Male Circumcision and the HIV/AIDS Myth

This year, 1.2 million male babies in the United States will have between 35 and 50% of healthy, functioning penile skin -- containing over 20,000 nerve endings and the five most sensitive areas of the penis -- removed in a procedure that all of the major medical associations in the world, including the American Academy of Pediatrics and the Canadian Paediatric Society, have deemed medically unnecessary.

Overall, routine, non-therapeutic circumcision costs over $2 billion a year; in most states, it is still covered by Medicaid, at a cost of tens of millions of dollars to the taxpayer. Despite near-universal recommendations against performing it routinely, it is the most common surgical procedure performed in the United States.

Having started among ancient Egyptians and ancient Semitic peoples as a religious sacrificial ritual, the practice didn't take hold in Western societies until the late 1800s, when Western society was mired in masturbation-related hysteria. Dr. John Kellogg (yes, the Corn Flakes guy) was seminally (ahem) influential in the fight against what he called the "practice of solitary vice", to prevent which he ardently recommended circumcision, writing:

"The operation should be performed by a surgeon without administering an anesthetic, as the brief pain attending the operation will have a salutary effect upon the mind, especially if it be connected with the idea of punishment, as it may well be in some cases. The soreness which continues for several weeks interrupts the practice, and if it had not previously become too firmly fixed, it may be forgotten and not resumed."

This recommendation was accepted and implemented widely for male children, likely buoyed by the belief that circumcision was, after all, part of Abraham's covenant with God, who doesn't really like dickheads. Because the application of phenol to a girl's clitoris wasn't part of this covenant, this second recommendation from Dr. Kellogg to prevent female masturbation -- an "excellent means of allaying the abnormal excitement" as he wrote in his book Plain Facts for Old and Young -- wasn't embraced as enthusiastically.

I personally debunked Dr. Kellogg's myth as a young, foreskinless pre-adolescent, sometimes several times a day. Science can be fun. But since Dr. Kellogg, many more myths have come and gone.

One had to do with a 1932 study by Abraham Wolbarst claiming that infant circumcision virtually eradicates the risk of penile cancer, an exceedingly rare condition that affects approximately 1 in 100,000 males in the United States. His research was later discredited on several grounds, including the fact that Wolbarst happened to an avid circumcisionist who also believed, like Dr. Kellogg, that circumcision prevented not only masturbation, but also epilepsy and infant death.

We now know that penile cancer is only slightly more prevalent in the uncircumcised, and routine circumcision is not the best way to go about preventing it, just as routine double mastectomy in women who are done with breastfeeding (and thus have no remaining physiological need for their breasts) is not a good approach to preventing breast cancer -- which is much more common than penile cancer. We also know that the human papilloma virus (HPV), which also causes genital warts, is the most important risk factor for cancer of the penis -- and genital warts are more easily contracted by circumcised men. Moreover, penile cancer is much less prevalent in countries like Denmark, where circumcision is uncommon, compared to the United States, where between 50-60% of males are circumcised.

Advocates of circumcision found more ammunition recently when it was reported that uncircumcised heterosexual males were more likely to contract HIV/AIDS than their circumcised counterparts. The finding, based on studies in Africa, specifically Kenya, Uganda, and South Africa, seemed to show that circumcision reduces the chances of heterosexual men contracting HIV/AIDS from women by up to 60%.

The World Health Organization got behind this immediately, and the WHO's HIV/AIDS Department director, Dr. Kevin De Cock (yes, that's his real name) stated unequivocally that circumcision would give a significant "additional benefit" to men trying to avoid HIV infection.

So how do you go about conducting a randomized, controlled intervention trial looking at HIV infection in circumcised adult men? Probably not the way that these researchers did.

First, to be included in the study, men had to be HIV-negative and uncircumcised. The men also had to consent to "avoid sexual contact (except with condom protection) during the 6 weeks following the medicalized circumcision."

The experimental group which underwent the circumcisions was given the following instructions:

"When you are circumcised you will be asked to have no sexual contact in the 6 weeks after surgery. To have sexual contact before your skin of your penis is completely healed, could lead to infection if your partner is infected with a sexually transmitted disease... If you desire to have sexual contact in the 6 weeks after surgery, despite our recommendation, it is absolutely essential that you use a condom."

So the males in the study that underwent circumcision were not only told to abstain from sex for a significant time period after the operation -- reducing their exposure time by six weeks compared to the uncircumcised (control) group -- but told to use condoms, taught how to use them, and educated about their benefits. During this six week period, the men in the uncircumcised group did not have the same restrictions.

There also doesn't seem to be any mention of the researchers calling up the circumcised men after six weeks to say, "Okay, time's up. Ease up on the condom use from here on." The possibility that many of these men might have become accustomed to using condoms, armed with knowledge about their benefits, didn't seem to be much of a concern.

Also, other routes of HIV transmission like blood transfusion, IV needle sharing, or a dentist with dirty instruments (not unimaginable in Africa) don't seem to have been taken into account. Individual variables like hygiene were also poorly controlled for.

Casting further doubt on the theory that circumcision prevents HIV transmission is a simple look at the prevalence of circumcision and the prevalence of HIV/AIDS in different parts of the world.

As a continent, Africa has the highest percentage of circumcised men, over 60%. Africa also has -- as most people know -- the highest prevalence of HIV/AIDS, with South Africa housing the world's largest HIV-infected population. In countries like Nigeria and Kenya, (the latter being one of the countries where the study was conducted) over 80% of males are circumcised, yet they contain the second and fourth largest HIV-infected populations in the world respectively.

Among industrialized nations, the highest prevalence of HIV/AIDS is in the United States, which has the 10th largest HIV-positive population in the world. And yes, the USA also ranks number one among all industrialized nations in its number and percentage of circumcised men: 56% as of 2003, compared to countries in Europe, where circumcision is markedly less common -- as is the prevalence of HIV/AIDS.

Finally, let's address a question that seems to have been largely overlooked: what about the women?

Well, last month, The Lancet -- which refused to publish the male circumcision trials due to certain ethical concerns -- published a study led by Dr. Maria Wawer at the Bloomberg School of Public Health in Baltimore, concluding that circumcising men did not reduce HIV transmission to their female partners.

Actually, it's quite possible that circumcised men are more likely to give their female partners HIV/AIDS than uncircumcised men. Dr. Wawer found that 18% of the women in her study contracted HIV/AIDS from circumcised men, compared to 12% of women who contracted it from uncircumcised men.

The result was not statistically significant, but the Findings section states, "The trial was stopped early because of futility." Futility? The study may not have been "futile" if, with a larger sample size and properly completed, it had showed that circumcised men were more likely to transmit HIV/AIDS to their female partners, would it? An unanticipated result is still a result, specially if there is pre-existing data supporting it, like this Johns Hopkins study suggesting that women are indeed more likely to get HIV/AIDS from a circumcised male partner.

In an interview with VoA, Dr. Wawer appeared to have had a preference regarding her results. "Yes, of course we are disappointed," she said. "But the data are what the data are."

At the end of the day, we're close to busting another myth, and back to where we started with this whole circumcision-HIV thing. Even if the researchers in the Africa trials were right, it would take over 70 circumcisions in Africa to prevent 1 case of HIV. If the data were applied to the United States, it would take over 300 circumcisions to prevent one case of HIV. The bottom line remains the same: the best way to prevent HIV and other sexually transmitted infections -- whether you're circumcised, uncircumcised, gay, straight, male or female -- is through education and condom use. Where these two conflict -- as they did with the Pope's fatwa on condoms this year -- please go with the condom use.

A recent study looking at sensitivity of the penis in the circumcised and uncircumcised male found that the five most sensitive areas on the penis are removed at circumcision, and that the keratinized glans on the circumcised penis is less sensitive than the foreskin-protected, mucosa-lined glans on the uncircumcised penis. The skin removed from the penis at circumcision makes up close to 50% of the total penile skin, amounting to 15 square inches in an adult.

Even the mildest form of female circumcision is illegal, and very rightly termed female genital mutilation. Male circumcision on the other hand, is demonstrably more severe than some of the milder forms of FGM, but still performed widely. It is still covered by many insurance providers, and Medicaid in most states, despite being completely unnecessary.

Suppose for a moment that females who have been circumcised are shown to have a lower risk of acquiring HIV/AIDS. Kind of like it says in this abstract here.

How appropriate would it be for a group of researchers to carry out a massive study like the African male circumcision trials for women?

How long would it take for Dr. Kevin De Cock at the WHO to recommend female genital mutilation -- even in its mildest form -- as a form of HIV/AIDS prevention?

I wouldn't hold my breath.

 

Follow Ali A. Rizvi on Twitter: www.twitter.com/aliamjadrizvi

Comments

[stopthecut]

Please have a look at my non-profit web site stopthecut.org. I have a lot to say. I have some photos of cut vs. uncut, lots of opinion and links.
Sincerely,
Dr. Savage

[KOTFrank]

The African studies are properly called "Cargo Cult Science". Intentionally made biased for results wanted. Years have gone by since and still no medical organization in the world has adopted these shameful studies and most likely never will. Providing clean running water will cut HIV infections in half, providing antiviral therapy will stop it. Circumcision is all about power over others. We have to ask why is the WHO, UNAIDS, PSI (Population Services International who had roots in eugenics) WHY? uptake these flawed studies as factual and beneficial? WHO continues to loose credibility in the world. See Wawer on youtube Circumcision & HIV and also Dean Edell on HIV. Check David Wilton's Circumcisi­onAndHIV.c­om for complete coverage. Read how James Prescott's "Origins of Violence" is in line with US congressional study stating the US is the most violent country in the world. Over 200 infants per year die from circumcision. Join Intact America.

[Lars Eriksson]

Even with latest modern medical science surgery is a risk, one can only imagine the toll in death and lifelong disablement that these primitive operations have taken through history.
 
If we are in doubt why man do hack away on genitals what would Occams razor suggest, it’s about sexuality, to try to control it?
 
No, no, no! the always super rational man does of course only do things that are of the highest rational purpose, it’s about hygiene or maybe some mystified cultural reason. In a time when man have so to say limited knowledge of natural science he did despite that the clear cut epidemiological conclusion on genital diseases. Probably also a cost benefit analysis of the surgical risk and hygiene benefits. That he in most all other cases explained diseases by the action of supernatural beings are of course irrelevant.
 
The famed medieval Jewish rabbi, physician and philosopher Moses Maimonides (1135-1204) “The Guide to the Perplexed”:
 
“Similarly with regard to circumcision, one of the reasons for it is, in my opinion, the wish to bring about a decrease in sexual intercourse and a weakening of the organ in question, so that this activity be diminished and the organ be in as quiet a state as possible. It has been thought that circumcision perfects what is defective congenitally. ... In fact this commandment has not been prescribed with a view to perfecting what is defective congenitally, but to perfecting what is defective morally.”

[Lars Eriksson]

2000 to 2006 in Sweden it was reported to the National Board of Health 16 cases of complications, 1 boy died and 1 on the edge to die, both performed by MD’s. In 13 cases it was severe infections, bleedings, gaping wounds, severe pain. 10 of the cases were performed by non authorized or MD authorized in other Scandinavian country. Survey of the Children’s clinics system where all infants go for routine check up indicates that there are more complications than is reported to the national health board.

The complication numbers indicates a huge risk for the child if people feel forced to do it even if it can’t be done reasonably safe. Religious leaders most probably insist it have to be done and it’s no risk for the child.

When religious leaders insist on risky surgical operations on small children even if it can’t be done safe Seven Weinberg’s saying on religion is quite appropriate:

“Religion is an insult to human dignity, without it we have good people doing god things and evil people doing evil things, it takes religion to make good people doing evil things.”

To make it safer the religious rite of circumcision shall be implemented in the national health care system from 1 October and probably in many regions at subsidized price. Isn’t a strange “old tradition” that needs modern medical science to be done reasonably safe? Why did the all mighty creator wait so long to bless small boys with this feature.

[Roger Tatoud]

Another article written against all scientific evidences. Men in the study were followed up for 18 months, a six week difference at the begining does not make any difference. The results were also adjusted for behaviour, and interestingly enough, circumcised men were more active than the non circumcised one. Both group did receive counseling about condoms use.

Everything else in the above article is irrelevant to the study and only muddle the important issue, that of HIV prevention. It is very difficult to comprehend why people favour and support obscurantism so easily.

[Hdaryl01]

HIV today. Masturbation prevention earlier. Even gastrointestinal problems and epilepsy. All debunked. HIV is merely the latest convenient excuse to continue the barbaric practice. Wasn't HIV discovered in the 1980's? Why exactly did we circumcise males before then? What was the justification du jour in say, the 1970's? What will it be in the 2010's and 2020's after the convenient HIV excuse gets debunked? Remember Syphllis? Syphllis prevention was a handy excuse and justification for male circumcision, until it was debunked. Funny that you don't mention Syphllis. Just like you don't mention the large clinical studies, like one conducted in New Zealand that show an INCREASE in HIV transmission by circumsised men compared to uncircumcised men.

The United States has the highest neo-natal male circumcision rate of any industrialized country by far, and has for many, many decades.

The United States has the highest HIV/AIDS infection rate of any industrialized country by far, and has for decades.

How do you expalin this dichotomy? Your method doesn't seem to be working...........

All genital cutting is mutilation, human rights violation, and barbaris. It all needs to stop now, globally.

The most fool proof and safest protection against HIV/AIDS is a latex condom that costs pennies. Focusing on circumcision as a dubious preventative measure, for ulterior motives, takes the focus off what works-CONDOMS.

[berkawoo]

As much as infant circumcision is no longer formally recommended by the the American Academy of Pediatrics, the real culprits in more than 6 decades have been the medical establishment in this country.
Infant male circumcision is easy profit for Doctors and Hospitals, one of many things in the culture of this country of pushing and selling of something that is not needed. There is also the issue of medical ethics with regards to violating the oath to "First Do No Harm". The other culprit is Parents who choose to circ their infants for many different medically and culturally ingrained reasons that are ultimately based in ignorance. This is especially true among Caucasian Parents. Many years ago Doctors and Hospitals convinced mothers to mutilate their newborn sons claiming it to be beneficial when it is not. The only way for this procedure to stop in the USA is for the medical establishment as a whole refuses to preform infant circumcisions.
Sadly I don't think that will happen, there is still EASY PROFIT in Routine Infant Circ. for Doctors and Hospitals.

[MJLL]

Awesome article, thanks for writing and sharing this.

[vikinggirl]

Ali what a great article! These things need to be said.

I also wanted to say HDaryl you are so right about the racism inherent in our different treatment of male and female genital cutting. The single most significant difference between MGC and FGC is that the latter doesn't have a powerful white lobby group promoting it. If it did we'd be having people point out that female genitalia have many more bacteria than male, that when unwashed have been shown to harbour HPV, and that when excised seem to provide a signifiant degree of protection against HIV and Syphilis. All the above are proven facts yet none is deemed to make the cutting of nerve rich genital skin from a female baby appropriate.... When the Indonesians cut foreskin from little girls saying it will keep her clean and protect them from cervical cancer the West says stop this is unnecessary. Must white people always be such bloody hypocrites?

[Hdaryl01]

Ever wonder why the United States has yet to ratify the UN Convention on the Rights of the Child? Hmm....the United States, and Somalia (with no government­).......ha­ven't ratified it....I wonder why?

Could it be that many countries that have adopted this convention have interpreted it to further prohibit routine neo-natal male circumcision on human rights grounds?

Whose choice is it? Whose foreskin is it? Whose body is it? What gives parents the right to "consent" to this most commonly performed in the US, albeit medically unnecessary surgery for their neonatal son? 3500 newborn males are forcibly and barbarically circumcised, one every 25 seconds against their will and without their consent, each day in hospitals in the United States.

The hypocrisy surrounding the circumcision debate is shocking. How many feminists indignantly protest against the abhorent practice of female circumcision, lobby for refugee status for females at risk of it, yet give birth to a son and immediately have him circumcised? Do we circumcise our dogs? Cats? Farm animals? Any other male mammal on planet earth?

How civilized are we? The United States is the ONLY country that routinely circumcises the majority of its male infants within hours of birth-regardless of religious custom. Men have not been granted reproductive or privacy rights in the United States. Don't women have the right to choose? Shouldn't THE male being circumcised have the right to choose to be circumcised or not? This is entirely impossible with routine neonatal male circumcision.

[Hdaryl01]

I believe Xenophobia and cultural arrogance contribute to the double standard for genital cutting between genders.

Muslims and Africans practice female circumcision. Muslims and Africans and Jews and Americans practice male circumcision. Both male and female circumcision are practiced by all cultures that practice them for the same reasons-"cultural" and "hygenic". However, male circumcision gets a pass because Americans and Jews practice it. IE it's "good" circumcision. However, female circumcision is "bad", and it is convenient that only Muslims and Africans practice it, since they don't have much cultural capital, and everything they do goes under the "barbaric" microscope. If Americans and Jews practice "good" male circumcision, it must be DIFFERENT from "bad" female circumcision (FGM) practiced by the heathen Muslims and Africans.

This is shocking really in the transparently arrogant, hypocritical, and self serving nature of the debate. Let's demonize the practice as applied to females when done by Muslims and Africans, while preserving and elevating the practice when done to males by Americans and Jews, and of course we need to allow, or even promote Muslims and Africans to freely perform it on males as well......otherwise we'd be hypocrites......

Male circumcision involves amputating the prepuce (foreskin). According to the WHO, amputating the female prepuce only constitutes type I(a) FGM. See http://www.who.int/reproductive-health/publications/fgm/fgm_statement_2008.pdf on page 24, which is on the 30th page of the 47 page report.

All genital cutting is mutilation, and should be outlawed universally.

[ml66uk2]

Circumcision is a dangerous distraction in the fight against AIDS. There are six African countries where men are more likely to be HIV+ if they've been circumcised: Rwanda, Cameroon, Ghana, Lesotho, Malawi, and Swaziland. Eg in Malawi, the HIV rate is 13.2% among circumcised men, but only 9.5% among intact men. In Cameroon, the HIV rate is 4.1% among circumcised men, but only 1.1% among intact men. If circumcision really worked against AIDS, this just wouldn't happen. We now have people calling circumcision a "vaccine" or "invisible condom", and viewing circumcision as an alternative to condoms.

ABC (Abstinence, Being faithful, Condoms) is the way forward. Promoting genital surgery will cost African lives, not save them.

[serogal]

Hi Mr. "I am circumcised and obsessed with the idea I've missed out on something". Thanks for having no idea about how HIV transmission occurs and then posting a long article about it here. Perhaps the "futility" of this trial had to do with the fact that transmission often has to do with viral load - something that is never mentioned in your article. So saying people acquired HIV from circumcised / non-circumcised partners without taking anything else into consideration is just crap science. If all the circumcised parntners had high viral loads and all the non-circumcised partners had undetectable viral loads it would entirely skew findings. Add this to waiving information about non-infected person having another STD etc and you have a totally useless study that tells us nothing. Interesting the study authors figured out to discontinue the tests due to futility, if only you understood what you were writing about, you would have made the same decision. Put on a condom everybody, you're risking your life whenever you don't THE END.

[deviantg]

"Perhaps the "futility" of this trial had to do with the fact that transmission often has to do with viral load"
Do you really think researchers would actually use groups with different viral loads?