six weeks sex prohibition he was sent home. And with the assurance: “Now you are on the safe side.” “Although the clinical studies that serve as proof for the effectiveness of circumcision worked with control groups – as the rules of solid research dictate, the circumcised study participants were not allowed to have sex for at least six weeks after the procedure, while the intact men in the control group were not required to practice this abstinence,” explains urologist Bührmann, “and were therefore subject to a higher risk of infection.” This distorted the results. Furthermore, the studies in South Africa by Frenchman Auvert – which were actually designed for 21 months – were prematurely abandoned. It was claimed that the results had already been clear by then. Therefore, to continue the experiment would not have been ethical because it would have entailed a higher deadly risk for the control group of intact men. Maybe so. Yet, in the view of international experts like Michel Garenne, researcher at the renowned Pasteur Institute in Paris, the termination came too early for deducing from it sufficient reason for surgical interventions upon millions of people. Critics claim that, besides, the study was based on way too few test persons. Also, a significant number of men who later tested HIV-positive did not get infected by sexual transmission at all, but by contaminated needles, blood transfusions and surgical equipment – an imprecision that researchers hardly took into account. In addition, many participants simply disappeared and could not be questioned or tested in the end. “From a scientific view, the reference studies used by the WHO are a catastrophe” summarizes urologist Wolfgang Bührmann. The so-called circumcision solution is everything but a solution. Also, Robert Van Howe, professor at Michigan State University, who for many years has conducted research on the topic, is convinced that “The circumcision policy will in the end increase the numbers of HIV infections”. [NOTE: Robert Van Howe, <a href="http://www.publichealthinafrica.org/index.php/jphia/article/view/jphia.2011.e4" rel="noopener" target="_blank">How the circumcision solution in Africa will increase HIV infections</a>. Journal of Public Health in Africa 2 (1), 2011.] TO ALL OF THIS Ernest Chisha is oblivious. In the Chilenje clinic, the provider dabs the blood off his freshly stitched penis, bandages it with gauze and tapes it to his belly, then Chisha steps out into life with a couple of painkillers in his hand. And in the belief in the miraculous power of circumcision. Also clueless is the army of the campaign’s foot soldiers. “I preach the word of circumcision like the pastor preaches the word of God” says mobilizer Margret Nkunika. George Sinzangwe of USAID strokes his trimmed goatee. His agency is responsible for hundreds of thousands of circumcisions in Zambia. “We know exactly what we are doing” he says at the conference table and adjusts the knot of his tie. “The US government will drive this campaign forward. We do an excellent job here.” But what about the evidence of more HIV-infections in certain population groups? What about the warnings of international experts? Sinyangwe: “We do not comment on critical opinions of scientists.” Instead, he holds up his brochures: numbers of circumcised men, bar diagrams, success curves. 2015 will be especially successful: 1.9 million removed foreskins. Is the Zambian physician himself circumcised? Sinyangwe’s facial expression suddenly appears to have turned into stone. His eyes wide open, his mouth gaping. “No” he finally says quietly. Is he planning to get circumcised? He hesitates. His advisor urges him: “Tell them that you plan to.” Sinzangwe gazes past the edge of the table, between his legs. “No!” the man of USAID says once more. Photo caption “With this campaign the bodies of Africans have become the playground of Western development politics!” says Edith Nawakwi, President of the Forum for Democracy and Development in Lusaka. One of her adversaries, George Sinyangwe of the aid organisation USAID, views it entirely differently: “We know exactly what we are doing. We really do excellent work.” Photographer MATTHIAS ZIEGLER and author MICHAEL OBERT did research in Zambian villages close to the famous Victoria Falls. After their return to Germany, Obert tried for weeks to get an official statement from the WHO. But the WHO remains silent. BACKGROUND: WHAT KINDS OF CIRCUMCISION ARE THERE? The UN and other organizations support the mass circumcision campaign of men with billions of dollars. At the same time, the same organizations fight female circumcision of girls and women with all their power. Is this unequal treatment justified? An overview. FEMALE CIRCUMCISION IS A CRIME. The mutilation of female genitals violates human rights. Nevertheless the practice is still widespread in 29, mainly African, countries. Although 24 of these nations have already prohibited female genital mutilation by law, it still is practiced to an extent that within the next ten years there will be 30 million cut girls and women added to the 130 million currently existing worldwide. The exact methods used by (male and female) circumcisers shows significant regional differences: It goes from piercing or nicking of the clitoral foreskin, to removal of the inner labia and clitoris to the so-called Pharaonic circumcision, an extremely brutal procedure during which all outer parts of the vulva are cut off, and it is sewn shut, except for a tiny opening. Many victims, not just of the extreme variety, suffer from the lifelong consequences of these very painful and traumatizing procedures. In men, circumcision of the foreskin is far less outlawed. But here, too, the consequences are severe, simply because of the dimensions of the phenomenon. A third of the male world population is circumcised, about one billion boys and men are cut, mostly for religious and cultural reasons, rarely for medical ones. The majority of circumcised men are Muslims, but also in the USA 60% of male newborns are circumcised (rate is declining), and in South Korea the rate is 76% of 14 to 19 year olds. As with girls, boys’ circumcision is so often strongly ingrained as an initiation rite in societies that parents succumb to considerable social pressure to have the surgery performed. With male circumcision, too, there are different procedures: From cutting of only the tip of the foreskin, to the complete removal of the entire foreskin, to the so-called subincision, a relatively rare procedure demanding that the penis be cut open along the urethra. HEALTH RISKS FOR BOTH GENDERS. Almost all forms of circumcision come with considerable health risks, especially when undertaken in traditional, often unhygienic, conditions. This is also true for male circumcision. In Southern Africa, half a million boys were treated in hospitals between 2007 and 2014 after unsuccessful circumcisions. More than 400 of them died. Even under very good hygienic conditions, medical problems have often been observed, among them scar adhesions, haemorrhage, wound infections, sensitivity disorders, and other long term effects. Even though the dramatic consequences are more obvious in women and girls, attempts to circumcise the majority of men in Southern Africa might very well, even by conservative estimates, lead to hundreds of thousands of complications, sometimes lifelong. In Germany the legislature answered the question clearly how female and male circumcisions are to be assessed. Female genital is a crime since 2013, while boys’ circumcisions within the first six months are allowed, even when not conducted by physicians. Debate over these laws is still ongoing. Some consider them a violation of the principle of equality. Others insist the two problems are not comparable. <a href="http://www.geo.de/magazine/geo-magazin/13193-geo-nr-07-15-verraeterische-spuren" rel="noopener" target="_blank">The original article by Michael Obert & Matthias Ziegler was published in Geo German edition, July 2015</a>: Weltgeschehen: Ein Einschnitt fürs Leben? Millionen afrikanischer Männer sollen sich beschneiden lassen, als Schutz vor HIV. Sinnvolle Hilfe oder gefährlicher Irrglaube? <a href="http://circumcisionharm.org/" rel="noopener" target="_blank">Translation with original photos available from circumcisionharm.org</a> <h2>Further information</h2> Further doubts on circumcision as the magic bullet for the African HIV-AIDS problem, and evidence that men in Zambia resent having been circumcised and find that it has a serious adverse impact on sexual sensation in <a href="https://www.circinfo.org/Global_Public_Health_questions_African_circumcision_programs.html" rel="noopener" target="_blank">special issue of Global Public Health, June-July 2015</a>. Critique of the Uganda circumcision campaign for misleading message that circumcision of males reduces risk for women (when male circumcision can actually increase the risk for women): Sarah Rudrum, John Oliffe, Cecilia Benoit, <a href="http://www.tandfonline.com/doi/abs/10.1080/13691058.2016.1214748" rel="noopener" target="_blank">Discourses of masculinity, femininity and sexuality in Uganda’s Stand Proud, Get Circumcised campaign</a>. Culture, Health and Sexuality, on-line first, 11 August 2016. Abstract This paper analyses discourses of masculinity, femininity and sexuality in Stand Proud, Get Circumcised, a public health campaign promoting circumcision as an HIV-prevention strategy in Uganda. The campaign includes posters highlighting the positive reactions of women to circumcised men, and is intended to support the national rollout of voluntary medical male circumcision. We offer a critical discourse analysis of representations of masculinity, femininity and sexuality in relation to HIV prevention. The campaign materials have a playful feel and, in contrast to ABC (Abstain, Be faithful, Use condoms) campaigns, acknowledge the potential for pre-marital and extra-marital sex. However, these posters exploit male anxieties about appearance and performance, drawing on hegemonic masculinity to promote circumcision as an idealised body aesthetic. Positioning women as the campaign’s face reasserts a message that women are the custodians of family health and simultaneously perpetuates a norm of estrangement between men and their health. The wives’ slogan, ‘we have less chance of getting HIV’, is misleading, because circumcision only directly prevents female-to-male HIV transmission. Reaffirming hegemonic notions of appearance- and performance-based heterosexual masculinity reproduces existing unsafe norms about masculinity, femininity and sexuality. In selling male circumcision, the posters fail to promote an overall HIV-prevention message. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource HIV/AIDS: Germany's GEO publishes hard-hitting critique of Zambia's circumcision campaign darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h1>Condoms: The real front-line or magic bullet against HIV-AIDS</h1> For all the poorly thought out chit-chat and media hoo-hah about circumcision, the real magic bullet against HIV-AIDS is the same as it has always been: restraint, fidelity, safe-sex and condom use. Or as the old saying goes, If you can't be good be careful. <h2> <a id="vatican1" name="vatican1"></a>AIDS control breakthrough: Vatican approves condom use</h2> For many years the struggle against HIV-AIDS, particularly in poor countries, has been weakened by the stance of the Catholic Church against the use of condoms. The basis for the ban is that they are a form of birth control, prohibited since the 13th Century on the word of the theologian Thomas Aquinas. Since condoms are about 95 per cent effective as a preventive of HIV and many other sexually transmitted infections, the prohibition has had much the same effect as would a ban on, say, smallpox vaccination or the use of penicillin as an antibiotic. The obstinacy with which the Vatican maintained this dogma has dismayed many compassionate people, including Catholics, who have reasonably pointed out that even if using a condom was a sin, it could not be a worse sin than infecting another person with a fatal and incurable disease. It now appears that the current Pope, Benedict XVI, has at last seen the cogency of this argument, and agreed that Catholics are entitled to use condoms if their purpose is not to prevent conception, but to prevent the spread of HIV. The following report is form Yahoo News. VATICAN CITY – In a seismic shift on one of the most profound – and profoundly contentious – Roman Catholic teachings, the Vatican said Tuesday that condoms are the lesser of two evils when used to curb the spread of AIDS, even if their use prevents a pregnancy. The position was an acknowledgment that the church’s long-held anti-birth control stance against condoms doesn’t justify putting lives at risk. “This is a game-changer,” declared the Rev. James Martin, a prominent Jesuit writer and editor. The new stance was staked out as the Vatican explained Pope Benedict XVI’s comments on condoms and HIV in a book that came out Tuesday based on his interview with a German journalist. The Vatican still holds that condom use is immoral and that church doctrine forbidding artificial birth control remains unchanged. Still, the reassessment on condom use to help prevent disease carries profound significance, particularly in Africa where AIDS is rampant. “By acknowledging that condoms help prevent the spread of HIV between people in sexual relationships, the pope has completely changed the Catholic discussion on condoms,” said Martin, a liberal-leaning author of several books about spirituality and Catholic teaching. The development came on a day when U.N. AIDS officials announced that the number of new HIV cases has fallen significantly – thanks to condom use – and a U.S. medical journal published a study showing that a daily pill could help prevent spread of the virus among gay men. “This is a great day in the fight against AIDS ... a major milestone,” said Mitchell Warren, head of the AIDS Vaccine Advocacy Coalition. Theologians have debated for years whether it could be morally acceptable for HIV-infected people to use condoms to avoid infecting their partners. The Vatican years ago was reportedly preparing a document on the subject, but it never came out. The groundbreaking shift, coming as it does from the deeply conservative pontiff, would appear likely to restrain any public criticism from Catholic conservatives, who insisted Tuesday that the pope was merely reaffirming the church’s moral teaching. … In the book, “Light of the World: The Pope, the Church and the Signs of the Times,” Benedict was quoted as saying that condom use by people such as male prostitutes indicated they were moving toward a more moral and responsible sexuality by aiming to protect their partner from a deadly infection. His comments implied that he was referring primarily to homosexual sex, when condoms aren’t being used as a form of contraception. However, questions arose immediately about the pope’s intent because the Italian translation of the book used the feminine for prostitute, whereas the original German used the masculine. The Vatican spokesman, the Rev. Federico Lombardi, told reporters Tuesday that he asked the pope whether he intended his comments to apply only to men. Benedict replied that it really didn’t matter, the important thing was that the person took into consideration the life of another. “I personally asked the pope if there was a serious, important problem in the choice of the masculine over the feminine,” Lombardi said. “He told me no. The problem is this: ... It’s the first step of taking responsibility, of taking into consideration the risk of the life of another with whom you have a relationship. This is if you’re a man, a woman, or a transsexual. ... The point is it’s a first step of taking responsibility, of avoiding passing a grave risk onto another,” Lombardi said. … UNAIDS estimates that 22.4 million people in Africa are infected with HIV, and that 54 percent – or 12.1 million – are women. Heterosexual transmission of HIV and multiple, heterosexual partners are believed to be the major cause of the high infection rates. Benedict drew harsh criticism when, en route to Africa in 2009, he told reporters that the AIDS problem couldn’t be resolved by distributing condoms. “On the contrary, it increases the problem,” he said then. In Africa on Tuesday, AIDS activists, clerics and ordinary Africans applauded the pope’s revised comments. “I say, hurrah for Pope Benedict,” exclaimed Linda-Gail Bekker, chief executive of South Africa’s Desmond Tutu HIV Foundation. She said the pope’s statement may prompt many people to “adopt a simple lifestyle strategy to protect themselves.” In Sierra Leone, the director of the National AIDS Secretariat predicted condom use would now increase, lowering the number of new infections. “Once the pope has made a pronouncement, his priests will be in the forefront in advocating for their perceived use of condoms,” said the official, Dr. Brima Kargbo. <a href="http://news.yahoo.com/s/ap/20101123/ap_on_re_eu/eu_pope_condoms" rel="noopener" target="_blank">Read full story at Yahoo News.</a> <h2> <a id="condom1" name="condom1"></a>More evidence that circumcision leads to lower condom use</h2> There is further evidence from Africa that the circumcision programs intended to reduce the risk of HIV infection are leading to reduced condom use. This is exactly what the critics of circumcision as an AIDS prevention strategy warned would be likely to happen, and events are proving the sceptics correct. In Zambia, a school headmistress complains that media campaigns are driving teenage boys into agreeing to circumcision without any explanation of the risks or likely effects, and that the boys believe being circumcised means that it is now safe for them to indulge in unprotected sex. In Swaziland, there are increasing fears that the aggressive circumcision programs there are discouraging men from using condoms, leading to an epidemic of unsafe sex. Men have realised that while the presence of the foreskin makes forms of safe sex such as masturbation highly enjoyable and satisfying, circumcision takes away most of the pleasure. Once circumcised, they find the only way to get satisfaction is by engaging in “bareback” sex with a partner. <h3>Zambia: Boys see circumcision as licence for unprotected sex</h3> THE recent headlines that circumcision has made are too loud for anyone to ignore. The media adverts coupled with other forms of campaigns for circumcision have certainly had an impact on the general public. Critics say circumcision is brutal and robs males of sexual sensation, but many in the medical community point to research that suggests circumcision reduces the risk of sexually transmitted infections including HIV. According to the National Male Circumcision Strategy and Implementation 2010 - 2020 Plan, 2.5 milllion males have been targeted before 2020. However, what is worrying is that information filtering about circumcision is one that has been received with misconception especially amongst the youths and school pupils in particular. Recently, the Education Post visited Kafue Boys Secondary School where close to ten pupils registered to get circumcised at a local health centre without the consent of school authorities. Confirming the development, school headmistress Catherine Mutale expressed disappointment at the decision by personnel at the health centre to enlist the pupils for circumcision without the school authorities’ approval. Mutale learnt about the circumcision campaign at her school through the posters that had been stuck on trees within the school premises and that a parent to one of the pupils had also called the school earlier inquiring on how their child had been circumcised without their approval. “We found posters promoting circumcision stuck on trees and by the time the deputy head pulled them out ,the pupils had already read the message on the posters and were booked in for circumcision the next day,” Mutale said. The headmistress said she then approached health personnel at Kafue Rural Health Centre over the matter who responded defensively, saying the boys were old enough to make their own decisions. “By the time we had gone there, five had already been circumcised, and five more were awaiting circumcision,” she said. Mutale complained that the practice had disturbed some pupils because they were absconding classes due to the nature of the operation. “Some have been missing class because they are having problems in walking and sitting. Our other concern is on the cleaning of the wounds; we don’t know whether the boys are doing the right thing. They are targeting boys because they want to meet the target. She also sadly noted that there was a misconception amongst pupils that once circumcised they could have unprotected sex without contracting STI’s and HIV. “These pupils think circumcision is a lee-way to indulge in unprotected sex and now my worry is they may decide to practice this whilst at home during holidays because then the school will have no control over them,” Mutale said. Lenganji Sikapizye, <a href="http://www.postzambia.com/post-read_article.php?articleId=15572">Boys see circumcision as a licence for unprotected sex</a>, The Post Online, 13 November 2010. <h3>Swaziland: “Skoon sex” crisis looming after circumcision</h3> EZULWINI – There is fear that male circumcision has led to people not using condoms and engage in “skoon sex”. As a result, there have been calls for a study to be conducted to determine whether the numbers between circumcision and condom distribution add up. “I’m concerned about male circumcision. Last year there was a circumcision campaign. I would like to see if the numbers tally between circumcision and condom distribution. If the condom distribution is low then we have a problem which probably means that the circumcised are not using condoms. We need to carry out research. If the circumcised don’t use condoms then we are heading for disaster because of those that are HIV positive,” submitted Vusi Nxumalo. A participant of the indaba said it was obvious the circumcision concept had not been properly communicated to the public. “A sibling at home is now telling us he is circumcised and therefore has ‘skoon’ sex,” she submitted. Another participant, identified as Magagula, made a statement that threw everyone into laughter when he said the penis foreskin was good for masturbation. “Now without the foreskin you can’t satisfy yourself but women can still do that through use of vibrators,” he said. However, Bertram Auvert [Western researcher behind the first circumcision clinical trial] said he had never heard of masturbation concerns from those that had circumcised. 16% of pupils have sex with four or more partners Sixteen per cent of surveyed pupils in the country are reported to be having sex with four or more sexual partners. This was revealed by Mzwethu Nkambule, Campaigns Manager of Lusweti, when making a presentation on Multi-Concurrent Partners (MCPs) and the HIV incidence in Swaziland. He said this was seriously perpetuating the spread of HIV/ AIDS, to the extent that Swaziland had become the leading country in the level of HIV/AIDS prevalence in the Southern Africa region. Nkambule also divulged that, “among the 15-19 year olds who had sex about a third had more than one partner.” He also disclosed that more women, according to statistics, are reported to have acquired HIV as compared to men. “Sixty-two per cent of the overall infections in 2008 were recorded among females while 38 per cent were recorded among men,” he said, while shedding light on the urgency of crafting initiatives that will lead to a Swazi HIV-free generation. [On the evidence so far, that objective will not be achieved by circumcision.] <a href="http://www.times.co.sz/News/23529.html" rel="noopener" target="_blank">‘Skoon sex’ crisis looming after male circumcision</a>, Times of Swaziland, 1 December 2010 <h2> <a id="Unsafe" name="Unsafe"></a>HIV-AIDS control in Africa: Circumcised men more likely to have multiple partners and forget the condoms</h2> From Africa there is ever-increasing evidence that men who have agreed to get circumcised because they have been told it will protect them from HIV infection believe they are immune. This is leading to an increase in high-risk behavior: increased promiscuity, multiple partners, more unsafe sex and failure to use condoms. As critics of the circumcision solution have warned from the beginning and emphasized on the rare occasions they have been allowed to get anything into print, such behavioural patterns are likely to increase the incidence of HIV infection, and at the very least must cancel out any benefits that might otherwise arise from the circumcision programs. As recent reports from Zambia, Kenya and Zimbabwe indicate, the much-vaunted circumcision programs are producing an epidemic of unsafe and high-risk sex, thereby defeating their own stated purpose. <h3>Zambia: 25% of men resume sex before wounds from circumcision fully healed, HIV risk to women increased</h3> Approximately a quarter of men undergoing circumcision resume sexual activity before their wounds have fully healed, Zambian research published in the online edition of the journal AIDS shows. Most of the men reporting the early resumption of sexual activity engaged in unprotected sex, often with multiple partners. The investigators calculated that early resumption of sexual activity at this level could undermine the protective effect of circumcision against HIV at a population level. Indeed, if the proportion of men engaging in sex during wound healing increased to 30%, then circumcision would lead to more new HIV infections in women than it would avert. “The prevalence of sexual activity and, in particular, risky sex during the wound healing period in the Zambian context is not trivial,” comment the investigators. “Even relatively small increases in early sex can have a deleterious impact on women to a point where new infections exceed averted infections in that year.” A number of randomised controlled trials have shown that circumcision can reduce a man’s risk of infection with HIV by approximately 66%. It has been calculated that universal male circumcision in sub-Saharan Africa could avert 2 million new HIV infections in the first ten years. Male circumcision programs are therefore being implemented in a number of countries in the region with generalised HIV epidemics. Zambia embarked on a national circumcision program in 2007. HIV-negative men aged between 13 and 39 years are targeted in this program and in 2010, some 61,000 men underwent circumcision. However, the protective effects of circumcision suggested by randomised trials can be undermined by a number of factors. One of the most important is early resumption of sexual intercourse before the wounds from surgery have healed. Men undergoing circumcision are therefore counselled not to resume sexual activity until six weeks have passed. Investigators wished to establish how many men were having sex within this six-week period. They also wanted to see if any factors were associated with the early resumption of sexual activity, and if sex in the post-operative period would have wider implications for the impact of circumcision programs on the prevention of new HIV infections. A total of 225 men were interviewed about their sexual behaviour before circumcision and again six weeks later. The men had a mean age of 21 years. At baseline they reported a mean of three lifetime sexual partners and 44% had a regular partner. Unprotected sex in the four weeks before circumcision was reported by 22% and 10% had been diagnosed with a sexually transmitted infection within the past twelve months. Just under a quarter (24%) of men reported resuming sex within the six-week healing period. Almost half (46%) of these men had sex within the first three weeks after surgery. Moreover, 81% of men resuming sex during the healing period reported unprotected sex, and 32% said they had had unprotected intercourse with two or more partners. Early resumption of sexual activity was associated with a higher number of lifetime sexual partners and unprotected sex in the period immediately before circumcision (p < 0.05). The investigators calculated that a 24% prevalence of sex during the six-week healing period among the 61,000 men circumcised in Zambia in 2010 would result in 69 more HIV infections compared to sexual abstinence for the duration of healing. Some 32 of these extra infections would be in men and 37 in women. The investigators caution that resumption of sex during healing could put women at risk of HIV. If 30% of men undergoing circumcision had sex within the healing period, then more new HIV infections in women would be generated than averted. “The study findings suggest that the prevalence of risky sexual behaviour during the wound healing period is high,” write the investigators. “Programs need to continue to emphasise to clients the risks associated with early resumption of sex.” Reference: Hewett PC et al. Sex with stitches: the resumption of sexual activity during the post-circumcision wound healing period in Zimbabwe. AIDS Official Journal of the International AIDS Society, 20 January 2012 26, online edition. DOI: 10.1097/QAD.0b013e32835097ff, 2012. Michael Carter, “Quarter of men resume sex before wounds from circumcision fully healed in Zambian study”, <a href="http://www.aidsmap.com/Quarter-of-men-resume-sex-before-wounds-from-circumcision-fully-healed-in-Zambian-study/page/2227154/">AIDSMap, 31 January 2012</a> <h3>Kenya: Circumcised men more likely to have multiple partners, believe they are immune to HIV</h3> THE Ministry of Public Health and Sanitation in conjunction with the National Male Circumcision taskforce have expressed concern over reports of multiple sex partners among those who recently underwent male circumcision. Nyanza provincial director of public health and sanitation, who is also the task force chairman Jackson Kioko, said there have been reports that those who have been circumcised are taking it as immunity against HIV. Speaking during the launch of the results of the third rapid results initiative on male circumcision, Kioko said the taskforce will conduct a study to ascertain post-male circumcision sexual behaviour. During the launch of the exercise, its critics including the Luo Council of Elders said the program will be disastrous if not well packaged and the beneficiaries sensitised on its implication. The council of elders argued that marketing male circumcision on the platform of preventing HIV was going to erode the overall goal since many men will take it as complete immunity. Studies conducted in Rabai in Uganda, Orange Farm in South Africa and Kisumu indicate that male circumcision can prevent HIV infection by over 60 per cent. The studies, however, warn that male circumcision should not be relied upon as a stand-alone intervention against HIV/AIDS. [So if you still have to use a condom after getting circumcised, why get circumcised at all?] Samuel Otieno, “Kenya: Cut Men Have Many Mates”, <a href="http://allafrica.com/stories/201201250042.html">AllAfrica.com, 24 January 2012</a> <h3>Kenya: Circumcised men and partners more promiscuous, less likely use condoms</h3> NAIROBI, 23 January 2012 A small Kenyan study has found that more women than men feel HIV is a less serious threat after their male partners are circumcised. The University of Illinois Chicago School of Public Health study of 51 young women was presented in December 2011 in Addis Ababa, Ethiopia, at the 16th International Conference on AIDS and Sexually Transmitted Infections in Africa. It found that more women than men were likely to perceive HIV as a less serious threat: 51 per cent of men compared with 76 per cent of female participants. Women were also more likely to believe that condoms were ‘less necessary” after circumcision: 4 per cent of men compared with 51 per cent of female participants. Significantly more women than men said after circumcision, they were more likely to have more than one sexual partner: (22 per cent of women compared with 2 per cent of men) and to have sex without a condom (28 per cent of women compared with 2 per cent of men. <a href="http://www.plusnews.org/report.aspx?reportid=94703" rel="noopener" target="_blank">PlusNews, 23 January 2012</a> <h3>Zimbabwe: Circumcision a “canal for new HIV infections”</h3> HARARE - Male circumcision is becoming a canal for new HIV infections as men are now reluctant to use condoms on the basis that they are 60 percent safe, a government official has said. MDC deputy spokesman and legislator for Bulawayo East Thabitha Khumalo said while circumcision was good in reducing the risk of HIV infections in men, the emphasis should be on the use of condoms [rather] than circumcision in order to save both men and women. Circumcision and the use of condoms, Khumalo said, should be used together if Zimbabwe’s goal of Zero to new HIV infections and Zero to HIV related deaths by 2015 is to be attainable. “We have a huge challenge where male circumcision has created a canal to those who do not want to use condoms. People should understand that circumcision is not a cure, it is just a way to help reduce the risk of infections, together with the use of condoms,” said Khumalo. Women will be the most affected because they have limited methods of protecting themselves. According to Khumalo, sub-Saharan Africa still records the highest figures of new infections with about 7,000 estimated infections, despite the increase in the numbers of men who are getting circumcised. More than 40,000 Zimbabwean adult men, according to reports, have been circumcised since the program began in 2010 and 100,000 more are expected to undergo circumcision by the end of 2012. Zimbabwe has set a goal of circumcising 1.2 million men by 2015. Sinokuthemba Xaba, Zimbabwe’s national male circumcision co-ordinator told the state media that approximately 11,000 men were circumcised by December 2010, with over 20,000 having been circumcised this year alone. He said preparations were under way for the launch of a neo-natal circumcision program, where the medical procedure will be performed free of charge on male babies as soon as they are born. In August, government started an ambitious program aimed at male cabinet ministers, MPs and councilors to undergo circumcision. Deputy Prime Minister Thokozani Khupe said research had shown that circumcised men are eight times less likely to contract HIV. <a href="http://dailynews.co.zw/index.php/news/34-news/6026-circumcision-canal-for-new-hiv-infections.html" rel="noopener" target="_blank">Daily News (Zimbabwe), December 15, 2011</a> Comment The fact that Zimbabwe is a crumbling semi-fascist kleptocracy run by a crazed dictator may help explain why the government is so confident that these targets will be met. If persuasion and bribes don’t work, there is always coercion, at the point of a gun if necessary. One wonders where Mr Khupe cooked up his wild claim that circumcised men are 8 times more likely to contract HIV; even at their most extravagant, the promoters of the African circumcision trials never claimed more than a 60 per cent reduction in risk – meaning that a circumcised man who continued to practise unprotected intercourse with infected partners would take a bit more than twice as long to get infected. But in a dictatorship, of course, as Jo Stalin convincingly showed, statistics are simply manufactured for any purpose for which they may temporarily be required. Epidemiological studies show that in Zimbabwe 2005-06 the incidence of HIV among circumcised men was 20 per cent, but only 19 per cent among uncircumcised men. In fact, throughout Africa, <a href="https://www.circinfo.org/Garenne_HIV.html">as French epidemiologist Michel Garenne has shown</a>, there is no consistent evidence that uncircumcised men are more vulnerable to HIV infection. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource HIV/AIDS: condoms more effective and circumcision reduces condom use darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h1>Australia is not Africa: Neonatal circumcision plan unscientific, irrelevant and unethical</h1> In their celebrated opinion piece ("Editorial") published in the Medical Journal of Australia on 19 September 2010, Cooper, Wodak and Morris propose near universal 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 significantly reduce the risk of a male’s acquiring HIV during unprotected sexual intercourse with an infected female partner. There are many objections to such a proposal. The most important 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. Lacks scientific rigour The proposal lacks scientific rigour because it uses hyperbolic language in describing circumcision as a “surgical vaccine”, when it is nothing of the sort; [2] misrepresents the risk of a person acquiring HIV in Australia; ignores African and other critiques of the clinical trials and the manner in which WHO recommendations arising from them have been implemented; [3, 4] and slides over the fact that it will be many years before we can know whether the current African circumcision programs have reduced HIV population prevalence, and consequently incidence, as hoped. Irrelevant to Australia's AIDS problem The proposal is irrelevant because Australia is not sub-Saharan Africa, where HIV is a generalised epidemic spread throughout the population and transmitted largely by heterosexual intercourse. [5] In Australia, AIDS is a relatively low prevalence disease, largely contained within the specific sub-cultures where it has always been found: mostly homosexual men (80 per cent), plus a very small population of injecting drug users (4 per cent). [6] The proposal is not so misguided as to suggest that these categories would receive any protection from circumcision, but relies instead on the small incidence of heterosexual transmission - currently running at a very low level. Indeed, the incidence of female to male heterosexual transmission of HIV (the only situation where here is evidence of circumcision having any protective effect) is so low in Australia that the idea of introducing universal circumcision is hardly worth even debating: to call it a case of using a steam hammer to crack a nut is putting it mildly. According to figures released for 2008, [6] only 13.5 per cent of newly diagnosed infections were due to heterosexual transmission, and 59 per cent of these were attributed to people from and/or those who had sex with people from a high prevalence country. Of the actual incident infections (people provably infected within the previous twelve months) only 10.7 per cent were attributable to heterosexual contact. Indeed, 83 per cent of incident infections occur where they have traditionally been found – among gay men. [6] Cooper, Wodak and Morris suggest that the incidence of female-to-male transmission is increasing, but the numbers are still very small (e.g. 18 men newly heterosexually infected in 2008), and the rate of increase is very slow when the 28-year stretch of the Australian epidemic is taken into account (16 men newly heterosexually infected in 2006, 16 in 2004, 12 in 2000). There is no evidence that uncircumcised men are over-represented in this group. Is it really a constructive health initiative to circumcise 128,000 boys each year merely to halve these tiny numbers? The proposal is also 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. Violates principles of evidence-based medicine 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, 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. One possible expression of the policy might be that sexual health advice targeted at this category of men would include circumcision as a prophylactic option among a comprehensive range of sexual health offerings, as the WHO policy has recommended. But this is not what Cooper, Wodak and Morris propose. What they prescribe is that parents be advised to circumcise their boys as neonates 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, since the risk reduction promised by the African data is only partial: somewhere between 38 and 66 per cent. [7] 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 Perera et al. point out, [8] moreover, the African trials on which Cooper, Wodak and Morris rely involved sexually active adult men, not infants, and there is actually no hard evidence that neonatal circumcision has any protective effect against HIV. Arguments concerning other possible, non HIV-related benefits of circumcision (all contested in the literature and rejected by paediatric authorities) are irrelevant in relation to HIV infection itself. In sum, the prescription offered has very little connection with the evidence cited. Violates principles of medical ethics and human rights But even if the proposal were relevant to the Australian situation, to be ethically acceptable a medical intervention must pass the five tests proposed by Beauchamp and Childress: Beneficence — Does the proposed procedure provide a net therapeutic benefit to the patient, considering the risk, pain, and loss of normal function? Non-maleficence — Does the procedure avoid permanently diminishing the patient in any way that could be avoided? Proportionality — Will the final result provide a significant net benefit to the patient in proportion to the risk undertaken and the losses sustained? Justice — Will the patient be treated as fairly as we would all wish to be treated? Autonomy — Lacking life-threatening urgency, will the procedure honour the patient’s right to his or her own likely choice? Could it wait for the patient’s assent? [9] Cooper, Wodak and Morris ignore ethical and human rights issues, but their proposal would not be acceptable in a country such as Australia unless it were established that non-therapeutic circumcision of non-consenting minors were permissible within the above guidelines. It has been persuasively argued that in the absence of a life-threatening disorder, surrogate consent for non-therapeutic surgery of this type is not ethically permissible and may not even be legally valid. [10, 11] References 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 (6): 318-319 2. Green LW, McAlister RG, Peterson KW, Travis JW. <a href="http://www.futuremedicine.com/doi/full/10.2217/17469600.2.3.193">Male circumcision is not the surgical vaccine we have been waiting for</a>, Future HIV Therapy 2008; 2 (3): 193-199 3. Myers A, Myers JE. Editorial: <a href="http://www.historyofcircumcision.net/index.php?option=content&task=view&id=85">Rolling out male circumcision as a mass HIV/AIDS intervention seems neither justified nor practicable</a>, South African Med J 2008; 98 (10): 781-782 4. Van Howe RS, Svoboda JS. <a href="https://www.circinfo.org/vanhowe1.html">Neonatal circumcision is neither medically necessary nor ethically permissible: A response to Clark et al</a>. Medical Science Monitor 2008; 14 (8) LE7-13 5. James Chin, <a href="http://www.h-net.org/reviews/showrev.php?id=13865">The AIDS Pandemic: The Collision of Epidemiology with Political Correctness</a>. Oxford: Radcliffe Publishing, 2007 6. National Centre in HIV Epidemiology and Clinical Research. HIV/AIDS, viral hepatitis and sexually transmissible infections in Australia,<a href="http://www.nchecr.unsw.edu.au/NCHECRweb.nsf/page/Annual+Surveillance+Reports"> Annual Surveillance Report 2009</a>. National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, NSW: Tables 1.1.1 and 1.2.1. 7. Siegfried N, Muller M, Deeks JJ, Volmink J. Male circumcision for prevention of heterosexual acquisition of HIV in men. Cochrane Database of Systematic Reviews 2009; Apr 15; (2): CD003362 8. Perera CL, Bridgewater FHG, Thavaneswaran P, Maddern GJ, <a href="https://www.circinfo.org/newsindepth.html#benefit">Safety and efficacy of nontherapeutic male circumcision: A systematic review</a>. Ann Fam Med 2010; 8 (1): 64-72 9. Beauchamp TL and Childress JF. Principles of Biomedical Ethics 1977; 6th edn, Oxford University Press, 2009, Part II 10. Svoboda JS, Van Howe RS, Dwyer JG. <a href="http://www.cirp.org/library/legal/conundrum/">Informed consent for neonatal circumcision: An ethical and legal conundrum</a>. J Contemp Health Law Policy 2000; 17: 61-133 11. Tasmania Law Reform Institute. <a href="http://www.law.utas.edu.au/reform/">Non-therapeutic male circumcision</a>. Issues Paper No. 14. Hobart: June 2009 </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource HIV/AIDS: circumcision irrelevant, unscientific and unethical darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h1>The new bogeyman</h1> 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, <a href="http://www.afao.org.au/library_docs/policy/Circumcision07.pdf">Male circumcision has no role in the Australian AIDS epidemic</a>. <h3>Cooper, Wodak, Morris call to boost circumcision rate to control HIV: Irrelevant and improper</h3> 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. <a href="https://www.circinfo.org/Circumcision_and_HIV-AIDS.html">Read full reply here: Australia is not Africa: Neonatal circumcision plan unscientific, irrelevant and unethica</a><a href="https://www.circinfo.org/Circumcision_and_HIV-AIDS.html">l.</a> 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<a href="http://www.gmfa.org.uk/londonservices/research/index"> Full text available here</a>. 2. For example, Richters J, Smith AMA, de Visser RO, et al.<a href="http://www.cirp.org/library/general/richters1/"> Circumcision in Australia: prevalence and effects on sexual health</a>. Int J STD AIDS 2006;17:547–54 Further articles available <a href="http://www.cirp.org/library/disease/HIV/">at CIRP HIV page.</a> The full text of the AFAO statement is printed below <h3> <a id="afao" name="afao"></a>Male circumcision has no role in the Australian HIV epidemic</h3> 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 <a href="/cdn-cgi/l/email-protection#127374737d527374737d3c7d60753c7367">[email protected]</a> <a href="http://www.afao.org.au/">www.afao.org.au</a> Briefing paper, 23 July 2007 Male circumcision has no role in the Australian HIV epidemic Key points <ul> <li> There is no demonstrated benefit of circumcision in men who have sex with men. </li> <li> Correct and consistent condom use, not circumcision, is the most effective means of reducing female-to-male transmission, and vice-versa. </li> <li> African data on circumcision is context-specific and cannot be extrapolated to the Australian epidemic in any way. </li> </ul> 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: <ul> <li> A partially effective technology may adversely affect condom use and negotiation. </li> <li> Partial efficacy is a difficult concept to communicate to obtain informed consent. </li> <li> Risk behaviour may increase as a result of perceived invulnerability to infection. </li> <li> Women aged 15-24 are at the greatest risk of HIV acquisition and circumcision and circumcision. </li> <li> programs will not reduce infections in women directly for at least 10-20 years. </li> <li> Circumcision may reduce women’s ability to negotiate condom use. </li> <li> Circumcision is a complex cultural practice. </li> <li> Circumcision status may become a marker of HIV status, as circumcision of HIV positive men is not being proposed. </li> <li> Ritual circumcision itself may be a route of HIV transmission. </li> <li> 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] </li> <li> Circumcision has a 2-10% incidence of complications. </li> <li> If circumcised men have sex before wound-healing their vulnerability to HIV infection increases. </li> </ul> 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 <a href="http://www.afao.org.au/">www.afao.org.au</a> <h3>British study finds higher incidence of HIV in circumcised men</h3> 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 <a href="http://www.sigmaresearch.org.uk/downloads/report02d.pdf">http://www.sigmaresearch.org.uk/downloads/report02d.pdf</a> <h2> <a id="relevance" name="relevance"></a>African health crisis is not an argument for circumcision in developed countries</h2> “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 <a href="http://www.historyofcircumcision.net/index.php?option=content&task=view&id=76">review in Archives of Sexual Behaviour</a>, Vol. 34, December 2005). <h3>Africa is not Australia</h3> 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. <h3>Circumcision as AIDS control strategy unlikely to be effective in real world situation</h3> 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. <a href="https://www.circinfo.org/Garenne_HIV.html">Read full paper here</a> <a href="http://www.historyofcircumcision.net/index.php?option=com_content&task=view&id=63&Itemid=52">Further details on “Solving the Negro rape problem”</a> <a href="http://jme.bmj.com/cgi/eletters/27/6/DC1">Further information on ethical aspects of prophylactic surgery as a disease control strategy on low income countries</a> 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, <a href="http://www.circumstitions.com/HIV.html#gaysurvey">Know the score: Findings from the National Gay Men’s Sex Survey</a> (London 2001); Laumann, EO, Masi CM, Zuckerman EW. <a href="http://www.cirp.org/library/general/laumann/">Circumcision in the United States: Prevalence, Prophylactic Effects, and Sexual Practice</a>. 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, <a href="http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0020124">“Why Most Published Research Findings Are False”</a>, Plos Medicine, Vol. 8, 2005. <h3>HIV: It’s what you do, not what you have, that counts</h3> 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). <h3>Comment from an AIDS educator</h3> 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: <a href="http://www.h-net.org/%7Ehistsex/">http://www.h-net.org/~histsex/</a> <h2> <a id="doubts" name="doubts"></a>Is the African data even useful for Africa?</h2> 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 <a href="http://www.measuredhs.com/countries/">National Health and Demographic Surveys</a>, and further information at <a href="http://www.circumstitions.com/HIV.html">Circumstitions</a>. 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 <a href="https://www.circinfo.org/africa.html">Read more about African circumcision sceptics on this site</a> <h3>Comparative studies show that education reduces HIV infection</h3> 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?, <a href="http://www.cirp.org/library/disease/HIV/moore1/">International Journal of Epidemiology, Vol. 33, 2004, pp. 542-8</a> <h3>Dangers of introducing circumcision</h3> 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: <ul> <li> a survey of its acceptability to Batswana (people of Botswana); </li> <li> its practice in certain Western nations; </li> <li> its alleged value in preventing HIV infection. </li> </ul> There are several medical, psychological, sexual, social, ethical, and legal problems with this proposal. Full article here: <a href="http://www.cirp.org/library/disease/HIV/boyle-sti/">http://www.cirp.org/library/disease/HIV/boyle-sti/</a> <h2> <a id="developed" name="developed"></a>Summary: Circumcision and HIV in the developed world</h2> 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. <ul> <li> 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. </li> <li> 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”. </li> <li> 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. </li> <li> 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. </li> <li> 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. </li> </ul> 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. <h2> <a id="info" name="info"></a>Further information</h2> On this site <a href="https://www.circinfo.org/AIDSnews.html">Rising incidence of AIDS infection among circumcised men</a> <a href="https://www.circinfo.org/vanhowe1.html">Neonatal circumcision neither necessary nor ethically permissible</a> <a href="https://www.circinfo.org/africa.html">African doctors question question Bush/Gates/WHO circumcision push</a> <a href="https://www.circinfo.org/Circumcision_HIV_doubts.html">HIV-AIDS control: Growing doubts on the circumcision solution</a> <a href="https://www.circinfo.org/Circumcision_and_HIV-AIDS.html">Cooper, Wodak, Morris call to boost circumcision rate to fight AIDS: Irrelevant, unscientific and unethical</a> <a href="https://www.circinfo.org/Circumcision_condoms.html">Condoms: The real magic bullet against HIV-AIDS</a> <a href="https://www.circinfo.org/Circumcision_HIV_doubts.html">HIV-AIDS control: Growing doubts on the circumcision solution</a> <a href="https://www.circinfo.org/Garenne_HIV.html">Circumcision as AIDS control strategy: Random clinical trials and the real world</a> <a href="https://www.circinfo.org/MJA_Cooper_letters.html">The case against boosting infant male circumcision in the face of rising heterosexual transmission of HIV: Replies to Cooper et al</a> <a href="https://www.circinfo.org/Circumcision_HIV_control_Australia.html">Not a surgical vaccine: There is no case for boosting infant male circumcision to combat heterosexual transmission of HIV in Australia</a> On other sites <a href="http://www.cirp.org/library/disease/HIV/">Circumcision Information and Resource Pages</a> <a href="http://www.circumstitions.com/HIV.html">Circumstitions</a> <a href="http://www.icgi.org/">International Coalition for Genital Integrity</a> <a href="http://www.circumcisionandhiv.com/">Male circumcision and HIV: A Public Heath Policy Weblog</a> <a href="http://www.norm-uk.org/circumcision_hiv.html">Norm-UK: Circumcision an inappropriate strategy in AIDS control</a> <a href="http://www.historyofcircumcision.net/index.php?option=content&task=view&id=77">Circumcision not a silver bullet: South Africa Medical Journal</a> F M Hodges, J S Svoboda and R S Van Howe, <a href="http://www.cirp.org/library/ethics/hodges3/">Prophylactic interventions on children: balancing human rights with public health</a>, Journal of Medical Ethics, Vol. 28, No. 1, February 2002 Lawrence Green et al, <a href="http://www.futuremedicine.com/doi/full/10.2217/17469600.2.3.193">Male circumcision is not the HIV vaccine we have been waiting for</a>, Future HIV Therapy, Vol. 2, 2008 Marie Fox and Michael Thomson, <a href="http://www.cirp.org/library/legal/UKlaw/fox-ijcr-2006/">Short Changed? The Law and Ethics of Male Circumcision</a>, International Journal of Children's Rights, Vol. 13, 2006 J. Steven Svoboda, Robert Van Howe and James G. Dwyer,<a href="http://www.cirp.org/library/legal/conundrum/"> Informed Consent for Neonatal Circumcision: An Ethical and Legal Conundrum</a>, Journal Of Contemporary Health Law and Policy, Vol. 17, Fall 2000 Michel Garenne, <a href="http://www.cirp.org/library/disease/HIV/garenne1/">Male circumcision and HIV control in Africa</a>, PLoS Medicine, Vol. 3, No. 1, 31 January 2006 </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource HIV/AIDS darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> The chapter on cancer of the penis in a new edition of an authoritative Oxford textbook on cancers points out that cancer of the penis is an extremely rare disease (in fact, less common than cancer of the male breast) and that the risk factors are preventable conditions, including pathological phimosis and infection with human papilloma virus. The foreskin is not a risk factor for cancer of the penis, and circumcision does not infallibly prevent it. The summary of the chapter follows: Penile cancers are rare primary malignancies located on the glans, foreskin, or shaft of the penis, excluding the urethra. The vast majority of penile cancers are epithelial tumors representing histological subtypes of squamous cell carcinoma (SCC). Most penile SCCs are believed to develop through preinvasive lesions known as penile intraepithelial neoplasia and penile carcinoma in situ. Penile cancers account for 0.1%–0.3% of all incident cancers (excluding non-melanoma skin cancers) in the United States and other developed countries and up to 1% of all cancers in some countries in sub-Saharan Africa. Annual incidence rates per 100,000 men (world standardized) are typically between 0.3 and 1.0 in developed countries, being 0.5 in the United States. During 2002– 2011, SEER data showed rather stable penile cancer rates with no statistically significant changes in incidence or mortality. Being rare in men younger than 40 years, penile cancers are typically diagnosed among men above age 60. The 5-year relative survival rate after penile cancer was 67% for all stages combined in US patients recorded in SEER registries during 2004–2010, with foreskin cancers having a more favorable prognosis than cancers at other penile sites. The two most important risk factors for penile cancer are pathological phimosis and infection with high-risk types of human papillomaviruses (HPV), which are both preventable conditions. Non-surgical strategies to reduce the frequency of pathological phimosis need consideration, particularly because rates of newborn circumcision are declining in the United States and elsewhere. Increased awareness among doctors and parents about the importance of non-interference with the physiological foreskin separation process in young boys, and the promotion of safe-sex practices, possibly combined with preadolescent gender-neutral HPV vaccination programs, will likely reduce the frequencies of pathological phimosis and sexually acquired HPV infections and, eventually, reduce the burden of penile cancer at the population level. Source: Frisch M. 2018. Penile Cancer. In: Thun M J, Linet M S, Cerhan J S, Schottenfeld D (Eds.), Cancer Epidemiology and Prevention (4th ed., pp. 1029-1038). Oxford University Press, New York. <a href="https://www.researchgate.net/publication/320958631_Penile_Cancer" rel="noopener" target="_blank">Full text available here</a> <h2> <a id="smegma" name="smegma"></a>Smegma is not carcinogenic</h2> Despite the importance of avoiding smegma so frequently stressed by enthusiasts for routine circumcision, there is no evidence at all that smegma is harmful. Why would it be? It's just a natural secretion like saliva, found in the genitals of both males and females. <a href="http://www.cirp.org/library/disease/cancer/vanhowe2006/">The carcinogenicity of smegma: Debunking a myth</a> RS Van Howe,* FM Hodges‡ *Department of Pediatrics, Michigan State University School of Human Medicine, Marquette, MI and ‡Berkeley, CA, USA, in Journal of the European Academy of Dermatology and Venereology, Vol. 20, 2006, pp. 1046-1054 Abstract Background: Smegma is widely believed to cause penile, cervical and prostate cancer. This nearly ubiquitous myth continues to permeate the medical literature despite a lack of valid supportive evidence. Methods: A historical perspective of medical ideas pertaining to smegma is provided, and the original studies in both animals and humans are reanalysed using the appropriate statistical methods. Results: Evidence supporting the role of smegma as a carcinogen is found wanting. Conclusions: Assertions that smegma is carcinogenic cannot be justified on scientific grounds. Extract from the conclusion The evidence does not support the theory that smegma is a cause of genital cancer. The smegma theory of disease was best stated by Boczko and Freed: "Smegma, a sterol, produced by Tyson’s glands in the epithelium of the retroglandular sulcus, has been implicated as the causative agent. It may be converted to a carcinogen by the action of the Mycobacterium smegmatis." [69] From the medical literature we have found that smegma is not a sterol, that there are no Tyson’s glands, that smegma is not converted to a carcinogen by M. smegmatis, and that M. smegmatis is not part of the normal genital flora. The myth is sustained only by its popularity among circumcision advocates. Some have extrapolated the smegma theory by hypothesizing that men with inadequate circumcisions may be at risk for cancer because smegma can accumulate under any foreskin remnants. [70] In similar fashion, Abraham Ravish expanded the smegma theory to indict smegma as the cause of prostate cancer by travelling upstream through the urethra to invade the prostate gland. [71] Davis-Daneshfar and Trueb speculated that chronic infection with M. smegmatis is the cause of plasma cell (Zoon’s) balanitis, [72] but Yoganathan et al. could not isolate the organism in any of their cases. [73] Some have shown an unwillingness to abandon the smegma theory. When it was postulated that sperm proteins caused cervical cancer, it was the smegma mixing with the sperm proteins that were to blame. [74] When diaphragm use was found to decrease cervical cancer, it was postulated that it provided a barrier to contact with smegma. [75] When it was clear that cervical cancer resulted from a viral infection, some still postulated that smegma was a necessary part for the viral exposure to be carcinogenic. [45] Those promoting the ‘cocoon’ theory prefer to think of smegma as a cofactor in the development of penile cancer. There are two reasons to dismiss this speculation. First, there is no scientific evidence to support the assertion. Second, it is analogous to declaring saliva a cofactor in the development of lip cancer in those who chew tobacco. Both saliva and smegma are bodily fluids that serve a function and, like any other bodily fluid, are present in organs than can develop a malignancy. The purpose of the scientific method is to distinguish between wishful thinking, strongly held pinion, and provable fact. The smegma theory of disease, which began as wishful thinking on the part of circumcision zealots such as Abraham Wolbarst and Abraham Ravich, has evolved into irrefutable dogma, but as modern physicians, we need to recognize that, until proved otherwise, smegma is harmless. References 69. Boczko S, Freed S. Penile carcinoma in circumcised males. N Y State J Med 1979; 79: 1903–1904. 70. Culp D. Penile cancer. J Iowa Med Soc 1973; 63: 201–202. 71. Ravich A, Ravich RA. Prophylaxis of cancer of the prostate, penis and cervix by circumcision. N Y J Med 1951; 51: 1519– 1520. 72. Davis-Daneshfar A, Trueb RM. Bowen’s disease of the glans penis (erythroplasia of Queyrat) in plasma cell balanitis. Cutis 2000; 65: 395–398. 73. Yoganathan S, Bohl TG, Mason G. Plasma cell balanitis and vulvitis (of Zoon). A study of 10 cases. J Reprod Med 1994; 39: 939–944. 74. Sandler B. Sperm basic proteins in cervical carcinogenesis. Lancet 1978; 2: 208–209. 75. Sandler B. Contraceptives and cervical carcinoma. Br Med J 1969; 1: 356–357. <a href="http://www.cirp.org/library/disease/cancer/vanhowe2006/">Full text available from CIRP.</a> Why mice don't live in the foreskins of horses The article by Boczko and Freed relied heavily on an eccentric experiment from 1947 in which A. Plaut and A. C. Kohn-Speyer tried to induce cancer in mice by doses of smegma harvested from horses. Despite persistent applications, it appears that they were successful in producing cancerous lesions in only about 60 of 400 victims, and I say “appears” because the presentation of their results is so confusing that it is very difficult to work out just what the results were. They also reported that up to 500 days the smegma-treated mice actually fared better than those who missed out: a survival rate of 47% and 30% respectively. Had they stopped the experiment at that point they would have been forced to conclude that horse smegma boosted mouse health. The most one can say about this preposterous exercise is that it explains one of the great puzzles of zoology: why mice don't live inside equine prepuces. Plaut A, Kohn-Speyer AC. Carcinogenic action of smegma. Science 1947; 105: 391–392. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Foreskin: not a risk factor for penile cancer darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> For men deprived of and missing their foreskin - either because it was taken without their consent when they were babies, or because they made a big mistake as an adult - there have been only two ways to cope with the loss: grin and bear it (and maybe not admit that there was a loss, like the fox who lost his tail), or attempt restoration by slowly stretching the remnant foreskin tissue. In the early years A.D. this method was used by young Jewish men who wanted to appear uncircumcised and thus take a greater part in Hellenic social life; but the method was slow, and would work well only if there was a fairly large quantity of foreskin tissue left to stretch. Men who had suffered a really tight circumcision had a far more difficult and often impossible task. But recent advances in regenerative medical techniques are now offering hope that it may be possible to regrow the foreskin, nerves and all, and restore it to something like what it would have been naturally. It is only an idea as yet, but similar techniques using stem cells have been successfully used to regrow some internal organs, and there are reports of successful vaginal reconstructions using similar methods. For the present the organisation behind the initiative, Foregen, is seeking to raise funds for further research and a pilot program. Where is the Gates Foundation when you need it? After providing hundreds of millions of dollars to circumcise Africans, the least it could do is offer a few hundred thousand to repair the damage. After all, when the HIV crisis is over and AIDS can be prevented or cured, many of those men may want their foreskins back. IntactNews recently interviewed Vincenzo Aiello, the founder of Foregen, a non-profit organization raising funds for foreskin regeneration using the latest regenerative medicine technologies. Foregen’s ambition is to provide foreskin regeneration surgeries for men who were circumcised without their consent. <a href="https://www.circinfo.org/Foreskin_restoration.html">Read the full interview here</a>. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Foreskin: new technologies offer restoration hope to circumcised men darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h1>AAP waves white flag as Vikings storm fortress circumcision</h1> The case for circumcision has been dealt a final, fatal blow. Danish research showing that the vast majority of normal (uncircumcised) boys never experience any “foreskin problems”, and that only a tiny minority of boys with a problem require circumcision to fix it, has forced the American Academy of Pediatrics to admit that the case for routine (prophylactic) circumcision is empty and bankrupt. The key facts from the paper by Ida Sneppen and Jorgen Thorup, are as follows: <ul> <li>5% of boys (aged 0-18) experienced a foreskin-related problem (mainly phimosis, BXO and frenulum breve).</li> <li>1.7% of boys required surgery to correct the problem.</li> <li>0.4% of boys required circumcision to correct the problem.</li> </ul> <h2>95 per cent of uncircumcised boys will never experience a foreskin problem</h2> What this really means is that: <ul> <li>95% of boys will never experience a foreskin problem.</li> <li>More than 98% of boys will not need foreskin-related surgery (mainly because most foreskin problems, especially phimosis, can be addressed by non-surgical means, such as topical medication).</li> <li>Only a tiny minority of boys (less than half a per cent) will need to be circumcised because their particular foreskin problems are not amenable, or did not respond, to medical treatment.</li> </ul> The paper also noted that meatal stenosis (narrowing of the urethral opening) is 3 times more common in circumcised boys. This website <a href="https://www.circinfo.org/news_2012.html#au93" rel="noopener" target="_blank">pointed out</a> some years ago that 93% of Aussie boys would never experience a foreskin problem, and thus that routine circumcision makes no medical sense at all. This latest, comprehensive Danish study confirms this assessment, and further shows that only a small minority of the unlucky few who do experience problems will require surgery. The case for precautionary circumcision in advance is now well and truly dead and buried. Source: Ida Sneppen and Jorgen Thorup, <a href="http://pediatrics.aappublications.org/content/early/2016/04/04/peds.2015-4340" rel="noopener" target="_blank">Foreskin morbidity in uncircumcised males</a>, Pediatrics 137 (5), May 2016. Advance access 6 April 2016 <h3>Waving the white flag:</h3> <h2>Astonishing admissions from American Academy of Pediatrics</h2> In response to this devastating avalanche of scientific evidence, the AAP has more or less conceded that its 2012 circumcision policy was not really concerned with the medical case for circumcision at all, but with cultural and religious issues. In an editorial accompanying the Sneppen/Thorup paper, Andrew Freedman, a member of the circumcision policy taskforce, makes the following amazing admissions: <ul> <li>Circumcision is basically and usually a religious or cultural preference on the part of the parents, not a medical decision.</li> <li>Parents and medical advisers use medical evidence selectively to bolster their prior ideological positions on circumcision.</li> <li>We did not recommend circumcision.</li> <li>Circumcision is not necessary for optimum health.</li> <li>Underlying aim of 2012 circumcision policy was to counter proposals to prohibit non-therapeutic circumcision of minors.</li> <li>“Given the role of the phallus in our culture”, it is legitimate to consider non-medical factors in the circumcision decision.</li> <li>Not all penises have to look the same.</li> <li>The risk/benefit equation we devised (“benefits outweigh risks”) is applicable and relevant only to those who have non-medical (cultural, religious, social) reasons for circumcision.</li> </ul> Source: Andrew Freedman, <a href="http://pediatrics.aappublications.org/content/early/2016/04/04/peds.2016-0594" rel="noopener" target="_blank">The circumcision debate: Beyond benefits and risks</a>. Pediatrics 137 (5), May 2016. Advance access 6 April 2016. The obvious questions arising from Dr Freedman's admissions are: 1. If circumcision is not a medical procedure, is not recommended and is not necessary for health, and if it is primarily a religious, cultural or social ritual, how can the AAP justify its recommendation that it is legitimate for health insurance providers to fund it? 2. Given the above, plus the acknowledged non-medical significance of the penis in our culture, how can the AAP justify its assumption that it is the parents, rather than the owner of the penis, who are the appropriate parties to make the circumcision decision? We must point out that it was Freedman who, when the <a href="https://www.circinfo.org/United_States_circumcision_policy.html" rel="noopener" target="_blank">AAP policy was under attack</a> back in 2012, notoriously stated that he did not circumcise his own boys for medical reasons, but because he felt the weight of centuries of ancestors breathing down his neck. It is evidence of his continuing commitment to circumcision as a cultural/religious rite that he makes no mention of bioethical or human rights issues, such as the <a href="https://www.academia.edu/17264543/" rel="noopener" target="_blank">child’s right to an open future</a>; nor does he acknowledge that the AAP’s risk/benefit calculation <a href="https://www.academia.edu/12035421/" rel="noopener" target="_blank">has been criticised</a> as empirically false, conceptually misconceived and inadequate to the complexity of the “circumcision decision”. Despite the title of his editorial, Freedman has not gone far enough beyond “benefits and risks”. The key point is that those who have sought to advocate or defend circumcision (whether for cultural or medical reasons) on the basis that the AAP had guaranteed the soundness of the health case in its favour now find that the cheque has bounced. The fact is that the AAP bank account is empty. The last remaining bastion of respectable circumcision advocacy has been the American Academy of Pediatrics; now that their fortress has been stormed by a devastating Viking raid, the case for circumcision is well and truly on its last legs. <h2>Importance of correct foreskin management</h2> One reason why the incidence of foreskin problems among Danish boys is so low is that Danish parents and doctors understand No I rule for managing the infant foreskin: leave it alone! Because circumcision never became established in Denmark, there was no loss of knowledge as to the nature of the foreskin and its natural development from infancy to puberty and adulthood. In anglophone countries, by contrast, the wide practice of routine circumcision led to a loss of medical knowledge about the foreskin and the growth of the myth that it should be retractable by age 3 at the latest, and even the harmful idea that it should be pulled back “for cleaning” as soon as possible, as the ignorant American obstetrician Alan Guttmacher wrote in 1941: “Present-day hygiene requires that the foreskin, the hoodlike fold of skin which covers the end of the penis (glans) be drawn back daily and the uncovered glans thoroughly washed.” ** This is wrong, wrong, wrong, and nothing more than a revival of a medical myth that developed in the late Victorian period. Its description of the foreskin is also wrong: the foreskin is not a bit of skin that covers the end of the penis, but rather a substantial and integral part of the penis. In most cases the infant foreskin is self-cleaning and should never be retracted for “hygiene” or any other purpose. Such misguided ministrations are likely to be very painful for the boy and to cause tears and lacerations that may require surgery later. A common cause of foreskin problems in infancy and childhood are efforts to pull the foreskin back before it is ready. Boys whose foreskins are not retractable are often said to be experiencing phimosis, but in most cases the phimosis (inability to uncover the glans) is a natural developmental stage that will resolve itself as the boy matures. Genuine phimosis is usually associated with pathological conditions, such as lichen sclerosus (balanitis xerotica obliterans), but such cases are rare and usually respond to medical treatment. ** Alan Guttmacher, Should the baby be circumcised? Parents Magazine, September 1941, 26. <a href="https://www.circinfo.org/Foreskin_care.html">Advice on foreskin care and maintenance</a> <a href="https://www.circinfo.org/phimosis.html">Advice on phimosis</a> <h2> <a id="effect" name="effect"></a>Effect of circumcision on incidence of sexually transmitted infections & cancer</h2> OK, you may be thinking that even if very few uncircumcised boys experience a foreskin-related disability when young, but what about the other supposed health benefits of circumcision emphasised by the AAP and other advocates, such as reduced risk of sexually transmitted infections as an adult. We have sought to put that canard to rest as a piece of medical folklore on several occasions, but it persists. To show how wrong it is, here are comparative statistics for HIV, gonorrhoea and syphilis in (uncircumcised) Denmark compared with the (circumcised) United States: HIV-AIDS Denmark: 0.1-0.2% (2014, adults 15-49) http://www.unaids.org/en/regionscountries/countries/denmark United States: 0.4-0.9% (2012) http://www.unaids.org/en/regionscountries/countries/unitedstatesofamerica/ Gonorrhoea Denmark: 12.1 per 100,000 (2012) http://ecdc.europa.eu/en/publications/Publications/sexually-transmited-infections-HIV-AIDS-blood-borne-annual-epi-report-2014.pdf United States: 110.7 per 100,000 (2014) http://www.cdc.gov/std/stats14/std-trends-508.pdf Syphilis Denmark: 6.1 per 100,000 (2012) http://ecdc.europa.eu/en/publications/Publications/sexually-transmited-infections-HIV-AIDS-blood-borne-annual-epi-report-2014.pdf United States: 6.3 per 100,000 (2014) http://www.cdc.gov/std/stats14/std-trends-508.pdf So the (circumcised) United States has 4 times the level of HIV, and 10 times the level of gonorrhoea as (uncircumcised) Denmark. This suggests that the foreskin is protective against, and circumcision increases the risk of, urinary tract infections such as urethritis and gonorrhoea, at least in adulthood – which is what <a href="http://www.historyofcircumcision.net/index.php?option=com_content&task=view&id=25&Itemid=51" rel="noopener" target="_blank">Jonathan Hutchinson</a> found in 1855, and <a href="https://www.circinfo.org/newsindepth.html#nsu" rel="noopener" target="_blank">Ferris et al</a> in 2010. <h3>Male breast cancer more common than cancer of the penis</h3> Nor is prevention of cancer of the penis a valid reason for circumcision. Since the days of Jonathan Hutchinson, circumcision advocates have made much of the value of circumcision in preventing cancer of the penis (Morris et al, 2011). Whether or not it does so is less significant than the fact that penile cancer is a rare disease of older men – so rare that accurate statistics on incidence are difficult to find, and so rare that it is even less common than male breast cancer. The American Cancer Society (2016) estimates that 2600 cases of male breast cancer will be diagnosed in 2016 and that 440 men will die of it. The figures for cancer of the penis are 2030 cases and 340 deaths. If prophylactic removal of infant male breasts is not recommended as a breast cancer preventive, there is certainly no need for prophylactic removal of the foreskin as a penile cancer preventive. What are the key statistics about breast cancer in men? <a href="http://www.cancer.org/cancer/breastcancerinmen/detailedguide/breast-cancer-in-men-key-statistics" rel="noopener" target="_blank">The American Cancer Society estimates</a> for breast cancer in men in the United States for 2016 are: <ul> <li>About 2,600 new cases of invasive breast cancer will be diagnosed.</li> <li>About 440 men will die from breast cancer.</li> </ul> What are the key statistics about penile cancer? <a href="http://www.cancer.org/cancer/penilecancer/detailedguide/penile-cancer-key-statistics" rel="noopener" target="_blank">The American Cancer Society estimates</a> for penile cancer in the United States for 2016 are: <ul> <li>About 2,030 new cases of penile cancer will be diagnosed.</li> <li>About 340 men will die from penile cancer.</li> </ul> </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Foreskin: 95% of boys never have a problem darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> Although the World Health Organisation has hailed circumcision as the "great white hope" against AIDS and poured billions into programs of mass circumcision of African men, many Africans, including doctors, are sceptical of the effectiveness, the ethics and the cost of such a strategy. On this page we summarise papers recently published in African medical journals and provide an update on South African efforts to protect boys from circumcision. Oddly enough, despite the advice of the new white witchdoctors, South Africa is one of the very few countries to have passed legislation making it an offence (in certain circumstances) to circumcise a minor. <h2> <a id="criticise" name="criticise"></a>Circumcision and HIV infection: African doctors wonder</h2> Clutching at straws to control the African HIV/AIDS epidemic has included strident advocacy for circumcision of males (MC) from some (mainly American) quarters, especially following three trials held in South Africa, Kenya and Uganda in 2006-2007. These seemed to show that circumcision did have a limited protective effect, and they were quickly hailed by the circumcision lobby as justifying an immediate “roll-out” of a massive circumcision campaign. Three contributions in the October 2008 edition of the South African Medical Journal, including an editorial, vigorously contest the usefulness, cost and ethics of circumcision in the prevention of HIV and condemn the indecent haste with which the Word Health Organisation, under pressure from American money, has sought to enforce mass circumcision on African men. <h3>1. South Africa: No difference in HIV incidence between cut and uncut men</h3> Objective. To investigate the nature of male circumcision and its relationship to HIV infection. Methods. Analysis of a sub-sample of 3,025 men aged 15 years and older who participated in the first national population based survey on HIV/AIDS in 2002. Chi-square tests and Wilcoxon rank sum tests were used to identify factors associated with circumcision and HIV status, followed by a logistic regression model. Results. One-third of the men (35.3%) were circumcised. The factors strongly associated with circumcision were age >50, black living in rural areas and speaking SePedi (71.2%) or IsiXhosa (64.3%). The median age was significantly older for blacks (18 years) compared with other racial groups (3.5 years), p <0.001. Among blacks, circumcisions were mainly conducted outside hospital settings. In 40.5% of subjects, circumcision took place after sexual debut; two-thirds of the men circumcised after their 17th birthday were already sexually active. HIV and circumcision were not associated (12.3% HIV positive in the circumcised group v. 12% HIV positive in the uncircumcised group). HIV was, however, significantly lower in men circumcised before 12 years of age (6.8%) than in those circumcised after 12 years of age (13.5%, p=0.02). When restricted to sexually active men, the difference that remained did not reach statistical significance (8.9% v. 13.6%, p=0.08.). There was no effect when adjusted for possible confounding. Conclusion. Circumcision had no protective effect in the prevention of HIV transmission. This is a concern, and has implications for the possible adoption of the mass male circumcision strategy both as a public health policy and an HIV prevention strategy. <a href="http://www.samj.org.za/index.php/samj">Full article here</a>. PDF available on request. Catherine Connolly, Leickness C Simbayi, Rebecca Shanmugam, Ayanda Nqeketo, Male circumcision and its relationship to HIV infection in South Africa: Results of a national survey in 2002, South African Medical Journal, Vol. 98, No. 10, October 2008 <h3>2. Neonatal circumcision does not reduce HIV/AIDS infection rates</h3> A second article by Sidler et al argues that there are profound objections on grounds of effectiveness, cost and ethics to the use of circumcision as a a tactic against AIDS. The article opens as follows: Non-therapeutic, non-religious circumcision is the surgical procedure most commonly published about, but for which substantive indications are lacking. Since its introduction to the USA during the Victorian period, when it was thought that it prevented masturbation, medical justifications for the procedure progressed to prevention of various infective conditions (sexually transmitted diseases, penile and cervical cancer) and controlling of the sexual drive. Recent Joint United Nations Programme on HIV/AIDS/World Health Organization (UNAIDS/WHO) policy proposes male circumcision for the prevention of HIV/AIDS. HIV/AIDS in Africa is mainly spread by multiple concurrent heterosexual relationships, compounded by female subjugation and poverty. Condoms, although highly protective, are infrequently used, particularly among circumcised males. The HIV/AIDS crisis demands extraordinary curtailment measures. It is, however, questionable how circumcision, and particularly neonatal circumcision, could achieve such a goal. A rational and critical analysis of the scientific evidence ought to conclude that non-therapeutic infant circumcision is merely the medicalisation of an old ritual that should not, in the 21st century, be advocated as prevention strategy for HIV/AIDS. Repeated publications of matching opinions do not necessarily lead to solid scientific evidence and policies. They rather suggest that the peer review process of journal publication may be unreliable. Information overload can cause limitations, for example influencing expert and public opinion with ideological and pseudoscientific content. This context and such therapeutic misconceptions contribute to circumcision still being practised as a non-therapeutic infant procedure. This mainly applies to English-speaking countries, where circumcision appears to have become a medicalised ritual. In contrast, in Europe non-therapeutic circumcision is not the norm. Many reviews question the necessity of non-therapeutic infant circumcision, showing it to have neither short- nor long-term medical benefits. It has been suggested that parents should be granted responsibility and final decision making authority after having thoroughly considered all the relevant facts. The reported increase in demand for preventive circumcision, long before publication of results of the three randomised controlled trials (RCTs) in South Africa, Kenya and Uganda that have shown that circumcision is partially protective against HIV, suggests that informed proxy consent, within the context of the HIV/AIDS epidemic and the prevalence of poverty and ignorance, has to be seriously questioned. The desperate hope and need for action of people ravaged by HIV/AIDS, rather than solid scientific evidence, may be driving the increased demand for preventive circumcision. A recent Centers for Disease Control (CDC) and WHO report confirms previous reports that circumcision does not prevent sexually transmitted diseases (STDs). <a href="http://articles.mercola.com/sites/articles/archive/2004/03/10/std-rates.aspx">Teens 15 years and older in the USA</a> have the highest rate of STDs in any industrialised country and half will contract a sexually transmitted disease by age, despite two-thirds of young males having been circumcised. Such reports suggest that the social experiment of circumcision to prevent STDs, including HIV, has already failed in the USA, which has the highest rate of non-therapeutic infant circumcision in industrialised countries and the highest rate of HIV in the developed world. <a href="http://www.samj.org.za/index.php/samj">Rest of article here with references</a>. PDF available on request Conclusion Male non-therapeutic infant circumcision is neither medically nor ethically justified as an HIV prevention tool. Circumcision is not equivalent to successful immunisation, is being practised with decreasing frequency in English-speaking countries, and is becoming illegal in South Africa under the new Children’s Act. There are far more effective prevention tools costing considerably less and offering better HIV reduction outcomes than circumcision. Finally, the WHO and UNAIDS appear to be basing these multi-million-dollar prevention programmes on limited and in some instances biased information. In order to prevent confusion and parents making misguided decisions on behalf of their infants, and to offer effective help in alleviating the suffering that is being created by HIV/AIDS, a much broader review process would be called for. Such a process would involve more objective scientific opinion, and the involvement of a representative panel of African experts, such as paediatric surgeons and neonatologists. D Sidler, J Smith, H Rode, Neonatal circumcision does not reduce HIV/AIDS infection rates, South African Medical Journal, Vol. 98, No. 10, October 2008, 764-766 <h3>3. Editorial: Rolling out male circumcision as a mass HIV/AIDS intervention seems neither justified nor practicable</h3> Two articles [1, 2] published in this issue address male circumcision (MC). Connolly et al.1 show in a national survey that MC, whether pre-pubertal or post-pubertal, has no protective effect on acquisition by males of HIV infection as measured by prevalence. Sidler et al. [2] state that neonatal MC continues to be promoted without adequate justification as a medicalised ritual, via an HIV prevention rationale. They caution that for MC to be a therapeutic as opposed to a non-therapeutic procedure, it is necessary to gather more corroborative and consistent evidence of its benefit, consider the potential harms (psychological, sexual, surgical and behavioural/disinhibition), examine the ethical implications, and examine effectiveness and efficiency (costs and benefits) at the population and societal levels. They point out that MC is not just a technical surgical intervention – it takes place in a social context that can radically alter the anticipated outcome. At the 2008 International AIDS Conference [3] in Mexico cultural, political and educational issues raised by the intervention, such as decreased condom use and marginalisation of women, were hotly debated. Some cultural interpretations may view MC as a licence to have unprotected sex. A case in point is Swaziland, where men are flocking to be circumcised with the understanding that this means they no longer need to use other preventive methods (e.g. wear condoms or limit the number of sexual partners). [4] The 2003 Cochrane review5 of observational studies of MC effectiveness concluded that there was insufficient evidence to support it as an anti-HIV intervention. Three randomised controlled trials (RCTs) from South Africa, Kenya and Uganda in 2006-2007 show a protective effect of MC. However, Garenne [6] has subsequently shown from observational data that there is considerable heterogeneity [inconsistency] of the effect of MC across 14 African countries. Despite the South African RCT showing a protective effect, he reports for the nine South African provinces that ‘there is no evidence that HIV transmission over the period 1994-2004 was slower in those provinces with higher levels of circumcision’. Interestingly, in both Kenya and Uganda, where two of the RCTs were done, a protective effect of MC was observed, but a harmful effect was observed in Cameroon, Lesotho and Malawi. The other eight countries showed no significant effect of MC. These somewhat discordant findings are difficult to interpret. While RCTs are theoretically strong designs, it is conceivable that their findings are not generalisable beyond their settings. Furthermore, there have been no trials of neonatal MC. Study flaws such as inability to obtain double blinding, and loss to follow-up in RCTs, may effectively degrade their quality to that of observational studies. Meanwhile other disturbing findings referred to by Sidler et al. are emerging, including the reported higher risk for women partners of circumcised HIV positive men, disinhibition, urological complications, relatively small effect sizes of MC at the population level, and relative cost-inefficiency of MC. Not all objections to MC as an HIV intervention have to do with evidence of effectiveness or cost. Sidler et al. raise ethical objections. Owing to the current climate of desperation with regard to the HIV epidemic, evidence in favour of MC frequently seems overstated. This reduces the scope for informed consent and autonomy for adult men considering the procedure. Further problems arise in the case of neonates whose parents may be considering the procedure. Whereas informed consent is at least possible for adult men, it is clearly not possible for neonates. Parents can only guess what the child’s wishes would be if he were presented with the information they have at their disposal. If it could be shown that circumcision was necessary in the neonatal period, parental consent on behalf of the neonate would be justified. But since no valid surgical indications for circumcision exist in this period, and the future benefit to the child in respect of HIV avoidance is not relevant before sexual debut, the duty of parents may well be to err on the side of caution, and defer the procedure until the child can make an autonomous decision. In the absence of compelling indications, a procedure such as circumcision could also be seen as a violation of the child’s right to bodily integrity. Furthermore, the ethical principle of non-maleficence cannot be upheld as there are clear harms attached to this practice, to which Sidler et al. refer in their article. Lastly, at a societal level MC may be unjust insofar as it could compete for resources with more effective and less costly interventions [7] and disadvantage women. Despite a strong pro-circumcision lobby driven by enthusiasts who have been promoting MC as an (HIV) intervention for many years, and impatience expressed by protagonists about the long delay after the 2006-2007 RCT results and the UNAIDS/WHO policy recommendations8 of March 2007, few mass campaigns have been launched in African countries. Given the epidemiological uncertainties and the economic, cultural, ethical and logistical barriers, it seems neither justified nor practicable to roll out MC as a mass anti-HIV/AIDS intervention. A Myers Humanities student, University of Cape Town J Myers School of Public Health and Family Medicine University of Cape Town Corresponding author: J Myers (<a class="__cf_email__" data-cfemail="4b2126322e39380b222a2d3922282a65282426" href="/cdn-cgi/l/email-protection">[email protected]</a>) References 1. Connolly C, Simbayi LC, Shanmugam R, Nqeketo A. Male circumcision and its relationship to HIV infection in South Africa: Results from a national survey in 2002. S Afr Med J 2008; 98: 789-794. 2. Sidler D, Smith J, Rode H. Neonatal circumcision does not reduce HIV infection rates. S Afr Med J 2008; 98: 764-766. 3. Male Circumcision: To Cut or Not to Cut (dedicated session, 7 August). AIDS 2008 – Mexico City 3-8 August 2008 – XVII International AIDS Conference. http://www.aids2008.org/Pag/ PSession.aspx?s=41 (last accessed 8 August 2008). 4. Swaziland: Circumcision gives men an excuse not to use condoms. http://www.irinnews. org/Report.aspx?ReportId=79557 (last accessed 7 August 2008). 5. Siegfried N, Muller M, Volmink J, et al. Male circumcision for prevention of heterosexual acquisition of HIV in men. Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD003362. DOI: 10.1002/14651858.CD003362. 6. Garenne M. Long-term population effect of male circumcision in generalised HIV epidemics in sub-Saharan Africa. African Journal of AIDS Research 2008; 7(1): 1-8. 7. New study shows condoms 95 times more cost-effective than circumcision in HIV battle. http://www.prweb.com/releases/2008/08/prweb1151894.htm (last accessed 7 August 2008). 8. WHO/UNAIDS Technical Consultation Male Circumcision and HIV Prevention: Research Implications for Policy and Programming. Montreux, 6 - 8 March 2007. Conclusions and Recommendations. http://data.unaids.org/pub/Report/2007/mc_recommendations_en.pdf (accessed 25 August 2008). October 2008, Vol. 98, No. 10 SAMJ See also A. and J. Myers, <a href="http://www.historyofcircumcision.net/index.php?option=content&task=view&id=77">Male circumcision: The new hope?</a>, South Africa Medical Journal, Vol. 97 (5), May 2007 <h2> <a id="uganda" name="uganda"></a>Ugandan writer attacks WHO circumcision propaganda</h2> The following editorial was published in the Ugandan newspaper Daily Monitor in December 2009. A few days ago I found it necessary to restate my position, calmly and quietly, that my sons – two so far – should under no circumstances be circumcised. Two very simple and I am persuaded, logical reasons. First, while I respect the standpoint of those who argue for circumcision, I personally do not believe in it. Circumcision is such a personal affair; nobody has the right to decide for anybody else whether or not they should undergo it. And since kids are too young to appreciate the merits (probably lack of them) of a matter as personal and important as losing their foreskin, I argue that it is improper for somebody else (parent though they be) to make that decision for them, unless it is a medical emergency that has implications on their immediate survival or potency. If as adults they decide to submit to the knife, that is their responsibility. The other reason is that the advocates of circumcision in Uganda today are advancing very lame, wrong and wholly incompetent reasons for it. Their message is two-fold: that circumcision will help protect men from contracting HIV – the virus that causes AIDS. Secondly we are told that circumcision promotes hygiene among men. As we speak, billions of shillings have been sunk into programmes about circumcision, telling every Ugandan that this is the new miraculous discovery that will keep them safe. This lie needs to be unmasked and exposed, because we are playing with fire. Who in their right mind would believe that a man can have unprotected sexual intercourse with an infected woman and come out intact just because he is circumcised? Any argument about how hardened a circumcised male organ is and how it is able to withstand whatever period of sexual intercourse and emerge without scratches and, therefore, without possibility of infection is purely academic … and deadly. The truth behind circumcision is that it is just a new excuse invented by unscrupulous and incompetent scientists, plus bureaucrats in the United Nations, African governments and civil society to eat free money. They have not told us who did the research, what methodology they employed or which experimentation humans they used. In the end, therefore, the current campaign for circumcision has nothing to do with your health and safety. It is all about people making money. Our young men will now believe that you can sleep with whoever it is and you’ll be safe just because you are circumcised. And they will die. Our girls will be told, “I am circumcised” and they will presume they are safe. And they will die. Strangely enough, the protagonists of circumcision argue that it affords only a 60 per cent chance at best of avoiding the virus and that circumcision should be used “in combination” with other safety measures such as condom use. I think the ABC strategy that Uganda had adopted is good enough to help us fight AIDS. Abstain from sex, or Be faithful to your (one) partner or if push comes to shove, use a condom. For hygiene I will encourage my sons to take a bath regularly. I will also take them through another course on how a man ought to keep himself clean. For now I find it important to put the country on notice: we are being duped and as your kids bleed all the way from hospital, a small clique is laughing all the way to the bank. Unmasking the Lie: Circumcision, Sex and HIV/AIDS By Gawaya Tegulle <a href="http://www.monitor.co.ug/" rel="noopener" target="_blank">Daily Monitor</a> (Uganda) December 12, 2009 <h2> <a id="legislate" name="legislate"></a>South African legislation against circumcision of minors</h2> Despite the AIDS crisis about which we hear so much, South Africa is one of the very few countries in the world that has actually passed a law regulating and to some extent prohibiting circumcision of male minors. This is a fact about which we hear very little. The relevant sections of the Children's Act (2005) are as follows. 7. (1) Whenever a provision of this Act requires the best interests of the child standard to be applied, the following factors must be taken into consideration where relevant, namely - (l) the need to protect the child from any physical or psychological harm that may be caused by ... (i) subjecting the child to maltreatment, abuse, neglect, exploitation or degradation or exposing the child to violence or exploitation or other harmful behaviour 12. (1) Every child has the right not to be subjected to social, cultural and religious practices which are detrimental to his or her well-being (3) Genital mutilation or the circumcision of female children is prohibited. ... (8) Circumcision of male children under the age of 16 is prohibited, except when (a) circumcision is performed for religious purposes in accordance with the practices of the religion concerned and in the manner prescribed; or (b) circumcision is performed for medical reasons on the recommendation of a medical practitioner. As you can see, there are problems with this. For a start there is gross gender discrimination, in that girls are given blanket protection against any kind of harm, but boys have to make do with qualified protection. The exception for "religious purposes" allows practising Jewish and Muslim parents to circumcise without constraint, but the failure to specify the religions accorded the exemption provides a loophole for anybody who wants to invent his own religion. More seriously, the reference to "medical reasons" fails to define what they are. If they mean a situation where circumcision is necessary to treat an injury, deformity or disease that has failed to respond to conservative treatment after reasonable efforts, that is one thing and will provide a significant level of protection If, on the other hand, they mean circumcision performed in the belief that it will reduce the risk of contracting diseases to which the child may be exposed at some later date (i.e. prophylactic or precautionary circumcision), that is quite another, and will provide no protection at all against the circumcision promoters. Most non-religious circumcision is prophylactic circumcision, but it should not be confused with therapeutic (i.e. treatment for an existing problem). It is significant that in its paper on the legal status of circumcision of male minors the Tasmanian Law Reform Institute is careful to explain that prophylactic circumcision is not therapeutic. Still, South Africa is way ahead of Australia and most developed nations in making some attempt to crack this difficult nut. <h3>South African Medical Association rejects circumcision</h3> Interestingly enough, the South African Medical Association does not consider the AIDS crisis a sufficient justification for routine circumcision of male infants or other normal male minors. In response to an inquiry from Nocirc of South Africa, the South African Medical Association stated that there was no justification for routine circumcision of infants or children. In letter to Nocirc SA, dated 4 February 2005, and signed by Professor Ed Coetzee, Chairperson of the SAMA Education, Science and Technology Committee, the Association states: “After lengthy DISCUSSION on the matter, the Committee RESOLVED that it be conveyed to NOCIRC-SA that, from a medical point of view, there was no medical justification for routine circumcision in males and children.” In this conclusion, SAMA joins medical authorities in Britain, Canada, the USA, Australia and New Zealand in agreeing that there is no medical case for routine circumcision. In fact, it goes slightly further than the Royal Australian College of Physicians, which states that there is “no medical indication”; SAMA says there is “no medical justification”, an even stronger rejection. Coming from a country with an extremely high incidence of HIV infection (and also a high incidence of male circumcision), this is a significant declaration. <a href="http://www.nocirc-sa.co.za/">Nocirc-South Africa website</a> <a href="http://www.samedical.org/">South African Medical Association website</a> <a href="http://www.cirp.org/library/statements/">Policy statements by medical associations</a> <h2> <a id="ritual" name="ritual"></a>Ritual circumcision leaves dozens killed and hundreds injured</h2> One of the concerns driving the South African legislation is the sad fact that each year traditional ritual circumcision of Xhosa teenagers leaves a trail of devastation: dozens of boys killed and many more injured. Appalled by the general indifference to this toll, the South African Medical Journal in 2003 called for "action to stop the carnage". <h3>EDITORIAL: Astonishing indifference to deaths due to botched ritual circumcision</h3> “Circumcision leaves 24 dead, 10 in hospital”, read the headline in The Star of Kuala Lumpur, Malaysia, on 16 July 2002. The report continued: “South Africa’s initiation season ended this weekend with a gruesome toll of 24 deaths reported to police and more than 100 teenagers hospitalised with gangrene and septicaemia after botched circumcisions and severe beatings. One boy’s penis dropped off as a result of gangrene, at least one other had to have his penis amputated, and another will have to have both legs amputated, authorities said”. Similar horrifying circumcision outcomes have been <a href="http://www.cirp.org/news/">observed again this year</a>, with reports of the deaths and mutilations being beamed across the world by all the major news services. No one understands why we as a country – or as communities – have seemingly stood by and done little or nothing as these deaths rock the country year after year. Anywhere else in the enlightened world, this kind of mayhem would have evoked community outrage and led to urgent and drastic action to prevent it. Why are we not sufficiently agitated by the slaughter to find ways to stop it? Perhaps in today’s South Africa, where violence constitutes one of the leading causes of death (including 23,000 officially acknowledged murders per annum), we have become hardened against the horror of needless death. In any event, deaths due to ritual circumcision largely occur in the impoverished and faceless rural and peri-urban communities, and those of us north of he railroad are in denial about this, just as we are about much of the other misery in that quarter. The communities themselves have perhaps come to accept these occurrences as part of their fate, along with unsafe minibus taxis and random street shootings. Middle class families from circumcising backgrounds ensure that their sons are circumcised in safe and nurturing environments. Unless this elite is moved and inspire to do something about the circumcision deaths among the less privileged, nothing will change. A further reason for playing down the deaths may be a deep-sated fear among the affected communities (largely in the eastern Cape and the Limpopo provinces) that this hallowed ancient tradition is under threat of extinction, and that any move to modernise it may push it over the edge. Certainly, some voices coming through on radio talk shows seem much more concerned with the survival of the ritual itself (often rather broadly if inaccurately labelled “our African culture”) than about the reported deaths and mutilations. Daniel J. Ncayiyana, Editor South Africa Medical Journal, Vol. 93, No. 8, August 2003 <h3>But the carnage continues</h3> In 2006 the British Medical Journal reported: Fourteen boys have died as a result of botched circumcisions in the past month in the Eastern Cape province of South Africa. Hundreds more boys have been maimed and mutilated in the same process which takes place annually at “circumcision schools,” usually conducted in the bush, away from towns and villages. In South Africa, in many groups, boys are circumcised between puberty and adulthood, and it marks the ritualised passing from boyhood to manhood. In the past few years, however, this “circumcision season” has been marred by untrained and bogus traditional surgeons trying to make money but whose technique lacks expertise and hygiene. The provincial department of health says that 243 deaths and 216 genital amputations from circumcisions were recorded between 1995 and 2004. Last year there were more than 20 deaths. Laws and regulations in the Eastern Cape were passed in the hope of controlling the practice and ensuring hygienic conditions. Traditional surgeons have to be officially recognised and register with the department. Surgeons caught running initiation schools without authority can be sent to prison. Pat Sidley, Johannesburg <a href="http://bmj.bmjjournals.com/cgi/content/short/333/7558/62-d?etoc">British Medical Journal, Vol. 333, 8 July 2006, p. 62</a> Further information <a href="http://www.historyofcircumcision.net/index.php?option=content&task=view&id=66">South African Medical Association calls for action to “stop the carnage”</a> <a href="http://www.nocirc-sa.co.za/">Circumcision in South Africa</a> And the story is much the same this year: see news reports at <a href="http://www.cirp.org/news/">CIRP</a> and <a href="http://www.circumstitions.com/">Circumstitions</a>. According to the latter, there have been 53 deaths so far this year in Eastern Cape Province. Not much evidence there that circumcision is improving child health. <h2> <a id="sama" name="sama"></a>“Unethical and illegal”: South African Medical association</h2> <h2>rejects circumcision of infants</h2> In a letter dated 23 June 2011, the South African Medical Association has stated that it does not support the practice of circumcision of infants as a means of preventing HIv transmission and that it considers circumcision of infants to be both unethical and illegal. The letter was signed by Ms Ulundi Behrtel, Chairperson of the Human Rights, Law and Ethics Committee. The full text of the letter follows: 23 June 2011 Mr Dean Ferris, Co-Director National Organisation of Circumcision Information Resource Centres South Africa Dear Mr Ferris CIRCUMCISION OF BABIES FOR PROPOSED HIV PREVENTION We refer to the above matter and your email correspondence of 16 February 2011. The matter was discussed by the members of the Human Rights, Law & Ethics Committee at their previous meeting and they agreed with the content of the letter by NOCIRC SA. The Committee stated that it was unethical and illegal to perform circumcision on infant boys in this instance. In particular, the Committee expressed serious concern that not enough scientifically-based evidence was available to confirm that circumcisions prevented HIV contraction and that the public at large was influenced by incorrect and misrepresented information. The Committee reiterated its view that it did not support circumcision to prevent HIV transmission. We trust that you will find this in order. Yours faithfully Ms Ulundi Behrtel Head: Human Rights, Law & Ethics unit Obo Chairperson: Human Rights, Law & Ethics Committee SA Medical Association A pdf of the letter is available on request through <a href="https://www.circinfo.org/contact.html">the contact form</a>. <h2> <a id="boyle" name="boyle"></a>Circumcision and HIV prevention: New study slams flaws in African clinical trials</h2> In 2007 the World Health Organisation recommended circumcision of adult males as an additional measure to control the spread of HIV-AIDS in African countries with high levels of HIV prevalence in the general population. The recommendation was based on limited evidence: no more than three clinical trials (in South Africa, Kenya and Uganda), the results of which appeared to show that circumcision could reduce a male’s risk of acquiring HIV through sexual intercourse with an infected female partner by a significant degree - commonly reported as 60 per cent, but subsequently estimated by the Cochrane Review as somewhere between 38 and 66 per cent. These trials have already been the target of <a href="http://www.circumstitions.com/HIV-SA-garenne.html">several critical reviews</a>, all of which have found them flawed in many crucial areas - most importantly that they exaggerate the protective effect of circumcision, while ignoring complications, ethical and human rights issues, and harm to sexual function and body image. A new critique by George Hill and Professor Greg Boyle, in the Journal of Law and Medicine, goes further: after a careful analysis of the data reported in the published reports of the trials, finds that the protective effect of circumcision was nothing like 60 per cent. The impression of significance was achieved by reporting the risk reduction in terms of relative risk, suppressing the fact the the absolute risk reduction was pretty insignificant - probably as low as 1.3 per cent. But even as an estimate of relative risk the 60 per cent figure was an exaggeration; after correcting for lead-time bias it should be lowered to 49 per cent. This is not the only problem. Boyle and Hill find numerous flaw in the methodology of the three trials, any one of which would be enough to cast doubt on the results: <ul> <li>researcher expectation bias;</li> <li>participant expectation bias;</li> <li>inadequate double blinding;</li> <li>lead-time bias;</li> <li>selection and sampling bias;</li> <li>experimental mortality; and</li> <li>early termination.</li> </ul> To measure researcher expectation bias, they analysed the references the researchers used and found significantly more pro-circumcision and fewer anti-circumcision or neutral references than are available in the HIV literature. In an appendix, the authors identify no fewer than 13 studies that found no association between circumcision and HIV status, and three studies that found a greater risk of HIV infection in circumcised men. These compare with only three studies (the famous African trials that supposedly gave us the “gold standard” of proof) finding a higher risk of HIV among the uncircumcised. No prizes for guessing which studies the media have highlighted, and which they have ignored. The authors point out that the early termination of all three trials would have amplified the protective effect of "lead-time bias" (delay by circumcised men in resuming sex). In at least four cases in the Kenyan trial, men apparently contracted HIV through circumcision. Just as seriously, in a separate trial of the effect of circumcision on male to female transmission of HIV, there appears to have been a 61 per cent relative increase in the incidence of HIV infection among the female partners of HIV-positive circumcised men. The authors also raise serious concerns about the ethical and human rights aspects of all the trials, and especially the male-to-female trial, in that the women were not informed that their partners were HIV-positive so that they could protect themselves. “Since some men acquired HIV without reporting unprotected sexual exposures, the RCT authors had a duty of care to investigate such non-sexual transmission," they say. "Researchers controlled the information available to men so that provision of fully informed consent may have been compromised.” Given all these problems, the authors conclude that “Male circumcision is a dangerous distraction and waste of scarce resources that should be used for known preventive measures.” It is obvious that if the circumcision solution is not the right approach for Africa's vast HIV problem, there is no shadow of an argument for the deployment of circumcision as an AIDS control measure in developed countries. Boyle GJ, Hill G. Sub-Saharan African randomised clinical trials into male circumcision and HIV transmission: Methodological, ethical and legal concerns. Journal of Law Med and Medicine, Vol. 19, December 2011: 316-34. The full article may be purchased from the <a href="http://sites.thomsonreuters.com.au/journals/2011/11/28/journal-of-law-and-medicine-update-december-2011/">Journal of Law and Medicine homepage</a>. For other options, contact Circumcision Information Australia through the <a href="https://www.circinfo.org/contact.html">contact page</a>. <h3> Relative vs absolute risk reduction</h3> According to most of the media reports, the African circumcision trials are supposed to have achieved a “60 per cent reduction” in the risk of acquiring HIV. This statement has been repeated so often that it has become a received “truth”, and has been been inflated into the totally false claim that “circumcision prevents AIDS.” Even if the data in the trials were valid, the most that could be claimed is that circumcision reduced the risk. But there are many misrepresentations in the report that the degree of risk reduction is “60 per cent”. The most serious are: 1. It is not stated that this reduction, even if true, occurs only in a highly specific context: unprotected vaginal intercourse with an infected female partner, in a population with a high level of HIV prevalence, widespread sexual promiscuity, a low level of condom use, and numerous infected females. 2. Analysis by the Cochrane review (a research unit that assesses clinical trials and similar studies)* concluded that the risk reduction was not 60 per cent at all, but somewhere between 38 and 66 per cent. On average, this would mean a risk reduction of about 50 per cent. All this means is that in a population such as that described in point 1, circumcised men who have sex with a variety of sexual partners and do not use condoms will take twice as long to get infected. 3. The magical 60 per cent figure is relative risk reduction, not actual risk reduction. What dos this mean? As Boyle and Hill explain, Across all the female to male trials, of the 5,411 men circumcised, 64 (1.18 per cent) became HIV-positive. Of the 5,497 controls (men who were not circumcised), 137 (2.49 per cent) became HIV-positive. As you can see, the actual numbers are very small (a measly 1.3%), but expressed as a percentage, the difference turns into an impressive “60%”. There were many reasons why the circumcised sample might have presented fewer infections, including less time to get infected (since they could not have sex while the circumcision would was healing), better knowledge of safe sex from the counselling they received, and greater condom use, since they were given condoms in the counselling sessions. There is actually no proof that the observed risk reduction was the effect of circumcision, rather than factors such as these. This is the entire extent of the evidence for circumcision having a protective effect against HIV, and the basis for billions of dollars being spent on bribing and coercing African men to get themselves and their male children circumcised, largely at the expense of Western taxpayers. For further analysis and graphic representation of the evidence, <a href="http://www.circumstitions.com/HIV-SA.html">see the deconstruction by Hugh Young at Circumstitions.com</a>. * Siegfried N, Muller M, Deeks JJ, Volmink J. Male circumcision for prevention of heterosexual acquisition of HIV in men (Cochrane Review). In: <a href="http://www.cochrane.org/cochrane-reviews">The Cochrane Database of Systematic Reviews</a>; Issue 2; 2009 Apr 15. Chichester ( UK ): John Wiley; 2009. <h3>Zimbabwe newspaper critical of circumcision solution</h3> Impact of male circumcision on HIV doubted by Gilbert Nyambabvu New Zimbabwe News, 22 February 2012 Dangerous distraction ... Circumcision impact questioned MALE circumcision is a dangerous distraction in the fight against HIV/AIDS, researchers have warned insisting that contrary to widespread claims the procedure only reduces transmission rates by no more than 1.3 percent. Zimbabwe is among several countries in sub-Saharan Africa that have launched mass male circumcision campaigns after the World Health Organisation (WHO) and UNAIDS recommended the procedure in 2007 as an effective HIVAIDS preventive measure. The WHO/UNAIDS recommendation was based on clinical trials carried out in Kenya, South Africa and Uganda which suggested that circumcision could reduce female-to-male HIV transmission by up to 60 percent. Thousands of men have undergone the surgical nip and tuck since Zimbabwe launched the campaign in 2009 with promoters enthusiastically claiming that if at least 80 percent of the adult male population was circumcised about 750 000 cases of HIV infections could be prevented. But new research has cast doubt on the supposed efficacy of the procedure with an article in the December Australian Journal of Law and Medicine citing numerous flaws in the Kenya, South Africa and Uganda studies. Researchers Gregory J. Boyle and Gregory Hill claimed the 60 percent reduction in transmission was only relative with the absolute reduction rate actually no more than 1.3 percent. Boyle and Hill said: “What does the frequently claimed ‘60 percent relative reduction’ in HIV infections actually mean? “Across all the three female-to-male trials, of the 5,411 men subjected to male circumcision, 64 (1.18 percent) became HIV positive while among the 5,497 controls 137 (2.49 percent) became HIV positive. “So the absolute decrease in HIV infection was only 1.31 percent, which is statistically not significant.” The authors of the article insisted that the WHO/UNAIDS recommendation “uncritically accepted” the findings of the Kenya, South Africa and Uganda trials, in the process ignoring a vast body of contradictory evidence. “Examination of epidemiological data shows that male circumcision does not provide protection against HIV transmission in several sub-Saharan African countries including Cameroon, Ghana, Lesotho, Malawi, Rwanda and Tanzania all of which have higher prevalence of HIV infection among circumcised men,” they said. “In Malawi, the HIV prevalence rate is 13.2 percent among circumcised men and 9.5 percent among those who are intact. (Again) in Cameroon prevalence among those circumcised is 5.1 percent compare to 1.5 percent for those who are intact. “If male circumcision reduces HIV transmission as the trials claim then why is HIV prevalence much higher in the United States (where most men are circumcised) than in developed countries where most men are intact (such as Europe, the United Kingdom and Scandinavia)?” The article warns that relying on male circumcision in the fight against HIV/AIDS is especially dangerous for sub-Saharan Africa women because circumcised men could still acquire and transmit the virus to their sexual partners. “Evidence suggests that mass circumcision programs may exacerbate the HIV epidemic among women (and) under these circumstances it would be irresponsible and unethical to advocate mass circumcision programmes in southern Africa,” the article concludes. “Male circumcision is a dangerous distraction and a waste of scarce resources that should be used for known preventive measures (such as condoms which are 80 percent effective.” <a href="http://www.newzimbabwe.com/news-7273-Circumcision%20HIV%20impact%20doubted/news.aspx" rel="noopener" target="_blank">New Zimbabwe News, 22 February 2012</a> <h2> <a id="samj" name="samj"></a>A case of medical colonialism?: South African Medical Journal</h2> <h2>condemns HIV-circumcision push</h2> In a hard hitting editorial that raises the spectre of neocolonialism, the South African Medical Journal has condemned the push for mass circumcision of African men as the solution to the nation’s HIV-AIDS problem. The editorial, by the journal editor Professor Daniel Ncayiyana, reviews the evidence for the claim that circumcision reduces the risk of female-to-male infection, and finds it less conclusive than assumed (and far less significant than regularly proclaimed in sensationalist newspaper headlines). The weakness of the case arises partly because the three clinical trials on which it is based were terminated prematurely, and partly because surveys show no consistency in the pattern of HIV infection among circumcised and uncircumcised men. (In some places there is little difference, and in some the incidence of HIV is higher in circumcised men.) There is certainly nothing in the results of the trials to justify the wild claim that circumcision provides “lifelong protection” against HIV; the most that could be said is that in areas of high HIV prevalence circumcision reduces the risk of female-to-male transmission in unprotected intercourse. Despite the much-touted “60 per cent” figure, nobody really knows the extent of the risk reduction in real world situations. Circumcision provides no protection to homosexual men or injecting drug users, and may increase the risk of male-to-female transmission. The editorial warns that an excessive and disproportionate focus on expensive surgical interventions such as circumcision will discourage condom use (known to be 90 per cent effective against HIV transmission) and deplete the resources needed in other critical health areas (such as malaria and tuberculosis). Already there is evidence that many men believe that the chief advantage of circumcision is that they will no longer have to wear condoms. At the same time, promoters of the circumcision solution still insist on condom use even after circumcision. Clearly, as Van Howe and Storms point out, this demand implies lack of faith in their own prescription: “Circumcision is either inadequate (otherwise there would be no need for continued condom use) or redundant (as condoms provide nearly complete protection).” * The editorial urges South Africa to follow the recommendation of the Australian Federation of AIDS Organisations, which has rejected circumcision and reiterated that “correct and consistent condom use … is the most effective means of reducing female-to-male transmission, and vice-versa.” ** Raising the spectre of human rights abuses and colonialism, the editorial is particularly concerned at the push for universal circumcision of infants and children, despite the fact that the South African Children’s Act specifically prohibits circumcision of boys under the age of 16 years. The editorial notes that much of the push for circumcision in Africa comes not from native Africans, but from international aid agencies dominated by United States funders and policy-makers, and that many programs are funded by the vastly wealthy Bill and Melinda Gates Foundation. It comments that it is “curious and even worrisome that the campaign to circumcise African men seems to be driven by donor funding and research from the North.” Mutilation of African native bodies by white and Arab slave traders and other exploiters was a sad feature of African experience in the dark days of colonialism, before the various nations achieved independence. In more modern times, western pharmaceutical companies have treated African and other “Third World” peoples as convenient guinea pigs on which to test their drugs – often with tragic results. It is strange to see such similar practices being revived and enforced by benevolent white medical missionaries, but their determination to carve their mark on the bodies of African men certainly looks like a new and particularly insidious form of cultural imperialism. Source: “Editorial: The illusive promise of circumcision to prevent female-to-male HIV infection: Not the way to go for South Africa”. <a href="http://www.samj.org.za/index.php/samj/issue/view/119/showToc">South African Medical Journal, Vol. 101, November 2011, 775-776</a>. References * Van Howe RS, Storms MR. <a href="http://www.publichealthinafrica.org/index.php/jphia/article/view/jphia.2011.e4/html_9">How the circumcision solution in Africa will increase HIV infections</a>. Journal of Public Health in Africa 2011;2:e4. doi:10.4081/jphia.2011.e4 A study of Nigerian prostitutes in 1988 found that, after counselling sessions, condom use increased markedly and that even occasional condom use had a significant protective effect: of 28 women who never used a condom, only eight escaped infection with HIV; but of 50 women who used them in approximately one third of sexual encounters, 27 (54 per cent) avoided infection. It is instructive to compare this with the results of the recent clinical trials of circumcision, which reported a risk reduction of between 50 and 60 per cent: about the same as the risk reduction achieved by condom use 30 per cent of the time. See E.N. Ngugi et al, “Prevention of transmission of human immunodeficiency virus in Africa: Effectiveness of condom promotion and health education among prostitutes”. Lancet, Vol. 332, No. 8616, 15 October 1988, 887-890. ** Australian Federation of AIDS Organizations. Male circumcision has no role in the Australian HIV epidemic. Briefing Paper, 23 July 2007. Available at http://www.afao.org.au/__data/assets/pdf_file/0019/4528/BP0709_Circumcision.pdf <h2> <a id="zimb" name="zimb"></a>Circumcision campaigns failing to reduce HIV incidence</h2> Health officials in Zimbabwe are worried that the massive drive to have 1, 2 million men circumcised by 2015 might backfire following indications that HIV prevalence is higher among men that have undergone the procedure. According to [very limited] research, circumcision reduces the transmission of the HIV virus by 60 percent [actually, by an unknown factor, believed to be somewhere between 38 and 66 per cent] among heterosexual men. But the latest Zimbabwe Health Demographic Survey (ZHDS 2010/2011), indicates that the HIV prevalence rate among circumcised men is 14 percent but only 12 percent among the uncircumcised. The findings are for circumcised males between the ages of 15 and 49. This is blamed on the misconception that circumcision completely shields people from HIV infection. National Aids Council (NAC) public health officer Blessing Mutede said authorities were concerned about the high rate of infection among the circumcised. Health officials say most men, after circumcision, harbour the false impression that they have been equipped with an invisible condom. “It is a worrying development that at a time when we are promoting male circumcision as a preventive measure to combat HIV, we are recording a high prevalence rate amongst the group that has been circumcised largely due to uninformed risky compensatory behaviours,” Mutede said. Source: <a href="http://www.theafricareport.com/index.php/20120711501815186/southern-africa/zimbabwe-concern-over-high-hiv-rates-among-circumcised-males-501815186.html">The Africa Report, 22 July 2012</a> Meanwhile, Mugabe's health advisor, Timothy Stamps, has rubbished claims that male circumcision reduces HIV and Aids prevalence rate at a time the country had embarked on a foreskin cutting crusade, ostensibly to lessen chances of contracting the deadly disease. The former minister of health said circumcision did not make any difference to the adult prevalence rate, noting researches had shown that countries with a higher number of circumcised men, like the US, also had a high HIV prevalence rate. He said instead of channelling funds towards circumcision, the money must be used to save pregnant mothers who die in huge numbers in this country. “When we are losing 960 mothers for every 100 000 pregnancies, should circumcision be a priority?” said Stamps. He said circumcision had led to men being more reckless in sleeping around. “Young men are happier to take risks and chances without the use of condoms or any other preventive measures because they are told circumcision will protect them,” he said. Source: <a href="http://allafrica.com/stories/201207231533.html">All Africa News, 22 July 2012</a> <a href="http://www.circumstitions.com/Images/zim-2005-12-750.png" rel="noopener" target="_blank">This diagram shows</a> that the incidence of HIV infection is consistently higher among circumcised men in Zimbabwe, and that while there has been s slight reduction in the over all incidence of HIV infection since 2005, the reduction has been just as great among the uncircumcised as among the circumcised. <h2> <a id="Zimb" name="Zimb"></a>Africa: Mass circumcision campaigns failing to reduce HIV incidence</h2> Recent reports from African countries that have pursued ambitious American-funded circumcision campaigns in the belief that they would solve their HIV-AIDS problem show that circumcision is not reducing the incidence of infection, but (as in parts of Kenya) actually increasing it. At the same time, opposition to the programs is growing, especially in Zimbabwe, where critics have accused the (highly authoritarian) government of misleading propaganda and unethical efforts to circumcise boys and infants rather than consenting adults. (This is contrary to the original recommendations of the World Health Organisation, which stressed that circumcision should be performed only as a free, informed choice, and that programs should be conducted in accordance with human rights principles.) <h3>Zimbabwe: Growing opposition to circumcision campaign</h3> In Zimbabwe critics of the American-funded circumcision campaign have accused the (authoritarian) government of misleading propaganda and unethical efforts to circumcise boys and infants rather than consenting adults. As in several African countries, the testing and circumcision procedures are being carried out by Population Services International, a US-based global health agency. One of their methods of persuading boys and adolescent to get circumcised is to send actors and entertainers into schools. Dr. Karin Hatzold, deputy head of PSI Zimbabwe said: “We have campaigns that are specifically targeting adolescents, people in schools — so during school holidays we are doing massive mobilisations on mass media. So get smart, get circumcised. Male circumcision is not only HIV prevention intervention, but it is improving hygiene, you are cleaner, you are smarter.” But some Zimbabweans have complained that such tactics were unethical in that the propaganda gave a false sense of security, failed to mention the risks and harms of circumcision and put pressure on schoolboys that amounted to coercion. Raymond Majongwe, a National Aids Council board member, said the media campaigns on male circumcision were mischievous in that they give a false sense of security to those who would have gone under the knife. “They then think they are macho and can go on bedding girls. It is like a licence to be promiscuous. I also do not believe in those said “celebrities” that are being used to promote the idea. Stunner for example, is another male circumcision ambassador who after being circumcised went on to shoot a sex video that went viral, exposing his circumcised manhood,” Majongwe said. He added that he has always been skeptical of the on-going male circumcision campaigns. Supporting Majongwe’s views is the Matobo senator Sithembile Mlotshwa who has called on the ministry of Health and Child Care to stop circumcising children under the 2009 medical male circumcision programme. “In our constitution, everyone is born with a right to life and I think it is wrong for a father and mother to sit down and decide to circumcise this young child who is a month old whereas the father was circumcised at the age of 40. This circumcised man's parents gave him all these years to mature and know the uses of all the organs of his body so as to decide how best to remake what is God-given. So then why does this person want to agree with his wife to circumcise an infant who is a third person who has a right to be fully developed as he is so that he makes his own decisions about his body organs?” Mlotshwa believes children should be allowed to make their own choices when they grow up instead of being circumcised under this programme funded by international donors. “I want to take our minister of Health to task because I believe that you don't have to circumcise infants.” A other member of parliament, Jessie Fungayi Majome said it is a sad or happy (depending on the circumstances) fact of life that children are bundled with the fate and decisions of their parents. “To cut or not to cut must be decided according to which of the two is in the best interests of the child as required in our new Constitution.” Since the authorities insisted that men should still wear a condom even after getting circumcised, it was obvious that the protection given could not be all that great. “I think more research must be done to give objective knowledge of the pros and cons of male circumcision.” Political activist Tabani Moyo said that “those agitating circumcision should engage in ethical advertising by outlining the dangers that come with the process so that when people decide to do it, they do so with all the critical information at hand. At the moment, there is too much high voltage advertising which borders on deceit that might end up leading to unintended consequences as the adverts seem to give an impression that your chances of getting HIV/Aids for example are reduced, this is irresponsible advertising.” <a href="http://www.bulawayo24.com/index-id-news-sc-national-byo-47989.html">Child circumcision ignites debate</a>. Bulawayo 24 Hours, 25 May 2014. <h3>Kenya: HIV increasing in regions of high circumcision incidence</h3> Meanwhile in Kenya, following the arrival of large sums of American cash, the authorities set a target of increasing the number of circumcised men from 85 to 94 per cent. Unfortunately, the governments on studies show that circumcision is not reducing the incidence of HIV, but that infections actually increasing in the regions where the circumcision program has been most successful. As a Kenyan newspaper reports: “Most studies on male circumcision, including the Kenya Aids Indicator Survey 2013 (KAIS), have so far concentrated on the quantity of procedures but none has shown it is achieving its primary objective of reducing HIV infections. Started almost seven years ago, on the promise that it could reduce the risk of infection by 60 per cent, the KAIS report showed a spike in prevalence in places like Nyanza where the circumcision programme is most intense.” If Kenya already had a severe HIV epidemic with 85 per cent of the male population circumcised, it is hard to see how circumcising a further 9 per cent is going to make any difference. Gatonye Gathura. <a href="http://www.standardmedia.co.ke/?articleID=2000122086&story_title=Kenya-study-male-cut-staff-overwhelmed-by-work">Male cut staff overwhelmed with work</a>. Standard Digital (Kenya), 22 May 2014. See also Joseph 4GI, <a href="http://joseph4gi.blogspot.com.au/2014/05/mass-circumcision-campaigns.html">Mass circumcision campaigns: The emasculation and harassment of Africa</a>. <h2> <a id="KenyaViolence" name="KenyaViolence"></a>Kenya: Circumcision as sexual violence and political oppression</h2> In Kenya, circumcision and other forms of sexual violence and genital mutilation are being used to terrorise minority groups and political opponents of the dominant tribal elites. This is the alarming conclusion of a study published in the journal Ethnicity and Health, which also reports that the US-led push for mass circumcision in Africa as a tactic against HIV-AIDS is producing major violations of human rights and doing little for health. In Kenya the majority of the population belong to tribal groups that traditionally practice circumcision as an initiation ritual in late childhood. There are, however, several minority ethnic groups that do not practise circumcision, and these have been subject to various forms of oppression and mistreatment by the majority, including forced circumcision, sometimes by mobs who kidnap men in the street, as Michael Glass reported in the Journal of Medical Ethics last year. These outrages are clearly a form of <a href="https://www.circinfo.org/Sexual_violence_against_males.html">sexual violence against males</a> and a blatant violation of both civil law and human rights principles, and further evidence that the US-funded campaign for mass circumcision in Africa is leading to shameful abuses and placing vulnerable minorities at the mercy of their traditional enemies: the law of unintended consequences at work. It is disgraceful that international human rights agencies have been silent on these developments. The Abstract of the paper follows. Background. As a contribution to ongoing research addressing sexual violence in war and conflict situations in the Democratic Republic of Congo, Kenya and Rwanda, this paper argues that the way sexual violence intersects with other markers of identity, including ethnicity and class, is not clearly articulated. Male circumcision has been popularized, as a public health strategy for prevention of HIV transmission, although evidence of its efficacy is disputable and insufficient attention has been given to the social and cultural implications of male circumcision Methods. This paper draws from media reporting and the material supporting the prosecutor at the International Criminal Court case against four Kenyans accused of crimes against humanity, to explore the postelection violence, especially forcible male circumcision. Results. During the postelection violence in Kenya, women were, as in other conflict situations, raped. In addition, men largely from the Luo ethnic group were forcibly circumcised. Male circumcision among the Gikuyu people is a rite of passage, but when forced upon the Luo men, it was also associated with cases of castration and other forms of genital mutilation. The aim appears to have been to humiliate and terrorize not just the individual men, but their entire communities. The paper examines male circumcision and questions why a ritual that has marked a life-course transition for inculcating ethical analysis of the self and others, became a tool of violence against men from an ethnic group where male circumcision is not a cultural practice. Conclusion. The paper then reviews the persistence and change in the ritual and more specifically, how male circumcision has become, not just a sexual health risk, but, contrary to the emerging health discourse and more significantly, a politicized ethnic tool and a status symbol among the Gikuyu elite. In the view of the way male circumcision was perpetrated in Kenya, we argue it should be considered as sexual violence, with far-reaching consequences for men’s physical and mental health. Source: Beth Maina Ahlberg and Kezia Muthoni Njoroge. ‘Not men enough to rule!’: Politicization of ethnicities and forcible circumcision of Luo men during the post-election violence in Kenya. Ethnicity and Health, Vol 18 (5), 2013. DOI http://dx.doi.org/10.1080/13557858.2013.772326 <h3>Syphilis 1855, HIV-AIDS 2007: Parallel responses</h3> In a related paper, Robert Darby considers the parallels between responses to syphilis in Victorian Britain and HIV-AIDS in contemporary Africa, and finds that circumcision was recommended in both cases for reasons that had little to do with an objective assessment of the value of the surgery, but had everything to do with cultural prejudice. He points out that many African countries hit hard by AIDS already had high rates of circumcision and that the majorities in these places welcomed the US-sponsored circumcision campaign as an excuse to force their non-circumcision minorities into line. Abstract In this paper, I discuss the parallels between responses to syphilis in nineteenth century Britain and HIV/AIDS in contemporary Africa. In each case, an incurable disease connected with sexual behaviour aroused fear, stigmatisation and moralistic responses, as well as a desperate scramble to find an effective means of control. In both cases, circumcision of adult males, and then of children or infants, was proposed as the key tactic. In the ensuing debates over the effectiveness and propriety of this approach, three questions occupied health authorities in both Victorian Britain and the contemporary world: (1) Were circumcised men at significantly lower risk of these diseases? (2) If there was evidence pointing to an affirmative answer, was it altered anatomy or different behaviour that explained the difference? (3) Given that circumcision was a surgical procedure with attendant risks of infection, was it possible that circumcision spread syphilis or HIV? I show that in both situations the answers to these questions were inconclusive, argue that circumcision played little or no role in the eventual control of syphilis and suggest that attention to nineteenth century debates may assist contemporary policy-makers to avoid the treatment dead-ends and ethical transgressions that marked the war on syphilis. Source: Robert Darby. Syphilis 1855 and HIV-AIDS 2007: Historical reflections on the tendency to blame human anatomy for the action of micro-organisms. Global Public Health, Advance access, 30 September 2014. http://dx.doi.org/10.1080/17441692.2014.957231 <h2> <a id="malawi" name="malawi"></a>Malawi sceptics blast United States circumcision obsession</h2> Malawians have questioned the motives of the United States and other Western NGOs that are promoting circumcision despite evidence showing that the questionable initiative does not reduce HIV as claimed. Vetting their anger and frustrations on social media, the people took to task the US for “prioritizing sex” and not real development. The US announced a $6.8 million (K3.8 billion) aid to support male circumcision which the US Ambassador to Malawi, Virginia Palmer, said has “has potential” to curb the spread of HIV. But all the comments that Malawi24 monitored on a story published by one of the local online publications expressed dismay at the focus of the aid, with many hinting that circumcision is not an effective means to fighting the spread of HIV. Athoko Chisale Mbewe wrote “American government is a joke. Chinese are giving money for development and all this ambassador cares about is sex? Ha ha ha …. if you want my foreskin I will trade it for K500,000.00. FYI My uncle has HIV /aids but he is circumsized”. While approving Athoko’s comment, Emmanuel Samikwa said that evidence from the Eastern region of the country back studies which question the credibility of circumcision to reduce HIV. Circumcision is common in the region, particularly among the Yao people, with people being circumcised during childhood. Most commentators made comparison between the support that the US and China are providing Malawi. The people called on the US to support initiatives that would savage Malawi’s ailing economy. “$6.8M for what?? Of all problems Malawi is facing, they think Male circumcision is top priority??. Why cant they learn from their Chinese counterparts?? This is laughable” posed Joseph Mutupha. Jonathan Pierre Ng’oma also urged the US to reflect on the priorities of its aid: “Come on, do we need money for such useless exercise? Our economy is in total shamble, will that going to help our economy?” Like others before him, Abram Nkasala commented by questioning the logic of the US to support circumcision which he observed is encouraging more people to engage in sex after circumcision, putting them at higher risk of infection. “Malawi needs food not jando this is encouraging AIDS because people are not caring after circumsion.People in Nsanje, Zomba are dying now”. Malawi24 previously revealed that there is not conclusive evidence to support claims that male circumcision reduce HIV infection. The Malawi Demographic and Health Survey, a study conducted in 2010 by country’s National Statics Office, also found that circumcised males were more likely to get HIV in Malawi. Another recent report also revealed that the HIV prevalence rate had doubled in Thyolo, one of the areas where medical circumcision was first rolled out in the country. Kondwani Mkhalipi-Manyungwa, <a href="http://malawi24.com/2015/10/25/malawians-blasts-the-us-we-dont-need-aid-for-circumcision/" rel="noopener" target="_blank">Malawians blasts the US: “We don’t need aid for circumcision”</a>. Malawi24, 25 October 2015 </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Circumcision push by WHO/US/Gates questioned by African doctors darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> There is little enough warrant in Western law or custom to coerce a person for the sake of his own health; there is none at all for the proposition that a person should be forcibly deprived of a functioning body part for the benefit of an unknown third party. In this extract from her article "Using male circumcision to understand social norms as multipliers" the American legal scholar Sarah Waldeck explains why the idea of circumcising male babies to reduce the risk of cervical cancer in adult women is not permissible: in summary, it is impossible because the person bearing the risk and suffering the deprivation is not the person reaping the benefit. <h3>Why it is wrong to circumcise baby boys, even if it did benefit adult women</h3> The argument that circumcision affects cervical cancer has floated in and out of the medical literature for years, but most studies attempting to document the connection have been disregarded because of profound methodological flaws, such as women inaccurately reporting the circumcision status of their husbands. Indeed, the AAP’s 1999 policy statement does not even mention cervical cancer prevention as a potential medical benefit. However, in April 2002, the New England Journal of Medicine published a report suggesting that the female partners of circumcised males are less likely to get cervical cancer than the partners of uncircumcised males. Specifically, researchers pooled data from Spain, Colombia, Brazil, Thailand, and the Philippines, and concluded that women whose male partners had six or more sexual partners and were circumcised had a lower risk of cervical cancer than women whose male partners had six or more sexual partners and were uncircumcised. In addition, circumcised males in the study had a lower incidence of the sexually-transmitted disease HPV. Because exposure to certain strains of HPV is a significant risk factor for cervical cancer, researchers hypothesized that circumcision protects against the cancer by reducing the incidence of HPV infection. As an editorial that accompanied the study explains, it does have some shortcomings. First, many risk factors for HPV are more common among uncircumcised men than circumcised men, such as poor genital hygiene and a history of multiple sexual partners. Because these variables are difficult to control for, they may help explain the higher incidence of HPV in uncircumcised males. In other words, because behavioral factors are so important, it is still not certain whether circumcision makes a quantitative difference in the rate of cervical cancer. In addition, progression from infection with a cancer-causing strain of HPV to invasive cervical cancer may take several decades. Therefore, at least some of the females in the study may have become infected by a different male partner, whose circumcision status is unknown. This sort of misclassification would either attenuate or exaggerate the association between non-circumcision and risk of cervical cancer. Finally, the study conflicts with some conducted in the United States which found that uncircumcised males have either the same or lesser incidence of HPV than circumcised males. Nonetheless, if the results of this most recent study are replicated elsewhere and become well-accepted, the medical utility of circumcision might be greatly enhanced. However, the issue of distributional fairness has gone largely undiscussed in the reporting of the recent findings about cervical cancer: who would receive the benefits of circumcision and who would bear the risks. The notion of shared risk is embedded in most public health initiatives, particularly those that involve children. Think, for example, of inoculations, to which circumcision is often compared. Under a universal vaccination policy, each child bears the risk of a complication, just as each child gains immunity to disease. If cervical cancer becomes the “medical argument for circumcision,” however, the non-negligible risks and considerable pain are borne by males, while the medical benefit is reaped by females. Circumcision would be a unique prophylactic intervention, one in which the health of one population was put at risk for the benefit of another population. From a legal prospective, the broad parental discretion to consent on behalf of the child is sharply curtailed when a medical procedure does not benefit the child but may aid third parties. The issue arises most frequently in the context of organ transplants. Whether the court uses a substituted judgment or best interest standard, the overarching focus is on what course of action will give the child the greatest net benefit. In answering this question, courts examine the relationship between the donor and donee, the effect of the procedure on the donor, the urgency of the donee’s need, and the probability that the procedure will be successful. Evaluated by these criteria, circumcision could not be performed or recommended as a prophylactic measure to prevent cervical cancer. First, the beneficiary’s need is far from urgent; many years will elapse before the boy is sexually active. No analogy can be drawn to the cancer patient who needs a bone marrow transplant, or the kidney patient who is kept alive by dialysis. Second, the case law emphasizes the necessity of a close, existing relationship between the child and person who will benefit from the surgery. Here there is not yet a relationship between the boy and the woman who would benefit from circumcision. Moreover, even the most recent study suggests that circumcision offers a protective benefit only to the female partners of men who have six or more sexual partners or engage in other behavior that puts them at high risk for HPV; the boy may end up not fitting this profile. For that matter, the boy may be homosexual and never have female partners. Without knowledge about what sort of man the boy will become, preventive circumcision is highly speculative. These considerations lead to the conclusion that if circumcision is done to prevent cervical cancer, it should be postponed until the boy is old enough to voice his own opinion on the matter. But while some cultures may believe that routine circumcision is more humane if done during adolescence, this is certainly not the American view: many parents say they circumcise during infancy to avoid the possibility that it will need to be done later. Thus, we can easily imagine a court assuming that any relationship between a male and his sexual partner will be close, and that if the procedure is going to be done at all, it has to be done during infancy. But even given these assumptions, circumcision would not pass muster under the usual standards for evaluating medical procedures that are performed for the benefit of third parties. When altruistic surgeries are performed on minors, the beneficiary is usually desperate and helpless. No alternative treatments are available, and without the aid of the minor, death is a near certainty. In contrast, women are capable of protecting themselves from cervical cancer that is connected to HPV. Not only can they practice safe sex, even more critically (and perhaps more realistically), they can receive simple annual Pap tests. Cervical cancer is easily cured if detected early, and for this reason, “[d]octors often say it is a disease that no woman should die of.” If prevention of cervical cancer becomes the medical rationale for circumcision, voiceless infants are subjected to a procedure for the benefit of adult women, who are fully equipped to take control of their own bodies and sexual well-being. Some readers may think that it is inappropriate to compare circumcision to surgeries that are performed for the benefit of third parties; all we are talking about are foreskins, not kidneys or bone marrow. But our exasperated “it’s only circumcision” merely reflects the social norm, which in turn shapes how we perceive the loss of the foreskin. To truly assess the fairness of removing healthy tissue from infants for the benefit of adult women, we need a thought experiment. Temporarily dispense with scientific disbelief and pretend that a new study concludes that amputating a male infant’s little toe would decrease cervical cancer rates in particular populations. Many physicians and the popular press start touting toe amputation as effective preventive medicine. Would you choose to cut off your newborn son’s little toe? Or, if it is difficult to imagine yourself with an infant son, would you think this recommendation represented appropriate public health policy? My guess is that the answer to both questions is no, even though the little toe is not more useful than the foreskin, and even if you think that the absence of a little toe might make the boy a more desirable sexual partner. You may be unwilling to subject infants to the pain of amputation; you may think that “normal” means having a little toe; you may believe it bizarre to amputate something that is likely to cause the boy little trouble beyond the occasional stub; you may be convinced that there are better ways to combat cervical cancer; you may just generally feel possessive about your son’s body parts. That we do not have similar reactions when it comes to cutting off the foreskin for the benefit of adult women is a testament to how deeply embedded the norm of circumcision really is. Of course, the analogy between the foreskin and the little toe is not strictly accurate, because toe amputation (like kidney transplants or bone marrow extractions) holds no possibility of potential health benefits for the child. Circumcision, in contrast, has potential health benefits. But it would be inappropriate to allow these potential benefits to cloud the issue of distributional fairness, because the medical establishment has already told us that the potential benefits are not enough to merit routine neonatal circumcision. Some would argue that the analogy between the foreskin and little toe is inapt for another reason: that, in fact, the foreskin has a sexual function that makes it far more useful than the little toe. In adult males, the foreskin comprises one third to one half of the penile skin and acts as platform for nerve and nerve endings, making it as sensitive or more sensitive than other parts of the penis. Except when the penis is erect, the foreskin protects the glans by hanging over it. Without the protection of the foreskin, the glans of a circumcised male becomes keratinized and develops layers of protective cells that act like a callous. But while the physical characteristics of the foreskin are well-understood, whether the loss of the foreskin affects sexual performance or sexual satisfaction is fiercely debated. Unfortunately, but perhaps predictably, the evidence is mixed and mostly anecdotal. The two studies that surveyed men who were circumcised later in life report conflicting results. In one study of 15 men, circumcision resulted in no statistically significant changes in male sexual function. In another study of forty-three men, participants reported a statistically significant reduction in erectile function as well as decreased penile sensitivity. In this same study, however, men were more satisfied with their penis after circumcision, based in large part on its new appearance. This suggests a point made in a large study of American sexual practices: the perception of sexual experience depends not only on the physical characteristics of the individuals involved, but also on the larger cultural and social context. Still, perhaps our thought experiment should be modified to include the possibility that amputation of the little toe negatively affects sexual function. (Remember that you are suspending scientific disbelief.) With this modification the reader is now probably even more reluctant to cut off a newborn’s toe because the sacrifice required of the infant simply seems too great, especially when adult women have a means of safeguarding their own interests. In sum, more research needs to be done before prevention of cervical cancer can be added to the list of circumcision’s potential health benefits. But because of the issue of distributional fairness, as well as the dubiousness of the parent’s ability to consent to circumcision when its purpose is to benefit adult women, we should view with caution any argument that promotes the prevention of cervical cancer as a justification for routine circumcision. Sarah E. Waldeck, Using male circumcision to understand social norms as multipliers, University of Cincinnati Law Review, Volume 72 (3), Winter 2003 455-526; pages 485-491 reproduced here, references omitted <a href="http://www.cirp.org/library/legal/USA/waldeck1/">Full article with references can be read here</a> </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Circumcision to reduce cervical cancer risk illegal darby