10 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>Phimosis and paraphimosis:</h1> <h3>How a new disease suddenly emerged in eighteenth century Europe</h3> In striking contrast to late nineteenth century Britain and twentieth century United States, there was no sign in eighteenth century Europe of the “congenital phimosis” which suddenly became so common in boys after the 1860s. Quite the contrary: in the sixteenth century Gabriele Falloppio had observed that it was considered shameful and unhealthy for the glans to be uncovered (in classical times regarded as a pathological condition known as lipodermos) and prescribed means for lengthening inadequate foreskins. He thought that a penis with an exposed glans looked like a horse’s rump. The English anatomist William Harvey (discoverer of the circulation of the blood) wrote that in some men “the glans is never uncovered” without regarding this as a problem in need of surgical correction. The concept of phimosis as a pathological condition requiring medical treatment emerged only in the late seventeenth century, probably as a result of the syphilis epidemic, since the disease often produced scabs which fused foreskin to glans. One of the first to notice phimosis was perhaps the French surgeon Pierre Dionis (d. 1718), who defined it as a condition in which “the extremity of the prepuce is so tight that it will not permit the glans to be uncovered”. He observed that it could occur naturally but more commonly arose from a wound or venereal chancre which caused the preputial orifice to shrink. The muzzled or phimotic condition was normal (“physiological”) in infants and boys, but if it persisted into adulthood and was troublesome, the patient should treat it himself by pinching the foreskin shut while urinating and allowing the pouch to fill with urine, taking advantage of its elasticity and thus stretching the skin. In cases of where the condition arose from an accident or disease, treatment involved nicking the lip just enough to permit retraction. In his Medicinal Dictionary (1743-45) the English physician Robert James (1705-76) included an entry for phimosis in which he pointed out that this was usually a natural condition which demanded no medical attention at all: Some … have the foreskin naturally so long and so straitened [i.e. narrow] that the glans can either be not at all or very little uncovered; but as this neither occasions trouble in discharging the urine, nor any impediment in procreation, it requires no aid from the surgeons, unless it be attended with an inflammation, violent pain or any remarkable inconvenience in coition. Phimosis became a medical problem only if the foreskin became “so contracted by a violent inflammation that it cannot be drawn backwards behind the glans”, the usual cause of which condition was “impure coition” (i.e. venereal disease) producing a chancre which caused inflammation and possibly adhesion of the foreskin to the glans. The first line of treatment was to bathe the parts in a decoction of “barley mixed with honey of roses”, followed by bleeding and fomentations; only if these measures failed was surgical intervention required – first by slitting the foreskin and, in desperate cases, by an operation similar to “the Jewish circumcision”, but noticeably less radical. Paraphimosis Cutting was never indicated for paraphimosis, cases of which occurred most commonly in young husbands with tight foreskins who exerted themselves vigorously during intercourse; and similarly endowed boys who “lasciviously” drew their foreskin back while the penis was flaccid but found they could not return it after the ensuing erection. The only treatment needed was cold water to make the erection subside; lubrication of the penis with olive oil or butter; and manual manipulation if that was not sufficient. Such benign and simple therapies naturally became unthinkable as the masturbation taboo tightened its grip on medical profession and public alike from the late eighteenth century onwards. The eighteenth century English anatomist John Hunter gave similar advice and tended to regard all true phimosis as arising from venereal disease, particularly chancres and syphilis which caused ulcers and scabs which fused the foreskin to the glans and/or caused the orifice to tighten. He also observed that the non-retractability of the foreskin in many boys before puberty was perfectly natural and was often overcome by the boys’ own manual explorations and fondling: This natural phymosis is so considerable in some children as not to allow the urine to pass with ease, but in general becomes larger and larger, as boys grow up, by frequent endeavouring to bring it over the glans, which effect often prevents the bad consequences that would otherwise ensue in it when affected by disease. This is an interesting comment, revealing what a down to earth observer Hunter was. What he is suggesting is that no treatment was needed for phimosis because boys naturally stretched their foreskin when playing with their penis, gradually loosening it and achieving mobility at their own pace. With the Victorian masturbation scare, genuine phimosis at older ages might have become more common, since boys were now instructed not to play with or even to touch their penis, with the result that these manipulations could have become less frequent, and this gentle process of loosening disrupted. <h3>An eighteenth century discovery ... or invention ... but only in adult men</h3> It was, therefore, only in the eighteenth century that a recognisably modern understanding of phimosis emerged, but even then it was a condition described only in adult men, never in infants or boys. John Marten makes no mention of phimosis in his description of the “defects, diseases and infirmities” of the genitals (1708), and describes only his treatment for a short frenum (frenulum breve), easily fixed by a snip to the offending filaments, in much the same way as recommended by Nicolas Venette and later practised by Philippe Ricord in France and William Acton in Britain. There is no mention of phimosis at all in Jane Sharp’s Midwives’ Book (1671), nor in any eighteenth century baby or child care manual. The conceptualisation of phimosis as pathological defect in immature boys had to wait until the identification of masturbation as a disease agent had spread from the denunciatory texts into mainstream medical works, and from there the demonisation of the foreskin followed. The increasing concern with phimosis in adult men was probably a response to the syphilis epidemic, which drove many to present themselves at doctors’ surgeries with suddenly non-retractable foreskins as a result of swelling, ulceration and other nasty side-effects of venereal disease arising from sexual promiscuity. Such infections often did produce sores which fused the foreskin to the glans as they healed and otherwise caused the foreskin to tighten and become less elastic. We have already seen the descriptions of these conditions by Pierre Dionis and John Hunter, both of whom stated that phimosis (non-retractability) in childhood was normal, and it is worth recalling Hunter’s streetwise observation that boys commonly loosened tight foreskins by their ineradicable urge to play with their penis. This, indeed, was the advice given by Robert James for treating paraphimosis: cold water to make the erection subside; lubrication of the penis with olive oil or butter; and manual manipulation if that failed. Such conservative therapies (especially the last) obviously became impossible once the masturbation taboo had taken hold. It was thus the conjunction of the venereal disease epidemic and the masturbation phobia which gave rise to the twin delusions that an adherent prepuce in boys was pathological, and that pre-emptive amputation of the foreskin was an effective defence against syphilis and chancre. In the late eighteenth and early nineteenth centuries the distinction between venereal chancre and phimosis was so blurred that the terms seemed almost interchangeable. The physician William Buchan barely mentioned phimosis in his Domestic Medicine (1772), leaving the subject to be covered in his Observations Concerning … Venereal Disease (1796), where he reported that phimosis was an occasional problem in adult men, usually associated with venereal infection, and that the best treatment was conservative: hot and cold poultices, fomentations and bathing. Small incisions were sometimes necessary in severe cases. Buchan accepted the great variability of foreskin length as a biological fact and did not try to impose his own standards of what was allowable: These parts are so differently formed in different men that some may be said to have a natural phimosis; while others have the reverse. I have seen the foreskin so long that above three inches of it were amputated [i.e. would need to be], in order to discover the glans. In others the glans is never covered but remains exposed during life. Neither of these is attended with any considerable degree of inconvenience, unless in a diseased state. Buchan also warned that phimosis, and more often paraphimosis, were often caused by ill-advised interference: I have known some young men bring on a violent paraphymosis by acting on a wrong principle. One who had pulled back the skin and kept it there until it could not be returned without making incisions on both sides, said he did it on purpose to keep the glans cool. In this case, though the stricture was removed … the foreskin remained thickened. Most cases of phimosis caused by venereal infection could be cured by conservative treatment, and it was only in rare and obstinate instances that surgery was needed. Only after “all endeavours” to draw the foreskin back, using fomentations etc, had failed was it necessary to slit it open. Buchan was aware that this was a desperate step, since “many people” considered incision to imply “mutilation”, and he was at pains to point out that such mutilation was necessary only when the problem had been neglected. Early treatment would ensure that no more than a small incision was required. He described any cutting of the penis as “mangling and maiming” and assumed that nobody would allow it to be done except to save his life, and that he would still regret it. <h3>The nineteenth century</h3> A similar classification of phimosis as a venereal disease was made in the 1820s by Sir Astley Cooper, who stated that phimosis arose from “slight inflammation of the cellular tissue, and effusion of serous matter into it”. The cure was mercury, purges, and fomentations. Although it was the consequence, not the cause, phimosis induced by venereal chancre or other infection was a serious condition, and treatment was certainly needed (not that the nineteenth century could offer any effective treatments). But the idea that phimosis (meaning non-retractability) was pathological in men neither infected with venereal disease nor suffering from other injury, and whose foreskins varied enormously in length and tightness, developed as a result of the confounding of these two quite separate categories. The outcome was the extension of phimosis as a disease condition to men who were perfectly healthy, and from there to infants and boys whose tightly covered penises were perfectly normal. For further details and references see Robert Darby, A Surgical Temptation: The Demonization of the Foreskin and the Rise of Circumcision in Britain (University of Chicago Press, 2005), chapters 2 and 10. </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 Phimosis and paraphimosis in medical history 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"> Phimosis derives from an ancient Greek word meaning “muzzled” and refers to a condition in which the foreskin cannot be drawn back to expose the glans. Nearly all babies have phimosis, which is the normal and proper condition of the infant penis, and in many boys the condition persists until puberty or his mid-teens. The idea that phimosis in childhood was in itself harmful and an “indication” for circumcision was an error committed by Anglo-American doctors in the Victorian period, who suddenly decided that it was an abnormality (“congenital phimosis”) which had to be surgically corrected. Up until that time doctors and midwives were more worried about a foreskin that was not long and tight enough, so much so that the Greek authority Soranus, author of a manual of baby and child care that remained in use for over a thousand years, gave instructions on how to lengthen an inadequate foreskin. “If the infant is male and it looks as though it has no foreskin, she [the nurse of midwife] should gently draw the tip of the foreskin forward or even hold it together with a strand of wool to fasten it. For if gradually stretched and continuously drawn forward it easily stretches and assumes its normal length, covers the glans and becomes accustomed to keep the natural good shape.” Soranus's Gynecology, trans. and ed. Owsei Temkin (Johns Hopkins University Press, 1956), p. 107 Soranus was the author of a famous manual of gynecology that remained in use for many centuries. His advice is consistent with the view of Greek and Roman physicians that a short or inadequate foreskin (one which did not provide ample coverage of the glans) was a physiological defect known as lipodermos. Their concern was to offer advice on how short foreskins could be lengthened. For further details, see <a href="http://www.cirp.org/library/history/hodges1/">Frederick Hodges, Phimosis in antiquity</a>, and his other study <a href="http://www.cirp.org/library/history/hodges2/">The ideal prepuce</a>. It was not really until the early eighteenth century that phimosis emerged as a disease concept, probably in response to observations that syphilis often caused scabs that tended to narrow the foreskin and gum it to the glans. But there was never any suggestion that a phimotic foreskin in an infant or child was at all abnormal or pathological. That idea had to wait until nervousness about boys handling their penis ("masturbation") led doctors to blame the foreskin for drawing their attention to it and to propose that an uncovered glans was more morally hygienic. <a href="https://www.circinfo.org/Phimosis_History.html">Further information on the history of phimosis on this site</a> <h3>Medical error</h3> One of the three main reasons for the introduction of routine circumcision in the nineteenth century was thus based on a gross medical error, sudden amnesia towards previous knowledge, and ignorance of the normal development of the male genitals. In a baby boy the lower end of the foreskin (including the tapering spout or nipple which extends beyond the glans) can represent more than half the total length and bulk of the penis. This proportion decreases as the boy grows up and the rest of the penis grows into the foreskin. In infancy the foreskin is very tight and is normally fused to the glans, thus guarding the urethra (the urine passage) against the entry of dirt and protecting the glans from irritation by urine or faeces and from abrasion. It was never meant to be pulled back at this early stage; in most cases (unless there is a serious problem) the first person to pull back his foreskin should be the boy himself. It is suspected that one of the most frequent causes of genuine phimosis is injury caused by premature retraction. Many men never have a fully retractable foreskin are perfectly happy with it, but persistent phimosis can be a problem. If it is and treatment is needed, there are several options before radical surgery. The most common of these is treatment with steroid cream. Doctors in Australia, Britain and Canada are concerned that too many boys between the ages of four and ten are being circumcised because of a premature or otherwise incorrect diagnosis of phimosis. They warn that some of these diagnoses may be fraudulent and no more than excuse to get a boy circumcised. It should be stressed that the standard treatment for phimosis these days is application of steroid ointment, and that old surgical remedies such as circumcision are out of date and unscientific. <a href="https://www.circinfo.org/phimosiscomment.html">Doctors warn against false diagnosis of phimosis</a> <h2>Recent studies of the effectiveness of steroid cream in treatment of phimosis </h2> Ashfield JE, Nickel KR, Siemens DR, MacNeily AE, Nickel JC. Treatment of phimosis with topical steroids in 194 children. J Urol. 2003 Mar;169(3): 1106-8. PURPOSE: Topical steroids have been advocated as an effective economical alternative to circumcision in boys with phimosis. We evaluated the effectiveness of topical steroid therapy as primary treatment in 194 patients with phimosis. METHODS: Between January 1996 and November 2000, 228 boys 16 years old or younger were referred for consideration of circumcision. When intervention was determined to be necessary, a 6-week course of topical steroids was used as primary treatment. Efficacy of treatment was evaluated at 3 months from initiation of therapy. RESULTS: Of the 228 patients 15 had such a mild degree of phimosis that no intervention was believed to be necessary, 19 were scheduled directly for circumcision due to cosmetic reasons, parent wishes, or severe phimosis with associated voiding problems and the remaining 194 received topical steroids as primary treatment. Of these 194 patients 25 had coexisting balanitis and 4 had a history of urinary tract infection. Conservative treatment was successful in 87%, 88% and 75% of patients with phimosis alone, coexisting balanitis and history of urinary tract infection, respectively. Overall, circumcision was avoided in 87% of patients treated with topical steroids. CONCLUSION: Topical steroids are becoming the standard conservative measure for treating phimosis. Our study supports this trend, with an overall efficacy of 87%. <a href="http://www.cirp.org/library/treatment/phimosis/ashfield1/" rel="noopener" target="_blank">Read full text at CIRP</a>. Ng WT, Fan N, Wong CK, Leung SL, Yuen KS, Sze YS, Cheng PW. Treatment of childhood phimosis with a moderately potent topical steroid. ANZ J Surg. 2001 Sep;71(9): 541-3. BACKGROUND: Recently, topical steroid application has been shown by a small number of studies to be an effective alternative to circumcision for the treatment of phimosis. However, only potent or very potent corticosteroids have been more thoroughly studied in this treatment option. A prospective study was conducted to determine whether comparable results could be achieved using a weaker steroid cream. METHODS: Boys, 3-13 years of age, with non-retractable foreskin due to a tight ring at the tip were offered the regimen of twice-daily preputial retraction and topical application of 0.02% triamcinolone acetonide cream. The degree of preputial retractability was assessed at presentation and at 4 and 6 weeks of treatment. Success was defined as full retraction or free retraction up to agglutination of the foreskin to the glans. RESULTS: Eighty-three boys completed the treatment. Successful retraction was achieved in 48/83 (58%) patients after 4 weeks and 70/83 (84%) patients after 6 weeks of application. The overall response rate aggregated from six published series using 0.05% betamethasone was 87% at 4 weeks and 90% on completion of treatment. Thus, the results appear inferior when analysed at 4 weeks but compare favourably with those reported for a more potent steroid on completion of the full course of treatment. CONCLUSIONS: Even though the triamcinolone cream used in the present study is less potent than the more commonly used 0.05% betamethasone valerate cream, it could effect comparable improvements in foreskin retractability after 6 weeks of treatment. <a href="https://www.circinfo.org/pdf/Phim-Ng.pdf" rel="noopener" target="_blank">Read full text as PDF (52 kb)</a> Berdeu D, Sauze L, Ha-Vinh P, Blum-Boisgard C. Cost-effectiveness analysis of treatments for phimosis: a comparison of surgical and medicinal approaches and their economic effect. BJU Int. 2001 Feb;87(3):239-44. OBJECTIVE: To compare the cost-effectiveness of surgery and topical steroids as treatments for phimosis (defined as a clinically verifiable, pathological, cicatricial stenosis of the prepuce) and to evaluate the financial basis of these treatments. METHODS: Data on treatment using topical steroids was obtained from published reports and those for circumcision from claims by private hospitals for children <13 years old registered at the health insurance department of our facility. The estimate of the French national financial cost of the treatments for 1998 was calculated from public and private institutional information. RESULTS: Treatment with topical steroids for 4-8 weeks was successful in approximately 85% of patients (mean age 5 years) and had no side-effects; the remaining 15% were treated by circumcision. Topical steroid therapy costs (in French francs) F 360 per patient. For those primarily treated by circumcision (81 boys, mean age 4.3 years) and diagnosed as having phimosis, the cost was F 3330 per patient in the private sector. The total number of circumcisions performed in France, regardless of sector (public or private) for 1998 was estimated to be 51 080, which represents an annual cost of F 195.7 million. CONCLUSION: As topical pharmacological treatment avoids the disadvantages, trauma and potential complications of penile surgery, including anaesthesia-related risks, the use of topical steroids as a primary treatment appears to be justified in boys with clinically verifiable phimosis. This treatment could reduce costs by 75%, which represents a potential annual saving of approximately F 150 million. <a href="http://www.cirp.org/library/treatment/phimosis/berdeu1/" rel="noopener" target="_blank">Read full text on CIRP</a>. <a href="https://www.circinfo.org/Treatment_of_phimosis.html">Further studies of phimosis treatment on this site</a> <h2>Phimosis in adolescents and adults</h2> Another non-surgical method of treating an uncomfortably tight foreskin that makes sexual activity difficult or uncomfortable in adolescents and young men (i.e. after puberty) is to adopt a method of masturbation that loosens the foreskin and helps it to slide easily over the glans. This procedure has been described by the French physician Dr Michel Beaugé, and has the great advantages of being free, enjoyable and suitable for those odd moments when a boy is by himself with nothing much to do. (Oh those naughty French! How they must scandalize prudish Americans, who would much prefer to force a boy to get it all cut off!) <a href="http://www.cirp.org/library/treatment/phimosis/beauge/">Details of the Beauge method here.</a> Cases of phimosis in adult men can usually be resolved by application of steroid cream, as described in many articles about the success of such treatment in children. Dutch sex therapists suggest that a tight foreskin in adult men may be more of a psychological phenomenon than a physical problem, arising from sexual inhibition and reluctance to handle his penis when young - a process that nearly always results in the loosening of the foreskin. In these cases they suggest that gentle stretching exercises and psychological counselling may fix the problem. Abstract Patients use different words to express their sexual concerns. Some problems will be presented as dysfunctions, some as physical complaints, some as a disturbance in sexual feelings and emotions. Men, in general, tend to emphasize the dysfunctional and the physical aspects, rather than the emotions. A tight foreskin will be experienced as a purely physical condition by most patients. Yet quite often the medical sexologist will find a psychosomatic explanation. At birth, almost all boys will have a tight foreskin. During childhood and early puberty, sexual experiments and masturbation will be effective in stretching the prepuce to its adult size. If a man at the age of 20 still has a tight foreskin, it will often be a sign of sexual inhibition. Genital manipulation has been avoided, because this activity has been linked to guilt feelings or fear of doing damage to the genital organs. In adulthood the problems related to a tight foreskin in the absence of organic disease can be solved by the patient himself, by doing stretching exercises. Circumcision can be avoided, if the consulting physician only recognizes the psychosomatic nature of the problem. Source Jelto J. Drentha & Jelto J. Drbnth M.D., The tight foreskin: A psychosomatic phenomenon, Sexual and Marital Therapy, Volume 6, Issue 3, 1991, 297-306. <h3>Further information</h3> <a href="http://www.cirp.org/library/treatment/phimosis/">Further information on treatment of phimosis from CIRP</a> <a href="http://www.circumstitions.com/phimosis.html">Further information on phimosis from Circumstitions.</a> <a href="http://www.norm-uk.org/phimosis_clinical_guidelines.html">Further information from Norm-UK.</a> <a href="http://www.essentialkids.com.au/health/family-health/the-facts-on-foreskins-20121120-29myl.html" rel="noopener" target="_blank">Phimosis information at Essential Kids</a> <a href="http://www.bubhub.com.au/community/forums/showthread.php?70500-Phimosis-Foreskin-Development-amp-Normal-Age-for-Retraction" rel="noopener" target="_blank">Phimosis information at the BubHub</a> There is also a website where adult men discuss their individual efforts to overcome phimosis without surgery: http://www.network54.com/Forum/244184/ <a href="https://www.15square.org.uk/phimosis-video-help/" rel="noopener" target="_blank">Video with advice on home treatment of phimosis and paraphimosis from Norm-UK</a> <h2>Paraphimosis</h2> Paraphimosis refers to a condition in which the foreskin has been retracted from the glans but becomes trapped there and cannot be brought forward to cover it again. In most cases the problem can be solved by gently compressing the glans by squeezing it and allowing the foreskin to fall forward, but in rare cases (where the condition has persisted for a long time and the foreskin has become swollen and threatens to strangle the penis), urgent medical attention is needed. In the meantime ice may help. Paraphimosis in infants and young boys is often caused by attempts at premature retraction, and can easily be prevented by observing the golden rule of foreskin care: leave it alone; don't try to pull it back. Some pro-circumcision websites urge uncircumcised men to draw their foreskins back and wear them retracted, so as to get the feel of a bare glans, which is supposed to be pleasantly like being circumcised. Quite apart from the fact that such a condition is nothing like being circumcised (the foreskin, after all, is still there), the exercise is very risky and can induce a genuine paraphimosis (inability to return the foreskin to its normal, position) that may require surgery. The eighteenth century English physician <a href="https://www.circinfo.org/Phimosis_History.html">William Buchan reported the case</a> of a "foolish young man" who tried this trick to keep his glans cool, but whose foreskin became inflamed and suffered permanent damage. The foreskin is meant to cover the glans, and attempts to keep it back are likely to end in tears. Further information <a href="http://www.circumstitions.com/Paraphim.html" rel="noopener" target="_blank">Useful information on handling cases of paraphimosis is given at Circumstitions</a> <a href="http://www.cirp.org/library/treatment/paraphimosis/" rel="noopener" target="_blank">Information on treatment of paraphimosis from CIRP</a> <a href="http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=5153" rel="noopener" target="_blank">Advice from Royal Children's Hospital, Melbourne</a> <a href="http://www.nhs.uk/conditions/phimosis/Pages/Introduction.aspx" rel="noopener" target="_blank">Phimosis (tight foreskin): Advice from British National Health Service</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 Phimosis and paraphimosis 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"> Looking back on the history of circumcision it can be seen that enthusiasts, whether motivated by religious, scientific or emotional zeal, have always sought to use the most feared diseases of the time as a bogeyman to scare people into accepting their favourite fix. Their implied argument was that it is worth sacrificing an immediate good in order to reduce the risk of a potential future harm, but in fact there have been few serious efforts to assess any of these factors. In the nineteenth century circumcision was hailed as the answer to masturbation, syphilis and cancer, and today it is promoted as the answer to HIV-AIDS. Following a few clinical trials in Africa, some enthusiasts in the health industry have suggested that circumcision should not merely be offered as an option to sexually promiscuous adult men, but forced routinely on innocent infants and children; and some extremists have got so carried away that they have seriously proposed that the operation should be legally compulsory - and not merely in underdeveloped countries with a high incidence of HIV infection, but even in developed nations where AIDS is far less prevalent and confined to specific sub-cultures. The question is whether such people are viewing circumcision as a tactic against AIDS, or whether they see AIDS as an opportunity to enforce circumcision. Here pediatrician Robert Van Howe and human rights expert J. Steven Svoboda criticise the authoritarianism in this sort of advocacy and expose the many flaws in their argument. <h2>Neonatal Circumcision is Neither Medically Necessary nor Ethically Permissible: A response to Clark et al.</h2> by Robert S. Van Howe, MD, MS, FAAP Assistant Clinical Professor, Department of Pediatrics and Human Development Michigan State University College of Human Medicine and J. Steven Svoboda, JD Executive Director, <a href="http://www.arclaw.org/">Attorneys for the Rights of the Child</a> Berkeley, California <a href="http://www.medscimonit.com/fulltxt.php?ICID=865808">Medical Science Monitor, Vol. 14, No 8, 200</a> <h3>Introduction</h3> In their review article, Clark et al. claim, “Neonatal circumcision is medically necessary and ethically imperative.”[1] This represents a double contradiction of, among others, the positions of the American Academy of Pediatrics,[2] the British Medical Association,[3] the Canadian Paediatric Society,[4] and the Royal Australasian College of Physicians.[5] To justify such a dramatic conclusion, the authors need to make a strong case. This is all the more true given the authors far-reaching intent to examine the medical evidence, give an ethical analysis, and develop guidelines to implement mandatory neonatal circumcision in sub-Saharan Africa. Unfortunately the authors stumble so badly on the first two steps that the third step becomes irrelevant. We will evaluate the accuracy and quality of the “medical evidence” Clark et al. use in their analysis by parsing the facts from the fantasy, providing an overview of the risk-benefit analyses of circumcision, evaluating the authors’ ethical justification of infant circumcision, and providing our own modest proposal. <h3> <a id="medical" name="medical"></a>Medical evidence</h3> When discussing the medical evidence surrounding circumcision it is important to first separate facts from fantasy, facts from speculations, and then to determine the strength of the evidence. Facts and fantasy Several of the statements made by Clark et al. have no factual basis or are factually inaccurate. 1. Without providing citations, the authors refer to studies that the foreskin has greater susceptibility to traumatic epithelial disruptions during intercourse. To our knowledge, such studies do not exist. To the contrary, the only study we are aware of found a non-significant trend that penile abrasions are more common in circumcised men.[6] 2. While Clark et al. suggest, again without citation, that the frenulum is “particular susceptible to injury during intercourse,” to our knowledge no studies substantiate such a claim. 3. The authors suggest, again without citation, that the micro-environment in the preputial sac “may be conducive to viral survival.” We are not aware of any studies to support this claim. To the contrary, the two sexually transmitted virus, herpes simplex type 2 and human papillomavirus, occur with equal frequency in circumcised and normal men.[7-10] The authors further state that this micro-environment “favors microorganism survival and replication.” Again, we are aware of no studies to support this claim. What is known is that the flora on the normal glans and the circumcised glans differ. The former have many gram-negative organisms, which are the bacteria most commonly found in the colon, while the later have more gram-positive organisms, which are most commonly found on the skin. This difference in flora may explain why circumcised newborn males are 12 times more susceptible to community-acquired methicillin-resistant Staphylococcus aureus infections.[11] 4. Clark and co-authors suggest that the pain of circumcision can be “minimized” by local anesthesia. While local anesthesia can reduce the pain of circumcision, studies indicate the procedure is still stressful and painful.[12] The pain of circumcision is minimized by general anesthesia and/or a caudal block. 5. The authors suggest that circumcision protects against the development of phimosis, paraphimosis, cervical cancer, herpes simplex type 2 infections, and other sexually transmitted infections. The medical literature tells another story. There is not a single comparative study that demonstrates that phimosis or paraphimosis is significantly more common in normal males than in circumcised males. Similarly, of the sixteen studies known to us that evaluated the impact of circumcision status of the male partner on cervical cancer risk in females, only one found a significant association, which is what would be expected by chance alone. For sexually transmitted diseases, syphilis and genito-ulcerative disease are more common in normal males in Africa, while genital discharge syndrome is more common in circumcised males.[7,13] The other sexually transmitted diseases have been shown not to differ with circumcision status; however, a meta-analysis of the risk of contracting any sexually transmitted disease as opposed to not being infected shows the risk is greater in circumcised men.[Van Howe, unpublished data] 6. Clark et al. suggest several times that neonatal circumcision minimizes the phenomenon of risk compensation. In making this claim, they cite an opinion piece by Rennie et al.,[14] which makes this claim without any reference. Once again no reference to research supporting this claim is given because, to our knowledge, no reference exists. Evidence to the contrary does exist. Laumann et al. found that circumcised men in the United States exhibit higher risk behaviors than normal men.[15] The authors’ concern about risk compensation is understandable because the impact on HIV infection rates of large increases in the circumcision rate can be undone with small decreases in the rate of condom use. If a man feels his circumcision is protecting him, he will be less likely to use condoms. Consequently, he is actually putting himself at a greater risk than if he had not been circumcised and used condoms more frequently. 7. The authors state that circumcision is more effective in preventing HIV infection if it is performed earlier in life. There is conflicting evidence regarding the impact on HIV risk of the age of circumcision. The studies used age cutoffs of 12 and 15 years and did not break out those circumcised neonatally as opposed to those circumcised later.[16,17] 8. The authors suggest that the majority of Muslims are circumcised at birth, when this is clearly not the case.[18] How did such an egregious statement escape the scrutiny of reviewers and editors? Clark et al. also suggest that 30% of males in the world are circumcised, but fail to include the important qualification that outside of the North America, Australia, and those of the Jewish faith, very few of these procedures are done on newborns. 9. Clark and collaborators erroneously suggest that HIV infection trends are “stable” and “increasing.” The HIV infection rates in Africa peaked in the late 1990s and are declining.[19] 10. The authors suggest that methods of HIV prevention that are less invasive and more effective than circumcision may be discovered between when a newborn is circumcised and when he reaches sexual maturity. Clark et al. thus obscure the fact that less invasive, more effective, less expensive methods already exist, in the forms of condoms and abstinence. 11. Clark et al. state that circumcision will reduce the risk of women becoming infected with HIV. Recently it has been reported that following circumcision the female partner of a HIV infected man is not protected and may be at greater risk of infection immediately following the circumcision.[20-22] 12. Without supplying a reference, the authors claim that neonatal circumcision is less expensive than circumcision later in life. Since most of the estimates of the cost of circumcising Africa are based on using local anesthetic and most of the difference in the cost of circumcision in developed nations is the cost of general anesthesia, it is hard to know where the difference in cost is coming from. The surgeon’s time, the local anesthetic, etc. would be similar for both procedures. The only difference is that it is easier to hold an infant down. 13. Clark and co-authors claim that neonatal circumcision has fewer complications than later circumcisions. Again, no references are provided. Most of the comparisons have been between studies that used different criteria for what constituted a complication. Only two studies have done a direct comparison, in a single setting, using parallel definitions, of complication rates from neonatal circumcisions and complication rates from post-neonatal circumcisions. One found no difference in the complication rates, while the second found more complications in the neonatal circumcisions.[23,24] The authors provide an incomplete discussion of the complication rates of circumcision and ignore studies that fail to support their premise. For example, one ignored study of circumcisions performed mostly on newborns in a medical facility in Ibadan, Nigeria found a 20.2% complication rate with 3.1% of the circumcisions resulting in part of the glans being amputated.[25] Expounding on the benefits of the allegedly low complication rate associated with circumcision, while ignoring the realities of performing the procedure in developing nations, is negligence that borders on recklessness and academic dishonesty. Facts and Speculation 1. The authors erroneously suggest that the “outer shaft of the penis is protected by a barrier of keratinized stratified squamous epithelium, much like the structure of skin found throughout the outer surfaces of the body. In these tissues, keratin provides a tough structural matrix that resist friction and fluids. The inner mucosa of the foreskin, however, is made up of non-keratinized squamous tissue and thus does not offer the same level of protection.” To the contrary, it has never been demonstrated that there is any difference in protection provided by keratinized and non-keratinized squamous tissue. Mucosal immunity works much differently than skin immunity, and so far there have been no studies that provide a comparison. 2. The authors provide a description on how Langerhans cells are believed to be involved in HIV infection. To date, this is speculation and has not been proven in vivo. Langerhans cells are effective at preventing HIV infection, as reflected by a low infection rate per unprotected sexual contact. It is only when the Langerhans cells are overwhelmed with a high viral load that the HIV virus gets into the system.[26] This may explain why antiretrovirals, by lowering the viral load, help reduce HIV transmission. Currently, the Swiss have stated that for HIV-positive individuals on antiretroviral therapy with low viral loads and no active sexually transmitted infections, there is no risk of HIV transmission.[27] The Langerhans cells also fight against other sexually transmitted diseases, which may explain why circumcised men have a greater overall risk for sexually transmitted diseases.[Van Howe, unpublished data] 3. The authors express the hope that “mandating neonatal male circumcision could open up discussions about HIV prevention and would allow time for the children to be educated on subjects such as condom use, testing for HIV, mutual monogamy, and partner reduction as they get closer to the age of sexual activity. This education, along with the preventative effects of the circumcision, would cause a major decrease in the spread of the HIV virus.” It is hard to understand how a procedure performed on infants would open up discussion about HIV prevention. Any discussion with an infant would likely be forgotten. Education and discussion would be most effective just prior to or around the age when sexual activity is initiated. It is hard to picture how this could be linked to infant circumcision, unless the parents are the objects of the discussion. For them, the opportunity for meaningful, effective discussion may have already passed. Further, a false sense of assurance obtained from an assertedly, but not in fact, effective HIV prevention measure such as circumcision could result in the stifling of further dialog regarding HIV prevention, as the matter would incorrectly seem to have been adequately resolved. 4. The authors state that neonatal circumcision will prevent HIV infections and save lives. This suggestion represents fantasy based on speculation. The speculation is that data from circumcision performed in randomized clinical trials in self-selected, well-paid, motivated, high-risk adults can be extrapolated to infants. The observational data from populations that perform primarily infant circumcisions indicate that it cannot. For example, the largest studies of heterosexual men in the United States have failed to find such an association. The first was a systematic population survey in the 1990s. It found that nine men out of 2567 interviewed were HIV positive and no significant association was found between HIV infection and circumcision status.[15] The second was a study of patients of a sexually transmitted disease clinic in San Francisco from 1996 through 2005. Among the 52,143 heterosexual men, those who had been circumcised were at slightly greater risk for HIV infection, although the trend was not statistically significant (OR=1.07, 95%CI=0.95-1.21).[28] While studies based in sexually transmitted clinics are susceptible to various forms of bias, it is extremely unlikely these forms of bias would erase the 50% to 60% protective effect the authors believe should result from neonatal circumcision. What is more likely is that infant circumcision performed on the general population has no impact on the risk of HIV infection. Strength of the evidence Much has been made of the results of the randomized clinical trials in Africa.[29-31] Although these trials were randomized, they still have a number of sources of bias, some of which were unavoidable and some of which were avoidable. These include selection bias, lead-time bias, expectation bias (both on the part of the participants and the researchers), attrition bias (700 men were lost to follow-up, while only 205 became HIV infected), length bias, improper randomization (Auvert study[29]), and early termination, which amplified the lead-time bias. Each of these forms of bias contributes positively to the treatment effect the investigators were hoping for. While the small absolute risk reductions found in these studies appear to be statistically significant due to the large number of subjects, their clinical importance has not been fully vetted. The participants in the randomized clinical trials were men who wanted to be circumcised and were mostly unemployed. For participating, they received a free circumcision (thereby saving themselves the equivalent of about two months of wages), cash (also equivalent to about two months of wages), cash bonuses for recruiting additional subjects, and up to two years of free health care. It is not clear whether subjects were given full disclosure regarding the negative consequences of circumcision. Although these studies were approved by various investigational review boards, a case could be made that these men’s participation in the studies was financially coerced and informed consent was inadequate. When interviewed by Nature, Helen Weiss, a statistical epidemiologist at the London School of Public Hygiene & Tropical Medicine, stated that given the results of the observational studies and randomized clinic trials, this is ”as convincing evidence as one ever gets in public health.”[32] A faculty member of a school of public health ought to know better. The findings of a randomized clinical trial do not necessarily result in public health benefits. To test and demonstrate the practical applicability of their findings, randomized clinical trials should be followed by translational studies. Quite often the patients included in a clinical trial are those individuals most likely to respond the intervention. When application of the intervention is expanded to a more general population, who are often less likely to respond, the positive response is often attenuated or can disappear completely. Compared to the populations in the clinical trials, the general population will be not be self-selected, will be less motivated, will be at lower risk for infection, and will not be paid to undergo the procedure. Likewise, the general population will not have similar access to care for the complications of the procedure and may not have same quality of care delivered at the time of the procedure. Consequently, there are many reasons why the results in the research setting may not translate into a public health success. Circumcision as a “vaccine” and other hyperbole Resorting as often as they do to hyperbolic statements, the authors make themselves look foolish. Statements like, “Innocent lives are being lost daily,” have no place in a serious discussion of this issue. If circumcision was such a great intervention, why do the authors need to resort to hyperbole to convince others? The authors repeatedly emphasize that WHO and UNAIDS have “recommended” circumcision. (UNAIDS as a non-scientific organization could more accurately be described as advocating for circumcision.) Before it can be recommended, circumcision as a preventive for HIV infection needs to be compared to the alternative interventions. As discussed below, the ABC (abstinence, be faithful, condoms) approach is more effective, less expensive, has fewer side effects, is less invasive, and is more readily available. The ABC approach also has the additional benefits of protecting against sexually transmitted diseases and unwanted pregnancies. The only unsettled component is compliance. Compliance can depend on social pressures and on how persuasively health care workers promote condoms. To recommend an intervention when more effective, less expensive, less harmful, and less invasive alternatives exist is unethical. Based on this comparison, it is unethical to recommend circumcision over the ABC approach. At best circumcision can be offered as an alternative while making it clear that it is less effective, more invasive, more expensive, and has more side effects than the ABC approach. The authors equate the impact of adult circumcision in a self-selected, well-paid, motivated, high-risk population with that of a vaccine. By doing so they are hoping to play on the impression that most people have of vaccines: minimal negative impact, protection rate of 85%, cost-effective, low rate of complications, non-interference with daily activities, and the best alternative available. Protection of 40% to 50% in a selected population that may not translate to the general population is pathetic compared to what most people would consider the “vaccine-level protection” of 85% or more provided by the vaccines currently in use.[33] Circumcision also has a much higher rate of complications that what would be expected from a vaccine. Early complication rates in developed countries are 2% to 6%.[34,35] In developing countries, they are as high as 20%.[25] Later complications, such as meatal stenosis requiring meatotomy, can occur in 5% to 8% of cases.[36] Serious complications, such as amputation of the glans and death, do occur. These rates are much greater than would be expected from vaccines. Moreover, issues result from tissue amputation that are not associated with vaccines. Circumcision removes nearly all of the fine-touch neuroreceptors and the most sensitive portion of the penis,[37,38] decreases the sensitivity of the glans,[38,39] and results in problems with erectile dysfunction, loss of sexual pleasure, premature ejaculation, difficulty with insertion, and loss of sensitivity.[40-43] Such a disruption in daily function from a vaccine would not be tolerated. Vaccines are used because they are effective, have an acceptable rate of side effects, and are the best available option. Circumcision of infants has not even been proven to be effective and is far from the best available option. For the illnesses that circumcision proponents believe to be impacted by neonatal circumcision, other less invasive, more effective interventions are available. If a vaccine were released that only offered 50% protection for HIV, but reduced condom usage, it would be rejected. <h3> <a id="risk" name="risk"></a>Risk Benefit Analysis</h3> The authors make multiple references to the balance of risks and benefits and how the benefits allegedly outweigh the risks without actually performing a risk-benefit analysis. Several analyses of the costs of neonatal circumcision have been published.[44-48] None has found neonatal circumcision to be cost-effective. The most recently published cost-utility analysis, which incorporated into the analysis an assumption that circumcision would reduce the rate of HIV by half, found that neonatal circumcision resulted in more costs and poorer health than for those not circumcising.[47] Even a cost-analysis published by one of circumcision’s most prominent proponents found that circumcision was more costly than not circumcising.[48] So based on the information in the medical literature and no further analysis in their article, it is not evident that neonatal circumcision has benefits that outweigh the risks. The conclusion that neonatal circumcision has fewer risks than benefits may come from a cultural bias rather than medical information. It has been well documented that in cultures that have high neonatal circumcision rates, the pain, harm, and risks of the procedures are either ignored or minimized, while the benefits are exaggerated and promoted.[49,50] Because of the cultural blinders and multipliers associated with this issue, purely rational discussions of neonatal circumcision have become nearly impossible.[50] The authors make much of the studies that extrapolate the findings from the shortened randomized clinical trials to the rest of Africa. Extrapolation from a small non-representative population over a short period of time to the rest of Africa over a lifetime is fraught with danger. These models may give a very rough estimate of the costs and benefits, but like most models the GIGO (garbage in, garbage out) principle applies. What is missing from the discussion of risk and benefits of those promoting circumcision as a preventive for HIV infection is a comparison of circumcision to other interventions. The authors state that circumcision of the neonate is “relatively inexpensive” without providing a comparison. For example, a study using aggressive surveillance and treatment of sexually transmitted infections found that one HIV infection could be averted for each $217.62 (1993 USD) spent.[51] A recent estimate places this in the $321 to $1665 range.[52] Gray et al. have estimated, based on their results in a research setting, that using circumcision, it would cost $1269 to $3911 to avoid one HIV infection.[53] This assumed that similar treatment effects and complication rates could be obtained outside of a research setting, which is not a very safe assumption. Treating sexually transmitted infections has the additional benefit of reducing the number of HIV infections. By contrast, the randomized clinical trials found that circumcision had no significant impact on gonorrhea, syphilis, or herpes type 2 seroconversion.[54] Once the infrastructure to deliver care is established, condoms cost approximately 2¢ each. For the price of one circumcision in Africa, one could purchase 3500 condoms, enough to provide a condom a day for nearly ten years. Condoms, if used consistently, can provide 99% to complete protection. In a cost comparison, relying on circumcision cost 95 times more to have the same impact as condom use.[55] Of course the infrastructure needed to provide circumcision under sterile conditions would much more costly than that needed to distribute condoms. So for primary prevention, condoms and abstinence are the most effective, least expensive, least invasive interventions. With complete protection available through condoms at very low cost, what value does circumcision add? It is either ineffective or redundant. Noting that the authors are part of a Catholic institution, there may be some reluctance to discuss condoms, but the authors may want to present a follow-up article on the ethics of interfering with condom distribution. Regarding the medical evidence, one can only conclude that it is not known whether infant circumcision will reduce the rate of HIV infection. Evidence from the United States indicates that it does not. <h3> <a id="ethical" name="ethical"></a>Ethical Analysis</h3> All medications have effects. Some we like, some we don’t. The latter we call side effects. Sometime a medication is used for its “side effects,” depends on the illness. The authors rely on an ethical analysis of dual effects. To prove their case, they must fulfill four conditions and three criteria associated with the fourth condition.[56,57] The authors try to demonstrate that the criteria are met. We find their arguments unconvincing. The first condition requires proof that neonatal circumcision is in and of itself good. The authors state that this condition has been met because neonatal circumcision “can effectively reduce male heterosexual HIV infection by 60%.” As noted above, this has not been demonstrated and there is ample evidence to the contrary. Until this can be proven, this condition is not met. The second condition is that the good effect is not produced by means of the evil effect. The author states this condition is met because circumcision “provides a degree of protection against acquiring HIV infection not only for the individual but for others in society.” Neither of these has been proven, so this condition is not met. One of the problems with circumcision is that the evil effects can produce more evil effects. For example, circumcision removes the most sensitive portion of the penis (an evil effect).[38] The foreskin is functional genital tissue that serves important protective, immunological, and erogenous functions (an evil effect). Moreover, the loss of tissue can lead to behaviors that are associated with an increased risk of HIV infection (another evil effect), such as less frequent condom use, an increase in the number of sexual partners, a greater likelihood to engage in anal sex,[15] and greater likelihood to be gay or bisexual.[28] The third condition is that the evil effect is not intended, but merely tolerated. The authors state this condition is met because “the direct intention of mandating neonatal circumcision is to provide a degree of protection to the individual against HIV infection and to offer a degree of protection for society as a whole.” Once again, neither of these desires the authors have for circumcision has been demonstrated. Throughout history, the intended effects of circumcision have been less than beneficial. In most cultures and religions that practice circumcision, it is used as way of controlling sexuality in contrast to having the full pleasure of the penis and having the freedom to choose what to do with it.[58-63] It may come down to which is evil: societal control or personal freedom? The fourth condition is that a proportionate reason exists for performing the action, in spite of its evil consequence. This condition has three criteria. The first criterion is that the means used will not cause more harm than necessary to achieve the value. If it is not clear that neonatal circumcision can achieve the goal, this criterion is not satisfied. As discussed above, condoms are less invasive, more effective, and less expensive than circumcision. Even if neonatal circumcision provided 60% protection, using circumcision causes more harm than necessary to achieve the goal of reducing HIV infection. The second criterion requires that no less harmful way exist to protect the value. Again condoms are more effective and less harmful. The third criterion mandates that the means to achieve the value will not undermine it. To meet this criterion the authors state that “mandatory neonatal male circumcision does not undermine the value of human life.” The authors talk about the loss of autonomy as a counter argument, but fail to address it. The author fail to recognize that the infant has the right to bodily integrity as guaranteed by a number of international human rights declarations.[64-66] An in-depth study of consent in children concluded that a preference for performing a procedure on infants rather than waiting until the child can assent is associated with a disrespect for the value of the infant as a person.[67] Circumcision is also performed for cultural reasons that benefit the society instead of the child.[68,69] The foreskin is considered community property. This approach treats the child as a means instead of as an end to himself, thereby diminishing his worth as a human in a manner that may make Kantians squirm.[70] A consistent thread in the articles that support newborn circumcision from an ethical perspective is the lack for respect for the newborn as a person.[71] More on point, circumcision undermines itself by leading to a lower usage of condoms and an increase in other high-risk behaviors. The ethical argument thus fails to meet any of the criteria and conditions. However, employing the types of arguments used by the authors, and in homage to Jonathan Swift, we offer a “modest proposal.” Using similar arguments as those put forth by the authors, we believe one could argue that neonatal penectomy is “medically necessary and ethically imperative.” The first condition would be met because penectomy would virtually eliminate all sexually transmitted HIV in both heterosexuals and homosexuals. It would also have the added benefit of eliminated nearly all sexually transmitted infections. It would also have a beneficial impact on overpopulation and unwanted pregnancies and an indirect positive impact on poverty. It could be predicted to also have a positive impact on the subjugation of women. The second condition is likewise met because the good effect of neonatal penectomy does not come from its evil effect (that is if there is an evil effect). The third condition is met because the direct goal of neonatal penectomy is to reduce HIV infections, which it would accomplish, along with the positive effects listed above. The fourth condition depends on three criteria. The first criterion would be met using the authors’ standards because the value of HIV prevention trumps any harms. The second criterion is met using the authors’ standards because neonatal penectomy offers vaccine level protection. It is probably more effective than any of the vaccines currently under development could hope for. The third criterion is met because neonatal penectomy does not undermine the value of human life any more than circumcision does and protects women and the rest of society. So using the authors’ logic, neonatal penectomy would be preferable to neonatal circumcision because it is more effective in preventing HIV and has many additional benefits. The reductio ad absurdum that the authors’ arguments produces speaks for itself. <h3> <a id="issues" name="issues"></a>Other issues</h3> Clark et al. manage to avoid discussion of broader issues that might provide a more nuanced perspective less consistent with their antipathy to the foreskin. There are two camps in the fight against HIV infection. There are those who feel there is a quick-fix biological cure.[72] Alternatively, there are those who realize that the HIV pandemic is driven by high-risk behaviors and that the pandemic will continue until the behaviors are addressed.[19,73] While the quick-fixers, such as the authors, point out the difficulties of getting people to adopt healthier sexual behaviors, the effectiveness of the ABC program in Uganda indicates that significant improvement is possible and that behavior can change and these changes can have a large impact on infection rates. The second issue that the authors breeze past is whether efforts should be focused on primary or secondary prevention. Advocating newborn circumcision for all Africans is primary prevention. The problem with primary prevention is that you may have to circumcise hundreds or thousands of infants to have a net benefit in one individual twenty years later. That approach expends a lot of resources that could be utilized elsewhere or while we are waiting. By contrast, secondary prevention (condoms or antiretroviral therapy) has been shown to be nearly completely protective, and focuses resources to where they will have the most positive impact. In his recent book, The AIDS Pandemic, James Chin expresses the opinion that primary prevention of AIDS is a waste of resources better focused on secondary prevention.[19] Circumcision may have a mild benefit for self-selective, well-paid, motivated, high-risk adult males in Africa, while its impact in other populations remains to be seen. Even so, the high costs, potential for complications, and disregard for individual autonomy make it difficult to justify a mandate for circumcision in high-risk adults. Doing so will squander resources that could be better applied to interventions that would have a much more positive impact. Extrapolating the weak protective effect in a selective adult population to infant circumcision without any data to support can best be described as silly. <h2> <a id="refs" name="refs"></a>References</h2> 1. Clark PA, Eisenman J, Szapor S. Mandatory neonatal circumcision in sub-Saharan Africa: medical and ethical analysis. Med Sci Monit 2007; 13(12): RA205-13. 2. American Academy of Pediatrics Task Force on Circumcision. <a href="http://www.cirp.org/library/statements/">Circumcision policy statement</a>. Pediatrics 1999; 103: 686-93. 3. British Medical Association. <a href="http://www.cirp.org/library/statements/">The law and ethics of male circumcision: guidance for doctors</a>. J Med Ethics 2004; 30: 259-63. 4. Fetus and Newborn Committee, Canadian Paediatric Society. <a href="http://www.cirp.org/library/statements/">Neonatal circumcision revisited</a>. Can Med Assoc J 1996; 154: 769-80. 5. Beasley S, Darlow B, Craig J, Mulcahy D, Smith G. Royal Australasian College of Physicians. <a href="http://www.racp.edu.au/page/health-policy-and-advocacy/paediatrics-and-child-health">Policy statement on circumcision</a>. Sydney, Australia: RACP; 2004. 6. Bailey RC, Neema S, Othieno R. Sexual behaviours and other HIV risk factors in circumcised and uncircumcised men in Uganda. J Acquir Immune Defic Syndr Hum Retrovirol 1999; 22: 294-301. 7. Weiss HA, Thomas SL, Munabi SK, Hayes RJ. Male circumcision and risk of syphilis, chancroid, and genital herpes: a systematic review and meta-analysis. Sex Transm Infect 2006; 82: 101-10. 8. Xu F, Markowitz LE, Sternberg MR, Aral SO. Prevalence of circumcision and herpes simplex type 2 infection in men in the United States: the National Health and Nutrition Examination Survey (NHANES), 1999-2004. Sex Transm Dis 2007; 34: 479-84. 9. Dickson N, van Roode T, Paul C. <a href="http://www.cirp.org/library/disease/STD/dickson1/">Herpes simplex virus type 2 status at age 26 is not related to early circumcision in a birth cohort</a>. Sex Transm Dis 2005; 32: 517-9. 10. Van Howe RS. <a href="http://www.cirp.org/library/disease/cancer/vanhowe2006b/">Human papillomavirus and circumcision: A meta-analysis</a>. J Infect 2007; 54: 490-6. 11. Nguyen DM, Bancroft E, Mascola L, Guevara R, Yasuda L. Risk factors for neonatal methicillin-resistant Staphylococcus aureus infection in a well-infant nursery. Infect Control Hosp Epidemiol 2007; 28: 406-11. 12. Van Howe RS. Anesthesia for neonatal circumcision: who benefits? J Prenatal Perinatal Psychol Health 1997; 12(1): 3-18. 13. Van Howe RS. Genital ulcerative disease and sexually transmitted urethritis and circumcision: a meta-analysis. Int J STD AIDS 2007; 18: 799-809. 14. Rennie S, Muula AS, Westreich D. Male circumcision and HIV prevention: ethical, medical and public health tradeoffs in low-income countries. J Med Ethics 2007; 33: 357-61. 15. 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>. JAMA 1997; 277: 1052-7. 16. Kelly R, Kiwanuka N, Wawer MJ, et al. Age of male circumcision and risk of prevalent HIV infection in rural Uganda. AIDS 1999; 13: 399-405. 17. Quigley M, Munguti K, Grosskurth H, et al. Sexual behaviour patterns and other risk factors for HIV infection in rural Tanzania: a case-control study. AIDS 1997; 11: 237-48. 18. Rizvi SAH, Naqvi SAA, Hussain M, Hasan AS. Religious circumcision: a Muslim view. BJU Int 1999; 83 (suppl 1): 13-6. 19.Chin J. The AIDS pandemic: the collision of epidemiology with political correctness. Oxford: Radcliffe Publishing; 2007. <a href="http://www.h-net.org/reviews/showrev.php?id=13865">Reviewed on H-Net</a> 20. Stephenson J. HIV prevention studies yield mixed results. JAMA 2008; 299; 1529-30. 21. Roehr B. Circumcision of men did not cut HIV transmission to their wives. Br Med J 2008; 336: 299. 22. Turner AN, Morrison CS, Padian NS, et al. Men's circumcision status and women's risk of HIV acquisition in Zimbabwe and Uganda. AIDS 2007; 21: 1779-89. 23. Yegane RA, Kheirollahi AR, Salehi NA, Bashashati M, Khoshdel JA, Ahmadi M. Late complications of circumcision in Iran. Pediatr Surg Int 2006; 22: 442-5. 24. Machmouchi M, Alkhotani A. <a href="http://www.cirp.org/library/complications/machmouchi2007/">Is neonatal circumcision judicious?</a> Eur J Pediatr Surg 2007; 17: 266-9. 25. Okeke LI, Asinobi AA, Ikuerowo OS. Epidemiology of complications of male circumcision in Ibadan, Nigeria. BMC Urol 2006; 6: 21. 26. de Witte L, Nabatov A, Pion M, et al. <a href="http://www.cirp.org/library/disease/HIV/de_witte2007/">Langerin as a natural barrier to HIV-1 transmission by Langerhans cells</a>. Nat Med 2007; advance online publication. doi:10.1038/nm1541. 27. Vernazza P. La prévention du sida devient plus simpl, mais aussi plus complexe! Bull Med Suisses 2008; 89: 163-4. 28. Mor Z, Kent CK, Kohn RP, Klausner JD. Declining rates in male circumcision amidst increasing evidence of its public health benefit. PLoS ONE 2007; 2(9): e861. 29. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: The ANRS 1265 Trial. PLoS Med 2005; 2(11): e298. 30. Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet 2007; 369: 643-56. 31. Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet 2007; 369: 657-66. 32. Butler D, Odling-Smee L. Circumcision for HIV needs follow-up. Nature 2007; 447: 1040-1. 33. Dennehy PH, Jost EE, Peter G. Active immunizing agents. In Feigin RD, Cherry JD, editors. Textbook of Pediatric Infectious Diseases, 4th Edition. Philadelphia: W.B. Saunders, Co; 1998. 34. O'Brien TR, Calle EE, Poole WK. Incidence of neonatal circumcision in Atlanta, 1985-1986. South Med J 1995; 88: 411-5. 35. Moreno CA, Realini JP. Infant circumcision in an outpatient setting. Tex Med 1989; 85: 37-40. 36. Van Howe RS. <a href="http://cpj.sagepub.com/cgi/content/abstract/45/1/49">Incidence of meatal stenosis following neonatal circumcision in a primary care setting</a>. Clin Pediatr (Phila) 2006; 45; 49-54. 37. Cold CJ, Taylor J. <a href="http://www.cirp.org/library/anatomy/cold-taylor/">The prepuce</a>. BJU Int 1999; 83 (suppl 1): 34-44. 38. Sorrells ML, Snyder JL, Reiss MD, et al. <a href="http://www.cirp.org/library/sex_function/taylor2007/">Fine-touch pressure thresholds in the adult penis</a>. BJU Int 2007; 99: 864-9. 39. Yang DM, Lin H, Zhang B, Guo H. [Circumcision affect glans penis vibration perception threshold] Zhonghua Nan Ke Xue. 2008; 14: 328-30. 40. Kim DS, Pang M-G. <a href="http://www.cirp.org/library/sex_function/kim2006/">The effect of male circumcision on sexuality</a>. BJU 2007; 99: 619-22. 41. Shen Z, Chen S, Zhu C, Wan Q, Chen Z. [<a href="http://www.cirp.org/library/sex_function/shen1/">Erectile function evaluation after adult circumcision</a>] Zhonghua Nan Ke Xue 2004; 10: 18-9. 42. Fink KS, Carson CC, DeVellis RF. <a href="http://www.cirp.org/library/sex_function/fink1/">Adult circumcision outcomes study: effect on erectile function, penile sensitivity, sexual activity and satisfaction</a>. J Urol 2002; 167: 2113-6. 43. Coursey JW, Morey AF, McAninch JW, et al. Erectile function after anterior urethroplasty. J Urol 2001; 166: 2273-6. 44. Chessare JB. <a href="http://www.cirp.org/library/disease/UTI/chessare/">Circumcision: is the risk of urinary tract infection really the pivotal issue?</a> Clin Pediatr Phila 1992; 31: 100-4. 45. Ganiats TG, Humphrey JB, Taras HL, Kaplan RM. <a href="http://www.cirp.org/library/procedure/ganiats/">Routine neonatal circumcision: a cost-utility analysis</a>. Med Decis Making 1991; 11: 282-93. 46. Lawler FH, Bisonni RS, Holtgrave DR. Circumcision: a decision analysis of its medical value. Fam Med 1991; 23: 587-93. 47. Van Howe RS. <a href="http://www.cirp.org/library/procedure/vanhowe2004/">A cost-utility analysis of neonatal circumcision</a>. Med Decis Making 2004; 24: 584-601. 48. Schoen EJ, Colby CJ, To TT. Cost analysis of neonatal circumcision a large health maintenance organization. J Urol 2006; 175: 1111-5. 49. Thomson M. Endowed: regulating the male sexed body. New York: Routledge; 2008. <a href="http://www.h-net.org/reviews/showrev.php?id=14510">Reviewed on H-Net </a> 50. Waldeck SE. <a href="http://www.cirp.org/library/legal/USA/waldeck1/">Using male circumcision to understand social norms as multipliers</a>. U Cinn L Rev 2003; 72: 455-526. 51. Gilson L, Mkanje R, Grosskurth H, et al. Cost-effectiveness of improved treatment services for sexually transmitted diseases in preventing HIV-1 infection in Mwanza Region, Tanzania. Lancet 1997; 350: 1805-9. 52. White RG, Orroth KK, Glynn JR, et al. Treating curable sexually transmitted infections to prevent HIV in Africa: still an effective control strategy? J Acquir Immune Defic Syndr 2008; 47: 346-53. 53. Gray RH, Li X, Kigozi G, et al. The impact of male circumcision on HIV incidence and cost per infection prevented: a stochastic simulation model from Rakai, Uganda. AIDS 2007; 21: 845-50. 54. Auvert B, Bailey R, Gray R. Results of the South African trial, the Kenyan trial, and the Rakai Trial. Centers for Disease Control and Prevention Consultation on Public Health Issues Regarding Male Circumcision in the United States for the Prevention of HIV Infection and Other Health Consequences. Atlanta, Georgia. April 26, 2007. 55. McAllister RG, Travers JW, Bollinger D, Rutiser C, Sundar V. <a href="http://www.mensstudies.com/content/r50274021323/?p=86538636b9bd4071bfbf851e4d6fd9bd&pi=0">The cost to circumcise Africa</a>. Int J Men Health, Vol 7, No. 8, Fall 2008. [<a href="http://www.icgi.org/2008/10/new-study-shows-condoms-95-times-more-cost-effective-than-circumcision-in-hiv-battle-2/">Now published; summary available here.</a>] 56. Mangan J. An historical analysis of the principle of double effect. Theolog Stud 1949; 10: 30–45 57. Kaczor C. Double-effect reasoning From Jean Pierre Gury to Peter Knauer. Theolog Stud 1998; 59: 297–316 58. Maimonides M. <a href="http://www.cirp.org/library/cultural/maimonides/">The Guide of the Perplexed</a>. Tr. Pines S. Chicago, IL: University of Chicago Press, 1963. 59. Hodges F. A short history of the institutionalization of involuntary sexual mutilation in the United States. In Denniston GC, Milos MF, editors. Sexual mutilations a human tragedy. New York: Plenum Press; 1997: 17-40. 60. Darby R. A surgical temptation: the demonization of the foreskin and the rise of circumcision in Britain. Chicago, IL: University of Chicago Press; 2005. 61. Immerman RS, Mackey WC. <a href="http://www.cirp.org/library/psych/immerman2/">A biocultural analysis of circumcision</a>. Soc Biol 1997; 44: 265-75. 62. Immerman RS, Mackey WC. <a href="http://www.cirp.org/library/psych/immerman1/">A proposed relationship between circumcision and neural reorganization</a>. J Genet Psychol 1998; 159: 367-78. 63. Hoffman LA. Covenant of Blood: Circumcision and Gender in Rabbinic Judaism. Chicago, Illinois: The University of Chicago Press; 1996. 64. <a href="http://www.arclaw.org/arc_human_rights_table/">Universal Declaration of Human Rights</a>, Article 25(2), G.A. Resolution 217A (III), UN Doc. No. A/810 (1948), adopted December 10, 1948. 65. <a href="http://www.arclaw.org/arc_human_rights_table/">International Covenant on Civil and Political Rights</a>, UN GA Resolution 2200 A [XXI], December 16, 1966. 66. <a href="http://www.arclaw.org/arc_human_rights_table/">Convention on the Rights of the Child</a>, UN GA Resolution 44/25, November 20, 1989. 67. Alderson P. Children’s Consent to Surgery. Buckingham, England: Open University Press; 1993. [<a href="http://www.cirp.org/library/ethics/levy1/">See also discussion here</a>.] 68. Darby R, Svoboda JS. A rose by any other name?: Symmetry and asymmetry in male and female genital cutting. In: Zabus C, editor. Fearful Symmetries: Essays and Testimonies Around Excision and Circumcision. Kenilworth, New Jersey; 2008 [forthcoming]. <a href="http://www.rodopi.nl/senj.asp?BookId=MATATU+37">[Now published - Amsterdam and New York: Rodopi]</a> 69. Svoboda, JS. “Three-fourths were abnormal”—Misha’s case, sick societies, and the law. In Denniston GC, Hodges FM, Milos MF, editors. Genital Cutting: Proceedings of the 2008 NOCIRC Conference. New York: Springer; 2009 (forthcoming). 70. Kant I. Critique of practical reason. Milwaukee, WI: Marquette University Press; 1998. 71. Benatar M, Benatar D. Between prophylaxis and child abuse: The ethics of neonatal male circumcision. Am J Bioeth 2003; 3(2): 35-48. 72. Gruskin S. Male circumcision, in so many words …. Reproductive Health Matters 2007; 15(29): 49-52. 73. Donovan B, Ross MW. Preventing HIV: determinants of sexual behaviour. Lancet 2000; 355: 1897-901. <h2>Further reading</h2> 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, International Journal of Children's Rights</a>, 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 Neonatal circumcision unnecessary 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>Soaring incidence of HIV among circumcised populations …</h1> <h3>… shows that foreskin not the problem and circumcision not the answer</h3> Reports from the United States and several African countries show that, despite the WHO push for circumcision as the key strategy against AIDS in underdeveloped countries, HIV infection rates are increasing rapidly among circumcised populations. The most recent evidence to undermine the hypothesis that circumcision is the most effective preventive intervention against AIDS is a report in the New England Journal of Medicine, which reveals an HIV epidemic in the (largely circumcised) USA that rivals the problem in (largely circumcised) regions of Africa. The NEJM reports that more than 1 in 30 adults in Washington, D.C., are HIV-positive — a prevalence higher than that found in Ethiopia, Nigeria, or Rwanda. Among men who have sex with men, the study reveals that in some parts of the USA as many as 30 per cent of active men are infected. With the overwhelming majority of adult males in the USA circumcised in infancy, these figures cast serious doubt the case that circumcision is a useful strategy against AIDS. In other news, we find that 6 out of 10 new HIV cases in British Africans are among Muslims (almost all circumcised), and that in Uganda “confused” young Muslim men are having to be reminded that circumcision is not an adequate protection against sexual diseases. In Kenya, where mass circumcision of young men has been funded by the WHO and touted as the solution to the AIDS problem, it has been revealed that in two areas of almost universal male circumcision, HIV infections are rising rapidly – reaching 8.3 percent in Kenya’s coastal province. On top of that, women are complaining that circumcision is giving promiscuous men a false sense of security, and discouraging condom use. The authors of the NEJM report suggest that ideology is hampering America’s approach to HIV prevention and point out that “Preventive interventions must be rooted in science, not driven by ideological concerns.” They mention homophobia as one of these ideologies, but we would suggest that posthephobia (irrational hatred of the foreskin) should also be listed among the ideological obsessions that hamper the fight against AIDS. Most recently, a study of 4,889 men published in the journal AIDS has shown that circumcised gay men are not less likely to become infected with HIV. Headlined in the press as “Circumcision may not cut HIV spread among gay men”, the study in fact showed that HIV infection was higher among circumcised men than among the uncut After controlling for sexual behaviours and demographic factors the report concluded there was no difference between the two groups. <h2> <a id="USA" name="USA"></a>1. HIV and circumcision in United States</h2> <h3>Social disadvantage and sexual networks to blame for AIDS spread, not foreskins</h3> Despite Americans’ faith in circumcision as the most reliable form of health insurance known to man, and the high incidence of circumcision among American males, the prevalence of AIDS in some part of the United States now exceeds the infection rate in several hard-hit African countries. An article in the New England Journal of Medicine reports (18 March 2010) that the incidence of HIV infection in New York is 1 in 40 among Blacks, 1 in 10 among men who have sex with men, and 1 in 8 among injection drug users. In Washington DC the prevalence is 1 in 30 adults. In some urban areas the HIV prevalence among men who have sex with men is as high as 30 per cent – many times higher than the over all incidence of 7.8 per cent in Kenya and 16.9 per cent in South Africa. The authors of the report attribute the high incidence of AIDS to promiscuity within specific communities, associated with interlocking sexual networks; social disadvantage, meaning poor education, less access to safe sex information, and greater probability of spending time in prison (where unsafe sex is the rule); and various health or moral ideologies that generate inappropriate control strategies. The following extracts from the article make clear that the authors do not consider that “lack of circumcision” (i.e. normal male anatomy) is part of the problem, and hence do not believe that yet more circumcision is part of the solution. 1. Promiscuity and sexual networks “Unlike the generalized HIV epidemics in sub-Saharan Africa, the U.S. epidemic primarily affects certain discrete geographic areas — especially urban areas of the Northeast and West Coast and cities and small towns in the South (see U.S. map). Within these areas, specific neighborhoods are often disproportionately affected (see New York City map), in part because of residents’ engagement in unprotected sex within relatively insular social– sexual networks. Many of the populations most affected tend to have limited social mobility; thus, partner selection tends to concentrate transmission patterns and amplify spread within defined geographic areas. … “The extent of the risk of acquiring HIV in the United States today is largely defined by a person’s sexual network rather than his or her individual behaviors. Understanding the context and settings in which risk is increased may lead to more robust and effective preventive interventions. For example, black men who have sex with men are at increased risk for HIV infection in part because of its high prevalence in their sexual networks and their likelihood of choosing racially similar partners; they have also been shown to be less likely than their white counterparts to be aware of their HIV status and thus are more likely to unknowingly transmit HIV.” 2. Social disadvantage “Most glaringly, HIV disproportionately affects poor black Americans who have substandard education, unstable housing, and limited social mobility. This confluence of factors may result in high rates of incarceration, which threaten a community’s social fabric. Such vulnerable populations must be engaged in research, program development, and interventions that are culturally relevant and address the socioeconomic milieu in which HIV transmission occurs. … The situation is similar for black and Hispanic women, whose increased risk of HIV acquisition is attributable in greater part to their vulnerable social and economic situations and their sexual networks than to their own risky behaviors. Socioeconomic disadvantage and instability of partnerships due to high rates of incarceration among men in their communities may lead women to engage in concurrent relationships or serial monogamy. In addition, they may be unaware of their partners’ HIV status or may be involved in abusive or economically dependent relationships and thus be unable to negotiate safer sex with their partners.” Prison = unsafe sex As the authors of the report acknowledge, the large number of Blacks and Hispanics in American prisons is a significant factor in the high and increasing incidence of AIDS among the Black and Hispanic population. A recent article in the New York Review of Books on the problem of rape and other sexual abuse in American gaols and juvenile detention centres points out that sexual contact, both forced and otherwise, is rife in such institutions, and that authorities, in their anxiety not to “condone” such practices, refuse to make condoms available. They thus ensure that most of the sexual contact that occurs is of the unsafe variety. The authors of the review quote the Report of the National Prison Rape Elimination Commission as suggesting that the increasing incidence of HIV among American Blacks is the result of rape and other unsafe sex in prisons: “In 2005–2006, 21,980 State and Federal prisoners were HIV positive or living with AIDS. Researchers believe the prevalence of hepatitis C in correctional facilities is dramatically higher, based on [the] number of prisoners with a history of injecting illegal drugs prior to incarceration. … The incidence of HIV in certain populations outside correctional systems is likely attributable in part to [sexual] activity within correctional systems. Because of the disproportionate representation of minority men and women in correctional settings it is likely that the spread of these diseases in confinement will have an even greater impact on minority men, women, and children and their communities.” (National Prison Rape Elimination Commission Report, pp. 129–130). The commissioners seem to be saying here, as delicately as they can, that they suspect prisoner rape has contributed to the way HIV infection in this country has shifted demographically: i.e., to the way in which AIDS has changed from being a predominantly gay disease to a predominantly black one. David Kaiser and Lovisa Stannow, <a href="http://www.nybooks.com/articles/23690">The rape of American prisoners</a>, New York Review of Books, 11 March 2010. 3. Ideology "Preventive interventions must be rooted in science, not driven by ideological concerns. Homophobia may have impeded the development of sexually appropriate prevention studies among men who have sex with men. Reluctance to fund studies of needle exchange or conditional cash transfer (providing financial incentives for healthy behavior) or to support work in high-risk venues, such as bathhouses, has hampered progress." The authors of the article discuss homophobia (hostility to men who have sex with men) and moralistic objections to people who take injecting drugs as obstacles to the development of effective strategies to control the spread of AIDS. They might also have mentioned the moralistic objections to sex education that have hindered instruction in safe sex and distribution of condoms, and the diversion of funds to laughably ineffective “abstinence education"; and the posthephobia (irrational hatred of the foreskin) that has caused medical bureaucrats to focus on lack of circumcision as the most important factor in susceptibility to HIV infection, and thus on yet more circumcision as the most promising intervention. But as officials in Africa have finally admitted (see below), circumcision is not sufficient to give immunity to AIDS. Only consistent use of condoms and practice of other forms of safe sex and the avoidance of promiscuity can guarantee that a person will remain uninfected; and if he is doing all that, there is no need for circumcision at all. He might as well hang on to his foreskin and exploit its vast potential for safe sex. Source: Wafaa M. El-Sadr, Kenneth H. Meyer and Sally L. Hodder, AIDS in America: Forgotten but not gone, New England Journal of Medicine, Vol. 362, 18 March 2010, 967-970 <h2> <a id="Britain" name="Britain"></a>2. Britain: 60 per cent of new AIDS cases among Africans are among African Muslims</h2> Meanwhile in Britain, the British Broadcasting Corporation reports that six out of ten new AIDS cases among British African men are among Muslims. Since the vast majority of these men were circumcised as infants or children in accordance with Islamic custom, it is evident that circumcision has done nothing to protect them from the disease. The BBC reports: According to Dr Shima Tariq, who has studied the transmission of HIV, more than half of newly diagnosed patients caught HIV through heterosexual sex, and two-thirds of them are of black African origin or descent. But most of this group are not Christian: six out of 10 are Muslim. Ibrahim, a Muslim who came to Britain from the Ivory Coast, is HIV positive. “It’s quite difficult for me because the thing is I can’t tell anybody. Because my family...nobody knows. None of my friends know. Nobody. Because if I tell them they will leave me alone and I will have to live alone and it will be a hard life for me.” Along with a conservative African culture, religion has played a significant role in creating this taboo. Ismael is 40 and originally from Sudan. “The imams don’t talk too much about it, but they start off by saying ‘this is a taboo, this is a sin, a punishment from Allah’. When you disclose it, straight away they think you are gay, or maybe you got it from a prostitute or you did something bad and Allah is punishing you. That is why it has to be kept secret.” The African HIV Policy Network has asked imams to break the taboo by talking openly about HIV. One of them, Mohamed Bashir of the North Brixton mosque in London, says imams need to acknowledge “that not everyone practises their religion to the letter”. There are Muslims who go to the mosque, who pray. They do everything similarly nicely and they suffer moments of lapse in judgement. They have extra-marital relations that they will not speak about, and engage in risky behaviour. Some imams might not want to admit that.” Mohamed Bashir has agreed to train other imams on how to tackle the taboo. He accepts that in the face of HIV, condoms may be the lesser of two evils, but says communicating that to a congregation is a sensitive issue. “It won’t be considered responsible for an imam to say ‘when you’re making a mistake make sure you use a condom’, because that could be misunderstood as condoning that particular activity. In our awareness programme, literature is presented to members of the Muslim community. They can go to GM clinics, they can anonymously stock up on condoms. But to actively share them out, that wouldn’t be proper for an Islamic centre or an imam probably to do that.” <a href="http://news.bbc.co.uk/2/hi/uk_news/8388047.stm" rel="noopener" target="_blank">BBC World News, 1 December 2009</a> <h2> <a id="Kenya" name="Kenya"></a>3. Kenya: Rapid rise in AIDS cases in areas of universal circumcision</h2> And in Kenya, where circumcision is already practised on most boys as a matter of tribal custom or adherence to Islam, and uncircumcised men have been assaulted in the streets and forcibly circumcised by angry mobs, the incidence of AIDS is rising rapidly in regions where circumcision is near universal. All Africa News reports Nairobi: As thousands of young men in Nyanza Province troop to health centres to be circumcised in hopes of fending off HIV, new studies show it might be too early to claim victory. Although circumcision has been touted as one of the ways to prevent HIV infection, recent findings show an increase in HIV infection in regions where most males are circumcised. According to findings of the Kenya Aids Indicator Survey (Kais) released last week, North Eastern and Coast provinces, where 97 per cent of males are circumcised, registered an increase in HIV prevalence. Within a span of five years, HIV prevalence in North Eastern and Coast provinces increased from 0 to 1.0 per cent and from 5.8 per cent to 8.3 per cent respectively. In the same period, HIV prevalence in Nyanza Province, where about 48 per cent of males are circumcised, stood at 15 per cent, the highest in the country. These are sobering statistics for young men who have rushed to get circumcised in he belief that doing so would provide complete protection from HIV infection. The new findings of growing HIV prevalence among circumcised males indicates the practice cannot completely protect an individual from HIV infection unless it is combined with other practices including using condoms, being faithful to one partner, or abstaining from sex. [In fact, using condoms, being faithful to one’s partner or consistently practising safe sex would provide near total protection from AIDS without the need for circumcision and all the risks, cost and loss that this surgery entails. The versatility, sensitivity and mobility of the foreskin provide greatly enlarged scope for safe sex practices.] Health officials acknowledge that getting people to look at circumcision in the larger context of other factors and strategies can be challenging. “The figures from these two provinces are sending a warning that circumcision alone is not the magic bullet to controlling the disease. Other methods have to be used in combination,” said Dr Ibrahim Mohammed, Head of National Aids and STD Control Programmes in the Ministry of Medical Services. The increase in prevalence in communities that circumcise indicates there are other factors that contribute to the spread of the disease among males in addition to being uncircumcised. Multiple sexual partners, low condom use and alcohol and drug abuse are some of the factors. “Unless we address all the reasons predisposing people to HIV infection, we might not make much headway,” said Judy Adero, who has lived with the virus for nine years. But scientists still believe circumcision will result in the lowering of HIV prevalence in provinces such as Nyanza. [No real scientist would continue to believe something if the evidence against it started to pile up, or if a hypothesis was not consistently confirmed by subsequent experience. Belief in the superior effectiveness of circumcision against AIDS is actually concentrated more among public health and medical bureaucrats who are under pressure to produce quick fixes. Their continuing faith in circumcision is a typical prejudice, driven more by religious belief, tribal custom and American cultural commitment to circumcision than by genuine scientific open-mindedness.] Women complain that circumcised men believe they are immune to AIDS and do not need to use condoms Following the World Health Organisation’s policy decision to pour billions of medical aid money into circumcision, clinics offering free operations have been opened in many African countries. Vigorous propaganda campaigns urge uncircumcised men to get themselves done at these centres. In Kenya, more than 30,000 men have been circumcised since the call first went out; the target of 100,000 circumcised men is expected to be reached by year’s end. Female activists, however, have criticised the way the whole operation is being carried out, arguing that it is making women more vulnerable as men engage in more frequent sex with multiple partners in the belief that their recent circumcision has made them immune to infection with HIV. Circumcision not enough to stop AIDS, experts warn, <a href="http://allafrica.com/stories/200909280393.html" rel="noopener" target="_blank">All Africa News, 26 September 2009</a> <h2> <a id="Uganda" name="Uganda"></a>4. Uganda: Muslim youth reminded that circumcision does not stop AIDS</h2> In Uganda, to, circumcised Muslim men are having to be reminded that circumcision does not give them immunity to HIV infection. As East Africa News and Entertainment reports: The Muslim Youth League has launched a campaign to fight against the spread of HIV among Muslims in the country. The Chairperson of the Youth League, Abdalla Karim Musitwa says the campaign will mainly target preventing HIV infection amongst the Muslim youths. Musitwa says recent researches showing circumcision helps to protect men from HIV infection has confused some Muslims to go on rampage having multiple sexual relationships without any protection hoping that they are safe because of being circumcised. He says the campaign will among others convince Muslims that circumcision is not a guaranteed protection against HIV infection. Musitwa says the Muslim Youth League will be promoting abstinence and being faithful as the major means of protection against HIV infection. He says without a HIV cure in place, prevention of infections remains the key intervention against the spread of HIV/AIDS. Uganda Health News: Muslim youth launch campaign against HIV/AIDS <a href="http://www.ugpulse.com/articles/daily/news.asp?about=Muslim+youth+launch+campaign+against+HIV/AIDS&ID=10638" rel="noopener" target="_blank">Ugpulse: East Africa News and Entertainment, 7 June 2009</a> <h2> <a id="Risk" name="Risk"></a>5. Circumcised gay men at greater risk of AIDS</h2> A study of 4,889 men published in the journal AIDS has shown that circumcised gay men are not less likely to become infected with HIV. Headlined in the press as “Circumcision may not cut HIV spread among gay men”, the study in fact showed that HIV infection was higher among circumcised men than among the uncut After controlling for sexual behaviours and demographic factors the report concluded there was no difference between the two groups. See abstract of article below. This result is similar to a British study of 12,433 gay men published in 2001 by Sigma Research, which indicated a significantly higher risk of HIV among circumcised men. After controlling for factors likely to influence circumcision status – such as age and living in London – the authors found no association between circumcision status and HIV. 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) <a href="http://www.gmfa.org.uk/londonservices/research/index">Full text available here</a>. Later report here: Hickson F, Weatherburn P, Reid D, et al, Consuming passions: Findings from the United Kingdom Gay Men’s Sex Survey 2005. London: Sigma Research, 2007. <a href="http://www.sigmaresearch.org.uk/">PDF available from Sigma research</a> <a href="https://www.circinfo.org/AIDSnews.html#Sigma">See below for letter</a> from Sigma researchers to <a href="http://sti.bmj.com/">Sexually Transmitted Infections</a> criticising the current foreskin obsession. <h3>Circumcised men may be at greater risk of AIDS</h3> Gust, Deborah A; Wiegand, Ryan E; Kretsinger, Katrina; Sansom, Stephanie; Kilmarx, Peter H; Bartholow, Brad N; Chen, Robert T Circumcision status and HIV infection among MSM: Reanalysis of a Phase III HIV vaccine clinical trial <a href="http://journals.lww.com/aidsonline" rel="noopener" target="_blank">AIDS (Official Journal of the International AIDS Society), On-line publication, 17 February 2010</a> Abstract OBJECTIVE: Determine whether male circumcision would be effective in reducing HIV transmission among men who have sex with men (MSM). DESIGN: Retrospective analysis of the VAXGen VAX004 HIV vaccine clinical trial data. METHODS: Survival analysis was used to associate time to HIV infection with multiple predictors. Unprotected insertive and receptive anal sex predictors were highly correlated, thus separate models were run. RESULTS: Four thousand eight hundred and eighty-nine participants were included in this reanalysis; 86.1% were circumcised. Three hundred and forty-two (7.0%) men became infected during the study; 87.4% were circumcised. Controlling for demographic characteristics and risk behaviors, in the model that included unprotected insertive anal sex, being uncircumcised was not associated with incident HIV infection [adjusted hazards ratio (AHR) = 0.97, confidence interval (CI) = 0.56-1.68]. Furthermore, while having unprotected insertive (AHR = 2.25, CI = 1.72-2.93) or receptive (AHR = 3.45, CI = 2.58-4.61) anal sex with an HIV-positive partner were associated with HIV infection, the associations between HIV incidence and the interaction between being uncircumcised and reporting unprotected insertive (AHR = 1.78, CI = 0.90-3.53) or receptive (AHR = 1.26, CI = 0.62-2.57) anal sex with an HIV-positive partner were not statistically significant. Of the study visits when a participant reported unprotected insertive anal sex with an HIV-positive partner, HIV infection among circumcised men was reported in 3.16% of the visits (80/2532) and among uncircumcised men in 3.93% of the visits (14/356) [relative risk (RR) = 0.80, CI = 0.46-1.39]. CONCLUSIONS: Among men who reported unprotected insertive anal sex with HIV-positive partners, being uncircumcised did not confer a statistically significant increase in HIV infection risk. Additional studies with more incident HIV infections or that include a larger proportion of uncircumcised men may provide a more definitive result. Real conclusion The real conclusion is that circumcision probably makes no difference to the risk of contracting HIV during male/male sex, but may increase the risk. Being Americans, these researchers are determined to go on wasting public money until they have manufactured enough verbiage to get the foreskin convicted. <h2> <a id="sigma" name="sigma"></a>6. Sigma researchers attack obsession with foreskin</h2> The authors of the Sigma Research study are critical of the current obsession with circumcision as the magic bullet against AIDS. In 2008 they pointed out he flaws in an editorial in the British journal Sexually Transmitted Infections that called for circumcision of men who have sex with men as a means of reducing their risk of infection with HIV. The editorial was just the sort of opinion piece – long on rhetoric and short on evidence – that newspapers love to headline, and blithely oblivious to the fact that most men who have sex with men find the presence of their foreskin an important component of their sexual experience. The Sigma researchers expressed concern at the medical researchers’ focus on the innocent foreskin at the expense of “much more promising interventions than circumcision”. Their letter was not published in the print edition of the journal, but only in the on-line edition, accessible only to subscribers. It is reproduced in full here in order to make it more readily available. The editorial to which Hickson et al replied was Abigail MacDonald, Joanna Humphreys, Harold W. Jaffe, Prevention of HIV transmission in the UK: What is the role of male circumcision?, Sexually Transmitted Infections, Vol. 84 (3), 2008, 158-160. Dear editor, If MacDonald, Humphreys and Jaffe (2008, STI, 84) are correct in their contention that circumcising men who have sex with men will result in a reduction in HIV incidence among this population, then we would expect circumcised MSM in the UK have a lower incidence of HIV than uncircumcised MSM. This should be reflected in HIV prevalence and since there is no reason to think that circumcision promotes diagnoses of HIV, this difference should be reflected in the prevalence of diagnosed HIV. In 2001 we carried out a short, community-based, self-completion survey among 12,433 White British men aged 16 and over, living in the UK, who had sex with another man in the last year and/or identify as gay or bisexual. Fieldwork was conducted over the summer at Gay Pride events (52.1% of respondents), on-line through commercial gay web sites (31.6%) and through community based HIV prevention organisations (16.3%). Self report is a valid measure of circumcision in MSM (Termpleton et al., 2008, STI, 84). Overall, 0.5% (n=64) indicated they did not know whether they had been circumcised or not. Excluding these men, 18.6% (2438/13,127) of respondents said they had been circumcised. Circumcised men were as a group, older than un-circumcised men (mean age 36.5 years, sd 12.0, median 35, range 16-82 compared with mean 32.3, sd 10.2, median 31, range 16-79). The proportion of men who were circumcised increased step-wise with increasing age (11.9% of teens, 14.7% among those in their 20s, 16.8% in the 30s, 21.7% in the 40s and 38.1% among those 50 and older). More of the circumcised men lived in London (24.8% compare with 19.6% of un-circumcised men ). Overall, 4.6% of respondents indicated they were living with diagnosed HIV infection. Circumcised men were not more or less likely to be living with diagnosed HIV (5.2% compared with 4.5% in un-circumcised men: chi squared = 1.84, p=0.175). In a multiple logistic regression controlling for age and living in London, the odds ratio of a circumcised man living with diagnosed HIV to an un-circumcised man doing so was 1.01 (95% confidence interval 0.81-1.25). This suggests that circumcising MSM will make no difference to HIV incidence in this population. Since HIV acquisition in the UK is highly concentrated in MSM (HPA, 2008) and since identification of future MSM pre -puberty is not feasible, this suggest circumcision has little part to play in the UK HIV epidemic. Those concerned with the UK epidemic should be looking elsewhere for solutions. We have no doubt that a multi-pronged approach to minimising HIV infections is required. We also have little doubt that maximising circumcision is not one of them among MSM in the UK. Minimising nitrite inhalant use during unsafe sex might, on the other hand, have a very real effect (McDonald et al. 2008, STI, 84). We support MacDonald, Humphreys and Jaffe's call for more experimental research about HIV among MSM in the UK but stress that these have yet to be done for much more promising interventions than circumcision. Source: Ford C.I. Hickson, David Reid, Peter Weatherburn, Michael Stephens, Circumcised MSM in the UK no less likely to be living with HIV, e-letter, Sexually Transmitted Infections, 5 August 2008. <a href="http://sti.bmj.com/" rel="noopener" target="_blank">Sexually Transmitted Infections</a> can be searched here. Articles published pre-2006 are freely available; after that, a subscription is required. <h2> <a id="malawi" name="malawi"></a>7. Malawi bucks the WHO witchdoctors</h2> Malawi is a small country in east central Africa, sandwiched between Mozambique, Zambia and Tanzania. The Secretary to the Office of the President, responsible for HIV/AIDS and Nutrition, Dr. Mary Shaba, has said Malawi cannot follow World Health Organisations recommendations to adopt widespread circumcision of men as a weapon to reduce the spread of HIV through heterosexual contact. Although the WHO claims that circumcised males are 60 percent less likely to contract HIV through sexual intercourse, Shaba points out that Malawi is not a circumcised country and that those cutting off their children’s foreskin are doing it for religious and cultural reasons. “So it is mainly the Moslems and the Yaos who are doing circumcisions and some of the Lhomwe group,” she said in Capital Radio interview. “Malawi the way it is when you look at the statistics, you find that the majority would already be asking “Are we all becoming Moslems?” if you go that line.” Shaba said Malawi has no policy and guidelines on circumcision. She said she has been asking for a report to study what condition circumcisions are done in countries doing it and what practices were followed after circumcision. “I have been asking for a report from all those people who have claimed that people are being protected, nobody has been able to give me the report. I want the report. I need to look at the methodology. I need to look at the cultural practices surrounding circumcision," said the free-speaking Shaba. She pointed out that in Malawi HIV is most prevalent in areas where circumcision is practiced, and that many have died of AIDS in those particular districts. “We are not a circumcised country as a nation. Circumcision is mainly practiced on a religious basis, and very few of the tribes practice circumcision. You can’t take what is done elsewhere and say we are going to do in Malawi.” She also pointed out that male circumcision will not be effective to fight HIV/AIDS because the new infection rate is highest among women. Shaba also noted that circumcision can cause some problems for the penis. Shaba says Malawi cannot follow Rwanda on circumcision to fight Aids, <a href="http://www.nyasatimes.com/health/shaba-says-malawi-cannot-follow-rwanda-on-circumcision-to-fight-aids.html/comment-page-3#comments">Nyasa Times, 26 January 2010</a> <h3>Officials annoyed by local reluctance, as private clinics try to take advantage of foreign health aid money</h3> LILONGWE, 13 April 2010 (PlusNews): Circumcision is controversial in Malawi and the government has yet to implement a program. But a chain of private clinics run by Banja La Mtsogolo (BLM) – Future Family in the local Chichewa language – has rolled out the procedure at its network of 30 national clinics in 2009. It is the only organization offering circumcision as part of an HIV prevention package. Following WHO directives, Malawi’s National HIV Prevention Strategy 2009-2013 acknowledges the role of circumcision, but it falls short of outlining a clear policy, and Brendan Hayes, the head of BLM, has admitted that circumcision has been a hard sell. “In Malawi, you’ve got very big differences in the HIV epidemic from north to south, and those differences don’t correlate to differences in circumcision prevalence. High HIV prevalence rates are in the southern part of the country, which is also where we have the most circumcision,” he told IRIN/PlusNews. “These differences aren’t totally inexplicable but I think it’s made people more cautious about moving forward with male circumcision.” Confusion and controversy Southern Malawi has a large migrant labour population and an HIV prevalence of about 18 percent, accounting for almost 70 percent of the country’s HIV infections, according to government figures. Circumcision is culturally less prominent in northern Malawi, where the prevalence of HIV is also lower. The mismatch between HIV prevalence and circumcision incidence has raised doubts among some high-level health officials, particularly Principal Secretary for HIV and AIDS within the Presidency, Dr Mary Shawa [or Shaba]. Earlier this year, Shawa argued that she had not yet been presented with enough clinical evidence on circumcision, and that its efficacy was questionable given the high HIV prevalence among traditionally circumcising populations in the south. Shawa also questioned the acceptability of the practice among ethnic groups that did not traditionally perform the procedure. <a href="http://www.plusnews.org/Report.aspx?ReportId=88790" rel="noopener" target="_blank">Source: PlusNews</a> <h2> <a id="Malaysia" name="Malaysia"></a>8. Malaysia: AIDS most prevalent among (circumcised) Muslims</h2> In Malaysia, the local AIDS Council reports that 72 per cent cent of AIDS/HIV Sufferers in Malaysia are Muslims. In view of the facts that only 60 per cent of the Malaysian population is Muslim, and that nearly all Muslim malls are circumcised when young boys, this figure must mean that the majority of AIDS cases there are found in circumcised men. KUALA TERENGGANU, June 9 (Bernama) -- More than 70 per cent of the 87,710 HIV/AIDS sufferers in the country are Muslims, Malaysian AIDS Council vice-president Datuk Zaman Khan said on Wednesday. Therefore, he said, the celebration for this year's World AIDS Day would emphasise efforts to enhance the participation of and awareness on AIDS among Muslims. He said what was more worrying a report by the United Nations General Assembly Special Session (UNGASS)on AIDS which stated that nine Malaysians were infected with the disease everyday. Also of concern was the spread of the disease among women, from 9.5 per cent in 2000 to 20 per cent last year, he said when speaking at a function to commemorate World AIDS Day here Tuesday night. He said that in 2000 the main cause of women being infected with HIV/AIDS was drug addiction, but lately, it had been attributed to heterosexual sex (30 per cent). This happened because of lack of concern and cooperation from the society to protect women from the disease, he added. On HIV/AIDS sufferers in Terengganu, he said, a total of 315 new cases were reported last year. Kelantan recorded the highest number of HIV/AIDS cases at 596, followed by Pahang (431) and Selangor (378), he added. <a href="http://www.bernama.com/bernama/v5/newsindex.php?id=504593" rel="noopener" target="_blank">Bernama: Malaysian National News Agency, 9 June 2010</a> <h3>Further information</h3> <a href="http://www.circumstitions.com/HIV-SA.html">Studies casting doubts on wild claims of African "circumcision to stop AIDS" experiments</a> <h2> <a id="swazi" name="swazi"></a>9. Swaziland: Circumcised men more likely to have AIDS</h2> Despite the hype about circumcision as the magic bullet against HIV infection, new figures from Africa show that AIDS is more common among circumcised men. Australian circumcision promoters are hitting the headlines with demands for mass circumcision of baby boys in Australia as a precaution against HIV acquired from unprotected heterosexual intercourse. In support of this proposal they refer to old evidence from Africa as to the protective effect of circumcision against heterosexually acquired HIV infection, as shown in three clinical trials. While the World Health Organisation rolled out circumcision programs with funds provided by Bill Gates and President Bush, sceptics warned that the trials were riddled with scientific flaws and that it was far too early to tell whether circumcision would have a significant protective effect in the real world - quite part from the vast cost and serious ethnical doubts. Recent news from Africa is proving the sceptics correct, as the incidence of AIDS in many Africa countries continues to rise among circumcised populations. In Swaziland, a small nation in south central Africa, where the government is planning particularly ambitious programs, it was recently revealed that the incidence of HIV infection was significantly higher among circumcised men. According to government figures, the incidence of HIV among circumcised men is currently at 22 per cent, but among uncircumcised men at only 20 percent. These are both astronomical figures (nothing like the situation in Australia), but they do not show any evidence of circumcision having a protective effect against HIV; on the contrary, looking at these figures, you would have to conclude that circumcision increased the risk of infection with AIDS. What is even more scandalous is that the Swaziland government was perfectly aware of these figures when it decided to roll out the circumcision programs. Makes you wonder how some of the Gates/Bush billions have been spent. <h3>Swaziland: Incidence of AIDS higher among circumcised men</h3> Times of Swaziland, 19 September 2010 MBABANE – Even though male circumcision is considered to have a protective effect for HIV infection, circumcised men have a slightly higher HIV infection than those who are not. The Times SUNDAY can today reveal that government has known this for close to three years. It is contained in the Swaziland Demographic and Health Survey (SDHS) of 2007 which still prevails. This report summarises findings of the 2006 survey carried out by the Swaziland Central Statistical Office (SCO). The report places the infection rate for circumcised males at 22 per cent while for those uncircumcised stands at 20 per cent. The report states that the protective aspect of male circumcision is based in part because of the physiological differences that increase the susceptibility to HIV infection among uncircumcised men. However, the relationship between HIV prevalence and circumcision is not in the expected direction. "It is worth noting that the relationship between male circumcision and HIV infection may be confounded by the fact that the circumcision may not involve the full removal of the foreskin, which provides partial protection," stated the report. But additional analysis is needed to determine if this lack of a relationship between male circumcision and HIV infection is a result of confounding factors or represents the true situation. In 2007 government introduced a policy on male circumcision, which has a goal of halting the spread of HIV infection to achieve an HIV-free generation. Cited in the report is that to meet this objective, male circumcision services, as part of the national comprehensive HIV prevention package, would have to be availed to men of all ages. To maximise the health benefit for HIV prevention, the primary targets of the services are men who are HIV-negative, in the age bracket of 15-24 and also newborn babies. Value of circumcision questioned Meanwhile, the belief that circumcision can provide a considerable measure of protection against HIV infection has been questioned by academicians and medical professionals of repute. Last week Occupational Health Specialist Dr Cleopas Sibanda questioned the rationale of circumcision to justify it being adopted as part of the national HIV and AIDS prevention strategy. "What exactly happened in Uganda as far as HIV and AIDS and population demographics are concerned to correctly attribute the observed previous decline in their national HIV and AIDS statistics to wholesale male circumcision?" Sibanda was quoted as having asked. But he noted that circumcision for the wrong reasons can be very dangerous, in fact it has increased episodes of diminished consistent use of condoms and increased incidences of HIV and AIDS affected populations. [As shown in an earlier report, printed below.] More circumcised men are HIV positive By MUSA SIMELANE <a href="http://www.times.co.sz/index.php?news=20909" rel="noopener" target="_blank">Times of Swaziland, 19 September 2010</a> <h3>After circumcision, men stop using condoms</h3> Times of Swaziland, 8 September 2010 MBELEBELENI – A traditional healer has related how he treats many men who have STIs due to their belief that after circumcision they will not contract HIV. The healer, who wished to be identified only as Nkambule, said he had been receiving an influx of male clients who wanted to be treated for sexually transmitted infections. He said when he questioned them on why they do not use condoms, the response was that they were of the view that since they were circumcised, they did not need to use one. "Most of them then require me to treat them with my traditional medicine," he said. Nkambule explained that in one instance his client asked him to prepare a concoction that would enhance his manhood as he would not be required to use a condom since he had undergone circumcision. "I always advise them to follow the laid-down procedures a person is expected to undergo after circumcision, but most of them insist that they be given traditional medicine. As a traditional healer, I support circumcision but it is now clear that people have different understandings of it," he said. Nkambule disclosed that he always advised his clients to test for HIV before opting for traditional treatment. "After observing the condition of my clients, I always advise them to check their status so that the necessary treatment can be administered," he explained.Judging from the number of people who came to him after circumcision, it was clear that people have this strong belief that circumcision prevented one from getting a sexually transmitted disease. "I treat people for different ailments, but the number of those who come with problems of sexually related diseases is increasing," he said. Inyanga's warning about circumcision By MBONGISENI NDZIMANDZE <a href="http://www.times.co.sz/index.php?news=20500" rel="noopener" target="_blank">Times of Swaziland, 8 September 2010</a> <h2> <a id="kenya" name="kenya"></a>Kenya: Circumcised men just as likely to be HIV-positive</h2> A recent study (yet another one) in Kenya has found no association between being uncircumcised and being at greater risk of infection with HIV. To put it another way, the study found that circumcision had no protective effect against HIV-AIDS. The study, by Matthew Westercamp et al and published by PlosOne, examined “the behaviors, beliefs, and HIV/HSV-2 serostatus of men and women in the traditionally non-circumcising community of Kisumu, Kenya prior to establishment of voluntary medical male circumcision services. A total of 749 men and 906 women participated. Circumcision status was not associated with HIV/HSV-2 infection nor increased high risk sexual behaviors. In males, preference for being or becoming circumcised was associated with inconsistent condom use and increased lifetime number of sexual partners. Preference for circumcision was increased with understanding that circumcised men are less likely to become infected with HIV.” That is, although there was no difference in HIV incidence between the circumcised and uncircumcised, the people in the survey believed the intensive American propaganda that circumcision gave significant protection against HIV infection. It is thus not surprising that there was a high level of acceptance of and interest in circumcision among the sample, many of whom stated their intention to get circumcised. The study found that those planning to get circumcised were more likely to have a history of high risk behaviour, involving numerous casual partners and inconsistent condom use. Matthew Westercamp et al, Male circumcision in the general population of Kisumu, Kenya: Beliefs about protection, risk behaviors, HIV, and STIs, PlosOne, December 2010; <a href="http://www.plosone.org/article/fetchArticle.action?utm_medium=feed&utm_campaign=Feed:+plosone/PLoSONE+(PLoS+ONE+Alerts:+New+Articles)&utm_source=feedburner&articleURI=info:doi/10.1371/journal.pone.0015552">Full text of study at PlosOne</a> <h3>Belief in witchcraft and burning of witches also common in Kenya</h3> Before we marvel at the readiness with which Kenyans accept the latest in proven scientific wisdom, we should bear in mind that Kenya is also a country in which there is a strong (and apparently rising) belief in witchcraft, and that burnings of suspected witches are becoming more common. Only last year a Kenyan correspondent for the BBC reported: I was witnessing a horrific practice which appears to be on the increase in Kenya - the lynching of people accused of being witches. I personally saw the burning alive of five elderly men and women in Itii village. I had been visiting relatives in a nearby town, when I heard what was happening. I dashed to the scene, accompanied by a village elder. He reacted as if what we were watching was quite normal, which was shocking for me. As a stranger I felt I had no choice but to stand by and watch. My fear was that if I showed any sign of disapproval, or made any false move, the angry mob could turn on me. Not one person was protesting or trying to stop the killing. Hours later, the police came and removed the charred bodies. Village youths who took part in the killings told me that the five victims had to die because they had bewitched a young boy. “Of course some people have been burned. But there is proof of witchcraft,” said one youth. Odhiambo Joseph, Horror of Kenya’s witch lynchings, <a href="http://news.bbc.co.uk/2/hi/africa/8119201.stm">BBC News, Kenya, 26 June 2009</a> <a href="http://www.randi.org/site/index.php/swift-blog/747-whats-the-harm-kenyan-edition.html" rel="noopener" target="_blank">Other reports at James Randi's skeptic site</a> Persecution of witches also in Nigeria, Angola and the Congo In Nigeria, Angola and the Congo anti-witch hysteria targets children rather than old men or women. Hundreds of boys and girls are reported to have been blinded, injected with battery acid, and otherwise tortured in an effort to purge them of the demons thought to be possessing them. Many more have been cast out by their families and left to roam the streets. Especially in Nigeria, the campaign against witches is led by the Evangelical churches, as reported in the Daily Telegraph (Sydney): In Nigeria as many as 1000 children may have been accused of witchcraft by pastors of evangelical Christian churches, many of whom have subsequently been tortured and burnt. The idea of witchcraft is hardly new, but it has taken on new life recently partly because of a rapid growth in evangelical Christianity. Campaigners against the practice say around 15,000 children have been accused in two of Nigeria's 36 states over the past decade and around 1,000 have been murdered. In the past month alone, three Nigerian children accused of witchcraft were killed and another three were set on fire. Some of the churches involved are renegade local branches of international franchises. Their parishioners take literally the Biblical exhortation, “Thou shalt not suffer a witch to live” [Exodus, 22:18]. Katharine Houreld, Church burns witchcraft children <a href="http://www.dailytelegraph.com.au/news/world/church-burns-witchcraft-children/story-e6frev00-1225788721635">Daily Telegraph (Sydney), 20 October 2009</a> <h3>Twin superstitions: Burn the witches; destroy the foreskins</h3> The justification traditionally given for burning witches is remarkably similar to the reasons commonly given for circumcising boys. A passing remark in the Old Testament is not the real reason or cause, but a post-hoc rationalisation: poor and ignorant people want to burn witches for their own traditional reasons, and the biblical text provides no more than a justification after the event, to be brought out when they are required to explain themselves. It is rather similar with circumcision: the circumcision promoters just want to do it for their own superstitious reasons (usually no more than habit), and when challenged to produce reasons they reach into the vast grab-bag of the medical literature and pull out a few choice quotes or stats. Just like the witch-burners leant on the Book of Exodus to justify the murder of innocent people, circumcision promoters deploy questionable or irrelevant statistics from medical journals to justify the genital mutilation of innocent and unwilling children. And for much the same reasons: because their own or their community’s health, in the opinion of the circumcision promoters, demands and requires such a measure. Like the witch-burners, they are convinced that a crisis situation, with disease (or the devil) rampaging through society is no time for sentimentality (or mercy) if society is not to be engulfed in epidemics, plagues and assorted other disastrous evils. As in ancient times, the best way to appease the angry gods is by sacrificing something precious. <h2> <a id="ugaids" name="ugaids"></a>Uganda: Circumcision campaign increases HIV infections</h2> Recent news reports from Africa reveal that circumcision as a tactic for stopping the spread of HIV is having the opposite effect, as men who have consented to be circumcised believe that they are now completely immune to infection and can have as much unsafe sex as they like, with as many partners as they can find, and don’t need to use condoms. In Uganda a report has found that “new HIV/AIDS messages meant to reduce the prevalence of the disease are instead facilitating its spread”, while in Swaziland a poster campaign is generally interpreted by men as meaning “that after circumcision, they would be safe from sexually transmitted illnesses”. This is exactly the result that critics of the circumcision solution have consistently predicted and warned against from the start. Suggesting that circumcision is a “surgical vaccine” against HIV, as many irresponsible researchers, circumcision promoters and journalists have done, gives people a false sense of security and encourages them to engage in unsafe sex - with inevitably tragic results. <h3>Uganda: New HIV/AIDS Messages Worsening HIV Situation</h3> A new report by PANOS Eastern Africa has shown that new HIV/AIDS messages meant to reduce the prevalence of the disease are instead facilitating its spread as they have created false impressions, especially with regard to multiple concurrent partnerships and male circumcision. The report, "Communication challenges in HIV Prevention: Multiple Concurrent Partnerships and Medical Male Circumcision", shows that majority of rural population believed that circumcision gives a complete protection to HIV/AIDS, while more than 88 per cent did not know what the sexual network was. The report also notes that most of these messages are urban-based with little or no translation for the rural people, while younger people are no longer scared of the HIV pandemic because it is no longer as scary as it used to be. These communications include the "Be a man" campaign, "Go together Know together", "Go Red" campaign and the "Fidelity" campaign. "Current Multiple Concurrent Partnership (MCP) policies, programmes and communication initiatives in Uganda are not addressing the social, cultural and economic issues that underline why people engage in MCP. Future attempts should incorporate an analysis of the social drivers of HIV," the report released last month reads in part. Speaking at the launch of the report in Kampala, the Director PANOS Eastern Africa, Peter Okubal, said the report was prompted by the increasing number of infections every year. Last year alone, 120,000 new infections were recorded. One of the lead researchers, Daudi Ochieng, from the Uganda Health Marketing Group, said that the messages have lost authority and have become cliché. "People are tired of the same old messages, campaigns are vague and boring, there is nothing shocking about them and they lack coherence as everyone gives a different message," Mr Ochieng said. Flavia Lanyero, New HIV/Aids Messages Worsening HIV Situation, <a href="http://allafrica.com/stories/201105050159.html">All Africa News, 5 May 2011</a> <h3>Swaziland: Circumcision campaign targets women</h3> A similar report from Swaziland reveals that a government campaign to encourage women to pressure their partners into getting circumcised has been interpreted as advice that circumcision gives complete protection agains HIV and means that a man can then give up condoms and have more partners. Although the Swazi government has launched a ferocious circumcision campaign, figures show that there is higher incidence of HIV among the circumcised than among: cut men - 21.8%, uncut men - 19.5%. The report in a Swazi newspaper reads: THE ministry of health has engaged on a campaign to encourage women to support their partners to circumcise. In an effort to publicise the campaign, billboards and public transport have been branded with posters of women who are supporting the campaign. The campaign is about the involvement of women in the male circumcision programme. However, this campaign has been misinterpreted by some people who thought that the message being sent out was that they were safe from contracting sexually transmitted infections when they were circumcised and therefore, could have more than one sexual partner. The posters on the public transport display pictures of a man and four women accompanied by the word; “ngingumancoba” (I am a conqueror). To some, this has implied that after circumcision, they would be safe from sexually transmitted illnesses, hence the decision to have multiple concurrent partners. Winile Masinga , New male circumcision campaign targets women, <a href="http://www.observer.org.sz/index.php?news=23934">Observer (Swaziland) 21 April 2011</a> <h2> <a id="heff" name="heff"></a>Zambia: Another study fails to find that foreskins increase risk of HIV …</h2> <h3>… but still recommends circumcision</h3> A study of the possible link between genital herpes and increased risk of HIV in Zambia did find that men with herpes were more likely to be HIV-positive, but also found that lack of circumcision did not increase the risk of HIV infection. Quite the contrary, the study found that uncircumcised men were less likely to contract HIV. In their discussion of the results, however, the authors of the study failed to mention this vital fact, and concluded by recommending that circumcision be promoted as an AIDS control strategy – thus violating the most basic principles of evidence-based medicine. The Zambian study was conducted by researchers from the United States Centers for Disease Control – well known for its pro-circumcision agenda. They recruited 1062 male farm workers at a sugar estate in Zambia to participate in an experiment known as a prospective cohort study.** The researchers were looking for a link between genital herpes (herpes simplex type-2 or HSV-2) infections and developing an infection with HIV-1. The study had two outcomes of interest. First, they looked at factors that affect the prevalence of HIV-1 infection (whether the men were infected at the time of recruitment). Second, they measured the incidence of HIV-1 infection (new infections detected during the follow-up period). At the time of recruitment 20.7% of the men were HIV-positive. Men with a positive blood test for past herpes were five times more likely to be HIV-positive at the time recruitment. Other factors significantly associated with being HIV-positive were self-reported genital ulcers in the past year, and being widowers (i.e. their wife had died). Rates of HIV-1 infection at the time of recruitment were the same in circumcised men and uncircumcised men (20.71% versus 20.76%). When adjusted for other factors, there was no significant association between circumcision status and HIV-1 prevalence. The second half of the study involved following 731 participants who started off as HIV-negative and who made at least one follow-up visit. Becoming HIV-positive during the follow-up period was independently associated with a positive blood test for herpes at the beginning of the study, and 18 times more likely in men who developed a first-time HSV-2 (herpes) infection during the follow-up period. During the follow-up period uncircumcised men developed 23 infections in 5686 months of patient follow-up (4.04 per 1000 months), while circumcised men developed four infections in 817 months of follow-up (4.89 per 1000 months). This means that uncircumcised men had a slightly lower (but probably not statistically significant) risk of HIV infection. When adjusted for other factors, circumcision status made no difference to the risk of infection with HIV. A significant weakness of the study is its reliance on self-reported circumcision status – something about which men are surprisingly uncertain. While the investigators assumed that all the HIV infections were transmitted sexually, it is also possible (even likely) that men with genital herpes would seek medical care, and in doing so placed themselves at greater risk of HIV infection through non-sterile medical treatment (iatrogenic infection) – notoriously common in the over-stretched health services of underdeveloped countries. This is yet another study that fails to confirm the “60% reduction in risk of HIV infection” claimed for circumcision in the three famous randomized clinical trials. Such a reduction is outside the 95% confidence intervals of this and several other studies, indicating serious doubts about the clinical trials. Despite this, the researchers in the Zambia study recommend that company health centres should “promote and provide medical male circumcisions” as a part of the effort to decrease infection rates: yet their own data that shows that circumcision would either have no impact, or might even increase the risk of HIV infection. It would appear that the authors, even in light of their own negative findings, are unwilling to stray from the CDC’s pro-circumcision agenda, and thus fail to observe the basic principles of evidence-based medicine: that recommendations for treatment must follow logically and directly from the evidence. According to the data in this study, to recommend circumcision as a preventive strategy in Zambia is ideological and plainly anti-scientific. Source: The article is: Heffron R, Chao A, Mwinga A, Sylvester Sinyangwe S, Sinyama A, Ginwalla R, Shields M, Kafwembe M Kaetano L, Mulenga C, Kasongo W, Mukonka V, Bulterys M. High prevalent and incident HIV-1 and herpes simplex virus 2 infection among male migrant and non-migrant sugar farm workers in Zambia. Sex Transm Infect 2011; 87: 283-8. ** A prospective cohort study is a cohort study that follows over time a group of similar individuals (cohorts) who differ with respect to certain factors under study, to determine how these factors affect rates of a certain outcome. <h2> <a id="zimbabwe" name="zimbabwe"></a>Zimbabwe: Despite circumcision propaganda, circumcised men still get AIDS</h2> Reports from Africa show that despite all the propaganda about circumcision providing protection against HIV infection, and strong pressure (including physical coercion) to get “snipped”, circumcised men are still getting infected with HIV. A report in the Zimbabwe newspaper The Standard states: Circumcised men are contracting HIV and Aids after ditching the use of condoms, under a misguided belief that male circumcision (MC) would prevent them from getting infected, The Standard has heard. This revelation comes at a time when the national programme is battling for recognition and relevance as an effective preventive tool for HIV and Aids in the country. Sex workers who spoke to The Standard last week said some circumcised men were no longer using preventive methods, including condoms, because they believed that their chances of getting infected were limited after getting circumcised. One of the sex workers, who only identified herself as Memory told a United Nations Populations Fund (UNFPA) media training workshop in Bulawayo last week, that most of her circumcised clients were not willing to use condoms. “I have problems with circumcised men because they do not want to use condoms. They always argue that because they have been circumcised they did not need to use condoms,” said the heavily pregnant Memory, who is also HIV-positive. Memory said even after disclosing her HIV status, they still insisted on sleeping with her without any form of protection. “I even take my antiretroviral drugs in their presence but they do not care and because I have a family to feed, I give in to their demands,” said Memory. But Ministry of Health and Child Care national male circumcision coordinator, Sinokuthemba Xaba maintained that the procedure reduced chances of getting infected by at least 60%, but urged men not to stop using condoms. He defended the programme saying it was a pity that some people were under the misguided opinion that by being circumcised they would not be infected. Source: <a href="http://www.thestandard.co.zw/2013/11/10/circumcised-men-indulge-risky-sexual-behaviour/">Circumcised men indulge in risky sexual behaviour</a>, The Standard, 10 November 2013. Obviously, if it is still necessary to use a condom, circumcision does not provide any meaningful protection against HIV infection. In fact, demographic reports show that the incidence of HIV in Zimbabwe has been consistently higher among circumcised men by about 2 percentage points. <h2> <a id="MSM" name="MSM"></a>Circumcision does not lower risk of HIV in MM sex</h2> A study by Crosby et al of Black men in a southern United States city with an “extremely high” HIV prevalence, found that there was no difference in the incidence of HIV and other sexually transmitted infections between circumcised and uncircumcised partners. Curiously, the study also found that circumcised men were twice as likely not to wear a condom when taking the active role in intercourse. This is an interesting result, confirming earlier research that circumcised men are less likely to wear condoms, thus raising the possibility that they may be at greater risk of HIV infection. These points are discussed in a response letter by Morten Frisch, who notes that the study provided no evidence of circumcision having any protective effect against HIV in MM sex, and who draws attention to its side-finding - that circumcised men are far less likely to use condoms. As he points out, this is consistent with other evidence that circumcision dulls the sensitivity of the penis, leading to the frequent complaint from circumcised men that they can’t feel anything through the latex and often lose their erection. The key point is that since condoms (even if worn inconsistently) are the most effective means of HIV prevention, anything that discourages condom use raises the risk of HIV infection. The full text of Dr Frisch’s letter follows I read with great interest the recent paper by Crosby et al., in which the authors failed to find any significant difference in the prevalence of HIV (or other sexually transmitted infections) between circumcised and intact young black men who have sex with men (MSM) in the United States [1]. Their findings are in line with those of a 2011 Cochrane review showing no significant association overall between circumcision/foreskin status and HIV infection in MSM, although a subanalysis suggested a possible reduction in HIV risk among circumcised MSM who predominantly take the insertive role during anal sex [2]. However, a subsequent British study found no evidence that circumcision is protective against HIV among MSM who predominantly engage in anal sex as the insertive partner [3]. Crosby et al. highlight an additional, potentially noteworthy finding in their article’s abstract [1]. They report that ‘‘The mean frequency of unprotected insertive anal sex for circumcised men was about twice as high compared to those intact (P = .04).’’ This finding is consistent with evidence from another recent study by Feldblum et al. [4], which pointed to reduced condom use following adult circumcision among a large sample of Kenyan men. Unfortunately, Crosby et al. make no mention anywhere in the main text about this statistically significant finding. Perhaps the authors considered it to be a chance finding because, apparently, it was the only statistically significant result in their study. However, there are reasons why this finding may actually deserve some attention. First, such a result is plausible on anatomical and behavioral grounds. Since circumcision removes the adult equivalent of approximately 50 cm2 of touch-sensitive tissue (see below), one might expect an overall reduction in penile sensitivity as a function of the surgery. Since condoms tend to decrease penile sensitivity [5], circumcised men may have conscious or unconscious motivations to avoid any further desensitization during sex, which could explain their reduced condom use. Laboratory investigations have sought to determine whether the foreskin is a particularly sensitive penile structure, and have produced conflicting results. Some researchers have provided evidence that the foreskin is the most sensitive part of the penis [6], while others fail to confirm such findings [7]. However, regardless of whether sensitivity per square centimeter is actually higher in the foreskin compared to other parts of the penis, or the foreskin is merely as sensitive as other parts of the sexual organ, the overall sensory input from a circumcised penis during sex will be reduced in a manner that plausibly depends—at least to some extent—on the amount of foreskin removed. The obvious reason for this is that any sensation that would be experienced in the foreskin itself is necessarily eliminated by circumcision [8]. The adult foreskin—with its rich supply of nerve endings and specialized sensory structures [9]—may comprise up to 100 cm2, with reported average values between 30 and 50 cm2 [10, 11]. The contribution of this motile sleeve of erogenous tissue to overall penile sensitivity is not known with certainty. However, any specific qualitative sensation elicited by the mechanical rolling and gliding movements of the foreskin during sexual activity will in fact be absent or reduced in circumcised men [8]. Consequently, Crosby et al.’s finding that circumcised MSM are significantly less likely than intact MSM to use condoms consistently during insertive anal sex [1] may plausibly reflect that individuals with already reduced penile sensitivity are less likely to adhere to HIV prevention recommendations that will make them feel even less during sex. I agree with Crosby et al. that their findings add to the evidence suggesting that circumcision is unlikely to be an effective strategy for HIV prevention among MSM. For future reference, I kindly ask the authors to provide the actual frequencies of unprotected insertive anal sex for circumcised and intact males, which they found to be around 100 per cent increased among circumcised men in their study. References 1. Crosby RA, Graham CA, Mena L, Yarber WL, Sanders SA, Milhausen RR, Geter A. Circumcision status is not associated with condom use and prevalence of sexually transmitted infections among young black MSM. AIDS Behav. 2015. doi:10. 1007/s10461-015-1212-x. <a href="http://link.springer.com/article/10.1007/s10461-015-1212-x" rel="noopener" target="_blank">Full text (behind paywall)</a> 2. Wiysonge CS, Kongnyuy EJ, Shey M, Muula AS, Navti OB, Akl EA, Lo YR. Male circumcision for prevention of homosexual acquisition of HIV in men. Cochrane Database Syst Rev. 2011;6:CD007496. 3. Doerner R, McKeown E, Nelson S, Anderson J, Low N, Elford J. Circumcision and HIV infection among men who have sex with men in Britain: the insertive sexual role. Arch Sex Behav. 2013;42(7):1319–26. 4. Feldblum PJ, Okech J, Ochieng R, Hart C, Kiyuka G, Lai JJ, Veena V. Longer-term follow-up of Kenyan men circumcised using the ShangRing device. PLoS One. 2015;10(9):e0137510. 5. Hill BJ, Janssen E, Kvam P, Amick EE, Sanders SA. The effect of condoms on penile vibrotactile sensitivity thresholds in young, heterosexual men. J Sex Med. 2014;11(1):102–6. 6. Sorrells ML, Snyder JL, Reiss MD, Eden C, Milos MF, Wilcox N, Van Howe RS. Fine-touch pressure thresholds in the adult penis. BJU Int. 2007;99(4):864–9. 7. Bossio JA. Examining sexual correlates of neonatal circumcision in adult men. PhD Thesis, Queen’s University, Kingston, Ontario, Canada; 2015. 8. Earp BD. Sex and circumcision. Am J Bioeth. 2015;15(2):43–5. 9. Cold CJ, Taylor JR. The prepuce. BJU Int. 1999;83(Suppl 1):34–44. 10. Werker PM, Terng AS, Kon M. The prepuce free flap: dissection feasibility study and clinical application of a super-thin new flap. Plast Reconstr Surg. 1998;102(4):1075–82. 11. Kigozi G, Wawer M, Ssettuba A, Kagaayi J, Nalugoda F, Watya S, Mangen FW, Kiwanuka N, Bacon MC, Lutalo T, Serwadda D, Gray RH. Foreskin surface area and HIV acquisition in Rakai, Uganda (size matters). AIDS. 2009;23(16):2209–13. Source: Morten Frisch. Higher Frequency of Unprotected Insertive Anal Sex Among Young Black MSM Who are Circumcised. AIDS Behavior, on-line first, 25 November 2015 <a href="http://link.springer.com/article/10.1007/s10461-015-1212-x" rel="noopener" target="_blank">Full text (behind paywall)</a> Also on this site <a href="https://www.circinfo.org/Circumcision_condoms.html">More evidence that circumcision leads to lower condom use</a> <a href="https://www.circinfo.org/Circumcision_HIV_doubts.html">HIV-AIDS control: Growing doubts on the circumcision solution</a> <h2>A fifth of African HIV infections caused by medical procedures</h2> New research confirms earlier claims that up to one in five HIV cases in Africa are infected during medical and surgical procedures by medical staff using dirty needles and non-sterile clinical equipment. Dr Potterat said that “The studies now show directly that many Africans are at risk from a wide range of common skin puncturing practices that may involve contaminated instruments and materials. By uncritically accepting the orthodox view that HIV is almost exclusively transmitted by sex, public health workers and researchers are complicit in prolonging avoidable suffering.” He and 11 other scientists have published a series of papers in the<a href="http://ijsa.rsmjournals.com/"> International Journal of STD and AIDS</a>, to coincide with World Aids Day on 1 December (Vol. 20, No. 12, December 2009). In one of the studies, patients at the University of Calabar Teaching Hospital in south eastern Nigeria who contracted HIV were significantly more likely to have had blood tests, vaccinations, blood transfusions or surgical procedures. Half of the patients who received tetanus vaccinations reported seeing needles being reused. Another study in the journal, published by the British Association of Sexual Health and HIV, an affiliate organisation of the Royal Society of Medicine, looked at rates of HIV infection among children in Swaziland. HIV infections there are the highest in the world at 26 per cent of the adult population, reducing the country’s average life expectancy to 32 years. Using data from the Swaziland Demographic and Health Survey, the authors found that one in five Swazi children aged two to 12 who are infected with the virus have HIV-negative mothers. These children had experienced many more medical injections and vaccinations than their uninfected brothers or sisters. Most of these related to anti-malaria health programmes. Africans are subject to a much higher proportion of injections and blood tests than patients in the West, according to a 1999 study for the World Health Organisation. That research found that a wide range of common symptoms such as colds, ear infections, fatigue and tonsillitis were treated with injections rather than oral medication. The study concluded that at least 50 per cent of these were unsafe, with needles being used repeatedly on one patient after another, without sterilisation. “HIV priorities have been and continue to be misplaced,” said Stuart Brody, a professor at the University of the West of Scotland, in Paisley, who has researched the spread of HIV in Kenya through tetanus vaccinations. “The mindset is to pretend this is not an issue, perhaps because of the received wisdom or because you don’t get funding if you question it, but this does not save lives.” But Dr Anna Thomas, head of economic and social development at ActionAid Kenya, said: “The use of unsterilised needles is one of the many issues affecting HIV/AIDS in Africa. “But the vast majority of the spread of HIV/AIDS is down to unsafe sex between men and women and that is where we need to continue to focus our efforts.” CIA comment: If is true that 20 per cent of HIV infections are caused by unsafe medical and surgical practices (such as circumcision?) this “vast majority” cannot be more than 80 per cent of cases. <a href="http://www.telegraph.co.uk/health/healthnews/6684230/One-in-five-HIV-infections-caused-by-medical-staff.html" rel="noopener" target="_blank">One in five HIV infections caused by medical staff</a> by William Payne and Mike Pflanz, Telegraph (London), 17 November 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 rates soar in circumcised populations 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"> <h2>Heterosexual HIV diagnoses decline as a proportion of total infections despite falling circumcision prevalence</h2> When the extremist Circumcision Foundation of Australia launched its current push for boosting infant circumcision to combat HIV in a <a href="https://www.circinfo.org/Circumcision_and_HIV-AIDS.html">Medical Journal of Australia editorial</a> in 2010, the argument depended entirely on the claim that heterosexual diagnoses were increasing as a proportion of total infections. They wrote: <blockquote> Regular surveillance indicates that HIV in Australia is slowly following the trend in Western Europe and North America toward an increased proportion of transmission occurring through heterosexual contact. Although the epidemic in Australia is likely to remain concentrated for some time among men who have sex with men, the proportion of new diagnoses attributable to heterosexual contact has risen... . This raises the question of whether low-prevalence countries such as Australia — with an increasing proportion of HIV cases attributed to heterosexual contact — should consider increasing the rate of infant male circumcision to reduce future HIV infections. [emphasis added] </blockquote> This argument was not seriously challenged at the time, partly because one of the authors, David Cooper, is director of the Kirby Institute, which is responsible for monitoring HIV in Australia, and therefore a recognised authority on the matter. The claim was repeated most recently by Adrian Mindel, the CFA’s sexual health “expert”, in a <a href="http://www.abc.net.au/radionational/programs/saturdayextra/circumcision/4259844">Radio National circumcision debate</a> on 15 September this year. The Kirby Institute has now released its 2011 HIV Surveillance report showing that as a proportion of total infections heterosexual transmission actually fell 17 per cent last year! So where does that leave the CFA’s argument? Pretty much in the same place as before, since it was bogus to begin with. It is meaningless to talk about the proportion of heterosexual infections, since changes in this measure are most likely the result of incidence changes in the other, much larger category of infection, male homosexual contact. In particular, it implies nothing at all about female-to-male sexual transmission of HIV, the only route of any possible relevance to circumcision. Detailed examination of the data shows that to the extent heterosexual transmission has risen in the past decade it is driven by two factors: a near doubling in the number of infected women “from a high prevalence country” and a rise in the number of cases among males over 40, who have the highest levels of circumcision. Among heterosexual men under 30 the rates of HIV infection are virtually unchanged, despite a <a href="https://www.circinfo.org/statistics.html">dramatic fall in the prevalence of circumcision</a> in this age group. When the 2011 surveillance report was released in October 2012 media coverage focused on the finding that the overall HIV prevalence had increased by 8% compared with 2010. They totally ignored the finding that the proportion of heterosexual infections had declined by double that amount. All the media were doing was repeating the information in the Kirby media release, which noted that “HIV continued to be transmitted primarily through sexual contact between men”, but failed to go into details. It is to the credit of Associate Professor David Wilson, the Kirby spokesman quoted in the media release, that he did not mention circumcision in his comments and observed that “some of the rise in reported HIV diagnoses could be attributed to changes in testing trends among men who have sex with men who are the most affected population group.” He added that “earlier diagnosis among these people and initiation of antiretroviral therapy would have large health benefits for the individual and reduce new infections in the community.” No mention of cutting babies here. Many studies have established that circumcision does not reduce the risk of HIV infection among homosexual men and injecting drug users. It is a sad indictment of the CFA, and Professor Cooper (who ought to know better) in particular, that they could engage in such cynical misrepresentation of the data about such a serious issue as HIV in order to prosecute their wrong-headed drive to resurrect infant circumcision. The 2012 Annual Surveillance Report of HIV, viral hepatitis, STIs can be <a href="http://www.kirby.unsw.edu.au/surveillance/2012-annual-surveillance-report-hiv-viral-hepatitis-stis">downloaded from the Kirby Institute website</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 HIV rates decline despite falling circumcision prevalence 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"> A medical trial in Thailand has raised hopes of a major breakthrough in the fight against Aids after scientists said an experimental vaccine had reduced the risk of HIV infection by a third. The world's largest HIV/AIDS vaccine trial of more than 16,000 volunteers was the first in which infection has been prevented, according to the US army, which sponsored the trial with the National Institute of Allergy and Infectious Diseases. A combination of two vaccines was tested on HIV-negative Thai men and women aged 18 to 30 at average risk of becoming infected. All the volunteers were given counselling and condoms to help them avoid HIV. Then half were randomly picked to receive the vaccine, while the other half got dummy shots. Until the trial ended, nobody knew who had been given the genuine vaccine and who had not. A relatively small number of people became infected with HIV – 51 of the 8,197 people given the vaccine, and 74 of the 8,198 who received dummy shots – but the difference was statistically significant, which means scientists believe it could not have happened by chance. It worked out at a 31% lower risk of infection for the vaccine group. Colonel Jerome Kim, who helped to lead the $105m (£64m) study for the US army, said it was "the first evidence that we could have a safe and effective preventive vaccine". Recent failures had led many scientists to believe that such a vaccine might not be achievable. In 2007, the drug company Merck abandoned what had looked at the time like the most promising avenue of research after disappointing trial results. Today the National Institute's director, Dr Anthony Fauci, warned it was "not the end of the road", but said he was surprised and very pleased by the outcome. "It gives me cautious optimism about the possibility of improving this result," he said. "This is something that we can do." Every day, 7,000 people worldwide are newly infected with HIV; 2 million died of AIDS in 2007, the UN agency UNAIDS estimates. The AIDS Vaccine Advocacy Coalition, an international group that has worked towards developing a vaccine, welcomed the results of the trial – the third major study since 1983, when HIV was identified as the cause of AIDS – as "a historic milestone". The executive director, Mitchell Warren, said: "There is little doubt that this finding will energise and redirect the AIDS vaccine field." Frances Gotch, professor of immunology at Imperial College London, said the results appeared to be statistically significant and may have been the effect of the two different vaccines working in tandem to more powerful effect. "The fact that they have seen a response with people with such a low incidence of infection is impressive," Gotch, who is also the principal investigator for the International AIDS Vaccine Initiative, told the Guardian. "Of course it's not 100% of people [protected] but 31% could make an enormous difference in the world. I think this is something we can work with." Thailand's ministry of public health conducted the study, which used strains of HIV common in Thailand. Scientists stressed it was not known whether such a vaccine would work against other strains elsewhere in the world. The study was done in Thailand because US army scientists carried out pivotal research in that country when the AIDS epidemic emerged there, isolating virus strains and providing genetic information on them to vaccine makers. The study tested a two-vaccine combination in a "prime-boost" approach, where the first one primes the immune system to attack the HIV virus, and the second one strengthens the response. Alvac uses canarypox, a bird virus, altered so it can't cause human disease, to ferry synthetic versions of three HIV genes into the body. AIDSVax contains a genetically engineered version of a protein on HIV's surface. It is unclear whether vaccine makers will seek to license the two-vaccine combination in Thailand. Before the trial began, the US Food and Drug Administration said other studies would be needed before the vaccine could be considered for US licensing. The full results of the trial will be presented at an international AIDS vaccine conference in Paris in October. The executive director of the Global HIV Vaccine Enterprise, an alliance of research bodies and funders like the Gates Foundation, said the results showed a vaccine was an achievable goal. "This is a historic day in the 26-year quest to develop an AIDS vaccine," said Dr Alan Bernstein. "This trial is the first demonstration in humans that, with more research, it will be possible to develop a vaccine that is fully protective against HIV." Deborah Jack, chief executive of the National AIDS Trust in the UK, said a vaccine, by far the most effective way of tackling serious infectious diseases, was desperately needed.. More work was needed, but the promising findings "justify the continuing investments and efforts of the international community, including the UK government, to develop a vaccine." The Terrence Higgins Trust said it was treating the results with "cautious optimism". "This is the first step on a very long road," said the policy manager, Vicky Sheard. "There's a lot of research needed into how a vaccine can be rolled out, how costly it's going to be, whether it's going to be effective against different strains." HIV breakthrough as scientists discover new vaccine to prevent infection First evidence of possible vaccine as US military-backed medical trial in Thailand cuts HIV infection rate by a third by Sarah Boseley and Haroon Siddique <a href="http://www.guardian.co.uk/world/2009/sep/24/hiv-infection-vaccine-aids-breakthrough" rel="noopener" target="_blank">Guardian (UK), 24 September 2009</a> <h3>Comment</h3> It will be noted that this is a far more scientifically sound clinical trial than the African circumcision experiments. <ul> <li>The number of subjects involved is much greater: one and half times more than the three African trials put together.</li> <li>The trials went on for much longer: three years versus 20 months.</li> <li>It was genuine random trial in that the participants did not know who was given the vaccine and who was not. This means that differing behaviours between the two groups cannot have influenced the result.</li> <li>All participants were given the same counselling, unlike the African experiments, where only those who agreed to get circumcised were given counselling on safe sex and provided with condoms.</li> <li>Since a vaccine will equally protect men from infection by women, women from men, men from men, children from mothers, and anyone from IV infection, whether medical, pseudo-medical ("needle men") or recreational drug use, the degree of protection stands for much more than the circumcision trials' much touted "60%" protection of men from infection by women only.</li> </ul> On top of all this, compare the tone of cautious optimism here with the overheated fanfares in praise of circumcision that greeted the results of the African experiments. The vaccine trials represent the true scientific spirit, consistent with a remark by Charles Darwin that "caution is almost the soul of science".* For all their scientific pretensions, that is not the spirit that animates the circumcision promoters. * Letter to Anton Dohrn, 4 January 1870, quoted in Janet Browne, Charles Darwin: The Power of Place, p. 393 </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: vaccine shows promise and more ethical than circumcision 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"> <h3>There is no case for boosting infant male circumcision to combat heterosexual transmission of HIV in Australia.</h3> In October 2010 the Medical Journal of Australia published an opinion piece by David Cooper, Alex Wodak and Brian Morris, calling for a significant “boost” in the incidence of infant circumcision in Australia in order to combat heterosexually acquired HIV infection. The editorial attracted much media attention, and so much criticism that the journal (eventually)<a href="https://www.circinfo.org/MJA_Cooper_letters.html"> published eight letters in reply</a>. A much longer and detailed rebuttal of the editorial by medical historian Robert Darby and pediatrician Robert Van Howe has now been published in Australia’s leading journal of public health issues, the Australian and New Zealand Journal of Public Health. A summary of the article follows. ABSTRACT Objective: To conduct a critical review of recent proposals that widespread circumcision of male infants be introduced in Australia as a means of combating heterosexually transmitted HIV infection. Approach: These arguments are evaluated in terms of their logic, coherence and fidelity to the principles of evidence-based medicine; the extent to which they take account of the evidence for circumcision having a protective effect against HIV and the practicality of circumcision as an HIV control strategy; the extent of its applicability to the specifics of Australia’s HIV epidemic; the benefits, harms and risks of circumcision; and the associated human rights, bioethical and legal issues. Conclusion: Our conclusion is that such proposals ignore doubts about the robustness of the evidence from the African random-controlled trials as to the protective effect of circumcision and the practical value of circumcision as a means of HIV control; misrepresent the nature of Australia’s HIV epidemic and exaggerate the relevance of the African random controlled trials findings to it; underestimate the risks and harm of circumcision; and ignore questions of medical ethics and human rights. The notion of circumcision as a “surgical vaccine” is criticised as polemical and unscientific. Implications: Circumcision of infants or other minors has no place among HIV control measures in the Australian and New Zealand context; proposals such as these should be rejected. <h3>SUMMARY</h3> 1. A conservative position To reject infant circumcision is to follow the policy of Australian medical authorities, which have discouraged routine circumcision since 1971. It was the suggestion in the Med J Aust that was radical, and far out of step with the policies of relevant medical authorities: Royal Australasian College of Physicians, British Medical Association, Canada Pediatric Society, Royal Dutch Medical Association, American Academy of Pediatrics. The timing of the editorial suggests that it was intended to influence or criticise the circumcision policy statement about to be released by the task force set up in 2007 by the Paediatric and Child Health Division of the Royal Australasian College of Physicians. This policy stated clearly that the evidence of the African circumcision trials were not relevant in developed countries and that routine circumcision was not warranted in Australia or New Zealand. 2. Doubts about the African clinical trials themselves <ul> <li>only a small protective effect – somewhere between 38 and 66 per cent, and not the mythical 60 per cent reported everywhere;</li> <li>uncertainty about why: anatomy or behaviour? No convincing biological mechanism yet found that would explain greater vulnerability of uncircumcised men;</li> <li>high drop-out rate: in some of the trials more men dropped out than were infected with HIV;</li> <li>inconsistent with epidemiological evidence from population surveys, which show no consistent pattern in HIV infection between cut and uncut;</li> <li>we don’t know how much transmission is non-sexual, probably through non-sterile medical procedures;</li> <li>even advocates of circumcision solution insist that condoms must still be used: so what’s the point of getting circumcised, with all the cost, risks, and loss of both appearance and function necessarily entailed?</li> <li>evidence from African trials might justify a modest circumcision program in high prevalence countries with high female to male transmission, as one element of a broad range of preventive measures, but not the multi-billion dollar promotion of circumcision pretty much to the exclusion of other interventions. <a href="https://www.circinfo.org/Circumcision_HIV_doubts.html#lomb">Criticism of excessive focus on circumcision</a> by report published by German Development Bank; plus Bjorn Lomborg and other leading economists at Georgetown conference, that circumcision on this massive scale is not cost-effective and bad way to tackle the problem.</li> </ul> 3. Not relevant to nature of Australia’s HIV problem <ul> <li>The WHO recommendations apply to adult men in underdeveloped countries with high HIV prevalence and a high incidence of female to male transmission via unprotected intercourse. They do not apply to the developed world, and they do not apply to children anywhere.</li> <li>Africa: high prevalence; mostly heterosexual; female to male transmission;</li> <li>Australia: low prevalence; mostly homosexual, plus a few injecting drug users – these categories get no protection from circumcision;</li> <li>no evidence that hetero transmission is increasing: only 23 new cases in 2009;</li> <li>infection from prostitutes common in Africa, but in Australia there has never been a single example of a prostitute infecting a male client;</li> <li>Australia’s HIV prevention program (condoms and safe sex education) has worked very well, and we have one of the lowest rates of HIV infection in the developed world – much less than in USA.</li> </ul> 4. Suggestion departs from principles of evidence-based medicine. <ul> <li>Trials involved consenting, sexually active adult men and did not provide any evidence that circumcision in infancy would provide protection. The trials cannot therefore be cited to justify circumcision of infants.</li> <li>In any case, infants are not sexually active, not at risk, and cannot give consent.</li> </ul> 5. Suggestion ignores harm of circumcision and underestimates level of complications. <ul> <li>Circumcision is always harmful. The foreskin is a sensitive, functional body part that many men value highly; it cannot be dismissed as nothing more than a piece of surgical waste.</li> <li>Complications are under-reported, and we have no benchmarks for acceptable risk. The bar must be set higher in cases where the surgery is not immediately necessary, and even higher when it is not elected by the individual, but imposed on him by somebody else.</li> </ul> 6. Suggestion totally ignores medical ethics and human rights. <ul> <li>But all humans have an inherent right to bodily integrity that may be violated only with very good reason. Ethics should not be dismissed as an obstacle to the roll-out of circumcision programs: if we don’t have ethical principles we cannot regard ourselves as civilized, and we shall end up in a dog-eat-dog world, without values and without respect for individual rights.</li> </ul> 7. Circumcision is not a surgical vaccine. <ul> <li>The suggestion misrepresents both the nature of vaccines and the nature and level of protection given by circumcision. It is both exaggerated and mischievous in that it is likely to give a false sense of security and encourage high risk behaviour. Already there are reports from African countries of men saying that now they are circumcised they don’t need to use condoms.</li> </ul> 8. Conclusion It is generally accepted that the rapid spread of HIV in Africa was associated with a high level of sexual activity, involving numerous concurrent but often transient sexual partnerships, widespread prostitution, both formal and informal, various forms of polygamy, and reluctance to practise safe sex or use condoms. It is also probable that a significant proportion of HIV infections are the result of non-sexual transmission, such as non-sterile medical procedures. These conditions were aggravated by poorly developed health services, the co-presence of numerous other epidemic diseases, such as malaria, tuberculosis and other STIs, and the refusal of local authorities to take action until the disease had spread through the population, provoked by the misconception that AIDS was a “gay disease”, confined to decadent developed world. This crisis situation stands in dramatic contrast to that of a wealthy, developed nation such as Australia, where effective action was taken early on, based on respect for the autonomy and agency of those at greatest risk, and an emphasis on safe sex education, needle and syringe programs, and provision of condoms. This strategy has been strikingly successful: AIDS in Australia remains a relatively minor public health problem, largely confined to the sub-cultures where it has traditionally been found. There is no heterosexual epidemic that would justify a costly, authoritarian program of the type and scale that Cooper et al propose. There is every reason to think that the strategy that Australia has pursued so successfully since the 1980s will continue to protect the vast majority of the population from this disease. Source (full text available through link): Robert Darby and Robert Van Howe, Not a surgical vaccine: There is no case for boosting infant male circumcision to combat heterosexual transmission of HIV in Australia. <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1753-6405.2011.00761.x/full">Australian and New Zealand Journal of Public Health, Vol. 35, October 2011</a>. Full text may be downloaded as PDF here: <a href="https://www.circinfo.org/documents/VaccineANZJPH.pdf">VaccineANZJPH</a><a href="https://www.circinfo.org/documents/VaccineANZJPH.pdf"></a> Figures on the incidence of HIV and other sexually transmitted infections in Australia are available from the Kirby Institute for Infection and Immunity in Society (formerly National Centre in HIV Epidemiology and Clinical Research), <a href="http://www.med.unsw.edu.au/NCHECRweb.nsf/page/Annual+Surveillance+Reports" rel="noopener" target="_blank">HIV/AIDS, Viral Hepatitis & Sexually Transmissible Infections in Australia, Annual Surveillance Reports</a> <h3>Argument confirmed by studies since paper written</h3> Results of African trials not replicated in other countries. 1. In the USA, study by Sansom showed that that the lifetime risk of HIV to Black men was 6.23% while 73% of Black men are circumcised, yet the lifetime risk to Hispanics was only 2.88% with a circumcision rate of only 42%. This suggests that there is no connection at all between circumcision and reduced susceptibility to HIV; or that circumcision increases the risk of HIV; or that being Black in the USA is a far greater risk factor for HIV than possessing a foreskin. (This last point may be related to the disproportionate number of Black men in American prisons, where unsafe sex is rampant.) Stephanie L. Sansom et al, <a href="http://www.plosone.org/article/comments/info%3Adoi/10.1371/journal.pone.0008723">Cost-Effectiveness of Newborn Circumcision in Reducing Lifetime HIV Risk among U.S. Males</a>, PLoS ONE 5(1): e8723. doi:10.1371/journal.pone.0008723. (<a href="https://www.circinfo.org/Foreskin_owner_decide.html">And see comment by Circinfo.org</a>) 2. <a href="https://www.circinfo.org/AIDSnews.html#heff">Study of HPV and HIV in Zambia</a> (Heffron et al) found that uncircumcised men had slightly lower incidence of HIV infection – but did not discuss this finding in their paper: Heffron R. et al, High prevalent and incident HIV-1 and herpes simplex virus 2 infection among male migrant and non-migrant sugar farm workers in Zambia. Sex Transm Infect 2011; 87: 283-8. 3. <a href="https://www.circinfo.org/Circumcision_HIV_doubts.html#kids">Study by Brewer in Mozambique</a> found that men circumcised as children had a higher incidence of HIV. Suggests that this is more evidence of non-sexual transmission: Brewer D.D. Scarification and Male Circumcision Associated with HIV Infection in Mozambican Children and Youth. WebmedCentral EPIDEMIOLOGY 2011;2(9):WMC002206 Excessive focus on circumcision criticised by economists Criticism of excessive focus on circumcision by report published by German Development Bank; plus Bjorn Lomborg and other leading economists at Georgetown conference, that circumcision on this massive scale is not cost-effective and bad way to tackle the problem. <a href="https://www.circinfo.org/Circumcision_HIV_doubts.html#lomb">See news report at Circinfo.org</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 HIV/AIDS: the case against circumcision in Australia 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>Medical Journal of Australia publishes replies to Cooper et al</h1> "An article in the 20 September issue of the Journal that suggested circumcision of infant boys could be considered a “surgical vaccine” against future heterosexually transmitted HIV has attracted strong criticism from many of our readers." <h3>[Contrary to policy of responsible medical authorities]</h3> In a recent editorial, Cooper and colleagues recommend increasing infant circumcision to combat increasing rates of heterosexual transmission of HIV infection, and contend that the major obstacle to increasing male circumcision in Australia is a Royal Australasian College of Physicians (RACP) policy. [1] In September, after a literature review and analysis, the RACP released a revised policy on infant male circumcision, concluding that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand. [2] While evidence of HIV prevention by circumcision is strong in high-prevalence settings with predominantly heterosexual transmission, [3] this is not so in low-prevalence environments where homosexual transmission is more important. [4] Evidence of the protective effect of circumcision against other sexually transmitted infections in Australia is limited. [5] Cooper et al’s comparison of circumcision with vaccines is misleading. Protection against HIV by circumcision is predominantly for males, and the risk for females may increase. [6] There is minimal protection against homosexual acquisition of HIV. [4] The RACP acknowledges the strong and differing opinions on this topic, ranging from the strong pro-circumcision views of Cooper et al to the equally strong diametrically opposed views of the Royal Dutch Medical Association, which believes that (for reasons of ethics and medical risks) legal prohibition of infant circumcision is warranted. [7] The RACP recognises the important role of parents in decision making, and recommends that parents contemplating circumcision of their newborn sons be carefully apprised of the risks and benefits. If they elect to proceed with circumcision, the procedure should be undertaken in a safe child-friendly environment, with appropriate analgesia, and by an appropriately trained, competent practitioner who is capable of dealing with complications. We believe that this approach safeguards the social and community interests of children, and offers protection from unnecessary surgical risks. [2] The RACP does not accept that its policy on circumcision of infant males represents an obstacle to effective public health policy — it believes that, at present, the evidence does not allow a recommendation for widespread infant male circumcision and that Cooper et al have misrepresented this evidence. In the interests of children, and of public health more generally, it is important that this evidence be kept under review and decisions that could lead to increased morbidity and mortality of children only be made when it is clear that the benefits very clearly outweigh any risks. David A Forbes, Chair, Policy and Advocacy Committee Paediatrics and Child Health Division, Royal Australasian College of Physicians, Sydney. 1. Cooper DA, Wodak AD, Morris BJ. The case for boosting infant male circumcision in the face of rising heterosexual transmission of HIV [editorial]. Med J Aust 2010; 193: 318-319. 2. Royal Australasian College of Physicians. <a href="http://www.racp.edu.au/page/policy-and-advocacy/paediatrics-and-child-health">Circumcision of infant males</a>. Sydney: RACP, 2010. 3. Siegfried N, Muller M, Deeks JJ, Volmink J. Male circumcision for prevention of heterosexual acquisition of HIV in men. Cochrane Database Syst Rev 2009; (2): CD003362. 4. Templeton DJ, Jin F, Mao L, et al. Circumcision and risk of HIV infection in Australian homosexual men. AIDS 2009; 23: 2347-2351. 5. Templeton DJ, Jin F, Prestage GP, et al. Circumcision and risk of sexually transmissible infections in a community-based cohort of HIV-negative homosexual men in Sydney, Australia. J Infect Dis 2009; 200: 1813-1819. 6. Wawer MJ, Makumbi F, Kigozi G, et al. Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial. Lancet 2009; 374: 229-237. 7. Royal Dutch Medical Association. <a href="https://www.circinfo.org/Dutch_circumcision_policy.html">Non-therapeutic circumcision of male minors</a>. Utrecht: KNMG, 2010. <h3>[Circumcision ineffective, risky and cruel]</h3> In their recent editorial, Cooper and colleagues propose newborn circumcision as primary prevention for heterosexual HIV transmission in Australia. [1] However, they cite no evidence for its effectiveness as a primary prevention measure, and their editorial references few high-quality studies, offering instead opinions from like-minded individuals. Experience in the United States suggests that circumcision is unlikely to be effective in preventing heterosexual HIV transmission. While having a high infant circumcision rate for the past 60 years, the US has had one of the highest rates of heterosexually transmitted HIV infection among developed nations. African Americans have the highest rates of both circumcision [2] and heterosexually transmitted HIV infection. [3] Circumcision removes the most sensitive tissue of the penis [4] and serious complications include death (about 0.9 deaths per 10 000 circumcisions). [5] If two-thirds of Australian newborn boys were circumcised at birth, around nine would die every year from complications. Cooper et al sidestep the ethical issues raised by non-therapeutic circumcision. Infants and children lack the legal capacity to grant consent but have human rights. The High Court of Australia holds that parents may grant consent only when surgery to the genital organs is therapeutic, [6] which does not include neonatal circumcision. Without valid consent, circumcision constitutes legal battery. It is far preferable legally and ethically for circumcision decisions to be deferred until the child is competent to make a fully informed decision for himself. Cooper et al state that infant circumcision is cost-effective, but the cost analysis that they reference does not directly assess cost effectiveness. [7] In fact, the data suggest that infant circumcision costs more than it saves. Another cost analysis showed that a circumcision program would be five times more costly in preventing HIV than providing free condoms, and that condoms are 95 times more effective than circumcision. [8] In summary, newborn circumcision for primary prevention of HIV remains unsupported by evidence of efficacy or cost-effectiveness, introduces potentially serious risks, and raises complex ethical and medico-legal issues. New 2010 Royal Australasian College of Physicians guidelines [9] continue to not recommend circumcision, despite pressure from a well funded, international, pro-circumcision lobby group. [10] Instead of adopting a circumcision experiment that has failed in the US, Australia should take its lead from the Royal Dutch Medical Association and condemn non-therapeutic circumcision in boys. [11] John W Travis, Adjunct Professor, School of Health Sciences, RMIT, Melbourne; Sarah J Buckley, General Practitioner, Brisbane; Paul Mason, Former Commissioner for Children, Tasmania; Ken McGrath, Senior Lecturer in Pathology, Auckland University of Technology; Robert S Van Howe, Clinical Professor, Department of Pediatrics and Human Development, Michigan State University; George Williams, Former Director, Newborn Intensive Care Unit, Sydney Children’s Hospital. 1. Cooper DA, Wodak AD, Morris BJ. The case for boosting infant male circumcision in the face of rising heterosexual transmission of HIV [editorial]. Med J Aust 2010; 193: 318-319. 2. Mor Z, Kent CK, Kohn RP, Klausner JD. Declining rates in male circumcision amidst increasing evidence of its public health benefit. PLoS ONE 2007; 2: e861. 3. Centers for Disease Control and Prevention. Racial/ ethnic disparities in diagnoses of HIV/AIDS — 33 states, 2001–2005. MMWR Morb Mortal Wkly Rep 2007; 56: 189-193. 4. Sorrells ML, Snyder JL, Reiss MD, et al. <a href="http://www.cirp.org/library/anatomy/sorrells_2007/">Fine-touch pressure thresholds in the adult penis</a>. BJU Int 2007; 99: 864-869. 5. Bollinger D. <a href="https://www.circinfo.org/USA_deaths.html">Lost boys: an estimate of US circumcision-related infant deaths.</a> Thymos 2010; 4: 78-90. 6. Secretary, Department of Health and Community Services v JWB and SMB (Marion’s case) (1992) 175 CLR 218, FC 92/010. 7. Schoen EJ, Colby CJ, To TT. Cost analysis of neonatal circumcision in a large health maintenance organization. J Urol 2006; 175: 1111-1115. 8. McAllister RG, Travis JW, Bollinger D, et al. The cost to circumcise Africa. Int J Men’s Health 2008; 7: 307- 316. 9. Royal Australasian College of Physicians. Circumcision of infant males. Sydney: RACP, 2010. 10. Llewellyn DJ. The circumcision lobby. The 11th International Symposium on Circumcision, Genital Integrity, and Human Rights. Genital Autonomy. Program and Syllabus of Abstracts; 2010 Jul 29–31; University of California, Berkeley. 11. Royal Dutch Medical Association. Non-therapeutic circumcision of male minors. Utrecht: KNMG, 2010. <h3>[Circumcision irrelevant to Australian conditions]</h3> We refer to a recent editorial in which Cooper and colleagues made a case for boosting infant male circumcision in Australia to reduce female-to-male HIV transmission. [1] The case is strong for hyperendemic countries, such as those in sub-Saharan Africa, given the evidence for circumcision reducing the prevalence of HIV when infections are primarily from heterosexual contact. [2] However, the epidemiology of the HIV epidemic in Australia paints a radically different picture from these countries. Most striking is that men who have sex with men (MSM) still comprise the largest group — around 83% — of people living with HIV. [3] Prevalence of HIV among men and women who report a history of heterosexual contact only remains at less than 0.5%4 while MSM continue to have the majority of new infections. [4] In short, efforts to reduce Australia’s HIV epidemic still require a primary focus on MSM. With this in mind, a recent meta-analysis of 18 international studies and a combined pool of 53 567 MSM5 showed only a small, statistically non-significant trend toward a protective benefit from circumcision with regard to HIV and other sexually transmitted infections. Hypothesised benefits are limited to the insertive partner; however, circumcised MSM who engaged primarily in insertive anal intercourse (IAI) were not significantly less likely to be HIV-positive than other MSM. The sexual repertoire of many MSM suggests that interventions designed specifically to protect those who engage in IAI are unlikely to be successful at a population level. Data from a national survey of 856 homosexual men, conducted recently by the Australian Research Centre in Sex, Health and Society, show that only 9% of those who had anal intercourse in the past 12 months reported taking an exclusively insertive role. Of the remainder, 8% were exclusively receptive and 83% were versatile, adopting each role at least once over the preceding 12 months. Uncircumcised men who engaged exclusively in IAI were just as likely to be HIV-negative as their circumcised counterparts (P=0.90). As infant male circumcision programs are rolled out in some hyperendemic countries, we encourage policymakers to tread carefully when considering such a move in Australia. Boosting education campaigns that promote HIV awareness and safer sex may prove to be more cost-effective and successful than largescale infant male circumcision programs which seem likely to offer, at most, a marginal benefit to the extremely small proportion of the Australian male population who are exclusively insertive partners in homosexual anal intercourse. Anthony N Lyons, Research Fellow; Marian Pitts, Director; Anthony Smith; Professor Jeffrey Grierson, Senior Research Fellow, Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne. 1. Cooper DA, Wodak AD, Morris BJ. The case for boosting infant male circumcision in the face of rising heterosexual transmission of HIV. Med J Aust 2010; 193: 318-319. 2. Doyle SM, Kahn JG, Hosang N, et al. The impact of male circumcision on HIV transmission. J Urol 2010; 183: 21-26. 3. Grierson J, Power J, Croy S, et al. HIV futures six: making positive lives count. Melbourne: La Trobe University, 2009. 4. National Centre in HIV Epidemiology and Clinical Research. <a href="http://www.nchecr.unsw.edu.au/NCHECRweb.nsf/page/Annual+Surveillance+Reports">HIV/AIDS, viral hepatitis and sexually transmissible infections in Australia: annual surveillance report 2009</a>. 5. Millett GA, Flores SA, Marks G, et al. Circumcision status and risk of HIV and sexually transmitted infections among men who have sex with men: a meta-analysis. J Am Med Assoc 2008; 300: 1674- 1684. <h3>[Circumcision: Not enough evidence of efficacy]</h3> In their recent editorial, Cooper and colleagues argue for a shift in Australian policy to boost neonatal male circumcision levels, in an effort to prevent future heterosexual acquisition of HIV. [1] There is very strong evidence for a protective effect of male circumcision against HIV acquisition in high-prevalence settings, where heterosexual intercourse is the most common mode of transmission and access to antiretroviral therapy is poor. However, Australia is a low-prevalence setting with an HIV epidemic that largely affects the homosexual population and excellent access to condoms and antiretroviral therapy. There have been very few studies on the protective effect of male circumcision in settings similar to Australia, and those that have been reported have produced variable results. [2] The publications cited by Cooper et al do not strongly support the notion that male circumcision confers similar protection in both high- and low-prevalence settings — the conclusions are based on expert opinion or other inconclusive, low-quality evidence. [2-4] There are also other issues to consider when discussing a population-based intervention strategy for a low-prevalence disease. Given that rates of male circumcision in Australia are currently low,1 compliance could be an issue, as parents may be unwilling to accept a surgical procedure for their newborns on the basis of predictions about future HIV protection. Is circumcision cost-effective compared with other modalities used to prevent or treat heterosexually transmitted HIV? Cost effectiveness studies have been carried out in the United States, where health care costs are likely to be significantly different to those in Australia. The Centers for Disease Control and Prevention consultation report cited by the authors acknowledges that the available cost and cost-effectiveness research on male circumcision is subject to a variety of “methodological limitations and data insufficiencies”. [3] Further, the case needs to be made that neonatal male circumcision is a more cost-effective option in preventing heterosexual HIV transmission than the current response — targeted education campaigns, antiretroviral therapy, and medical advice regarding safe sex practices. In conclusion, the jury is still out with regard to the role of male circumcision in HIV prevention in Australia on two counts: efficacy and cost-effectiveness. To justify a shift in policy towards actively encouraging routine neonatal circumcision at a national level, we should have access to high-quality, relevant data. Until such information is available, the environment doesn’t exist for parents or policymakers to make a truly informed decision about this issue. Niall Conroy, Public Health Registrar, Sir Albert Sakzewski Virus Research Centre, Queensland Paediatric Infectious Diseases Laboratory, Brisbane. 1. Cooper DA, Wodak AD, Morris BJ. The case for boosting infant male circumcision in the face of rising heterosexual transmission of HIV [editorial]. Med J Aust 2010; 193: 318-319. 2. Smith DK, Taylor A, Kilmarx PH, et al. Male circumcision in the United States for the prevention of HIV infection and other adverse health outcomes: a report from a CDC consultation. Public Health Rep 2010; 125 Suppl 1: 72-82. 3. Centers for Disease Control and Prevention. Male circumcision and risk for HIV transmission and other health conditions: implications for the United States [CDC HIV/AIDS science facts]. Atlanta: CDC, 2008. 4. Morris BJ. Why circumcision is a biomedical imperative for the 21st century. Bioessays 2007; 29: 1147- 1158. <h3>[Circumcision violates principles of medical ethics and human rights]</h3> In a recent editorial, Cooper and colleagues asserted that infant male circumcision reduces heterosexual (female-to-male) transmission of HIV. [1] However, they failed to acknowledge the serious methodological flaws of the three African randomised controlled trials (RCTs) on which the claim is based, including early termination and loss of participants to follow-up. These RCTs reported on circumcision of adults in Africa and, therefore, are not relevant to children in Australia. In a major oversight, the editorial did not cite contradictory RCT evidence that male circumcision increases heterosexual (male-to-female) HIV transmission by 61.4%. [2] Therefore increased male-to-female transmission of HIV would negate any reduction in female-to-male HIV transmission. Common law recognises the right of bodily integrity. International human rights law enshrines the right to security of the person. The High Court of Australia opines that parents may grant surrogate consent only when a surgical intervention is therapeutic. As male circumcision amputates healthy, functional, protective, erogenous tissue, imposing male circumcision on unconsenting minors violates these rights. It has been strongly argued that non-therapeutic infant circumcision is tantamount to criminal assault. [3] Unlike America, which has a high incidence of male circumcision and a high prevalence of HIV infection (0.6%),4 in the Australian context there is a low incidence of male circumcision among men aged under 35 years combined with a very low prevalence of HIV (0.1%). [4, 5] HIV infection in Australia occurs mostly among homosexual men. [6] It has been reported that any prophylactic value of male circumcision in preventing homosexual transmission of HIV is not statistically significant, [7] so male circumcision would be of little value in reducing future Australian HIV infection rates. Despite calling for increased non-therapeutic infant male circumcision, Cooper et al unequivocally stated “Condom use remains essential”. Since this is the case, what is the purpose of inflicting lifelong bodily and psychosexual harm [8] on defenceless children, contrary to ethical or moral principles? Furthermore, circumcision of unconsenting minors may amount to criminal assault. Gregory J Boyle, Professor of Psychology, Bond University, Queensland; George Hill, Independent Consultant, Port Allen, La, USA. 1. Cooper DA, Wodak AD, Morris BJ. The case for boosting infant male circumcision in the face of rising heterosexual transmission of HIV. Med J Aust 2010; 193: 318-319. 2. Wawer MJ, Makumbi F, Kigozi G, et al. Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial. Lancet 2009; 374: 229-237. 3. Boyle GJ, Svoboda JS, Price CP, Turner JN. <a href="http://www.cirp.org/library/legal/boyle1/">Circumcision of healthy boys: criminal assault?</a> J Law Med 2000; 7: 301-310. 4. UNAIDS. <a href="http://cfs.unaids.org/">Country factsheets.</a> Geneva: UNAIDS, 2010. http://cfs.unaids.org/ (accessed Dec 2010). 5. National Centre in HIV Epidemiology and Clinical Research. <a href="http://www.nchecr.unsw.edu.au/NCHECRweb.nsf/page/Annual+Surveillance+Reports">HIV/AIDS, viral hepatitis and sexually transmissible infections in Australia: annual surveillance report 2009.</a> Sydney: NCHECR, 2009. 6. 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: 547-554. 7. Millett GA, Flores SA, Marks G, et al. Circumcision status and risk of HIV and sexually transmitted infections among men who have sex with men: a meta-analysis. JAMA 2008; 300: 1674-1684. 8. Boyle GJ, Goldman R, Svoboda JS, Fernandez E. <a href="http://www.cirp.org/library/psych/boyle6/">Male circumcision: pain, trauma and psychosexual sequelae.</a> J Health Psych 2002; 7: 329-343. <h3>[Violates principles of evidence-based medicine]</h3> Cooper and colleagues propose circumcision of male infants in Australia as a strategy for reducing the incidence of heterosexually transmitted HIV infection. [1] They base this suggestion on evidence, from three clinical trials in Africa, that circumcision of adult men can reduce the risk of men acquiring HIV during unprotected sexual intercourse with an infected female partner. The proposal must be rejected because it is irrelevant to the Australian situation and departs from the principles of evidence-based medicine. The proposal is irrelevant because it targets infants, who are not at risk of infection by sexual contact and will not be at risk until they become sexually active in 16–20 years time, by which time treatment and prevention options, and the virus itself, may have altered beyond recognition. Evidence-based medicine requires that recommendations for treatment or prophylaxis follow logically and directly from the evidence. In this case, there is a radical disconnect between the evidence and the recommendation. Even assuming the African evidence is reliable and applicable (and ignoring the many critiques), [2, 3] the logical prescription arising from these data is that sexually active adult men who have regular intercourse with numerous different female partners and who do not always use condoms should consider circumcision for themselves as a means of lowering their risk of infection. This is not what Cooper et al propose. What they prescribe is that parents be advised to circumcise their boys in infancy as a precaution against a risk they will not face until they are adults, and against a disease that is very rare among heterosexually active adult men in Australia. Even if circumcised, they would still have to use a condom to be sure of avoiding infection, as the risk reduction promised by the African data is only partial — between 38 and 66 per cent. [4] We have no data at all on what the risk reduction in Australia might be. If it is still necessary to wear a condom there seems little point in getting circumcised. As others point out, [5] moreover, the African trials on which Cooper et al rely involved sexually active adult men, not infants, and there is no hard evidence that neonatal circumcision has any protective effect against acquiring HIV. Arguments concerning other possible, non-HIV-related benefits of circumcision (all contested in the literature and rejected in the policy statement on circumcision recently issued by the Royal Australasian College of Physicians [6]) are irrelevant to HIV infection itself. In sum, the prescription offered has so little connection with the evidence on which it relies that it cannot be taken seriously. Robert J L Darby, Independent Researcher, Canberra, ACT. 1. Cooper DA, Wodak AD, Morris BJ. The case for boosting infant male circumcision in the face of rising heterosexual transmission of HIV [editorial]. Med J Aust 2010; 193: 318-319. 2. Green LW, McAlister RG, Peterson KW, Travis JW. <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>. Futur HIV Ther 2008; 2: 193- 199. 3. Myers A, Myers JE. <a href="http://www.historyofcircumcision.net/index.php?option=com_content&task=view&id=85&Itemid=0">Rolling out male circumcision as a mass HIV/AIDS intervention seems neither justified nor practicable</a> [editorial]. S Afr Med J 2008; 98: 781-782. 4. Siegfried N, Muller M, Deeks JJ, Volmink J. Male circumcision for prevention of heterosexual acquisition of HIV in men. Cochrane Database Syst Rev 2009; (2): CD003362. 5. Perera CL, Bridgewater FHG, Thavaneswaran P, Maddern GJ. <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: 64-72. 6. Royal Australasian College of Physicians. Circumcision of infant males. Sydney: RACP, 2010. <h3>[Proposed cure worse than the disease]</h3> I write in response to the editorial by Cooper and colleagues, which advocates an increase in male infant circumcision as an anti-HIV strategy. [1] The authors claim that male circumcision is effectively a surgical vaccine for preventing female-to-male HIV transmission and, while the authors do present evidence in favour of this, they fail to canvass the serious and inevitable long-term adverse effects of the procedure. Far from being an inconsequential snip, male circumcision is a highly mutilating operation which seriously impairs penile function. Glibly quoting four articles which “prove” that circumcised and uncircumcised males are equally satisfied sexually, the authors totally ignore a large and expanding body of evidence to the contrary, [2-4] and indeed growing popular movements against circumcision and for restoration of the foreskin. Circumcision typically removes nearly half the skin of the penis [3] — including its most sensitive areas — and, by exposing the glans to the elements, induces keratinisation of its formerly moist mucosal surface — making it rougher, dryer and less sensitive. It also destroys the “sliding” or “rolling” action of the shaft in the skin tube and most certainly impairs both male and female sexual satisfaction. [4,5] It is totally inappropriate to suggest that circumcision is akin to vaccination: needle vaccination generally confers high-level immunity to the majority of its recipients with few, if any, long-term sequelae. In contrast, circumcision confers moderate immunity at best, and does so at the cost of mutilating and de-functioning every penis so treated. I strongly urge my colleagues who still believe that male circumcision is a trivial operation to type “foreskin restoration” into a search engine and see what they find. Finally, I implore us all to refrain from removing body parts from our unconsenting children without immediate and direct surgical need. Bruce R Paix, Anaesthetist, Department of Anaesthesia, Flinders Medical Centre, Adelaide. 1. Cooper DA, Wodak AD, Morris BJ. The case for boosting infant male circumcision in the face of rising heterosexual transmission of HIV [editorial]. Med J Aust 2010; 193: 318-319. 2. Zoossmann-Diskin A, Blustein R. Challenges to circumcision in Israel. In: Denniston GC, Mansfield Hodges F, Milos MF, editors. Male and female circumcision: medical, legal and ethical considerations in pediatric practice. New York: Kluwer Academic/ Plenum Publishers, 1999: 343-350. 3. Taylor JR, Lockwood AP, Taylor AJ. <a href="http://www.cirp.org/library/anatomy/taylor/">The prepuce: specialized mucosa of the penis and its loss to circumcision</a>. Br J Urol 1996; 77: 291-295. 4. Fleiss PM, Hodges FM, Van Howe RS. <a href="http://www.cirp.org/library/disease/STD/fleiss3/">Immunological functions of the human prepuce.</a> Sex Transm Infect 1998; 74: 364-367. 5. Cold CJ, Taylor JR. <a href="http://www.cirp.org/library/anatomy/cold-taylor/">The prepuce.</a> Br J Urol 1999; 83 Suppl 1: 41. <h3>[Circumcision for HIV prevention not relevant to children]</h3> I read with interest the editorial by Cooper and colleagues in which the authors argue for infant male circumcision as a population-wide strategy to reduce HIV transmission. Circumcision is an irreversible body-altering procedure and, therefore, as far as possible, individuals should participate in the decision of whether or not to be circumcised. Male circumcision in infancy removes an individual’s ability to participate in the decision-making process. Further, the protective benefits of infant circumcision with regard to reduction of HIV transmission are not conferred until an individual becomes sexually active and is capable of understanding the risks and benefits. Deferment of circumcision to a later age would allow individuals to fully appreciate the magnitude of the procedure and participate in the decision-making process, and it would not necessarily negate the protective benefits. This should be considered by anyone who advocates infant male circumcision as a strategy to reduce HIV transmission. Jeremy J Chin, Intern, Northern Health, Melbourne. Source: Medical Journal of Australia, Vol. 194 (2), 17 January 2011, 97-101. Headings to the letters have been added by Circumcision Information Australia. <h1>Circumcision and HIV: Cooper, Wodak and Morris reply to their critics</h1> <h3>... and get themselves into even deeper water</h3> They write: In our editorial we, just as other academic experts in various countries, [1-4] likened infant male circumcision to a “surgical vaccine”. Both vaccination and male circumcision effectively, safely and inexpensively afford lifelong protection against a wide array of adverse, sometimes fatal, medical conditions. Both are most effective if provided early in life. Both are criticised vigorously and relentlessly by opponents. There is now an impressive and growing number of high-quality research publications attesting to the wide-ranging benefits of male circumcision. [2, 4] The letters to the Journal in response to our editorial rely largely on opinions, and often cite superseded and spurious references. Forbes ignores the high prevalence in Australia of sexually transmitted infections (STIs), which male circumcision protects against, including oncogenic human papillomaviruses. Moreover, male circumcision provides similar protection against heterosexual HIV infections in men in low-prevalence settings as those in high-prevalence settings. [1-5] In the United States, infant male circumcision is cost-saving for HIV prevention. [6] In claiming that male circumcision increases HIV risk to women, Forbes, Boyle and Hill cite an outlier study, ignoring a meta-analysis and new data which show that male circumcision reduces the risk of male-to-female transmission. [7, 8] There is no reason to expect that male circumcision would protect a man who engages in receptive anal intercourse, the primary mode of HIV transmission in Australia and the US. Australian data show, however, greater than 90% protection protection against HIV and syphilis in the smaller proportion of homosexual men who are insertive only. [9] While there are few Australian studies of other STIs and male circumcision in heterosexual people, research in the US and elsewhere, including randomised controlled trials (RCTs), shows strong protection. [2,4] Paix argues that circumcision is a “highly mutilating operation which seriously impairs penile function”, while Travis and colleagues assert that circumcision “removes the most sensitive part of the penis”. However, there is now strong research evidence, including RCTs, showing not only no loss of function, satisfaction, sensitivity or sensation, [2] but, in one large RCT, that sexual experience is enhanced by male circumcision. [10] In rejecting male circumcision for HIV prevention, Travis et al and Boyle and Hill present arguments against circumcision repudiated previously by 48 international academic experts. [11] Moreover, in response to Darby, it is well established that condoms are often not in place during sex, whereas male circumcision always is. Also, population- level condom use does not correlate with reduced HIV transmission. [12] Parents have a duty to help prevent renal damage, physical, inflammatory and hygiene problems, STIs and cancers in their sons and their sons’ future sexual partners. They can do this by arranging for their son to be circumcised. The level of risk and severity of such adverse medical conditions in Australia is sufficiently high to support infant male circumcision. Not to do so may have legal ramifications. [13] Chin argues that male circumcision should be delayed until the boy can make up his own mind. He fails to recognise that, as for vaccination, infancy is by far the safest, quickest, cheapest and most convenient time for male circumcision; when performed in infancy, circumcision confers immediate benefits with very limited short and long-term risks. [1-4] While our warning of a future HIV epidemic in Australia unless infant male circumcision is increased is based on a rise in the proportion of new infections attributable to heterosexual sex (from 841 in 2000–2004 [20% of total diagnoses] to 1185 [23%] in 2005–2008), [14] there are currently epidemics of other STIs, many of which could have been prevented by male circumcision. The very low risk and considerable benefits of male circumcision attest to the wisdom of performing the procedure in infancy to maximise individual and public health gains. David A Cooper, Director, National Centre in HIV Epidemiology and Clinical Research, Sydney; Alex D Wodak, Director, Alcohol and Drug Service, St Vincent’s Hospital, Sydney; Brian J Morris, Professor of Molecular Medical Sciences, University of Sydney. 1. Schoen EJ. Circumcision as a lifetime vaccination with many benefits. J Men’s Hlth Gender 2007; 4: 306-311. 2. Morris BJ. Why circumcision is a biomedical imperative for the 21st century. Bioessays 2007; 29: 1147- 1158. 3. Ben KL, Xu JC, Lu L, et al. [Male circumcision is an effective “surgical vaccine” for HIV prevention and reproductive health] [Chinese]. Zhonghua Nan Ke Xue 2009; 15: 395-402. 4. Tobian AA, Gray RH, Quinn TC. Male circumcision for the prevention of acquisition and transmission of sexually transmitted infections: the case for neonatal circumcision. Arch Pediatr Adolesc Med 2010; 164: 78-84. 5. Warner L, Ghanem KG, Newman DR, et al. Male circumcision and risk of HIV infection among heterosexual African American men attending Baltimore sexually transmitted disease clinics. J Infect Dis 2009; 199: 59-65. 6. Sansom SL, Prabhu VS, Hutchinson AB, et al. Cost effectiveness of newborn circumcision in reducing lifetime HIV risk among US males PLoS One 2010; 5: e8723. 7. Weiss HA, Hankins CA, Dickson K. Male circumcision and risk of HIV infection in women: a systematic review and meta-analysis. Lancet Infect Dis 2009; 9: 669-677. 8. Hallett TB, Alsallaq RA, Baeten JM, et al. Will circumcision provide even more protection from HIV to women and men? New estimates of the population impact of circumcision interventions. Sex Transm Infect 2010; Oct 21 [Epub ahead of print]. 9. Templeton DJ, Jin F, Mao L, et al. Circumcision and risk of HIV infection in Australian homosexual men. AIDS 2009; 23: 2347-2351. 10. Krieger JN, Mehta SD, Bailey RC, et al. Adult male circumcision: effects on sexual function and sexual satisfaction in Kisumu, Kenya. J Sex Med 2008; 5: 2610-2622. 11. Wamai RG, Weiss HA, Hankins C, et al. Male circumcision is an efficacious, lasting and cost-effective strategy for combating HIV in high-prevalence AIDS epidemics. Future HIV Ther 2008; 2: 399-405. 12. Slaymaker E. A critique of international indicators of sexual risk behaviour. Sex Transm Infect 2004; 80 Suppl 2: ii13-ii21. 13. Russell T. Non-circumcision a legal risk. Aust Doctor 1996; Sep 20: 57. 14. National Centre in HIV Epidemiology and Clinical Research. HIV/AIDS, viral hepatitis and sexually transmissible infections in Australia: annual surveillance report 2009. <h3>Criticism of the reply</h3> <h2>A feeble argument is not strengthened by adding more weak links to the chain</h2> Cooper, Wodak and Morris were given generous space for their reply (twice as many words as any of their critics), but instead of strengthening their case they have succeeded in weakening it even further. What is most remarkable about their reply is the speed with which they fell into the trap identified in the letter from Dr Robert Darby: evidently fearing that the case for neonatal circumcision as a preventive of heterosexually acquired HIV was not strong enough to stand alone, they have sought to shore it up with numerous other alleged (and far from proven) benefits. Not only will widespread (ideally universal) circumcision save the world from AIDS, it will also protect us from all other sexually transmitted diseases, herpes and cancers caused by wart viruses, not to mention “renal damage”, and all those terrible “inflammatory and hygiene problems” in boys. On top of all that, circumcision will preserve the health of any future sexual partners they may be able to attract and vastly improve their experience of sex. Methinks the lady doth protest too much. It’s the old litany of the “benefits of circumcision” first trotted out by the anti-masturbation crusaders of late Victorian England, brought to perfection by <a href="http://www.historyofcircumcision.net/index.php?option=com_content&task=view&id=62&Itemid=0">Dr Peter Charles Remondino</a> in his History of Circumcision: Moral and Physical Reasons for its Performance (1891), the very chap who invented the illogical and anti-scientific notion of circumcision as a surgical vaccine. The only benefits of circumcision missing from the list are such old favourites of Professor Morris as infallible protection from zipper injury, avoidance of those nasty splashes on the bathroom floor, banishing that terrible foreskin smell, and vastly improved aesthetic appeal (at least to Prof. Morris). Cooper, Wodak and Morris seem determined to make life difficult for themselves. In their original article they only had to prove that: <ul> <li>the incidence of heterosexually transmitted HIV in Australia is rising to a dangerous level, comparable to the epidemics in sub-Saharan Africa;</li> <li>circumcision is the only effective way of countering this challenge;</li> <li>widespread circumcision of infants is the only way of achieving a sufficient circumcision incidence to stave off an HIV epidemic on the African scale.</li> </ul> But after their reply, in addition to this rather tall order, they now also have to prove that circumcision is necessary: <ul> <li>to prevent epidemics of other sexually transmitted diseases;</li> <li>to protect males and females from genital cancers;</li> <li>to prevent renal damage and inflammatory problems (whatever they are);</li> <li>to ensure “hygiene”;</li> <li>to improve everybody’s sex life.</li> </ul> A very tall order indeed, particularly as the most recent comprehensive survey of the benefits of infant circumcision (<a href="https://www.circinfo.org/newsindepth.html#benefit">Perera et al 2010</a>) found the benefits to be minimal or non-existent. It is perfectly obvious that if Cooper, Wodak and Morris have to adduce all these additional benefits, however dubious, they are all too conscious that their original case for boosting neonatal circumcision as the only possible response to an alleged rising incidence of heterosexual transmission of HIV in Australia is too feeble to stand alone. Their original article was limited to asserting that neonatal circumcision was needed to prevent an AIDS epidemic among the heterosexual population, and that the evidence for the protective effect of circumcision was to be found in the three much-vaunted clinical trials in Africa. The proposal stands or falls on the robustness of the African data; whether its is applicable to Australia; whether there is “rising heterosexual transmission of HIV” in Australia, and if so whether the rise is sufficient to justify and demand such a radical, costly and controversial response; whether the African evidence can be extrapolated to a developed country such as Australia, where AIDS is very rarely found among heterosexuals and is a problem almost entirely confined to homosexual sub-cultures; and whether the African evidence justifies circumcision of infants, as opposed to (sexually active) adult men. Cooper, Wodak and Morris make no attempt to address these crucial issues. On top of this failure they make any number of unsubstantiated claims, the most serious of which are (1) their assertion that circumcision must be performed in infancy to provide the necessary protection; (2) their blatant misrepresentation of the statistics on heterosexual HIV infection in Australia; and (3) their snide insinuation that opponents of circumcision are also against vaccination. <h3>Why circumcision in infancy?</h3> There is no evidence that circumcision must be performed in infancy to provide a protective effect against HIV. All the evidence for circumcision having a protective effect comes from circumcision of sexually active adult men in the African clinical trials. If the aim is to forestall a heterosexual AIDS epidemic in Australia, it will be sufficient to ensure that sexually active adult men who plan to enjoy a wide variety of partners and are careless about condoms can choose to get themselves circumcised. And in truth, any adult male in Australia who wishes to get himself circumcised, for this or any other reason, can do so without difficulty or trouble, and get the operation subsidised by Medicare. No further action is needed. Why, then, do our gang of three insist on neonatal circumcision? Quite simply because it is obvious that the vast majority of adult men prefer to hang on to their foreskins and will not be persuaded to submit to circumcision. To force them to do so would be impractical, to bribe them (as in Africa) would be too expensive; and to coerce them (e.g. at gunpoint) would be illegal. But if it is immoral, unethical or illegal to forcibly circumcise an adult male, why is it any less immoral, unethical or illegal to forcibly circumcise an adult-to-be (that is, a child)? Sexual intercourse without consent is rape, and society regards the crime as all the more wicked if the victim is a child; yet it could be argued that circumcision – an irreversible physical disfigurement, as Paix and Chin point out – is a more serious assault than rape. Even if that argument is not accepted, it is clear that if adult men do not wish to get themselves circumcised as a precaution against HIV, it is morally unacceptable to force the operation on children. Fundamentally, Cooper, Wodak and Morris lack faith in their own prescription. If the argument for circumcision as a precaution against heterosexually transmitted HIV was as cogent as they claim, men would be lining up to get it done. That they do not suggests both that the argument is weak and that men are not convinced. Recognising this reluctance, the gang of three fail to propose what is logically suggested by the evidence (circumcision to be available for men at high risk of heterosexually transmitted HIV ), and instead turn their sights on those too young to defend their own interests – children, who are at zero risk of sexually transmitted infections, and who will not be at risk for the foreseeable future, by which time treatment and prevention options, and the virus itself, may well have changed beyond recognition. <h3>Misrepresentation of statistics on HIV infection</h3> For all Cooper et al's assumption of a looming epidemic of heterosexual HIV infection in Australia, the fact is that HIV contracted through unprotected intercourse with an infected female partner (the only avenue of infection of which there is any evidence of circumcision having a protective effect) remains extremely rare here. As the <a href="http://www.nchecr.unsw.edu.au/NCHECRweb.nsf/page/Annual+Surveillance+Reports">2010 surveillance report</a>, issued by the very organisation of which Professor Cooper is director, states: <ul> <li>“the annual number of new HIV diagnoses has remained relatively stable at around 1000 over the past four years”;</li> <li>“HIV continues to be transmitted primarily through sexual contact between men”;</li> <li>“of 1185 cases of HIV infection newly diagnosed in 2005-2009, 58% were in people from high prevalence countries or their partners” - i.e. were not contracted in Australia unless from a partner.</li> </ul> From 1995 to 2005 fewer than 1000 people a year were diagnosed with HIV in Australia [1] and in no year since the beginning of the HIV epidemic has the number of diagnoses of Australian-born men acquired by heterosexual contact ever approached 100. Of the 1001 people diagnosed in total in 2008, 271 were infected by heterosexual contact, of whom 144 were men, of whom in the vicinity of 60 were Australian-born, of whom only a fraction were intact. It is only to this tiny sub-sub-sub-subgroup that circumcision could have afforded some reduction in risk. Had all 5 million Australian-born males in the susceptible age range been circumcised instead of only two thirds [2, 3] (an additional 1.7 million circumcisions) then, based on the hypothetical assumption that circumcision would have reduced infection in that group by 60%, the total number of diagnoses in Australia would have been cut by a measly 2%. Life tables for intact men and circumcised men based on age-specific prevalences of circumcision among Australian-born men [2, 3] current age specific incidence rates of HIV infection by heterosexual contact [4], and the hypothetical assumption that circumcision reduces female-to-male transmission of HIV by 60% show that the estimated lifetime risk for an intact Australian-born man of acquiring HIV by heterosexual contact is less than 1 in 1,000 and that the number of circumcisions required to prevent one infection during a lifetime is greater than 1,800. Contrary to the authors’ contention, circumcising 1,800 babies in 2010, in the hope that it may prevent one HIV infection sometime from 2030 onwards (but only if no progress has been made in reducing the incidence of HIV in the next 20 years, assuming the characteristics of the virus do not change, that it remains as lethal as now, and that treatment methods do not improve), does not make sense. 1. <a href="http://www.avert.org/usa-transmission-gender.htm" rel="noopener" target="_blank">AIDS & HIV statistics by transmission route and gender</a> 2. Smith, A. et al. Australian Study of Health and Relationships Australian and New Zealand Journal of Public Health, Volume 27, Number 2, April 2003 3. Ferris JA, Richters J, Pitts MK, Shelley JM, Simpson JM. Ryall R, Smith AMA. <a href="https://www.circinfo.org/newsindepth.html#nsu">Circumcision in Australia: further evidence on its effects on sexual health and wellbeing</a>, Australian and New Zealand Journal of Public Health, 34:2, pp160-4 4. <a href="http://www.nchecr.unsw.edu.au/NCHECRweb.nsf/page/HIV-AIDS-Datasets">Australian Public Access Datasets</a> on newly diagnosed HIV infection and AIDS This is not the only area where Coooper, Wodak and Morris have misrepresented or misunderstood the data. In their original article they also made misleading claims as to the recommendations made by the World Health Organisation on circumcision as a tactic for AIDS control in Africa, and also about the incidence of circumcision in Australia. <h3>Misrepresentation of WHO recommendations on circumcision</h3> In their original paper Cooper et al state: “The protection conferred to heterosexual males by circumcision is similar in hyperendemic and low-prevalence settings (refs. 3-5).” This is untrue, and shown to be untrue by their own references. Reference 3 states: “Male circumcision, together with other prevention interventions, could play an important role in HIV prevention in settings similar to those of the clinical trials.” (http://www.cdc.gov/hiv/resources/factsheets/circumcision.htm) That is, it is not recommended in countries with low HIV prevalence such as Australia. Reference 4 states: “Together, these three trials provided strong evidence that MC can significantly reduce men’s risk of acquiring HIV infection in the contexts in which the trials were conducted.” (Public Health Rep 2010; 125 Suppl 1: 72-82) Reference 5 is to Morris BJ. Why circumcision is a biomedical imperative for the 21st century. Bioessays 2007; 29: 1147-1158. This is simply an opinion piece by one of the authors of the article under consideration. The one reference in this that might bear on the issue proves to be to yet another opinion piece by the same author. No researchers have published any results of clinical trials of male circumcision outside Africa, and very limited observational data exist on the association between circumcision status and HIV infection among men – but much of what does exist shows that circumcision is of no benefit at all. Mor et al.’s study of nearly 58,000 men attending San Francisco's STD clinics found “no significant differences between circumcision status and the risk of HIV or syphilis infection” in either men who have sex with men or heterosexual men. [5] The claim that circumcision prevents heterosexual HIV transmission from women to men is based on three non-double-blinded, non-placebo-controlled Randomised Controlled Trials in Africa [6,7,8] in which a total of 5,400 men were circumcised, all called off after less than two years, at which time a total of 64 of the men in the circumcised experimental groups had HIV, compared to 137 in the non-circumcised control groups. 673 men in total were lost from those trials, their HIV status unknown. But even granting that those trials proved that circumcision grants “60% reduction” in female-to-male heterosexual HIV transmission (the most widely quoted figure, even though the Cochrane Review estimates it as between 38 and 64 per cent, and we have no idea as to that the risk reduction in Australia, if any, might be), a case for widespread neonatal circumcision does not follow. 5. Mor Z, Kent CK, Kohn RP, Klausner JD (2007) Declining Rates in Male Circumcision amidst Increasing Evidence of its Public Health Benefit. PLoS ONE 2(9): e861. doi:10.1371/journal.pone.0000861 6. 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:e298. 7. 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. 8. Gray RH, Kigozi G, Serwadda D, Makumbi F, Watya S, et al. 2007. Male ircumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet 369:657-666. <h3>Misrepresentation of statistics on the incidence of circumcision in Australia</h3> Cooper, Wodak and Morris claim: “Despite official discouragement, Medicare statistics show a rise in the rate of infant male circumcision in Australia from 13% in 1998 to 19% in 2009.” In fact, the national rate of infant male circumcision, based on Medicare claims statistics [9] and births data published by the Australian Bureau of Statistics [10], has not exceeded 13% at any time during the period for which Medicare statistics are available on-line (July 1993 to the present). Since public hospitals in most states do not provide non-therapeutic circumcisions, the total number of infant circumcisions has probably gone down, but this would not have been reflected in Medicare statistics (except perhaps by a rise in the number of claims on Medicare). It is therefore likely that the decline in the real rate of infant circumcision that began some 40 years ago has continued in recent years. Certainly, the rate fell sharply in Tasmania and Northern Territory several years ago, has recently fallen substantially in Queensland, and is well below 10% in the majority of states and territories. A charitable explanation is not that Cooper et al are statistically illiterate, but that they have confused figures for New South Wales with figures for the nation as a whole. It is apparent that there is a gaggle of circumcision promoters centred around Professor Morris in Sydney, and that they are having an effect on the incidence of circumcision in that state. Elsewhere, however, respect for the principles of evidence-based medicine and medical ethics take precedence over their emotion-driven hatred of normal human anatomy. 9. https://www.medicareaustralia.gov.au/statistics/mbs_item.shtml 10. <a href="http://www.abs.gov.au/">Australian Bureau of Statistics</a> <h3>Circumcision and vaccination</h3> Perhaps the most scandalous gambit in the Cooper et al reply to critics is their insinuation that opponents of circumcision as a tactic against HIV control in Australia are also against vaccination. This allegation is unfounded and untrue: no prominent critic of circumcision has ever attacked vaccination, nor did any of the letters to which Cooper et al were responding. There may be some individuals among the general public who are opposed to both circumcision and vaccination, but most critics of circumcision, both within the medical profession (such as the Royal Australasian College of Physicians in its recent policy statement) and among the informed public (<a href="https://www.circinfo.org/controversy.html#vacci">such as this website</a>) are not merely not opposed to vaccination, but fully support it as a valid instance of preventive, evidence-based medicine. Circumcision promoters seem unable to grasp the fundamental difference between amputating body parts to provide limited protection against a rare disease to which the individual is unlikely to be exposed, and giving a person a needle that confers a high level of immunity to common or contagious diseases. The justification for vaccination of non-consenting children is that the diseases to which it confers immunity are common and/or highly contagious. Airborne diseases, such as smallpox, diphtheria, measles and scarlet fever were all major killers before vaccines were developed. Edward Jenner’s vaccine against smallpox was one of the few preventive health success stories of the nineteenth century. Because such diseases are spread by breathing, one person can quickly infect many others: a single child can infect a class or a whole school, just by being there. Vaccination thus protects both the individual who receives the treatment and the people with whom he comes into contact. Unlike these diseases, HIV is a low-virulence disease. It is very difficult to pass on a disease that is spread by bodily fluids such as blood and sperm, which must enter the bloodstream of the other person before they can do any harm. No matter how much close social interaction with other people there is, there is no risk that an HIV-positive person can pass on the virus to anybody else – unless he or she has unprotected sexual intercourse or otherwise transfers bodily fluids into the other person’s system. Even in cases of unprotected intercourse, the risk of infection is quite low – estimated at rather less than 10 per cent. Quite apart from the vital matter of disfigurement, the justification for vaccination against highly contagious diseases simply does not apply to HIV-AIDS. It is actually quite hypocritical for Cooper, Wodak and Morris to attack critics of circumcision by suggesting that they are anti-vaccination. Morris himself is on record as disparaging the vaccine (Gardasil) recently developed to protect women against varieties of human papilloma virus that cause <a href="https://www.circinfo.org/cervical.html">cervical cancer.</a> So let’s have no more of this anti-scientific nonsense. Circumcision is amputation of a prominent, functional body part that causes injury, loss and harm for a merely speculative gain. Vaccination is a harmless pinprick that strengthens the body’s natural defence mechanisms and confers a high level of immunity against contagious diseases. </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: the case against circumcision 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"> In this paper, French demographer and reproductive health expert Michel Garenne 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. <h2>Mass Campaigns of Male Circumcision for HIV Control in Africa:</h2> <h3>Clinical Efficacy, Population Effectiveness, Political Issues</h3> 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. Keywords: Male circumcision; HIV/AIDS; Clinical efficacy; Population effectiveness; Randomized controlled trials; Ecological studies; Sub-Saharan Africa <h3>Introduction</h3> In the study of the impact of public health interventions, two types of evidence can be opposed: the measure of “clinical efficacy,” or “biological effect,” shown in general by clinical trials or epidemiologic studies, and the measure of “population effectiveness,” or “demographic impact,” shown by their effect in large populations or by comparison between populations. Clinical trials aim primarily at demonstrating a biological effect, but they do not guarantee a large demographic impact. Conversely, a demographic impact is sometimes observed even when clinical trials tend to indicate a low effect. When clinical efficacy is very high (say above 95%), the population impact is usually marked, and close to what can be expected from clinical trials. When clinical efficacy is moderate (say around 50%), the population impact is often small, when not negligible. In rare studies, one also finds cases of population impact despite low clinical efficacy. Let us give a few examples in the field of vaccines. The measles vaccine has a very high clinical efficacy, considered to be above 95%. This has been shown repeatedly in numerous randomized clinical trials all over the world, and similar values are found in case control studies (Redd et al., 1999). The measles vaccine is also an “efficient” vaccine: when administered on a large scale, not only does it protect those who received it, but it also tends to reduce the transmission, and even to stop epidemics through herd immunity. Measles was virtually eradicated from the United States in the early 1980s by mass vaccination campaigns, and came back only because it was re-introduced from foreign countries (Wood and Brunell, 1995). The cholera vaccine has an efficacy of about 50% in clinical trials, but has virtually no demographic impact: it does not stop epidemics, and its protection is short lasting (Tacket and Sack, 2008). This is why it is not recommended in public health programs. The pertussis vaccine (whooping cough) is a vaccine that has a very low efficacy in clinical trials, and has been shown to provide no protection against infection by the germ (Bordetella pertussis). However, it has a very large population effect, stopping epidemics and protecting individuals against the severe forms of the diseases, and its population effectiveness is close to that of the measles vaccine (Edwards and Decker, 2008; Pollard, 1980). This is why it is used in most vaccination programs, and it is part of the Expanded Program on Immunization recommended by the World Health Organization. Similar comparisons can be made in the field of contraception, an issue more closely related to the control of sexually transmitted infections (STIs). The hormonal contraceptives (pill, injectables, implants) or the barrier methods, such as the Intra-Uterine-Device (IUD), have a very high efficacy in clinical trials, usually above 99%. They also have very high population effectiveness: women who use them properly have no unwanted pregnancy, and populations who use them on a large scale have a low fertility, close to that desired by couples. On the contrary, the Rhythm Method (Knauss-Ogino Method), which is based on very sound biological evidence and has a moderate efficacy in clinical trials (around 50%), has virtually no population effect nor any individual effect: women who use it tend to become pregnant sooner or later, and no country was able to control its fertility only with this method (Labbok and Queenan, 1989). Its only visible effect is a lengthening of birth intervals, which does not permit to bring fertility from 7 or 8 children to 2 children, as do very effective methods. The withdrawal method (coitus interruptus) will never be investigated in clinical trials since it involves primarily a very personal behavior, but was shown empirically to have a major population impact since this was the most common method to control fertility in Europe before 1950. The case of efficacy and effectiveness of male circumcision for controlling HIV transmission bears some similarity with that of the rhythm method to control fertility. In a series of recent clinical trials, male circumcision was found to have an average clinical efficacy against HIV transmission (Auvert et al., 2005; Bailey et al., 2007; Gray et al., 2007). Is this enough to make recommendations for general use? Beyond clinical efficacy and demographic impact, are there not other issues related with such a practice? In this paper, we will focus on a lack of evidence showing a demographic impact of male circumcision on the HIV epidemics in sub-Saharan Africa, the continent most hard hit by the disease. We also address briefly some of the ethical issues raised by the recommendation for male circumcision (WHO/UNAIDS, 2007), viewed from an international health perspective. <h3>Methods</h3> In order to investigate the population impact of male circumcision, we will use several comparisons: <ul> <li>comparing population groups that are circumcised and not circumcised in the same country, which assumes comparable exposure to the disease (prevalence or incidence);</li> <li>comparing sub-groups known to have different risks, in the same way;</li> <li>comparing countries that are practicing or not practicing circumcision.</li> </ul> There are serious caveats involved in these comparisons. In Africa, sub-groups practicing—or not practicing—male circumcision are usually defined by ethnicity or religion, sometimes associated with social status or urban residence, and may not be comparable in terms of exposure, since they have different value systems, different marriage patterns, and different sexual behaviors. The case is even worse for country comparisons, where many other factors could bias the comparisons, and we will see some examples later. Nevertheless, when a public health intervention is very efficient, its demographic impact is largely independent of any social variable, such as social status, religion, or ethnicity. There are many examples in the literature, and they apply similarly to the fields of vaccination, contraception, or medical treatments. The effect of vaccines, hormonal contraceptives, antibiotics, anti-malarial drugs, etc., is basically the same in all countries in the world, and their population effect is simply proportional to the population coverage. Therefore, when there is no visible demographic impact, one can seriously question the usefulness of a public health intervention. <h3>Results</h3> HIV Prevalence and Proportion Circumcised at National Level The first comparison deals with HIV prevalence between circumcised and intact men in generalized epidemics, some 20–25 years after the onset of the HIV epidemic, that is the situation in years 2002–2007. It measures basically a net effect of circumcision, before changing behavior (condom use, reducing number of partners) really took off and changed the ecological correlations. The data are drawn from the Demographic and Health Surveys (DHS), which are large scale surveys based on representative samples of African populations [all available on the DHS website], and on a similar survey conducted in South Africa, not part of the DHS program (South Africa, 2002). For a statistician, this is the best scenario for testing a potential demographic impact, since the surveys display at the same time the HIV serologic status and the circumcision status for men aged 15–49 or 15–59 years. A first analysis was done a few years ago, and published in 2008 in the African Journal of AIDS Research (Garenne, 2006, 2008). The data were updated with more recent surveys (Congo, Zambia, South Africa), so that 18 countries’ surveys are now included, covering about 55% of the population of sub-Saharan Africa. Table 4.1 HIV seroprevalence by circumcision status in African countries <table class="table100pc" summary="HIV seroprevalence by circumcision status in African countries"> <tbody> <tr> <th class="lightblue"> </th> <th class="lightblue">Percent</th> <th class="lightblue" colspan="2">Percent HIV+</th> <th class="lightblue" colspan="2">Ratio circumcised/intact</th> </tr> <tr> <th class="lightblue">Country</th> <th class="lightblue" width="15%">Circumcised</th> <th class="lightblue" width="15%">Circumcised</th> <th class="lightblue" width="15%">Intact</th> <th class="lightblue" width="15%">RR</th> <th class="lightblue" width="15%">Significance</th> </tr> <tr> <td class="grey">Burkina Faso</td> <td class="grey">89.7</td> <td class="grey">1.8</td> <td class="grey">2.9</td> <td class="grey">0.62</td> <td class="grey">NS</td> </tr> <tr> <td>Cameroon</td> <td>91.8</td> <td>4.1</td> <td>1.1</td> <td>3.73</td> <td>∗</td> </tr> <tr> <td class="grey">Côte d’Ivoire</td> <td class="grey">96.0</td> <td class="grey">2.8</td> <td class="grey">3.8</td> <td class="grey">0.74</td> <td class="grey">NS</td> </tr> <tr> <td>Congo Kinshasa</td> <td>97.7</td> <td>1.0</td> <td>0.0</td> <td>1.00</td> <td>NS</td> </tr> <tr> <td class="grey">Ethiopia</td> <td class="grey">92.3</td> <td class="grey">0.9</td> <td class="grey">1.1</td> <td class="grey">0.82</td> <td class="grey">NS</td> </tr> <tr> <td>Ghana</td> <td>95.3</td> <td>1.6</td> <td>1.4</td> <td>1.14</td> <td>NS</td> </tr> <tr> <td class="grey">Kenya</td> <td class="grey">83.4</td> <td class="grey">3.0</td> <td class="grey">12.6</td> <td class="grey">0.24</td> <td class="grey">∗</td> </tr> <tr> <td>Lesotho</td> <td>48.6</td> <td>22.8</td> <td>15.2</td> <td>1.50</td> <td>∗</td> </tr> <tr> <td class="grey">Liberia</td> <td class="grey">97.8</td> <td class="grey">1.1</td> <td class="grey">0.0</td> <td class="grey">1.00</td> <td class="grey">NS</td> </tr> <tr> <td>Malawi</td> <td>20.7</td> <td>13.2</td> <td>9.5</td> <td>1.39</td> <td>∗</td> </tr> <tr> <td class="grey">Niger</td> <td class="grey">99.5</td> <td class="grey">1.0</td> <td class="grey">0.0</td> <td class="grey">1.00</td> <td class="grey">NS</td> </tr> <tr> <td>Rwanda</td> <td>11.1</td> <td>3.5</td> <td>2.1</td> <td>1.67</td> <td>NS</td> </tr> <tr> <td class="grey">South Africa</td> <td class="grey">35.3</td> <td class="grey">12.3</td> <td class="grey">12.0</td> <td class="grey">1.03</td> <td class="grey">NS</td> </tr> <tr> <td>Swaziland</td> <td>8.2</td> <td>21.8</td> <td>19.5</td> <td>1.12</td> <td>NS</td> </tr> <tr> <td class="grey">Tanzania</td> <td class="grey">69.7</td> <td class="grey">6.5</td> <td class="grey">5.6</td> <td class="grey">1.16</td> <td class="grey">NS</td> </tr> <tr> <td>Uganda</td> <td>24.9</td> <td>3.8</td> <td>5.6</td> <td>0.68</td> <td>∗</td> </tr> <tr> <td class="grey">Zambia</td> <td class="grey">12.5</td> <td class="grey">10.8</td> <td class="grey">12.5</td> <td class="grey">0.86</td> <td class="grey">NS</td> </tr> <tr> <td>Zimbabwe</td> <td>10.5</td> <td>16.6</td> <td>14.2</td> <td>1.17</td> <td>NS</td> </tr> <tr> <td class="grey">Meta-analysis</td> <td class="grey"> </td> <td class="grey"> </td> <td class="grey"> </td> <td class="grey">1.00</td> <td class="grey">NS</td> </tr> </tbody> </table> Results show no effect of male circumcision in national African populations: the standardized odds-ratio was 1.00 (95% CI: 0.96–1.05), which means that, on the average, circumcised and intact men have the same HIV prevalence (Table 4.1). Out of the 18 countries studied, 12 have an odds ratio equal or higher than one (more HIV among circumcised men), 3 of them statistically significant (Cameroon, Lesotho, Malawi), and 6 have an odds ratio lower than one (less HIV among circumcised men), 2 of them statistically significant (Kenya and Uganda). Note that these results are based on large numbers: some 73,800 men sampled, who are representative of the general population. This is the most reliable evidence that we have on the population impact of male circumcision in Africa. Case Studies Let us give a closer look at a few selected countries, for which, contrary to expectations, the risk ratio of HIV prevalence (circumcised/intact) is higher than 1. In Tanzania, HIV prevalence is moderate, with some 6.3% of men infected. The epidemic has been going on for about 25 years, since the western part of the country is close to the epicenter of the epidemic, located around Lake Victoria. There are some 110 ethnic groups recorded in Tanzania, some 70% practicing male circumcision. This is a quasi-experimental situation. In Tanzania, HIV prevalence is higher among the circumcised groups (6.5% versus 5.6%). This is due in part to a correlation with urbanization: urban areas are at the same time more circumcised and have more HIV. But even if one controls for urbanization, the HIV prevalence is the same in the two groups: 9.7 and 9.5% in urban areas; 5.2 and 4.6% in rural areas, none of these differences being significant (Tanzania, 2005). Lesotho is a tiny country embedded in South Africa. The main feature of Lesotho is its ethnic homogeneity, all people belonging to the same group: the Southern Sotho. The country has been exposed for about 15 years to HIV, and prevalence is very high, with 19.3% of adult men infected. About half of the men are circumcised, which is again a quasi-experimental situation, almost ideal given the homogeneity of the ethnic composition. Here again, the profile of HIV prevalence is contrary to expectations: circumcised men are more infected by HIV: 22.8% versus 15.2% for intact men, and this is true in both urban (28.6% versus 17.3%) and rural areas (21.8% versus 14.5%), in the various ecological zones, and for various measures of social status (Lesotho, 2005). Malawi is a country located in South-Eastern Africa. Malawi has a rather high prevalence, with about 10% men infected, and the epidemic has been going on for about 20 years. Malawi is characterized by a strong dichotomy between North and South, and the dozen of ethnic groups recorded have major differences in demographic profiles and sexual behavior. The North is less circumcised and has less HIV, whereas the South is more circumcised and has more HIV, again contrary to expectations. As was the case in other countries, controlling for urbanization does not change the main picture: more HIV among the circumcised men. Ironically, when stratified by region, the relationship between circumcision and HIV prevalence is inverted: the more circumcised in a region, the higher is the seroprevalence (Malawi, 2005). A recent publication, based on a 2002 survey, also showed a similar pattern in South Africa, where about a third of the population is circumcised and HIV prevalence amongst the highest on record: there was no difference in HIV prevalence in 2002 between the two groups, even after controlling for a variety of factors (Connolly et al., 2008). HIV Incidence, and Dynamics of the HIV Epidemic in South Africa Some authors have argued that male circumcision could change the dynamics of the epidemic by strongly reducing incidence and the net reproduction rate (Ro). This is not the case in South Africa, the only country where one can pursue this type of analysis, because routine HIV prevalence is recorded every year and published over a long period of time. South Africa also has a useful feature for analysis: about one third of men are circumcised; circumcision is primarily ethnic specific, and provinces are also largely ethnic specific. So, by comparing the dynamics of the HIV epidemic by province, one may infer the effect (or lack thereof) of circumcision in the general population. The nine provinces were classified into three groups: low, medium and high level of circumcision. Two indicators of the dynamics of the epidemic were computed: the average incidence between 1994 and 2004, and an estimate of the net reproduction rate of the epidemic between 1994 and 2004. Results again show no clear relationship between the prevalence of male circumcision and the prevalence of HIV: differences in incidence were small: 2.0, 2.5, 2.1%, and differences in net reproduction rates were even in the opposite order: higher in provinces with high level of circumcision than in those with low level (see details in Garenne, 2008). If one compares two contrasted provinces: one with no circumcision, the North-West province, populated by Tswana, and one with widespread circumcision, the Eastern Cape province, populated by Xhosa, one finds no difference in the dynamics of the epidemic from 1994 to 2004, and levels of seroprevalence were basically the same in 2004. In conclusion, large-scale demographic surveys, as well as routine seroprevalence surveys among pregnant women, do not show any consistent population impact of male circumcision on either HIV prevalence or HIV incidence. Male circumcision does not appear to be the “Magic Bullet” presented by other researchers and based on results from clinical trials. Other Evidence of a Lack of Demographic Impact These findings are not really new, and could have been anticipated. Robert Van Howe conducted a large scale meta-analysis of the effect of male circumcision on HIV and other STIs in many risk groups, and found no protective effect. He even found a small increased risk in his meta-analyses (Van Howe, 1999a, b). Comparing the United States, where male circumcision is widespread, to Europe where it is rare, also goes rather in the opposite direction: more HIV in the former, and even more HIV transmitted heterosexually if one excludes cases imported from Africa in Europe. Even in the USA, the African-American population is more circumcised than average, and it is also more affected by HIV (Siegfried et al., 2007). Let us also remember that, in Africa, about 70% of men are already circumcised, probably the highest rate in any continent: this did not hamper Africa to host the largest epidemic in any continent. A quick comparison with Eastern Asia (China, Japan) where virtually no men are circumcised and where HIV prevalence is extremely low is illuminating: the correlation goes in the opposite direction— the less circumcision, the less HIV prevalence. In contrast, when one makes similar comparisons with vaccination coverage for diseases or with contraceptive use for fertility, one finds the expected correlations. Controversy About Geographical Correlations Several studies conducted in the 1980s argued that African countries more affected by HIV were also less circumcised (Bongaarts et al., 1989; Moses et al., 1990; Weiss et al., 2000). This has been confirmed by recent population based studies, but is obviously correlated with other important confounding factors affecting sexual behavior, in particular, religion: Islam recommends male circumcision, but is very much opposed to any form of premarital and extramarital intercourse for women, therefore strongly reducing the risk of sexual transmission of diseases. In another paper, we argued that HIV was more closely related with marriage pattern and permissiveness, both being measured simultaneously by premarital fertility (having a birth prior to first marriage). The map displaying premarital fertility levels is in fact close to the map of HIV prevalence levels, revealing the other confounding factors (Zwang and Garenne, 2008). Therefore, the ecological correlation between HIV prevalence and male circumcision appears misleading, and seems to reflect primarily other determinants of HIV spread. However, one should note that no country for which we have reliable data where male circumcision is widespread (>85% circumcised), including non-Muslim countries, such as Congo-Kinshasa, had a high level of seroprevalence (>5% among adults 15–49). This fact has never been properly explained, and deserves more research. In summary, whatever the correlations, one has to remember that even a country half circumcised, such as Lesotho, can have a very large epidemic, with levels of seroprevalence close to the highest on record. This seems to give a far better picture of what could be the potential impact of mass circumcision campaigns: basically negligible in generalized epidemics. Population Impact Versus Clinical Efficacy The difference between the effect of male circumcision in clinical trials and the lack of any significant demographic effect may seem puzzling at first glance. The main reason seems to be the low level of clinical efficacy: a 50% reduction in risk is likely to have only a small demographic effect. Indeed, under repeated exposure, any circumcised man will eventually become infected, as will intact men. Circumcision does not really provide any protection, but simply reduces the risk at each exposure. This may delay the time to infection, but will rarely change the ultimate outcome, a situation similar to the effect of the rhythm method for contraception. The potential effect of mass circumcision campaigns will lead only to a very small impact, which will be buried into the many other factors of HIV transmission. If male circumcision had a 99% protective efficacy, the situation would have been different. <h3>Discussion</h3> Rationale for Making Public Health Policies Let us ask now a simple question, based on the findings of the clinical trials: is a 50% reduction in risk enough to make a policy? The answer is clearly no. For instance, if one compares with the field of contraception: the rhythm method is also 50% efficient in clinical trials, but is not recommended, because there are much better strategies available for birth control. Likewise, the cholera vaccine is also 50% efficient in clinical trials, but is not recommended, because there are much better strategies available for controlling cholera. There are also better alternative strategies to control HIV, summarized under the acronym “ABC” (for Abstinence, Be faithful, Condom use), which have worked in Africa and elsewhere: changing risky behavior worked well, for instance, in Uganda (Low-Beer, 2002; Low-Beer and Stoneburner, 2003), and condom use worked extremely well in Thailand (Brown et al., 1994). We do not have a full account of what has been happening in Africa since year 2000, but in almost all countries for which data are available, prevalence and incidence among young adults have been going down over the past 10 years, as a result of changing behavior. These ABC strategies seem to be able to change the course of the HIV epidemics. On the other hand, no country has ever been able to control an STI with male circumcision only. Let us remember the case of Japan: this country has among the lowest rates of HIV and of any STI, and makes a very wide use of condoms. This seems to be a far better strategy for controlling sexually transmitted infections. Ethical Considerations This paper focuses on the lack of demographic impact to be expected from male circumcision. Of course, there are many other dangers associated with mass circumcision campaigns. Firstly, at population level, shifting from ABC strategies, which, from experience, are the most likely to change the course of the epidemic to a strategy that has no chance of doing so, seems to be a serious mistake. Secondly, at the individual level, giving the impression that male circumcision “protects” against HIV transmission may have adverse effects: by giving a false sense of protection, it may induce riskier behaviors, and ultimately increase transmission. In this case, it will also have negative effects on the confidence that individuals have in the health system and in health education messages. Ultimate Rationale of Male Circumcision Male circumcision is a form of genital mutilation with numerous implications, amply documented in this book and in the ten international symposia organized over the past 20 years. This in itself raises many ethical issues, widely documented elsewhere (Aggleton, 2007; Doctors Opposing (male) Circumcision, 2006; Clark, 2006). Beyond individual cases when it is recommended for medical reasons, at population level male circumcision appears as a form of power abuse, especially when made compulsory, or at least strongly recommended. It is especially questionable when used on infants, children, or adolescents since it violates their rights, but is also questionable when recommended for consenting adults. Numerous studies have highlighted the stakes behind this practice. For traditional societies, where circumcision is compulsory for adolescents, the power abuse comes from the elders. This is best expressed by Margaret Mead (1949), who had such a powerful insight on male circumcision. In her famous book, Male and Female, she says: in South America, in Africa and in the South Seas, there are tribes in which the old men’s antagonism to the springing sexuality of the young induces fears that are later reduced in pantomine, cruel initiatory rites in which the young men are circumcised, their teeth knocked out, and, in various ways they are reduced and modified and humbled, and then permitted to be men. When religious leaders recommend circumcision for newborns or young boys, the power abuse comes from religious hierarchy and applies to the whole society: by requesting the parents to accept the circumcision of their sons, the religious establishment ensures its power over the whole family. Robert Darby (2005) in his book, A Surgical Temptation, showed that the development of male circumcision for newborn infants in Victorian England is also a form of power abuse, this time coming from the medical establishment over the families. This came at a time when the political power of physicians and surgeons in society increased dramatically, and a new form of “biopower” emerged. The question that can be raised now is whether recommending mass circumcision campaigns for Africans, in the absence of clear evidence of any demographic impact, is not a new form of power abuse, this time from newly established groups: international institutions and lobbies? This question certainly deserves further comments and in-depth discussions. <h3>References</h3> Aggleton P. (2007) Just a snip? A social history of male circumcision. Reprod Health Matters. 15(29):15–21. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. (2005) Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: The ANRS 1265 trial. PLOS Med. 2(11):e298, 1–111. Bailey RC, Moses S, Parker CB, Agot K, MacLean I, Krieger JN, Willams CFM, Campbell RT, Nidnya-Achola JO. (2007) Male circumcision for HIV prevention in young men in Kisumu, Kenya: A randomised controlled trial. Lancet. 369:643–656. Bongaarts J, Reining P, Way P, Conant F. (1989) The relationship between male circumcision and HIV infection in African populations. AIDS. 3(6):373–377. Brown T, Sittitrai W, Vanichseni S, Thisyakorn U. (1994) The recent epidemiology of HIV and AIDS in Thailand. AIDS. 8(Suppl 2):S131–S141. Clark PA. (2006) To circumcise or not to circumcise? Health Prog. 87(5):1–9. Connolly C, Simbayi LC, Shanmugam R, Nqeketo A. (2008) Male circumcision and its relationship to HIV infection in South Africa: Results of a national survey in 2002. S Afr Med J. 98(10):789–794. Darby R. (2005) A Surgical Temptation: The Demonization of the Foreskin and the Rise of Circumcision in Britain. Chicago, IL: University of Chicago Press. Demographic and Health Surveys. Web site: www.measuredhs.com Doctors opposing male circumcision. (2006) Medical Ethics and the Circumcision of Children. Report, 2006. Available on web site: http://www.doctorsopposingcircumcision.org/pdf/A4-medicalEthicsReport.pdf Edwards K, Decker M. (2008) Cholera vaccine. In: Plotkin SA, Orenstein WA. (eds.) Vaccines. Philadelphia, PA: Elsevier-Saunders. Garenne M. (2006) Male circumcision and HIV control in Africa. PLoS Med. 3(1):e78.[Letter] Garenne M. (2008) Long-term population effect of male circumcision in generalized HIV epidemics in sub-Saharan Africa. Afr J AIDS Res. 7(1):1–8. Gray RH, Kigozi G, Serwadda D, Makumbi F, Watya S, Nalugoda F, Kiwanuka N, Moulton LH, Chaudhary MA, ChenMZ, Sewankambo NK,Wabwire-Mangen F, BaconMC,Williams CFM, Opendi P, Reynolds SJ, Laeyendecker O, Quinn TC, Waver MJ. (2007) Male circumcision for HIV prevention in men in Rakai, Uganda: A randomised controlled trial. Lancet. 369:657–666. Labbok MH, Queenan JT. (1989) The use of periodic abstinence for family planning. Clin Obstet Gynecol. 32(2):387–402. Lesotho – Ministry of Health and SocialWelfare (MOHSW), Bureau of Statistics (BOS), and ORC Macro. (2005) Lesotho Demographic and Health Survey 2004. Calverton, NY:MOH, BOS, and ORC Macro. Low-Beer D. (2002) HIV incidence and prevalence trends in Uganda. Lancet. 360(9347):1788. Low-Beer D, Stoneburner RL. (2003) Behaviour and communication change in reducing HIV: Is Uganda unique? Afr J AIDS Res. 1(2):9–21. Malawi – National Statistical Office (NSO), and ORC Macro. (2005) Malawi Demographic and Health Survey 2004. Calverton, NY: NSO and ORC Macro. Mead M. (1949) Male and Female: A Study of the Sexes in a Changing World. New York, NY: [Reprinted by Harper-Collins, 2002]. Moses S, Bradley JE et al. (1990) Geographical patterns of male circumcision practices in Africa. Int J Epidemiol. 19(3):693–697. Pollard R. (1980) Relation between vaccination and notification rates for whooping cough in England and Wales. Lancet. 1(8179):1180–1182. Redd SC, Markowitz LE, Katz SL. (1999) Measles vaccine. In: Plotkin SA, Orenstein WA. (eds.) Vaccines. Philadelphia, PA: W.B. Saunders, pp 222–266. Tacket C, Sack D. (2008) Cholera vaccine. In: Plotkin SA, Orenstein WA. (eds.) Vaccines. Philadelphia, PA: Elsevier-Saunders. Siegfried N, Muller M, Volmink J, Deeks J, Egger M, Low N, Weiss H, Wlaker S, Williamson P. (2007) Male circumcision for prevention of heterosexual acquisition of HIV in men (Review). The Cochrane Library. South Africa. (2002) The Nelson Mandela/HSRC study of HIV/AIDS, 2002. Human Science Research Council, Cape Town, South Africa. [available on web site: www.hsrcpress.ac.za] Tanzania – Commission for AIDS (TACAIDS), National Bureau of Statistics (NBS), and ORC Macro. (2005) Tanzania HIV/AIDS Indicator Survey 2003–2004. Calverton, NY: TACAIDS, NBS, and ORC Macro. Van Howe RS. (1999a) Does circumcision influence sexually transmitted diseases? A literature review. BJU Int. 83(Supp 1):52–62. Van Howe RS. (1999b) Circumcision and HIV infection: Review of the literature and metaanalysis. Int J STD AIDS. 10:8–16. Weiss HA, Quigley MA, Hayes RK. (2000) Male circumcision and risk of HIV infection in sub-Saharan Africa: A systematic review and meta-analysis. AIDS. 174:2361–2370. Wood DL, Brunell PA. (1995) Measles control in the United States: Problems of the past and challenges for the future. Clin Microbiol Rev. 8(2):260–267. WHO/UNAIDS. (2007) Recommendations from expert consultation on male circumcision for HIV prevention. Available at: http://www.who.int/hiv/mediacentre/news68/en/index.html Zwang J, Garenne M. (2008) Premarital fertility and HIV/AIDS in Africa. Afr J Reprod Health. 12(1):64–74. Michel Garenne, Mass Campaigns of Male Circumcision for HIV Control in Africa: Clinical Efficacy, Population Effectiveness, Political Issues, in George C. Denniston, Frederick M. Hodges and Marilyn Fayre Milos (eds), Genital Autonomy: Protecting Personal Choice (Dordrecht, Heidelberg, London, New York: Springer, 2010; ISBN 978-90-481-9445-2 e-ISBN 978-90-481-9446-9) Professor Garenne is a demographer and reproductive health expert with the IRD (French Institute for Research and Development) and Institut Pasteur, Paris, France; e-mail: <a class="__cf_email__" data-cfemail="39545e584b5c57575c7951564d54585055175a5654" href="/cdn-cgi/l/email-protection">[email protected]</a> The book may be purchased <a href="https://www.amazon.com/Genital-Autonomy-Protecting-Personal-Choice/dp/9048194458/ref=pd_rhf_p_t_1">from Amazon</a>. Individual chapters may be bought and downloaded from <a href="http://www.springerlink.com/content/978-90-481-9445-2#section=758210&page=1&locus=0">the publishers, SpringerLink</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 HIV/AIDS: randomised control trials and the real world 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"> <h2>New book throws doubt on circumcision as a useful strategy against AIDS in Africa</h2> <a href="http://www.cirp.org/library/disease/HIV/gisselquist1/gisselquist1.pdf">David Gisselquist and several colleagues</a> have long been critical of the proposition that nearly all HIV cases in Africa and other underdeveloped countries are spread by sexual contact. On the contrary, they have argued that at least a third of new HIV infections are the result of unsafe medical procedures, such as unsterilised needles or scalpels, and contaminated blood supplies. These arguments have not been accepted by the AIDS industry - at least not in relation to men. Western agencies seem to have had no trouble acknowledging that non-sterile procedures such as genital cutting spread AIDS and other infections when performed on women. It is not clear why female circumcision should thus be acknowledged as a potential source of transmission and male circumcision ignored - until you appreciate that the agencies want to stop circumcision of women but promote circumcision of men and boys. This is the well-known double standard by which circumcision of women is known as female genital mutilation while male genital mutilation continues to be downplayed as circumcision. In his intriguing new book, David Gisselquist exposes the unsafe health care system as a significant factor in HIV transmission in Africa and other regions with generalized HIV epidemics. While he spends little time discussing the issue of circumcision directly, his book is another nail in the coffin for the theory that promoting circumcision will significantly reduce HIV infections. According to Gisselquist's evidence, the introduction of more health care services, in the form of mass circumcisions, is more likely to place Africans at greater risk of HIV. Health care practices are simply too unsafe to cope with the existing surgical burden, let alone a massive increase. Gisselquist makes a strong case that exposure to infected blood through health care services (particularly contaminated equipment and unsanitary practices) is responsible for about a third of HIV transmission in Africa, and criticizes the way in which the forces in charge of public policy are ignoring this evidence and sweeping this problem under the rug. While WHO and UNAIDS publicly claim that exposure to contaminated blood in health care settings account for a tiny percentage of HIV transmissions, Gisselquist presents convincing evidence to the contrary. After Points to Consider, nobody could doubt that unsafe health care is a major factor in HIV transmissions in Africa and other underdeveloped countries. He may be exaggerating to argue that more surgical services, such as circumcision, will place Africans at greater risk of HIV, but Gisselquist certainly makes a strong case that the current obsession with circumcision as the key strategy against AIDS is hopelessly misguided. David Gisselquist. Points to Consider: Responses to HIV/ AIDS in Africa, Asia, and the Caribbean. London: Adonis and Abbey, 2008. $25. <a href="https://www.amazon.com/Points-Consider-Responses-Africa-Caribbean/dp/190506845X/ref=sr_1_6?ie=UTF8&s=books&qid=1235778130&sr=1-6">Available from Amazon</a>. <h2>South African Medical Journal attacks WHO-UNAIDS circumcision push</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 WHO, under pressure from American money, has sought to enforce mass circumcision on African men. <a href="https://www.historyofcircumcision.com/templates/pages/south_african_medical_journal_attacks_who_circumcision_push.html">The three articles are available here.</a> <h4>Intercision-circumcision:</h4> <h4>Golden Compass movie raises spectre of genital mutilation</h4> If you type intercision AND circumcision into Google you will find lots of links to Internet discussions of Philip Pullman's fantasy trilogy His Dark Materials, the first volume of which (Northern Lights) has been adapted into a brilliant movie called The Golden Compass. Quite a few readers and movie-goers have picked up on the possibility of a parallel between the variety of child cutting that goes on at Bolvangar (intercision - separating a child from his or her daemon) and the variety that is common in the United States, the Middle East and Africa (circumcision - separating a child from part of his or her genitals). The similarity is in fact drawn explicitly by the witch queen Ruta Skada in The Subtle Knife: explaining why they should join the forces opposing the Magisterium, she says that the forms of child cutting common in the south lands (cutting children's sexual organs) is different from what is done at Bolvangar, but that they are "just as horrible". <a href="https://www.historyofcircumcision.com/templates/pages/intercision_circumcision.html" style="font-weight: 400;">Read more about the parallels between intercision and circumcision in His Dark Materials.</a> ***** Several recent articles by prominent scholars have added to the growing chorus of doubt as to the effectiveness, cost, ethics and general propriety of male circumcision as a solution to Africa’s AIDS problem. Writing in the American Journal of Preventive Medicine, Dr Laurence Greene and colleagues argue that the three clinical trials that provide on which the circumcision programs are based do not provide sufficient evidence for the effectiveness of circumcision as an HIV preventive. Even more seriously, there is no evidence that a protective effect observed in the artificial or “laboratory” conditions of supervised trial will be replicated in the real world – neither in Africa and certainly not in the developed world. In the Journal of Medical Ethics, Marie Fox and Michael Thomson argue that on the evidence so far it is premature to promote circumcision as a reliable strategy for combating HIV. They point out that both the sponsors and the media, both popular and scientific, have exaggerated the protective effect of circumcision suggested by the clinical trials, and that questions of medical ethics, human rights and personal choice have been swept aside in the rush to roll out circumcision programs. Meanwhile, several new papers by British and American researchers have confirmed the conclusions of many other studies that circumcision would have little or no protective effect on sexual transmission of HIV among men who have sex with men. It has further been well established that male circumcision does not protect women against HIV transmission. <h2> <a id="real" name="real"></a>Circumcision not so effective in the real world</h2> Writing in the American Journal of Preventive Medicine, Dr Laurence Greene and colleagues argue that the three clinical trials that provide on which the circumcision programs are based do not provide sufficient evidence for the effectiveness of circumcision as an HIV preventive. Even more seriously, there is no evidence that a protective effect that is observed in the artificial or “laboratory” conditions of supervised trial will be replicated in the real world. Thee study concludes: Recommending mass circumcision by generalizing from the particular RCCTs to the diverse populations of Africa highlights problems of external validity identified in several areas of preventive medicine and public health research. Studies published since the RCCTs show that (1) male circumcision is not correlated with lower HIV prevalence in some sub-Saharan populations; (2) circumcision is correlated with increased transmission of HIV to women; and (3) male circumcision is not a cost effective cost effective strategy. This new evidence warrants caution and further study before recommending circumcision campaigns. In addition, ethical considerations, informed consent issues, and possible increase in unsafe sexual practices from a sense of immunity without condoms must be weighed. The global health community understands that the most important modifıable factor in sexually transmissible HIV is human behavior. The policy questions to be considered are not whether a link exists between male circumcision and reduced rates of HIV infection, but, rather, whether mass circumcision is (1) an ethical and safe public health choice, and (2) the most cost-effective use of limited resources. Lawrence W. Green, John W. Travis, Ryan G. McAllister, Kent W. Peterson, Astrik N. Vardanyan, Amber Craig. Male Circumcision and HIV Prevention: Insufficient Evidence and Neglected External Validity. American Journal of Preventive Medicine, Vol. 39 (5), November 2010, 479-482 <h2> <a id="ethics" name="ethics"></a>Ethical and human rights issues ignored</h2> In the Journal of Medical Ethics, Marie Fox and Michael Thomson argue that on the evidence so far it is premature to promote circumcision as a reliable strategy for combating HIV. They point out that both the sponsors and the media, both popular and scientific, have exaggerated the protective effect of circumcision suggested by the clinical trials, and that questions of medical ethics, human rights and personal choice have been swept aside in the rush to roll out circumcision programs. Abstract In April 2009 a Cochrane review was published assessing the effectiveness of male circumcision in preventing acquisition of HIV. It concluded that there was strong evidence that male circumcision, performed in a medical setting, reduces the acquisition of HIV by men engaging in heterosexual sex. Yet, importantly, the review noted that further research was required to assess the feasibility, desirability and cost-effectiveness of implementation within local contexts. This paper endorses the need for such research and suggests that, in its absence, it is premature to promote circumcision as a reliable strategy for combating HIV. Since articles in leading medical journals as well as the popular press continue to do so, scientific researchers should think carefully about how their conclusions may be translated both to policy makers and to a more general audience. The importance of addressing ethico-legal concerns that such trials may raise is highlighted. The understandable haste to find a solution to the HIV pandemic means that the promise offered by preliminary and specific research studies may be overstated. This may mean that ethical concerns are marginalised. Such haste may also obscure the need to be attentive to local cultural sensitivities, which vary from one African region to another, in formulating policy concerning circumcision. Marie Fox, Michael Thomson. HIV/AIDS and circumcision: lost in translation. Journal of Medical Ethics 2010;36:798-801 <h2> <a id="male" name="male"></a>Circumcision has no protective effect in male-male sex</h2> Several recent papers have confirmed that circumcision has little or no effect in lowering the risk of HIV transmission among men who have sex with men. Chongyi Wei, H. Fisher Raymond, Willi McFarland, Susan Buchbinder, Jonathan D. Fuchs. What Is the Potential Impact of Adult Circumcision on the HIV Epidemic Among Men Who Have Sex With Men in San Francisco? Sexually Transmitted Diseases. Vol. 37 (12) December 2010, 1-3 Abstract: With the help of a community-based survey, we assess the potential effect of circumcision on the HIV epidemic among men who have sex with men (MSM) in San Francisco. Only a small minority of MSM would both derive benefit from circumcision (i.e., were uncircumcised, HIV-negative, predominantly insertive, and reported unprotected insertive anal sex) and be willing to participate in circumcision trials (0.7%) or be circumcised if proven effective as a prevention strategy (0.9%). Circumcision would have limited public health significance for MSM in San Francisco. Conclusion: public health significance for MSM in San Francisco. High existing rates of MC, coupled with low rates of predominant IAI and lack of interest in undergoing the procedure for HIV prevention limit the potential impact of this intervention, even if it were found to be efficacious. Although our results may have limited generalizability, the parameters that affect the utility of circumcision for HIV prevention are not expected to vary greatly among MSM in other US cities. Both national samples of US men and MSM have found similarly high rates of circumcision.13,14 Moreover, there is little reason to believe that sexual behaviors of MSM in other US cities would differ significantly from that of MSM in San Francisco. Therefore, it may be likely that MC among MSM would have little effect on HIV transmission throughout the United States. Kristen Jozkowski, Joshua G. Rosenberger, Vanessa Schick, Debby Herbenick, David S. Novak, Michael Reece. Relations Between Circumcision Status, Sexually Transmitted Infection History, and HIV Serostatus Among a National Sample of Men Who Have Sex with Men in the United States. AIDS Patient Care and STDs. August 2010, 24(8): 465-470. Abstract: Circumcision’s potential link to HIV/sexually transmitted infections (STI) has been at the center of recent global public health debates. However, data related to circumcision and sexual health remain limited, with most research focused on heterosexual men. This study sought to assess behavioral differences among a large sample of circumcised and noncircumcised men who have sex with men (MSM) in the United States. Data were collected from 26,257 U.S. MSM through an online survey. Measures included circumcision status, health indicators, HIV/STI screening and diagnosis, sexual behaviors, and condom use. Bivariate and regression analyses were conducted to determine differences between HIV/STI status, sexual behaviors, and condom use among circumcised and noncircumcised men. Circumcision status did not significantly predict HIV testing ( p>0.05), or HIV serostatus ( p>0.05), and there were no significant differences based on circumcision status for most STI diagnosis [syphilis, gonorrhea, chlamydia, human papilloma virus (HPV)].* Being noncircumcised was predictive of herpes-2 diagnosis, however, condom use mediated this relationship.** These data provide one of the first large national assessments of circumcision among MSM. While being noncircumcised did not increase the likelihood of HIV and most STI infections, results indicated that circumcision was associated with higher rates of condom use, suggesting that those who promote condoms among MSM may need to better understand condom-related behaviors and attitudes among noncircumcised men to enhance the extent to which they are willing to use condoms consistently. * Translation: There were no significant differences based on circumcision status for most STI diagnosis, namely, syphilis, gonorrhea, chlamydia, human papilloma virus (HPV). ** Translation: Circumcised men were more likely to use condoms, and it was condoms, not being circumcised, that protected them from herpes. This suggests that being circumcised increased their risk of the other STIs. This is why circumcision has no place in efforts to control AIDS in Australia, where nearly all sexual transmission of HIV occurs during male-male sexual activity. McDaid LM, Weiss HA, Hart GJ. Circumcision among men who have sex with men in Scotland: limited potential for HIV prevention. Sexually Transmitted Infections, Vol 86 (5), October 2010, 404-406 Abstract: Objective Male circumcision has been shown to reduce the risk of HIV acquisition among heterosexual men but the impact among men who have sex with men (MSM) is not known. In this paper, we explore the feasibility of research into circumcision for HIV prevention among MSM in Scotland. Methods Anonymous, self-complete questionnaires and Orasure oral fluid collection kits were distributed to men visiting the commercial gay scenes in Glasgow and Edinburgh. Results: 1508 men completed questionnaires (70.5% response rate) and 1277 provided oral fluid samples (59.7% response rate). Overall, 1405 men were eligible for inclusion in the analyses. 16.6% reported having been circumcised. HIV prevalence was similar among circumcised and uncircumcised men (4.2% and 4.6%, respectively). Although biologically, circumcision is most likely to protect against HIV for men practising unprotected insertive anal intercourse (UIAI), only 7.8% (91/1172) of uncircumcised men reported exclusive UIAI in the past 12 months. Relatively few men reported being willing to participate in a research study on circumcision and HIV prevention (13.9%), and only 11.3% of uncircumcised men did so. Conclusion The lack of association between circumcision and HIV status, low levels of exclusive UIAI, and low levels of willingness to take part in circumcision research studies suggest circumcision is unlikely to be a feasible HIV prevention strategy for MSM in the UK. Behaviour change should continue to be the focus of HIV prevention in this population. <h2> <a id="women" name="women"></a>Male circumcision does not protect women from HIV</h2> Maria J Wawer et al, Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial. Lancet, Vol. 374 (9685), 18 July 2009, 229-237 Background: Observational studies have reported an association between male circumcision and reduced risk of HIV infection in female partners. We assessed whether circumcision in HIV-infected men would reduce transmission of the virus to female sexual partners. Methods: 922 uncircumcised, HIV-infected, asymptomatic men aged 15-49 years with CD4-cell counts 350 cells per ?L or more were enrolled in this unblinded, randomised controlled trial in Rakai District, Uganda. Men were randomly assigned by computer-generated randomisation sequence to receive immediate circumcision (intervention; n=474) or circumcision delayed for 24 months (control; n=448). HIV-uninfected female partners of the randomised men were concurrently enrolled (intervention, n=93; control, n=70) and followed up at 6, 12, and 24 months, to assess HIV acquisition by male treatment assignment (primary outcome). A modified intention-to-treat (ITT) analysis, which included all concurrently enrolled couples in which the female partner had at least one follow-up visit over 24 months, assessed female HIV acquisition by use of survival analysis and Cox proportional hazards modelling. This trial is registered with ClinicalTrials.gov, number NCT00124878. Findings: The trial was stopped early because of futility. 92 couples in the intervention group and 67 couples in the control group were included in the modified ITT analysis. 17 (18%) women in the intervention group and eight (12%) women in the control group acquired HIV during follow-up (p=0·36). Cumulative probabilities of female HIV infection at 24 months were 21·7% (95% CI 12·7-33·4) in the intervention group and 13·4% (6·7-25·8) in the control group (adjusted hazard ratio 1·49, 95% CI 0·62-3·57; p=0·368). Interpretation: Circumcision of HIV-infected men did not reduce HIV transmission to female partners over 24 months; longer-term effects could not be assessed. Condom use after male circumcision is essential for HIV prevention. <a href="http://www.circumstitions.com/HIV.html" rel="noopener" target="_blank">For further analysis, see coverage at Circumstitions</a> <h2> <a id="kids" name="kids"></a>Men circumcised as children at greater risk of HIV</h2> A study in Mozambique has found that men circumcised as children are 2 or 3 time more likely to be infected with HIV than uncircumcised men. The study, by Dr D.D. Brewer, confirms earlier research in Kenya, Lesotho and Tanzania that young people without sexual experience were more likely to be HIV-positive if they had been circumcised or if they had gone through traditional cutting rituals such as scarification. The results confirm the argument of David Gisselquist and others that a significant number of African AIDS cases are not the result of heterosexual intercourse, but of non-sterile medical procedures. The increasing evidence of non-sexual transmission of HIV casts further doubt on the value of mass circumcision campaigns as the magic bullet against AIDS. <h3>Scarification and Male Circumcision Associated with HIV Infection in Mozambican Children and Youth</h3> Background: In sub-Saharan Africa, significant numbers of children with seronegative mothers are HIV infected. Similarly, substantial proportions of African youth who have not had sex are infected with HIV. These findings imply that some African children and youth acquire HIV through blood exposures in unhygienic healthcare, cosmetic care, and rituals. In prior research, male and female Kenyan, Lesothoan, and Tanzanian adolescents and virgins who were circumcised were more likely to be infected with HIV than their uncircumcised counterparts. Methods: I examined the association between male circumcision, scarification, and HIV infection in Mozambican children and youth with data from the 2009 Mozambique AIDS Indicator Survey. I excluded from analysis children under age 12 who had HIV seropositive biological mothers. I coded children and youth as exposed to circumcision or scarification only if it had occurred within the prior 10 years. Results: Circumcised and scarified children and youth were two to three times more likely to be infected with HIV than children and youth who had not been circumcised or scarified, respectively. Circumcision and scarification were each associated with HIV infection for both virgins and sexually experienced youth. Males circumcised by medical doctors were almost as likely to be infected as those circumcised by traditional circumcisers. Circumcision and scarification were also independently associated with HIV infection in males. Conclusions: To determine modes of HIV transmission with confidence, researchers must employ more rigorous research designs than have been used to date in sub-Saharan Africa. In the meantime, Mozambicans and other Africans should be warned about all risks of blood-borne HIV transmission, including scarification and medical and traditional circumcision, and informed about how these risks can be avoided. Source: Brewer D.D. Scarification and Male Circumcision Associated with HIV Infection in Mozambican Children and Youth. <a href="http://www.webmedcentral.com/article_view/2206">WebmedCentral EPIDEMIOLOGY 2011;2(9):WMC002206</a> <h2> <a id="lomb" name="lomb"></a>Economists slam African circumcision programs</h2> In recent months the African circumcision programs have come under strong attack from leading economists, who warn that the programs are not cost effective and are distorting the health budgets of recipient countries. The circumcision programs were introduced after three clinical trials appeared to show that circumcision could reduce a male’s risk of acquiring HIV through unprotected sexual intercourse with an infected female partner. The degree of risk reduction is estimated by the authoritative Cochrane Review as somewhere between 38% and 66% – which has not prevented circumcision advocates and an uncritical media from bandying a mythical “60 per cent protection” as though it was the same thing as immunity. The excessive stress on HIV control, and within this on circumcision as the best tactic, is criticised in a paper by Michael Grimm and Deena Cass, published by the German Development Bank; while Bjorn Lomborg and economists at the Copenhagen Consensus Center have criticised the African circumcision programs as too expensive, and far less effective than cheaper interventions that have the additional advantages of being both less risky and less controversial. <h3>Economists say circumcision not the best way to fight HIV-AIDS</h3> Some of the world’s most prominent economists have criticised the African circumcision programs as far less cost effective than other methods of prevention. The criticism was made Bjorn Lomborg and a group of Danish economists at the Copenhagen Consensus Center, a Danish think tank focused on cost-effective public spending. They conducted a cost-benefit analysis of circumcision as an HIV control measure, comparing the costs of prevention and treatment options per lives saved, and found that it was far less effective than other strategies, such as preventing mother-to-child transmission, ensuring that blood transfusions and other medical procedures were safe, and putting more effort into developing a vaccine. The economists estimated the cost-benefit ratio for adult male circumcision at 23:1, while preventing mother-to-child transmission by treating HIV-positive pregnant women with medication had a cost benefit of 95:1, and ensuring a safe blood supply a ratio of 393:1. Such interventions were so much cheaper and more effective than circumcision that they “jumped to the top of the list”, Lomborg said. He criticised the notion of circumcision as a “surgical vaccine” as misleading and likely to encourage high risk behaviour. <a href="http://www.usatoday.com/news/world/story/2011-09-28/global-hiv-prevention-circumcision/50594330/1" rel="noopener" target="_blank">Read report in USA today.</a> <h3>Need for healthy balance in AIDS fight</h3> Lomborg’s criticism of the African circumcision programs comes hot on the heels of a critique by Michael Grimm and Deena Cass, published by the German Development Bank in June. They suggest that the massive funding for HIV-AIDS control in Africa is based on inaccurate and exaggerated assessments of the extent and impact of HIV infection, and an unproven assumption that nearly all infection is through unprotected heterosexual intercourse. In fact, there is good evidence that a significant proportion of infections are the result of non-sterile medical procedures. “More experts accuse [leading world health organisations, such as WHO and UNAIDS] of a biased presentation of the facts to distort priorities in favour of the treatment and prevention of AIDS compared to other disease and global health issues. Experts estimate that [HIV aid] receives 25% of international healthcare aid. In some countries HIV aid clearly exceeds total domestic health budgets.” This leads to poorer health outcomes overall, as other diseases are neglected or ignored. Accordingly, they argue that the stress on circumcision programs is excessive, distorts the health budgets of the poverty-stricken countries in which they have been introduced, and leads to neglect of other diseases, some of which are more serious killers. “Infant mortality due to acute respiratory infections, diarrhoea, measles, malaria and malnutrition in general causes more than twice as many deaths as AIDS”, they write. “Despite these facts, UNAIDS is still calling for a drastic budget increase.” The authors also criticise the way in which HIV has been regarded as a special disease, requiring separate programs, when it should be incorporated with other health problems within a general public health strategy. They call for a “rebalancing” of the effort against HIV, with less stress on circumcision, and greater attention to raising the general level of health among these underprivileged populations. Michael Grimm is Professor of Applied Development Economics at the International Institute of Social Studies, Erasmus University, Rotterdam. Source: The fight against HIV/AIDS must be brought into balance: Policy brief by Michael Grimm and Deena M. Class; published by the KfW, German Development Bank, in the series “Meinungsforum Entwicklungspolitik” (No. 3, 24 June 2011) A copy of the <a href="http://www.iss.nl/News/The-fight-against-HIV-AIDS-must-be-brought-into-balance">full report in English can be downloaded</a> from the Institute of Social Studies, Erasmus University. <a href="http://thinkafricapress.com/health/hiv-exceptionalism-and-male-circumcision" rel="noopener" target="_blank">Read the report at Think Africa News</a> <h2>Circumcision ineffective against AIDS in developed countries</h2> VIENNA, Austria, July 22 – Adult circumcision has been proposed as a possible HIV prevention strategy for gay men, but a new study by the University of Pittsburgh Graduate School of Public Health presented at the XVIII International AIDS Conference suggests it would have a very small effect on reducing HIV incidence in the United States. Circumcision is thought to reduce the risk of HIV transmission by removing cells in the foreskin that are most susceptible to infection by the virus. Clinical trials conducted in Africa have found it reduces the risk of HIV in heterosexual men, yet there is little evidence that it can reduce transmission among American gay men. The study was based on surveys of 521 gay and bisexual men in San Francisco. Findings indicated that 115 men (21 percent) were HIV-positive and 327 (63 percent) had been circumcised. Of the remaining 69 men (13 percent), only three (0.5 percent) said they would be willing to participate in a clinical trial of circumcision and HIV prevention, and only four (0.7 percent) were willing to get circumcised if it was proven safe and effective in preventing HIV. The researchers extrapolated these findings to the entire gay and bisexual male population of San Francisco, an estimated 65,700 people, and determined that only 500 men would potentially benefit from circumcision. "Circumcision in the U.S. already is very common, making it applicable to a limited number of men as a potential HIV prevention strategy in adulthood,” said Chongyi Wei, Dr.P.H., study author and post-doctoral associate, Pitt's Graduate School of Public Health. “Our study indicates that any potential benefit may likely be too small to justify implementing circumcision programs as an intervention for HIV prevention.” <a href="http://www.scimag.com/news-circumcising-gay-men-would-have-limited-impact-on-072210.aspx" rel="noopener" target="_blank">Circumcising gay men would have limited impact on preventing HIV</a> by EurekAlert </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: growing doubts about circumcision darby