As San Francisco is denied a vote on banning circumcision of boys, US-backed mass circumcision programmes in Africa gather pace.
In July a judge stopped a proposed ballot on plans to outlaw the circumcision of male children in San Francisco. It is the latest in a raging debate over whether the practice of circumcision is justified. Preventing the transmission of the virus that causes AIDS is at its heart.
On the one hand people argue it is a quick and effective way of reducing HIV infection. Others say it should be classed, like female circumcision, as a form of genital mutilation.
Those in the first camp argue that circumcision helps protect against HIV because cells under the foreskin are vulnerable to the virus. When the foreskin is removed, the skin on the head of the penis becomes less sensitive and so less likely to suffer micro-cuts, thereby reducing the risk of infection.
Medical research ‘inconclusive’
Those in the second camp point out that research on whether circumcision reduces the likelihood of men contracting infections is inconclusive.
The British Medical Association’s line is that ‘the medical harms or benefits have not been unequivocally proven but there are clear risks of harm if the procedure is done inexpertly.’
Dr Antony Lempert, chair of the Secular Medical Forum, proposed a motion to the BMA annual congress conference in Cardiff this June, calling for doctors to stop performing ‘irreversible, clinically unnecessary surgery on the genitalia of non-consenting minors’. The motion was not debated.
‘Even if there were twenty such studies all showing statistically significant protection from a minor form of female cutting, there’s no way that any form of female circumcision would ever be promoted. Why the double standard?’
Stuart Worthington, Activist
But that didn’t stop NORM-UK — an anti-circumcision group— lobbying delegates in Cardiff in its first official demonstration. The group wants doctors to stop viewing the procedure as a minor and inconsequential op, in adults as well as children. Its members argue circumcision reduces penile sensation, might harm the immune system, reduces pheromone production and disrupts the body’s natural function.
Last year the Royal Dutch Medical Association adopted as official policy the line that the circumcision of boys is medically unnecessary and advocated a ‘strong policy of deterrence’.
Yet so far as Western health policy in Africa is concerned, the benefits of the procedure are incontrovertible.
In 2005, a randomized controlled trial of men in a South African township found that circumcision had helped reduce HIV infection by some 60%.
This trial caught some major players’ attention. The World Health Organisation, UN, Bill Gates and the Global Fund now all support circumcision as a preventative measure against HIV. With their financial backing, African countries have embarked on vast circumcision drives, aimed at adults and parents of newborn boys.
In July 2010 Bill Gates used a video from a Swaziland circumcision clinic to illustrate his call for mass circumcisions in Africa. A few months later the country launched its Soka Uncobe (Circumcise and Conquer) campaign. This aimed to operate on 80 per cent of the 18 to 49 year old male population by the end of 2011- a programme funded by the US to the tune of some $30 million.
‘This sort of major scale up of adult voluntary male circumcision programs has never been attempted with this size population or in this short a time frame,’ said a press release announcing the launch this January.
Events funded to encourage circumcision included a pool tournament funded by the Swaziland National Sports Council, which was only open to the circumcised.
A top football team publicly opted for the procedure and the polygamous Swazi king, Mswati III, issued a personal plea to his subjects to fight the ‘terrorist virus through circumcision‘.
Focusing on newborns
While the initial focus on the campaign was adult men, Swazi policymakers are now shifting their attention to newborns.
Data presented at the International Aids Society conference this July makes it hard to argue against Swaziland’s approach. Following a circumcision campaign in the same region of South Africa as the original trials, researchers found 20.0% of men who remained uncircumcised had HIV, compared with just 6.2% in those men who were circumcised.
The researchers observed that men who opted for circumcision tended to be younger and better educated. Despite this, they still calculated that circumcision reduced HIV prevalence by 55%.
They also reported positive results in every aspect of sexual health six months after circumcision. The subjects were 18% more likely to report overall satisfaction with intercourse and 6% less likely to complain of a lack of interest in sex.
However critics have questioned whether these improvements are a kind of placebo effect created by the publicity and pressure surrounding circumcision. And there is a substantial body of opinion that argues the Orange Farm results might not be able to be replicated elsewhere.
Other issues have also been raised. In the same month as Bill Gates aired his promotional video, the Swaziland Times revealed that the government had sat on research from 2007 showing that circumcised men had higher rates of HIV than uncircumcised.
A 2009 report, ‘Levels and Spread of HIV Seroprevalence and Associated Factors: Evidence from National Household Surveys‘ by USAID, also found that: ‘There appears to be no clear pattern of association between male circumcision and HIV prevalence. In 8 of 18 countries with data, as expected, HIV prevalence is lower among circumcised men, while in the remaining 10 countries HIV prevalence is higher among circumcised men.’
And 40 senior professionals endorsed an article in the American Journal of Preventative Medicine last year warning that the South African trials should not be used to justify mass circumcisions in different African populations.
The report quoted studies conducted since the South African trials showing that male circumcision is not correlated with lower HIV prevalence in some sub-Saharan populations but is correlated with increased transmission of HIV to women.
‘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,’ it said.
Health officials in Malawi announced last year that, unlike its neighbours, it would not be adopting a policy of mass circumcision due to a lack of evidence. The chairman of the country’s National Aids Commission, Archbishop Bernard Malango, said no difference had been found in HIV infection rates between Muslim districts, where most men are circumcised, and Christian areas, where circumcision is not practised.
Dr Antony Lempert, chair of the Secular Medical Forum
Critics have also warned complication rates have not been properly assessed. The original trials reported low levels of complications. But, as with other aspects of the study, these may not be replicable across Africa. Rates of surgery-related complications observed in three randomised controlled trials of male circumcision for HIV prevention were 1.7 percent in Kenya, 3.5 percent in South Africa, and 7.6 percent in Uganda.
Despite the controversy – and Malawi’s stance – Swaziland-style campaigns are taking place all over Africa. Gates has also funded circumcision drives in Kenya and Zambia, which held a Mr Male Circumcision contest last year and has a target of 80% of newsborn boys to be circumcised by 2020. Zimbabwe has recruited a reggae star to back its Be Smart Get Circumcised campaign.
Botswana wants 80 % of its adult males circumcised in 5 years. Rwanda is aiming to circumcise two million men by 2013; Tanzania is targeting 2.8 million. If the same rates of surgery-related complications found in Uganda afflicted Tanzania, over 200,000 men would have problems.
A commentator in Malawi is now asking whether its officials’ public statements on circumcision had anything to do with the country failing to qualify for a Global Fund grant for HIV in 2012. Malawi’s application for ‘Round 10′ funding had included plans for mass circumcision, contradicting the officials’ statements.
Meanwhile in San Francisco the man behind the proposed vote, Lloyd Schofield, says his group is likely to appeal. If he succeeds, Africa’s circumcision programmes – and their wealthy backers – are likely to come under even closer scrutiny.
Neither will Norm-UK be supporting the African campaigns, despite the latest research from Orange Farm. Activist Stuart Worthington points to a 2005 study which showed a link between female circumcision and lower HIV rates.
‘Even if there were twenty such studies all showing statistically significant protection from a minor form of female cutting, there’s no way that any form of female circumcision would ever be promoted. Why the double standard?’
The HIV and sexual health charity, The Terrence Higgins Trust, also sounds a note of warning. Jason Warriner, governance director at the Trust, said: “In the UK there’s no evidence that circumcision reduces HIV prevalence amongst gay men. Condoms are the most effective way to prevent HIV infection.”
August 10th, 2011 at 4:15 pm (#)
Thanks so much for this article.
I have been arguing against mass circumcision for years.
I am not a doctor, I am a sociologist. I’ve learned how to do research and how to parse statistics and my opinion is that there are way too many variables that are not being included in these reports.
Take for instance the Orange Farm results – what the latest report doesn’t tell you is that the French doctors have been in that community for almost a decade and have been educating the population about HIV for most of that time – of course there will be a decline in HIV – regardless of circumcision. There are billboard adverts, radio and TV adverts, group sessions, mobile clinics etc. and participants receive free medical attention. The number of participants below 20 (or even 18) is huge and the number over 30-40 is small, this says a lot in and of itself.
The cultural/tribal significance of circumcision needs to be looked at by anthropologists also.
A previous WHO recommendation for mass circumcision was discovered to have been founded on research done by an Australian doctor who seems to have been fixated on circumcision, even evangelical about it.
This issue needs to be investigated as a matter of urgency.
August 10th, 2011 at 5:27 pm (#)
The great medical principle is that mutilation is unethical as a preventive measure.
The principle must be applied. Full stop.
August 10th, 2011 at 5:40 pm (#)
Infants must not suffer from their elders sexual misbehaviour.
August 10th, 2011 at 6:35 pm (#)
Nicely balance article. It must be remembered that that only people pushing circumcision in Africa are circumcised outsiders. Bill Gates, a circumcised American, almost gets giddy over the prospect of more men having genital reduction surgery. While he may be one of the richest men in the World, all of his money won’t bring back what he is missing.
The WHO recommendation reflected the zealotry of a few well-placed people more than any convincing science. When the data from the three randomized controlled trials are examined closely, it becomes apparent that approximately half of the men who became infected with HIV during the trials were not infected through sexual content. The investigators made no effort to determine the source of these infections, so there is no way to demonstrate that circumcision prevented sexually-transmitted HIV. The studies also had built in biases that nearly guaranteed the results these investigators were hoping for. This is all laid out in a recently published critique in the Journal of Public Health in Africa
http://www.publichealthinafrica.org/index.php/jphia/article/view/jphia.2011.e4/pdf_22
While a 60% reductions sounds great, if you are willing to believe the results of these trials, circumcision only prevented an infection in approximately 1% of the thousands of men who participated. Not much of a treatment.
It also clear that circumcision is now becoming last year’s (actually 2007′s news) as treatment with ARTs is now being recognized as the best form of prevention. Those who are diagnosed with HIV and treated with ARTs have virtually no chance of transmitting the virus sexually. Likewise condoms are nearly 100% effective. While circumcision will remain the prevention of choice for the circumcision enthusiasts at the WHO and UNAIDS, people who are interested in preventing HIV infections have moved on to secondary prevention with ARTs because it is more effective, less costly, and less invasive. It is time to pull the money away from an unproven intervention and apply to something that will work.
August 10th, 2011 at 8:25 pm (#)
I’m glad that some are waking up to the fact that there is a MUCH BIGGER picture to be had here. There is a LOT of money behind this and a lot of MOTIVE. In the U.S.A. (where circumcision used to be performed at a very high rate,but is now declining) foreskins are sold to boitech companies. They are VERY valuable and used in many things from research to face cream. DON’T be fooled, they simply need a new source of this tissue now that the U.S. is ending this practice. A little bit of ‘outside the box’ thinking is all you need to see this for what it is. http://www.youtube.com/user/whatUneverknew
August 10th, 2011 at 10:13 pm (#)
Thanks for writing this nuanced analysis. While I support the rights of informed adults to choose circumcision for themselves, and understand the urgency of finding even a stop-gap solution in countries where the HIV rate is close to 20%, I’m nevertheless troubled by the medicalization of circumcision by countries who who practice cultural circumcision (including foreign intervention).
August 10th, 2011 at 10:17 pm (#)
This is a very good report.
Male circumcision amputates an important part of the male phallus. This causes emotional issues in men who have been victims of male circumcision.
These men tend to have an acute need to justify and rationalize their involuntary loss of part of their phallus by finding a medical justification for circumcision.
It appears that at least two, and possibly three, of the three RCTs were conducted by circumcised men. They have an acute bias in favor of finding a justification for circumcision. That would explain the huge methodological flaws in the three studies. Please see this paper for a fuller explanation of the effect of circumcision upon the medical literature:
http://www.doctorsopposingcircumcision.org/pdf/Hill_2007.pdf
August 11th, 2011 at 12:09 am (#)
I’m happy to add the perspective of a Jewish Intactivist. There is a growing number of Jews of all denominations who are refusing to circumcision and instead doing alternative rituals that honor our religion without harming children.
Jewish Voices: The Current Judaic Movement to End Circumcision: Part 1
http://intactnews.org/node/104/1311886091/jewish-voices-current-judaic-movement-end-circumcision-part-1
The Judaic Movement to End Circumcision: Part 2
http://intactnews.org/node/105/1311886372/jewish-voices-current-judaic-movement-end-circumcision-part-2
Interview with Jewish Intactivist Miriam Pollack
http://www.beyondthebris.com/2011/07/defying-convention-interview-with_27.html
Jews who believe that circumcision should be against the law.
http://intactnews.org/node/103/1311885181/jews-speak-out-favor-banning-circumcision-minors
Brit Shalom Celebrants by Mark D. Reiss, M.D.
http://www.circumstitions.com/Jewish-shalom.html
Brit B’lee Milah (Covenant Without Cutting) Ceremony
http://www.nocirc.org/religion/Naming_ceremony.php
August 11th, 2011 at 2:41 am (#)
There were three trials, not one; in Rakai, Uganda and Kisimu, Kenya as well as Orange Farm, South Africa, but they were not altogether independent: the researchers are in contact with each other and have published papers together.
While the “60% reduction” factoid has been given huge publicity, the results on which it is based are not nearly so impressive. A total of 5,411 men were circumcised while control groups totalling 5,497 men were left intact. After less than two years, 64 of the circumcised men and 137 of the control groups had HIV. The difference of 73 men is the whole basis of the prevention claim.
Meanwhile 703 men, 327 of them circumcised, dropped out of the trials, their HIV ssatus unknown, easily enough to conceal a complete lack of effectiveness for circumcision.
There was no contact tracing, so it is not known how much of the transmission was in fact heterosexual or even sexual. Transmission by contaminated needles wielded by street-corner “needle men” is a real problem in Africa.
The trials were not double-blinded or placebo-controlled, the true gold standard of randomised trials, and there was every opportunity for the “Hawthorne effect” – just taking part in a trial affects the outcome – to apply.
There is no evidence that circumcision has any effect on male-male transmission of HIV, the main route in the USA, and Wawer et al. in Uganda, using some of the same men as in the trial above, started to find that circumcising men INcreases the risk of transmission to women (who are already at greater risk) but (so?) that trial was cut short for no good reason before that could be confirmed.
It is not argument ad hominem to point out that virtually all the research claiming benefits for circumcision comes out of the USA, or is carried out and funded from there, and is therefore largely done by circumcised men. (More largely than the general population? It would be intersting to know.) No need for conspiracy – each man defends his own condition. Science is a human activity, and it is part of science to seek out human bias within it.
Circumcision is not a recently invented medical technique whose effects are being dispassionately studied. It is unique. A preshistoric magical disfigurement that was taken up as a religious ritual, then medicalised at a time of anti-masturbation hysteria as a treatment for a condition no longer regarded as harmful, it has continued seeking justification after failed justification. People should be skeptical, if not cyncial, about each new claim.
And it is no coincidence that it removes the most intimate part of man’s most prized possession. Yet that fact is often ignored or even denied, when the foreskin is described as “extra”.
August 11th, 2011 at 12:08 pm (#)
In 2005, a randomized controlled trial of men in a South African township who were circumcised and told to use condoms, found that circumcision and condom use while having reproductive sex with HIV+ prostitutes had helped reduce HIV infection by some 60%. It was never just circumcision alone as those proponents of circumcision claim to justify their beliefs. They have to lie and tell half truths to make themselves sound right. Circumcised men still get HIV from having unprotected reproductive sex with HIV+ prostitutes. It is irrespocible to promote this new superstition that circumcision prevents HIV.
August 11th, 2011 at 12:16 pm (#)
“They also reported positive results in every aspect of sexual health six months after circumcision. The subjects were 18% more likely to report overall satisfaction with intercourse and 6% less likely to complain of a lack of interest in sex.”
This means that the young men who are coersed to become circumcised will be having more reproductive sex.
August 11th, 2011 at 12:21 pm (#)
“When the foreskin is removed, the skin on the head of the penis becomes calloused and less sensitive and so less likely to suffer micro-cuts, thereby reducing the risk of infection.” This calloused surface of the glans causes vaginal erosion while having reproductive sex, so if the man is HIV+ and doesn’t use condoms, his women are more likely to become HIV+.
August 11th, 2011 at 12:35 pm (#)
In the U S studies show that right now, most new cases of HIV infections are not homosexuals or intact men but black women.
Why “black women” is not known. Some speculate it’s poverty level. I think it might have something to do with immune systems of European and Asian people. In the Northern hemisphere where the Black Plague wiped out millions, the survivors had an evolutionary adaptation to the bacteria that kept it in check, and is also known to work on the AIDS/HIV virus as well.
August 11th, 2011 at 12:53 pm (#)
In the US, Islael, and Islamic countries, where infant circumcision is in mass portions of the populations, the physical and psychological dysfunctions caused from excision before puberty’s brain chemistry and growth is complete, is causing mass dissension and paranoia between religions, mass schizophrenia between polititians, increasing incidense of mass murder/suicidal depression, and increased hysterectomies(1:3 over 50) for the women of circumcised men. Mass denial and studies to promote and justify the covenant law sacrice as a way to fight HIV are the results.
I suggest we stop putting the needs of the Lord before the needs of the Lady, Mother Nature.
August 11th, 2011 at 1:19 pm (#)
Does no one else think it strange that most if not all of the research supporting circumcision is done by people from countries where routine circumcision is the norm? “It was good enough for me, so it’s good enough for you” is not science. The very first sentence of this article says it all: “… US-backed mass circumcision programmes in Africa gather pace”
August 11th, 2011 at 2:22 pm (#)
Thank you for this article. THe psychological motivations for promoting circumcision are stronger than any of the flimsy excuses. It needs to be asked why those who claim to be so intent on “saving lives” by circumcising others are also so intent on ignoring how lives are ruined by circumcision. Wherever adults are coerced into circumcision, and especially wherever circumcision is forced upon children there are casualties, and botched surgeries resulting in ruined lives. Surgical accidents and death never factored into the circumcision promoters propaganda; when confronted they’ll blandly say, “every surgery carries risks, but the risks outweigh the benefits.”
When the motivation for cutting the genitals of others needs is understood, then the whole rush to coerce Africans into circumcision can be seen for what it is, medical fraud.
August 11th, 2011 at 4:41 pm (#)
Why does no-one ever talk about the Wawer study into the effects of male circumcision on male-to-female transmission of HIV? That showed a 54% higher rate of infection in the group where the men had been circumcised. HIV in women has been linked to circumcision in men before, but no-one seems to want to talk about that as there seems to be an irrational enthusiasm for cutting parts off men’s genitals.
August 11th, 2011 at 5:20 pm (#)
Like several people have said, it’s interesting that while medical societies all over the world are condemning circumcision (Dutch, South African, et cetera…), the ones who are promoting circumcision are the Americans – the only country in the world that has routine circumcision. I expect that if Alice Miller the psychologist were still around, she would have a lot to say about that. You know – the cycle of abuse… victims reenacting their trauma onto others… The fact is that the vast majority of men on the planet are not circumcised and they are very glad to be that way. Most men who have been circumcised as adults have said their sex life is basically ruined by it. We know that circumcision is dangerous and has a lot of negative side effects, and we also know that the only effective method of protecting against HIV transmission (apart from abstinence) is proper use of condoms. Condoms give 99.9% protection, with no side effects. It’s barmy to circumcise for the sole purpose of preventing AIDS, because it doesn’t! Okay, if adult men want it for whatever reason – fine, but for god’s sake don’t start on babies! They have no say in the matter, and in any case they are at zero risk from sexually transmitted HIV. They won’t BE having sex for about 15 years or so – it is very likely that a vaccine or some other kind of preventative method will be available by then, meaning you will have traumatised them and mutilated their genitals for nothing.
August 11th, 2011 at 8:50 pm (#)
“Events funded to encourage circumcision included a pool tournament funded by the Swaziland National Sports Council, which was only open to the circumcised.”
Coercing men to undergo surgery instead of promoting safe sex and condoms usage is a human rights violation. Why haven’t Amnesty International and other human rights groups spoken out against this violation of basic human rights?
August 12th, 2011 at 7:27 am (#)
“Those in the first camp argue that circumcision helps protect against HIV because cells under the foreskin are vulnerable to the virus. When the foreskin is removed, the skin on the head of the penis becomes less sensitive and so less likely to suffer micro-cuts, thereby reducing the risk of infection.”
It must be pointed out that none of these hypotheses have ever been actually demonstrably proven.
The idea that the inner mucosa and the non-keratinized head of the penis was more susceptible to HIV tranmsission because of the thinner tissue, and because it “could develop cuts” etc. was first proposed in 1986 by Aaron J. Fink, and he invented it out of thin air, before there were any “studies” on the matter.
This hypothesis was never actually proven. In fact, it has been completely DIS-proven, yet proponents of the “studies” and mass circumcision in Africa can’t seem to stop selling this lie. Here are two studies that disprove the above theory:
Dinh, MH; McRaven MD, Kelley Z, Penugonda S, Hope TJ (2010-03-27). “Keratinization of the adult male foreskin and implications for male circumcision.”. AIDS 24 (6): 899-906. PMID 20098294. http://www.ncbi.nlm.nih.gov/pubmed/20098294. Retrieved 2011-06-28. “We found no difference between the keratinization of the inner and outer aspects of the adult male foreskin. Keratin layers alone are unlikely to explain why uncircumcised men are at higher risk for HIV infection.”.
Dinh, Minh H; Sheila M Barry, Meegan R Anderson, Scott G McCoombe, Shetha A Shukair, Michael D McRaven, Thomas J Hope (2009-12-06), “HIV-1 Interactions and Infection in Adult Male Foreskin Explant Cultures” (PDF), 16th Conference on Retroviruses and Opportunistic Infections, Montreal, Canada, http://retroconference.org/2009/PDFs/502.pdf, retrieved 2011-06-28, “No difference can be clearly visualized between the inner and outer foreskin.”
Once the hardened skin theory was destroyed, “researchers” moved to indict the Langerhans cells, saying that they are the “prime port of entry” for the HIV virus. deWitte has demonstrated that, contrary to circumcision researchers’ assertions, the Langerhans cells actually help FIGHT the HIV virus, because they release Langherin, a secretion that destroys HIV on contact.
de Witte, Lot; Alexey Nabatov, Marjorie Pion, Donna Fluitsma, Marein AW P de Jong, Tanja de Gruijl, Vincent Piguet, Yvette van Kooyk, Teunis B H Geijtenbeek (2007-03-04). “Langerin is a natural barrier to HIV-1 transmission by Langerhans cells” (PDF). Nature Medicine. doi: 10.1038/nm1541. http://www.circumcisionandhiv.com/files/de_Witte_2007.pdf. Retrieved 2011-06-28.
The quip that “circumcision reduces HIV by 60%” has become pop-science mantra, but scientists and circumcision “researchers” have yet to demonstrably prove that circumcision prevents HIV. Millions are being spent on “mass circumcision campaigns,” and boys and men are being circumcised in Africa, some by force, all using “studies” that are based on completely debunked hypotheses.
I’m glad to read that there is finally actual journalism going on, and people are questioning the matter-of-fact assertion that circumcision prevents anything.
Assuming the studies are true, “researchers” need to explain why their results fail to correlate with other countries in Africa where circumcision is already prevalent. Why was HIV prevalence found to be higher in circumcised men in 10 out of 18 countries, according to UNAIDS? Swaziland was one of these countries, yet millions are being spent on Soka Uncobe, which, if I’m correct, isn’t having too much success.
Why is HIV more prevalent in America, where 80% of the men have already been circumcised from birth, than in Europe, where circumcision is rare? Why are some US HIV hotspots higher in HIV prevalence than HIV hotspots in Africa?
http://www.washingtonpost.com/wp-dyn/content/article/2009/03/14/AR2009031402176.html
Somebody needs to explain how something that never worked in our own contry is going to start working miracles in Africa. Somebody needs to tell Bill Gates, PEPFAR etc. they need to help the people in their own country first before they can pretend to be “humanitarians” in Africa. How can you pretend to help others before you even help your own?
“Physician, heal thyself.”
~Aesop
August 12th, 2011 at 8:58 am (#)
If cutting off childrens noses prevented the spread of HIV/AIDS then this would never be agreed. Children are having part of their body removed without their consent and the procedure is irreversible. From a children’s rights perspective this contravenes the United Nations Convention on the Rights of the Child.
The London Child Protection Procedures now include a section about male circumcision because of concerns following deaths of babies following the procedure. The focus in the guidance (see London Safeguarding Children Board website) is the means by which the procedure is carried out rather than defining the procedure itself as abusive. However, it is the first time this subject has been included in child protection protocols.