posted by Phoebe Gleeson at 9:04 AM
2009 rates fell to 32.5 % of babies circumcised
Cosmopolitan Reports on the Decline of Circumcision in the United States http://www.drmomma.org/2010/08/cosmopoli
"Thanks to Phoebe Gleeson of NOCIRC"
A Chat About Circumcision
So what is circumcision, anyway? Don't they just take a little bit off the top?
It's surgical removal of the foreskin, frenulum and about one-third to one-half of the skin of the penis.
Wait, one-half of the skin of the penis? How can that be?
There's no precise point where the foreskin ends and the skin of the penis begins. During a circumcision, the skin of the penis is peeled back like a banana to expose the mucosal tissue of the head and shaft - tissue like the inside of your mouth. The two types of tissue can be clearly seen on the circumcised penis and the tissue covering the head and upper shaft is very different from the skin below the circumcision scar.
But it just slides back and then they clip it off or something?
No, actually it doesn't even begin to slide back until around age 2 or 3 at the earliest, and frequently much later. In a newborn, the opening of the foreskin is big enough to let urine through and the foreskin itself is tightly fused to the head and shaft of the penis - like a fingernail is fused to the nail bed. It doesn't slide back at all.
Then how do they get it off of there to cut it?
They use a blunt probe to separate them. It feels about like having a fingernail ripped off... except it's on the most sensitive part of the body. The head of the penis looks like the finger minus the fingernail too, very raw and bloody.
So then they just cut it off?
They cut a slit in the side of it and then they usually crush it with a clamp for a few minutes. Then they cut it off. Alternately, they put a plastic bell over the head, and tie a ligature around the foreskin, then cut the foreskin off.
I'm having a tough time visualizing this.
That's understandable. Here's a description of the procedure, with photos.
That all sounds really painful! But they use anesthetic of course.
Um, most often no they don't.
Oh come on! That's barbaric!
It is, isn't it. Sometimes they use a topical cream and even less often they use a shot of stuff like Novocaine. Well under half of all circumcisions are performed with any pain relief at all, and most of those are not especially effective. Here's a video of a circumcison performed with a topical anesthetic, for instance. To read the transcripts of what is said between the doctor and the father, please go here.
It's just skin though. It can't be that important.
It's not "just skin". It's skin on the outside with a thin, sensitive muscle sheath underneath and the same exquisitely sensitive mucosa as the inner edges of your lips on the inside. Right around the edge of the foreskin is a ridged band of tissue which attaches at the frenulum to the underside of the glans. (Together, that band and the frenulum are considered the primary erogenous zone in males - the head of the penis is secondary and much less sensitive.) Not to mention tens of thousands of nerve endings and specialized immune cells.
Hey, most circumcised guys say if they were any more sensitive they'd explode! How is more sensitivity a plus, here?
Probably because the term 'more sensitive' isn't defined. Men needlessly circumcised as adults have reported the sensitivity and sensation before and after as the difference between color vision and only seeing in black and white. Using this analogy, a man circumcised at birth might say "How could I possibly see any better? I can see everything so clearly as it is, and it's beautiful! If there was any more light, I'd go blind!" because without experiencing color, he cannot conceive of how it could be different, richer or better - only brighter.
Well, at least it's beneficial medically. It's much healthier to circumcise, right?
No. There is no medical reason for routine infant circumcision, and no national or international medical association recommends it. It doesn't stop urinary tract infections, it doesn't stop HIV infection, it doesn't stop cancer of the penis or of the cervix. It doesn't stop (or even significantly reduce) any disease.
Doesn't everyone need it done eventually?
Nope. In countries where nonreligious routine infant circumcision is rare (like the UK or Denmark or pretty much everywhere but the United States) at most one in 200 men is circumcised later in life, and the actual number who need it because they cannot be treated in any way but with amputative surgery is 1 in 18,000. Even here in the US, where many doctors recommend circumcision needlessly because they do not know how to treat the foreskin, the rate is less than 8 in one hundred. Circumcising all boys at birth to prevent later need for circumcision is somewhat like removing the breast tissue of all girls to prevent later breast cancer... except the risk of getting breast cancer over a woman's lifetime is one in eight, whereas the need for circumcision for any reason is at less than one-half of one percent.
But, still, it could prevent, uh, something?
Whether there is any true preventative value in amputating the foreskin may never be known, as all of the studies that have ever been done are very ambiguous. What is known is the fact that we don't remove healthy, normal, functional body parts on baby girls, or any other part of baby boys on the off chance it will prevent some nebulous health problem. Presumably if we amputated the toes of newborns we would have far fewer cases of athlete's foot each year, and toe cancer as well. But of course we don't do that - we treat the body if it gets sick, we don't amputate normal bits to prevent possible problems. The foreskin is much the same, and, as the American Academy of Pediatrics has found, the complications and risks of the circumcision procedure outweigh any potential benefits.
It doesn't do any real harm though, beyond the initial healing period.
Assuming you mean other than the harm of removing the foreskin itself, which causes the glans of the penis to become dry and desensitized every time, and the meatus (the opening of the urethra) to scar up and frequently narrow, requiring surgery to fix it about ten percent of the time, yes, it causes harm. The latest statistics show that circumcising is actually the cause of more medical expense over a child's lifetime versus not circumcising. It could easily be said that circumcision essentially turns the penis permanently inside out, and it has about the same effect as it would if we cut off eyelids, or nostrils, or lips. Complications are rampant. Even if circumcisions were free, it would still cost more to circumcise than to leave the penis alone.
OK, so there are no medical reasons, but it's cleaner, isn't it?
It's not cleaner or dirtier to be circumcised or not circumcised. Either way parents should teach their children to wash their genitals the same way they teach them to wash their ears. The foreskin requires no special care.
But I have to keep it clean for him before he's old enough! That sounds complicated!
It's not complicated at all! Here's the three steps to cleaning the intact child too young to attend to his own bathing:
1. Wash the outside of the penis like a finger.
2. Don't try to pull the foreskin back or retract it.
3. The End.
Won't other kids make fun of him?
It's not too likely, seeing as how barely half of the boys born in America today are circumcised (52% in 2003 and decreasing each year) and worldwide around 85% of men and boys are not circumcised. Besides, kids make fun of lots of things. Best to raise a child to be happy with his normal body, rather than cut healthy parts of it off.
I think the foreskin makes the penis look... weird.
That's mainly because a circumcised penis is what you are used to seeing. We don't carve up other healthy, normal parts of our kids' bodies without their consent because they offend our personal aesthetics - the genitals should be the same!
He'll just want it done when he gets older though.
If men actually preferred being circumcised versus being whole and intact, then most of the men in the world would be circumcised as adults. But the thing is, they aren't, because they don't. Cultures where circumcision is common circumcise sexually immature infants and children, or adolescents on the cusp of puberty - all people who cannot give consent. Now, that said, should your son decide he wants to be circumcised he can be, and the operation is much less traumatic and less prone to complications as an adult with a mobile foreskin and an adult-sized penis.
There has to be a reason why people are doing this then?
Well, really there are many "reasons", but the main reason babies and children are genitally cut in any culture and for either sex is because their parents were genitally cut, and thus think of their altered state as normal. It's crazy when you think about it, but there you have it.
Yeah, what about when the father or older brother is circumcised? Shouldn't they look the same?
There are so many inborn differences between fathers and sons and between brothers. Some will have brown eyes, some will have blue, some will have their mother's nose and their grandfather's hands. A child will never be a carbon copy that looks just like his father and it is silly to insist that the son have cosmetic surgery on his normal penis so it will look like Dad or big bro. What if the father is missing a finger or has scars from an accident or any other surgery? We don't mark the son similarly then! If older brothers are circumcised it's easy to tell the boys that when the older brother was born his penis looked like the younger boy's penis but back then the parents thought it was a good idea to cut off his foreskin (and that they thought that was a good idea when Daddy was born, too, if that's relevant) but now we don't do that anymore. It really is that simple!
It's traditional in my family to circumcise the boys.
In America (unless you're Jewish or Muslim) your "family tradition" is likely about two or three generations old at most and involves your father, possibly his father, and you. The real tradition is to have a whole, normal penis, not one with an amputated foreskin. Newborn circumcision was unknown in the U.S. outside of Jewish families until the beginning of the 20th century, and the circumcision rate peaked in the 1970s at about 90%. It's been dropping ever since, and is now right around 50%. Many Jewish and Muslim families are opting to leave their children intact and let them decide whether they want to be circumcised, as well.
So let me see. No medical reason, in fact it can actually cause more harm... hmm, not any cleaner, and and we don't perform cosmetic surgery on any other normal body parts without consulting the owner of the body... Well gosh. There's really no reason to do it at all!
More information can be found here:
Hey! It's A Boy!
Dr. Dean Edell on Circumcision
Circumcision Information Resource Pages
"Circumcised my son and I regret it" thread at Mothering Magazine forums
Catholics Against Circumcision
Jewish Circumcision Resource Center
- Name:Phoebe Gleeson
- Location:Oklahoma, United States
Mother of four
- NOCIRC articles on circumcision
- Position statements of medical organizations worldwide
- Circumcision Information Resource Pages
Informational Pamphlets in Adobe Acrobat PDF format
- About NOCIRC
- NOCIRC Resource Guide
- About Infant Circumcision
- Your Young Son's Intact Penis
- Your Young Son's Circumcised Penis
- Forcible Retraction of Foreskin
- Circumcision After Neonatal Period
- Care of the Intact Penis for Elderly
- Female Circumcision
- Bioethics of Infant Circumcision
- More Information Available at NOCIRC.
Science Fact or Science Fiction:
Could Circumcision Really Prevent AIDS?
by Norm Cohen, Director, NOCIRC of Michigan
AIDS has been a major fear of sexually active people worldwide. The claim that circumcision might somehow prevent it has been widely circulated in the popular media and in medical journals. This claim may seem quite surprising to Americans, who have lived with circumcision far longer than they have lived with AIDS. In South Africa, however, with an HIV infection rate 31 times that of the United States, this proposal is being taken seriously.1
In a Class All By Itself
As a preventative, circumcision is in a class all by itself. Nowhere else in medicine has universal surgery been recommended as a means of preventing disease. Nowhere else is surgery on a healthy organ considered an alternative to proper hygiene.
The extraordinary history of circumcision as a medical panacea, and as ancient religious and tribal rites, strongly suggests that latter-day claims in favor of circumcision should be regarded with a high degree of skepticism. For 140 years, circumcision has been proposed as a solution to the most frightening diseases of the times. Over 60 different diseases have been supposedly prevented or cured by circumcision. These diseases have included .masturbation insanity,. syphilis, gonorrhea, penile cancer, cervical cancer, urinary tract infections, and now AIDS.
Each time, evidence was subsequently produced (but not widely publicized) that negated the claim. It is from this historical context that calls forcircumcization (mass circumcisions) to prevent AIDS in Africa should be examined.
Whenever a lack of scientific understanding of ills associated with the penis is combined with the urgency of fear, the circumcision proposition finds fertile ground. Since there has not been much success in reducing the AIDS epidemic in Africa, it is very tempting to believe in quick fixes and miracle cures. Ironically, this proposal may negate any protective effects claimed by accepting risky sexual behavior as the status quo and by encouraging circumcisions in unsterile conditions.
Here are the main arguments that explain why circumcision to prevent AIDS is not good public health policy and cannot be taken seriously:
A Study in Contradictions
When presented with a proposed solution, a test of the solution should be made in populations other than those used to promote the solution to check for consistent results. Proposals that fail this test are inevitably bad science, no matter how fancy a study appears to be.
January 21, 2007 1 of 18 NOCIRC of Michigan
The proposal that circumcision prevents HIV infection fails this test. Of the 35 observational studies included in a stringent review, 16 gave inconsistent results for the general population.2 At least 20 published observational studies do not show support for circumcision in preventing HIV infection.
All of the randomized controlled trials of circumcision were limited to three countries in southern Africa. Researchers detected an annual HIV incidence rate incircumcised men over 6 times higher than the annual incidence rate for African-American men in the United States.3 Due to this .success., they stopped the trials early.
The probable mode of transmission for HIV (e.g. heterosexual sex) is often reported when a new infection is reported. The World Health Organization estimates that heterosexual sex has accounted for 75% of the HIV infections in adults worldwide.4 Heterosexual intercourse has been the dominant route of transmission in Africa, Asia, South America, Central America and the Caribbean. In Western Europe, more than half were acquired during heterosexual intercourse.5 In the United States, one-third of HIV infections are transmitted through heterosexual contacts.6
The circumcision status of a man is not normally reported when a new infection is reported. Therefore, it is difficult to make estimates of the numbers of circumcised men who acquired the infection from heterosexual sex.
For the purpose of a worldwide estimate, and lacking other data, we will use the claim by researchers that there is roughly a 50% reduction in the incidence of HIV infection among circumcised men.7 The estimates of adult males who are already circumcised is 62% in Africa8, 75% in the United States9, and 20% in the rest of the world10.
So even if circumcision reduced the risk of HIV infection by 50%, over3.5 million circumcised men worldwide are living with an HIV infection that they acquired through heterosexual sex. This hardly qualifies circumcision as an AIDS vaccine!
The rate of circumcision and the rate of HIV infection in the United States are the highest among all developed nations. Over 500,000 circumcised American men have been infected with HIV from sex since the epidemic began.11 Regional differences in American circumcision rates don.t match up with regional differences in HIV infections. No studies of men in the United States have been able to demonstrate a correlation between heterosexually acquired HIV infection and the presence of a foreskin.
The Xhosa people of South Africa circumcise, while the Zulus do not. However, both tribes have the same HIV infection rate. In Ethiopia, 93% of the men are circumcised.12 In Uganda, 25% of the men are circumcised.13 However, both countries have the same rate of HIV infection. In Cote dIvoire and Gabon, 93% of the men are circumcised, but the HIV infection rate is even higher in those countries than in Ethiopia.
January 21, 2007 2 of 18 NOCIRC of Michigan January 21, 2007 3 of 18 NOCIRC of Michigan
In Lesotho, the HIV infection rate is substantially higher among circumcised men (23%) than among males who are not circumcised (15%).14
The lowest rates for all sexually transmitted diseases, including AIDS, remains the Scandinavian nations, where circumcision is virtually unknown.
On the graph that follows there are several examples of countries that contradict the claim that circumcision prevents HIV infection.gan
Making Fiction from Science
The claim that circumcision prevents AIDS was made on the basis of observational studies of men already circumcised and randomized controlled trials where men underwent a circumcision at the start of the study.
All of the studies attempted to predict what happened on a microscopic level by studying conditions on a macro level, which is far less precise. Researchers were not able to observe exactly when, where, or how each individual got infected. Therefore, a fundamental assumption was made that it is possible to draw conclusions about themode of transmission of HIV by enumerating the success of transmission in specific populations.
This assumption could produce misleading conclusions about the role of the foreskin in HIV infection. The rules of evidence in medicine are much lower than the rules of evidence in our legal system. The exactcause of changes in HIV infection rates did not have to be proved by the studies, and was not. In fact, the cause cannot be proved statistically.
Circumcised status and HIV infection are the two variables that researchers compared statistically. The researchers claim that there is acorrelation between the rate of HIV infection and circumcision status. Correlation is the interdependence between two variables. It does not mean that a change in the rate of HIV infection is necessarily caused by a change in circumcision status. Correlation is not the same thing as causation, but the researchers also claimed that the correlation was caused by circumcision status.
The researchers maintain that the difference in HIV infection rates isnot due to many other, confounding factors that might also influence infection rates. If these infection rates do actually depend on other confounding factors, then the results will be reinforced by these other influences.
In an attempt to prevent this, researchers try to .control for. these other factors. In an ideal experiment, all of the confounding factors that could possibly affect the experiment are kept constant so as to eliminate their effects on the outcome. These controlled factors are never supposed to change.
Researchers often claim to have adjusted for .potentially confounding factors,. but this can.t be done completely because all of these factors are simply not known. In practice, researchers can only control for known factors, and only then if they are measured without errors. Even if an attempt is made to control for these known factors, in practice, the control group is not always unpolluted by them.
When a researcher is able to control for the actual factors for the spread of a disease in a population, the hypothetical reason may be found to be wrong. Alternately, if a researcher
So convenient a thing it is to be a reasonable creature, since it enables one to find or make a reason for everything one has a mind to do.
January 21, 2007 5 of 18 NOCIRC of Michigan
did not control for the actual factors in the spread of a disease because it was not measured or is not known, then the conclusions drawn from the study will be wrong. If all the variables controlled for are not independent of each other, then the results of the study will be misleading and unreliable.
Since circumcision is practiced for religious and cultural reasons, it is not chosen or practiced at random. Foreskins are found among men who have risk factors that actually spread HIV without any help from their foreskins. Significant factors such as sexual practices, number of partners, limited healthcare, poor hygiene, and drug use all have some association with having or not having a foreskin. These and other confounding factors were often not controlled for in the studies and make meaningful comparisons impossible.15
Any study may also introduce confounding factors by virtue of its existence. For example, the men studied were those who had easy access to a health clinic and willingly showed up there to be interviewed.
Observational studies comparing HIV infection rates in circumcised versus uncircumcised men were poorly designed, inconsistent, and misleading. The observational data varied widely, with no definitive support for circumcision. The studies often contradicted each other in their findings.
When several observational studies were refined with an analysis for confounding factors, the perceived advantage of circumcision disappeared.16, 17 Controlling for confounding factors eliminated the difference between HIV infection rates between the circumcised and intact groups, indicating that circumcision was not the real reason for a decreased HIV infection rate.
If confounding factors are controlled for, the researcher has to somehow isolate the research subjects having those factors. This often divides the target population into smaller subgroups, thereby reducing the statistical power of the results. A positive correlation could be due merely to the over or under sampling of a subgroup.
The confounding factors listed below have all been associated with an increase or decrease in HIV infection. Some of these confounding factors have probably created a spurious correlation between circumcision status and HIV infection rate by operating in favor of the results.
age at circumcision
non-sterile medical procedures
age at first intercourse
number of partners
other sexually transmitted infections
drug and alcohol use
duration of intercourse
retractability of the foreskin
severity of circumcision
frequency of intercourse
sex during menses
Doctors Opposing Circumcision
The Use of Male Circumcision to Prevent HIV Infection
A statement by Doctors Opposing Circumcision
Introduction. There have been a number of exaggerated claims made for the alleged efficacy of male circumcision in preventing female-to-male infection with the human immunodeficiency virus (HIV) This statement examines those claims and puts them in proper perspective.
History. The theory that male circumcision may be protective against HIV infection was invented and developed in North America. According to Professor Valiere Alcena, MD, he originated the theory that removing the foreskin can prevent HIV infection in an article1 in August 1986.2 The late Aaron J. Fink, MD, a noted North American advocate of male circumcision, then promoted Alcena's theory in letters to medical journals.3-5 North American Gerald N. Weiss, MD, who operates a website to promote circumcision, and others contributed to the development of the theory through a paper, which was published in Israel (1993), identifying the prepuce as a possible entry point for HIV.6 North American circumcision enthusiasts have further promoted male circumcision with opinion pieces in medical journals.7,8 Stephen Moses, Daniel T. Halperin, and Robert C. Bailey are other well known North American promoters of male circumcision.8,9
Numerous observational studies were carried out in Africa, but the evidence-based Cochrane Review (2003) found insufficient evidence to advocate a circumcision intervention to prevent HIV infection.10
Randomized controlled trials. After the failure of observational studies to show a clear protective effect, circumcision advocates obtained funding from the United States National Institutes of Health to conduct randomized controlled trials (RCTs) in Africa. Three RCTs to study the value of male circumcision in reducing HIV infection have been conducted in Africa since the publication of the Cochrane Review. The studies were intended to find out if circumcision is an effective intervention to prevent female-to-male HIV infection. A RCT under the supervision of Bertran Auvert, French circumcision proponent, was carried out in Orange Farm, South Africa;11 a RCT was carried out in Kenya under the supervision of North American circumcision proponent Robert C. Bailey and Stephen Moses;12 and a RCT was carried out in Uganda under the supervision of North American circumcision proponent Ronald H. Gray.13 Dr. Auvert has been a circumcision proponent since at least 2003.14 Professor Moses has been an advocate of circumcision at least since 1994.9 Professor Bailey has been a circumcision advocate since at least 1999.8
All three studies found that non-circumcised males contract HIV infection more quickly than circumcised males. This may be because the circumcised males required a period of abstinence after their circumcision. All three studies were terminated early, before the incidence of infection in circumcised males caught up with the incidence of infection in the non-circumcised males. If the studies had continued for their scheduled time, it is probable that there would have been little difference between the circumcised group and the non-circumcised group. Mills & Siegfried point out that early termination of such studies cause the benefits to be exaggerated.16
Cultural bias. When studying circumcision, cultural bias must be considered:
Circumcision practices are largely culturally determined and as a result there are strong beliefs and opinions surrounding its practice. It is important to acknowledge that researchers' personal biases and the dominant circumcision practices of their respective countries may influence their interpretation of findings.10
More than 50 percent of infant boys in North America still are subjected to non-therapeutic circumcision. There is a well known cultural bias in favor of circumcision in North America,17-20 which may influence doctors at the National Institutes of Health as well as those directing the studies. Doctors conducting these studies may not possess the necessary attributes of neutrality and objectivity. Ideally, researchers from circumcising cultures, circumcised themselves, would recuse themselves from considering the data.
Risks, complications, and drawbacks. The reported complication rate of 1.7 percent seems unreasonably low. Williams & Kapila estimated the incidence of complications at 2-10 percent;21 In the survey by Kim & Pang, 48 percent reported decreased masturbatory pleasure, 63 percent reported increased masturbatory difficulty, and 20 percent reported a worsened sex life after circumcision.22
Effectiveness. Circumcision does not prevent HIV infection. The Auvert study in South Africa reported 20 infections in circumcised males.17 A study in Kenya reported 22 infections in circumcised males. Brewer & found higher rates of HIV infection in circumcised virgins and adolescents.23 The United States has the highest rate of HIV infection and the highest rate of male circumcision in the industrialized world. Male circumcision, therefore, cannot reasonably be thought to prevent HIV infection.
There are many methods of HIV transmission, including:
- mother-to-child infection,
- transfusion of tainted blood24
- infection with non-sterile needles used in health care,24
- infection by homosexual and heterosexual anal intercourse,25
- infection by needle sharing to inject illegal drugs,
- traditional African scarring practices,
- tribal (ritual) circumcision,23
- female circumcision,26
- male-to-female heterosexual transmission, and
- female-to-male heterosexual transmission.
Male circumcision might only reduce infection by the last method, so the overall influence on the HIV epidemic in Africa, at best, would be likely to be slight, however, the risk of male-to-female transmission is much higher than that of female-to-male transmission, so a means of partial prevention that targets only the second means at the expense of the first would be counterproductive.
There is no indication that male circumcision would protect women. Viral load is the chief predictor of the risk of HIV transmission.27 Malaria infection increases viral loads, so enhances infectivity.28 Male circumcision would not reduce viral loads and would not reduce infectivity to the female partner. One study, however, has shown female circumcision to be strongly protective.29
Condom usage. Condoms have been shown to be effective at preventing HIV transmission.30 The use of condoms is necessary to prevent infection whether or not the male is circumcised.
Effect on condom use. Male circumcision removes nerves from the penis31 and causes significant loss of sexual sensitivity and function.32 For this reason, many circumcised men are reluctant to use condoms. A program of mass circumcision may reduce condom usage and have an adverse effect on the overall HIV infection incidence.
Vaginal abrasion. "Dry sex" is practiced in sub-Saharan Africa.10 3 Women place various drying agents in their vagina to absorb vaginal lubication. This practice may itself cause abrasion and fissures that provide a portal for the HIV virus.10 28 Circumcision also reduces vaginal lubrication, curtails the gliding action, increases friction and vaginal abrasions,34 so, when combined with "dry sex", may increase the risk of female HIV infection through abrasions. The combination of dry sex and circumcision appears to sharply increase the risk of male-to-female transmission of HIV. A recent preliminary report found that the female partners of circumcised males experience higher rates of HIV infection.35
Relevance to developed nations. These African studies were carried out in HIV hot-spotsplaces where the incidence of HIV infection in the population is high and where the method of transmission is heterosexual intercourse. They are not relevant to developed nations, such as the United States, where the incidence of infection is low and where the predominant methods of transmission are through homosexual anal intercourse or through needle-sharing by drug addicts.36
Circumcision of children. These RCTs cannot be used to support the practice of non-therapeutic circumcision of children. Infant boys do not engage in sexual intercourse so they are not subject to sexually-transmitted HIV infection. They, however, are subject to various complications of circumcision, including infection through an open circumcision wound with various pathogens, such as deadly CA-MRSA.37,38 Other risks include hemorrhage, exsanguination, and death;39 and various surgical accidents, including urethral fistula,40 penile denudation,41 and traumatic amputation of the glans penis.42 By the time todays newborn boys became sexually active, HIV vaccine is likely to be available so circumcision today, in an attempt to prevent HIV infection in the distant future, is contraindicated.
The high infant mortality rate in the African countries hardest hit by the HIV epidemic means many childen will die before they become sexually active, further vitiating any protective effect of infant circumcision. The time, effort and money would be better spent on community health measures that would preserve their lives and those of their parents.
Discussion. Effective methods of reducing HIV infection include education and behavior change.45 Abstinence before marriage and fidelity after marriage offer men and women the greatest protection in avoiding HIV/AIDS transmission.
Men who have been circumcised may consider themselves immune to HIV and at no risk to their female partner. That, however, is not the case. Circumcised men may still contract HIV and pass it on to their next partner.
The reported complication rate of 1.7 percent seems unreasonably low. Williams & Kapila estimated the incidence of complications at 2-10 percent;21 In the survey by Kim & Pang, 48 percent reported decreased masturbatory pleasure, 63 percent reported increased masturbatory difficulty and 20 percent reported a worsened sex life after circumcision.32
The authors of the RCTs have engaged in the promotion of circumcision.46,47 Van Howe and colleagues argue that their true motivation may be the introduction of universal male circumcision, using fear of HIV as the tool with which to accomplish their goals.46
Social problems. The introduction of male circumcision into a non-circumcising society may present problems such as:
- adverse psychological and sexual effects caused by the diminishment and desensitization of the penis,48
- increased antisocial behavior,48
- violations of human rights,48
- violations of laws that protect children,48 and
- inability to discontinue male circumcision when the need for it no longer exists.48
Politics. The HIV/AIDS epidemic is quite severe in several African nations. In some areas, a high percentage of the population is HIV+. Public health organizations are under intense pressure to solve the problem. The use of male circumcision to prevent HIV infection is akin to a drowning man grasping at a straw. Although male circumcision is likely to be proposed for political reasons, it is likely to have little effect on the overall incidence of HIV infection and may cause later problems. According to Ntozi:
It is important that, while circumcision interventions are being planned, several points must be considered carefully. If the experiment fails, Africans are likely to feel abused and exploited by scientists who recommended the circumcision policy. In a region highly sensitive to previous colonial exploitation and suspicious of the biological warfare origin of the virus, failure of circumcision is likely to be a big issue. Those recommending it should know how to handle the political implications.49
Opposing evidence. Both the public and the medical community must guard against being overwhelmed by the hyperbolic promotion of male circumcision and must receive these new studies with extreme caution. There is contradictory evidence that male circumcision is not as effective as proponents claim. One study found that male circumcision had no protective effect for women50 and another study found that male circumcision increased risk for women.51 Grosskurth found more HIV infection in circumcised men.52 Barongo et al. found no evidence that lack of circumcision is a risk factor for HIV infection.53 A study from India found little difference between circumcised and non-circumcised men in the conjugal relationship.54 A study carried out in South Africa found that male circumcision offered only a slight protective effect.55 A study carried out among American naval personnel found no difference in the incidence of HIV infection between non-circumcised and circumcised men.56
The future. The development of a vaccine is the best hope for the solution to the HIV epidemic.57 Several teams of scientists are working to develop vaccines that will prevent infection with HIV and other vaccines that will treat those already infected.58 Phase II trials are now getting started.59 The Bill & Melinda Gates Foundation has contributed $287 million to 16 research groups for development of a vaccine.60
Conclusion. Male circumcision is a highly emotive operation that generates strong feelings in many men,10 especially those who have been circumcised,61 as have most North Americans. The trauma associated with the operation may generate a desire to repeat or reenact the trauma.62 Other men may feel a need to justify their own circumcision by the generation of claims of health benefits.61 The medical literature is full of protective claims for various diseases, such as sexually transmitted disease (formerly called venereal disease),63 male and female cancers, and urinary tract infection.64 All such claims have been disproved.
The RCTs on which the current claims are based have been carried out by men who have a previous history of promoting circumcision. DOC has little confidence in such studies, especially since contradictory evidence exists.
Male circumcision may increase male-to-female transmission of HIV and mitigate any reduction in female-to-male transmission. A preliminary report confirms the increased risk to women.65
Instituting a program of male circumcision is of dubious value. It will divert resources from proven methods of epidemic control and it may generate a false sense of security in males who have been circumcised. The desensitization of the penis that frequently results from male circumcision is likely to make men less willing to use condoms. A program of male circumcision very likely may worsen the epidemic.
Calls are being heard for the circumcision of children although (assuming that male circumcision is effective at controlling female-to-male infection) this could not be helpful until the child becomes sexually active. The non-therapeutic excision of healthy body parts from non-consenting children is a violation of human rights43 and medically unethical.44 Therefore, the true motivation of the circumcision proponents must be questioned.46 It may be perpetuation of neonatal circumcision, not control of HIV.
DOC believes that more emphasis on education, behavior changesuch as abstinence before marriage and fidelity after marriage, provision of condoms, treatment of other sexually transmitted diseases, treatment of genital ulcer disease, control of malaria, and provision of safe healthcare would be more likely to produce beneficial results. The ultimate answer is likely to be one or more of the vaccines now in development.
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Doctors Opposing Circumcision
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Revised March 2007