From: http://www.circinfo.org/hiv.html#9

HIV-AIDS and Circumcision
The latest argument for circumcising normal male infants is that, even if all the other reasons for circumcision have proven to be rubbish, at least it will protect them from the AIDS virus.

The claim is wrong because circumcision does not protect against HIV infection, and it is irrelevant because, even if it did, infants and boys are not at risk because they do not have sex with carriers of the virus.

On this page

Introduction

African health crisis is not an argument for circumcision in developed countries

HIV: It’s what you do, not what you have, that counts

Dangers of introducing circumcision

A typical newspaper article, with critical comments

Comment from an AIDS educator

( Luo Female demonstrate to “Raila” in “chiro mbero” that they refer their men to use condom not foreskin chopping?)

HIV-AIDS: Many African cases not caused by sexual contact

British study finds higher incidence of HIV in circumcised men

Comparative studies show that education reduces HIV infection

Why circumcision will not save the world from AIDS
Further information

Introduction
Over the last ten years or so a small band of mostly American researchers have been trying to convince the world that the male foreskin is the most important risk factor for HIV infection and therefore that circumcision is the most effective strategy against AIDS.

There is nothing new in this sort of argument. Whenever a horrible and incurable disease appears, people look for scapegoats, and if it is a sexually transmitted disease they focus on the genitals. In the nineteenth century it was claimed that circumcision gave immunity to syphilis, and the claim that it will do the same for HIV is pretty much a rerun of the same sad delusion.

Although they have received massive publicity in the media, these efforts have not been very successful. The UNAIDS organization – the international body responsible for coordinating the global response to the AIDS crisis – has not been impressed, and it does not consider circumcision to be a useful tactic.

At the most recent world conference on AIDS (Bangkok, July 2004) circumcision hardly got a look in, and the word does not appear in the UNAIDS report for 2004. Instead, researchers have focused on African sexual behaviour, with its high level of promiscuity and the frequency of prostitution. Even Roger Short is now recommending lemon juice instead of the removal of normal body parts.

The approaches recommended are those which have been proven to be successful in reducing the incidence of HIV infection. The most important of these is safe sex education, since nobody is at risk of sexually-transmitted infection with AIDS unless he or she engages in unsafe sex (usually unprotected intercourse) with an infected person.

On top of this, recent research has shown that up to a third of African HIV cases are not transmitted sexually at all, but by unsafe medical practices – such as non-sterile instruments and needles. If this is true, circumcision is likely to be spreading AIDS, not stopping it.

Other studies suggest that the epidemic level of HIV in Africa is due to genetic factors – that Africans lack a resistance gene found in Europeans.

This would explain a major puzzle: why HIV infection is at a low level in Europe, where hardly anybody is circumcised, but rages at pandemic levels in Africa, where about a third of the population is traditionally circumcised as part of religious or tribal customs.

Logically, you would think that if circumcision made such a big difference, AIDS would be a bigger problem in Europe than in Africa.

Although the claim that circumcision provides significant protection against HIV infection has received a lot of publicity, it would not be relevant in a developed country like Australia even if it was true.

In third world countries like Africa, AIDS is a disease affecting heterosexual people, and now more women than men. In Australia AIDS is a significant problem only within small communities, such as male homosexuals and intravenous drug users.

In Australia, people do not live in poverty without access to medical care or running water. Men do not commonly practise polygamy or have frequent unprotected intercourse with prostitutes. African women are likely to be under the patriarchal thumb; women in Australia can say, “If it’s not on, it’s not on”.

Australian children do not engage in the sort of sexual practices which put them at risk of HIV. Circumcision will not protect them from infection from dirty needles or contaminated blood should they need a transfusion. When a boy grows up and if he wants to engage in casual sex, he is old enough to know about safe sex and condoms.

Safe sex education in Australia has kept the level of HIV infection at a low level. If they are going to be sexually promiscuous, people know that they should use condoms, and they can buy them cheaply at any supermarket.

Sexual behaviour, possibly abetted by genes, not anatomy, is the explanation for the spread of AIDS. It is irrational and unscientific to blame normal body parts for the action of micro-organisms.

African health crisis is not an argument for circumcision in developed countries “Ex Africa semper aliquid novi”, said the ancient Romans, “always something new out of Africa”. So it is today, when we hear nothing but bad news from the dark continent – drought, disease, war, famine and now circumcision.

After many years of fruitless endeavour and an expenditure running into hundreds of millions of dollars, evidence has finally come to light that in Africa men who have unprotected intercourse with HIV positive partners are less likely, or will take longer, to become infected with HIV if they have been circumcised.

The protective effect is estimated at 50 per cent, meaning that if it takes an uncircumcised man eight sessions of unsafe sex to get infected, it will take a circumcised man twelve sessions.

How this rather limited protection justifies talk of a “vaccine”, or authorises circumcision of sexually inactive – and thus not at risk – infants and boys, is not at all clear. The media hype surrounding the results of the clinical trials [1] on which these conclusions are based have been out of all proportion to their real significance.

The point to remember is that the developed world is not Africa, which faces such a crisis situation (poverty, poor levels of health and education services, very high levels of HIV infection and of prostitution etc) that resort to desperate measures is understandable.

There is no such crisis in developed countries, where HIV has been successfully managed and is confined to specific sub-cultures (homosexual men, especially those who take the passive role in anal intercourse, to whom being circumcised will be no help at all), intravenous drug users (ditto) and immigrants from … well, Africa.

You would not know it from the media coverage, but the World Health Organisation/UNAIDS are not recommending indiscriminate circumcision, but only that circumcision be offered as a preventive option to high risk groups in Third World countries where other (more effective) means of protection (such as safe sex education, fidelity, abstinence and condom use) seem to be impossible to achieve).

Who is at risk?
Infants and children, especially in the developed world, are not an at-risk population because they are not sexually active.

You might argue that it is better to take away a boy’s foreskin now than to see him contract AIDS at some unknown date in the future – and who would disagree? But the argument is valid only if circumcision were the only way to avoid AIDS and if it were pretty certain that he would get AIDS if he were not circumcised.

In fact, the main risk factor for AIDS is not the foreskin, but unsafe sex; the best, cheapest and most certain way to avoid this easily avoidable disease is not to engage in unsafe sex practices and to avoid sex with partners likely to be HIV positive, such as prostitutes, casual sex workers and the generally promiscuous.

There is plenty of time to get this message across to boys before they become sexually active.

Prostitution a bigger problem than anatomy
The prevalence of prostitution is a major factor in the spread of heterosexually transmitted AIDS, yet government agencies have been extremely reluctant to regulate the sex industry or restrict the activities of the prostitutes in any way because such action might infringe their civil or human rights.

At the same time, they have recommended widespread circumcision of male infants and boys, whose own civil and human rights are thus treated as non-existent or of no account.

It is of interest that in Senegal, one of the few African countries where the AIDS threat was faced early on and efforts were made to regulate the sex industry and ensure that prostitutes received regular health checks, the incidence of HIV infection is only around 2 per cent, compared with 30 or 40 per cent in places such as Tanzania or Botswana. (For Senegal, see Martin Meredith, The State of Africa: A History of Fifty Years of Independence (London: Free Press, 2005), p. 367.) The sad fact is that little boys are an easier target.

As Philip Setel has shown in A Plague of Paradoxes: AIDS, Culture and Demography in Northern Tanzania (University of Chicago Press, 1999), there is a very high incidence of prostitution, of various kinds, throughout sub-Saharan Africa, and a very high incidence of HIV infection among the prostitutes. (See review in Archives of Sexual Behaviour, Vol. 34, December 2005).

Africa is not Australia
In Africa the problem that circumcision is meant to address is heterosexually acquired HIV through Female to Male transmission via unprotected intercourse. in the West there is negligible F to M infection, and most workers in the sex industry are insistent on safe sex and condoms.

In the West, the at risk populations are promiscuous male homosexuals [1] and intravenous drug users. Circumcision will not affect HIV transmission in these groups.

Western countries such as Australia have low rates of HIV infection because our policies of safe sex education have been successful. What children need to be taught is how to avoid this easily avoidable disease; they do not need, and they do not deserve, to have their natural anatomy forcibly altered.

The data from the Africa trials [2] say nothing about the effectiveness of infant or child circumcision, since the trials were confined to sexually active adult men who consented to the procedure.

Circumcision does not confer immunity to HIV infection. The level of risk reduction shown (50 per cent) is not sufficient to warrant talk of a vaccine. The protection is not lifelong, and it is far less than the 90 per cent protection given by regular condom use and observation of other forms of safe sex.

There is no evidence that circumcision later in life is more risky or harmful than in infancy. On the contrary, all the evidence is that the younger it is done the more harmful, risky and painful it is, because of the tiny size of the organ, ignorance as to the eventual size of the penis and length of foreskin at puberty, and the impossibility of safe and effective anaesthetic.

If those urging compulsory circumcision of children in preference to optional circumcision of sexually active adult men believe that circumcision in adulthood is so risky, why did they not raise concerns about the dangers of the African circumcision trials, conducted as they were on adults? (Is it the presence of consent that upsets them?)

History urges scepticism
In the days of the Roman Empire many African peoples already practised circumcision (both male and female) as a cultural ritual. The arrival of imperialism in the form of Roman soldiers and administrators meant that such practices were discouraged as abhorrent to civilized people.

Today western medical imperialism is having the opposite effect, spreading circumcision from circumcising to non-circumcising cultures, with the excuse that it is the only measure that can stop the AIDS pandemic.

Desperate fears produce desperate reactions, but one wonders how much emotional baggage is bound up in this massive effort. It is interesting to recall that in nineteenth century United States respectable doctors demanded compulsory (legally mandated) circumcision of American Negroes to control syphilis (the AIDS of that era), and even to protect white women from sexual assault.

Further details on “Solving the Negro rape problem”
Further information on ethical aspects of prophylactic surgery as a disease control strategy on low income countries

NOTES
1. Because AIDS is not a really serious public health issue in the developed world, there is not much research on the difference in rates of HIV infection between circumcised and uncircumcised men in developed countries, but two significant studies (in Britain and the USA) both found a higher incidence of HIV among circumcised men:

David Reid, Peter Weatherburn, Ford Hickson, Michael Stephens, Know the score: Findings from the National Gay Men’s Sex Survey (London 2001)

Laumann, EO, Masi CM, Zuckerman EW. Circumcision in the United States: Prevalence, Prophylactic Effects, and Sexual Practice. Journal of the American Medical Association 1997;277(13):1052-7

2. The clinical trials are, in any case, a bit fishy for several reasons.

(1) They were not blind (as they should have been).

(2) They were not random, in that the men chose whether to be or not to be circumcised, thus allowing the likelihood that the former group were more cautious than the latter.

(3) There is no reason to suppose that the two groups men then had similar sexual experiences: more of the circumcised men might have had more sex with negative partners than the other group, or they might have engaged in less risky sexual practices, meaning that they were less exposed to risk; in these cases you could not know whether it was the differing behaviour or the altered anatomy that conferred the protection.

(4) The trials were terminated prematurely, allowing suspicions that the most favourable moment for statistical purposes was chosen.

(5) It is common for the early results of clinical trials to be highly and misleadingly positive, inspiring premature optimism. For an analysis of why this is so, see John P.A. Ioannidis, “Why Most Published Research Findings Are False”, Plos Medicine, Vol. 8, 2005, online at

HIV: It’s what you do, not what you have, that counts
It is sexual behaviour, not anatomy, which is the main factor determining whether a person will become infected with STDs. This fact seems to elude those naive but brutal researchers who think they have found a miracle solution to the AIDS crisis in penile surgery.

They might as well advocate the pre-emptive excision of a lung so as to reduce the danger of SARS, or cauterisation of the nasal and throat passages so as to block the many common infections which get in that way. To say nothing of what might be done to women to reduce the area of their susceptible (”treacherous”) genital mucosa.

It’s interesting that arguments about cultural autonomy does not seem to carry much weight here. It seems to work only one way.

According to many defenders of traditional tribal practices, who tend to be romantically anti-western and anti-modern in their tenderness for the exotic and the primitive, we are not allowed to discourage circumcising cultures from dropping the practice. But it’s fine and commendable for American medical bodies to try to foist circumcision on non-circumcising cultures in Africa, and even India, as a supposedly valuable tactic in the fight against AIDS.

One would have thought that such a blatant example of medico-cultural imperialism, and from the USA at that, would have sent those who value the specificity of other cultures up in arms. Isn’t it an example of racist stereotyping for Americans to assume that sex-crazed black men will never be able to direct their sex drive into safe channels, but must be forced to have their penises surgically altered?

The idea that pre-emptive surgery is the miracle-working answer to the AIDS crisis should be treated very sceptically. The evidence for it is on a par with the abundant evidence in nineteenth century medical journals that masturbation caused tuberculosis, madness, pimples and premature decay (et tutti quanti), and the equally promoted delusion that circumcision provided immunity to syphilis. Whenever an incurable illness turns up, desperate people try to find scapegoats: in the Black Death it was witches and Jews. In the nineteenth century, when sexuality was seen as the root of most evil, doctors blamed “sexual excess” for many diseases, the foreskin for premature sexual arousal, masturbation, epilepsy and a host of other illnesses, and the clitoris for hysteria, catalepsy and other nervous complaints.

American medicine has a particularly fine record in this area. In 1896 the Medical Record listed the following indications for male circumcision:

Hygienic indications: phimosis, paraphimosis, redundancy (where the prepuce more than covers the glans), adhesions, papillomata, eczema, oedema, chancre, chancroid, cicatrices, inflammatory thickening, elephantiasis, naevus, epithelioma, gangrene, tuberculosis, preputial calculi, hip-joint disease, hernia.

Systemic indications: onanism, seminal emissions, enuresis (Bed wetting), dysuria, retention [of urine], general nervousness, impotence, convulsions, hystero-epilepsy. (Medical record, Vol. 49, 1896, p. 430).

Dangers of introducing circumcision
For those who wish to read further than hysterical and misleading media beat-ups (the main source of the delusion that forcible mass circumcision is the answer to the AIDS crisis), the following thoughts by Professor Greg Boyle may be of interest.

G.J. Boyle
Bond University
Issues associated with the introduction of circumcision into a non-circumcising society
Sexually Transmitted Infections, Vol. 79, 2003, pp. 427-428

A team lead by Kebaabetswe propose the introduction of infant circumcision in Botswana, based on:

A survey of its acceptability to Batswana (people of Botswana); its practice in certain Western nations; its alleged value in preventing HIV infection.

There are several medical, psychological, sexual, social, ethical, and legal problems with this proposal.

Full article here: http://www.cirp.org/library/disease/HIV/boyle-sti/
Nocirc USA, Position Statement on the Use of Male Circumcision to Limit HIV Infection

A typical newspaper article, with critical comments
Circumcision shown to deter HIV spread
Washington Times, April 25, 2003, p. A16

Circumcised men are at least 50 percent less likely to contract the virus that causes AIDS during unprotected sex than uncircumcised men, according to a soon-to-be released report by the U.S. Agency for International Development (USAID).

Based on a systematic review of 28 scientific studies published by the London School of Hygiene and Tropical Medicine, the USAID report “found that circumcised males are less than half as likely to be infected by HIV as uncircumcised men.”

“A sub analysis of 10 African studies found a 71 percent reduction among higher risk men,” said the report obtained by The Washington Times.

[These studies have since been rejected as misleading and inconclusive by the Cochrane Review.]

“There is really an incredible preponderance of evidence. There is really a strong association,” between circumcision and HIV protection, Dr. Anne Peterson, assistant administrator for global health at USAID, said yesterday in an interview.

[All that has been found is a correlation: the studies reveal nothing about causation. Since they have a narrow focus on tying to prove the connection between the foreskin and HIV infection, they simply ignore dozens of cultural, behavioural and biological factors which may be relevant.]

According to the scientific studies, the skin on the inside of the male foreskin is “mucosal,” similar to the skin found on the inside of the mouth or nose. This mucosal skin has a high number of Langerhan cells, which are HIV target cells, or doorway cells for HIV.

[The female genitals are full of Langerhans cells as well: that's what the body is made of in mucosal areas. Presumably something will also have to be done about the vulnerable mucosal tissue in the mouth, urethra and all other areas where it is found. If the tissue of the foreskin is like that of the mouth, how come there are no reliable reports of oral infection with HIV? It is well known that oral sex is safe (or at least safer) sex.]

The rest of the skin on the penis is more like the outer skin on the rest of the body, a barrier that protects against germs.

[How many germs get into the body through the mucosa of the mouth? Very few, unless there is a cut or abrasion.]

“HIV looks for target cells, like the Langerhans; it’s a lock and key,” said Edward G. Green, senior researcher at Harvard University, who has been looking at circumcision and HIV in Africa for 10 years. “The rest of the skin on the penis is armorlike.”

[I am not sure that anybody would want the skin of his or her genitals to be like armour. This rather proves the point about circumcision reducing sexual responsiveness. Doctors used to cauterise tissue to destroy the nerves and make it impervious - but that was nineteenth century medicine. The idea is like the Victorian practice of squirting the urethral tract with silver nitrate to control gonorrhoea.]

He said that it is better to be circumcised as a baby, rather than as a teenager in “rite-of-passage” ceremony, because many teenage boys in Africa are already sexually active.

[American scientists want to change traditional African cultural practices so that they are uniform with hospital American practice. The claim about "already sexually active is untrue": where circumcision is prevalent, women shun uncircumcised men as "boys" who are not yet allowed to have sex with women. What he really means is, "We have to get them before they've enjoyed sex with a whole penis, or they'll never submit to it."]

Mr. Green said that if all males in Africa were circumcised, the HIV/AIDS prevalence rate could be reduced from 20 percent in some regions to below 5 percent.

[Wild speculation.]

In addition, circumcision reduces the transmission of other sexually transmitted diseases, is more hygienic, reduces infections associated with poor hygiene and makes it easier to use a condom, Mr. Green said.

[Too many advantages make this sound like the claims of a nineteenth century quack like Dr P.C. Remondino. Studies in Australia by Donovan et al have shown that circumcised men actually find it harder to use a condom, and they have fewer options for safe sex owing to the reduced capabilities of their penis.]

“This is something the tribal healers, the herbalists, faith healers and witch doctors have known for years,” he said.

[Interesting to see the convergence of American scientific gurus and tribal witchdoctors.]

The 60-page USAID report is based on presentations given at a USAID conference in September, and will be available on the USAID Web site “soon,” Dr. Peterson said.

She said that while the information “looks profound and wonderful,” she cautioned there may be other factors that reduce HIV transmission in circumcised men.

[Desperate times induce unrealistic hopes: it's the ancient idea that if you sacrifice something to the gods, they will spare you from affliction. The claim that a surgical operation which still causes deaths and serious infections in American hospitals could be done safely in the primitive and unhygienic conditions of poverty-stricken African villages is absurd. USAID's efforts would be better directed at securing supplies of clean running water so that people could wash.]

She said clinical trials in Kenya and Uganda, under the auspices of the National Institutes of Health (NIH), Johns Hopkins University and the Gates Foundation, would give a clearer picture. Until then, she said USAID would move cautiously to educate and promote male circumcision.

Dr. Peterson said there is no evidence the female circumcision, sometimes called genital mutilation, offers any benefit whatsoever.

In fact, the scarring produced in the procedure may enhance the transmission of disease, she said. “We are adamantly opposed to female circumcision.”

[Notice the culturally determined sexual double standard. It is logically impossible that female circumcision would not have exactly the same effects in reducing the vulnerability of women to HIV infection as circumcision in men. If the genital mucosa is the trojan horse, then it should be removed equally from both males and females. Why should it be only men who get the benefit of armour-plated genitals? It may well be that the lower rates of HIV in regions of Africa where circumcision is common is due to female circumcision, not male, and that this is what USAID should be promoting. Western culture finds that idea abhorrent, however, and would not even investigate the possibility. Also, if female circumcision transmits AIDS, as western anti-FGM activists insist (and they are probably right), it follows that male circumcision will do likewise; no doubt the same instruments are frequently used for both surgeries.]

Another concern is that by promoting circumcision, circumcised men may mistakenly believe they are invulnerable to HIV. They are not, said Dr. Peterson.

“It reduces your risk. It does not protect you outright,” said Dr. Peterson. “People who are circumcised still get HIV. It is still better to abstain, be faithful in marriage, or use condoms”, she said.

[In that case, why circumcise at all?]

Comment from an AIDS educator
The danger of newspaper headlines about circumcision providing immunity to AIDS is that circumcised men start to think they are safe and stop using condoms. AIDS educators are concerned that the enormous publicity this theory has attracted is the main reason why cases of HIV in Australia are rising at the moment, as circumcised men drop safe sex and stop using condoms, saying, “Oh well, apparently if you’re cut you can’t get infected.” They can and do get infected.

The following comment was from a Canadian AIDS educator on the H-Hist-Sex discussion list.

The literature from which the report on circumcision and HIV transmission was based came from 27 studies in Africa. Science is not my field, but from what I remember, for a scientific study to support a hypothesis such as foreskins affect the rate of HIV transmission, then the study needs to be replicated elsewhere, or are African foreskins different than other foreskins?

Considering all the research done on gay men in North America, isn’t it strange that, after 20 years, no one has found that, say, more gay Muslims and gay Jews don’t/do contract the virus than, say, gay Catholics? (Maybe the transmission has nothing to do with the foreskin, but that the HIV virus has a strong religious bias.)

Does this type of research truly stop the transmission of HIV, or is it just a means to start/stop circumcisions? You cannot transmit the virus, with or without a foreskin, unless you have the virus. You can not get the virus, with or without a foreskin, unless you are involved in unsafe practices with someone who has the virus. More skin, whether penile or vaginal, creates a higher probability, but the salient word in the study was “unprotected” sex. You have a higher probability to be bit by playing with two rabid pit-bulls than with one, but you won’t get bit at all if you put muzzles on them beforehand.

How will information such as the one on foreskins and HIV be perceived by the general public? Anyone who has been involved in the HIV community since the beginning will remember all the crazy beliefs people had to protect themselves from the virus, many based on “scientific research”, instead of just not sharing blood or sperm. Why won’t this study be used the same way, as the author of the study by the US Agency for International Development worries? When I was a teenager, I heard guys saying that they couldn’t get VD because they had a hood. I heard men saying their wives couldn’t get ovarian cancer because they were Jewish (read: circumcised). I can see straight teenagers (the group with the largest increase of HIV transmission) now having sex without condoms because they are circumcised. (And let’s not forget about all those who share uncircumcised needles.)

It is easier to find something/someone to blame (”Patient Zero”, gays, loss of religious beliefs, the media’s constant promotion of sex, the West, Democrats, foreskins) than to work hard at changing one’s activities, regardless of countries or traditions. Education has been shown to be the best way to prevent HIV transmission. With such a small amount of money going into HIV/AIDS research - particularly on women and HIV- and money for medication for people living with HIV/AIDS, isn’t focusing on the [uncondomed] penis (the favorite activity for all men) side-stepping the real issues of HIV transmission?

Full discussion available here: http://www.h-net.org/~histsex/

HIV-AIDS: Most African cases not caused by sexual contact: Dirty doctors, not dicks, to blame
1. African HIV linked to poor medical care, not lack of circumcision

African HIV is spread more by contaminated implements than by sexual intercourse, say three new medical articles. Transmission includes doctors and nurses in clinics and hospitals as well as traditional healers and circumcisers using unsterile instruments.

Experts have assumed that heterosexual sex transmitted 90% of HIV in Africa. HIV in Africa is associated with urban living, having a good education, and having a higher income; people who visit their doctor more often.

These articles point out that all 13 of the previous studies, which purported to prove HIV can be prevented by circumcision, failed to consider this stunning 2/3 versus 1/3 fact. The end result is this, whether a man is circumcised or not is inconsequential. Ironically, circumcisions - whether done in a village ceremony or in a city hospital – are probably spreading HIV because of unclean instruments.

This new research, based on hundreds of studies, suggests only about a third of HIV infections in Africa are sexually transmitted. Specifically, HIV is not transmitted by “sex”, but only by specific high-risk practices.

2. Sex may not be behind Africa’s Aids problem

Poor medical practice may be to blame for the spread of Aids through Africa.

New research based on hundreds of studies suggests only about a third of HIV infections in Africa are sexually transmitted. The authors suggest contaminated medical injections make up the biggest risk.

They said their findings have “major ramifications for current and future HIV control in Africa, whose focus has been almost exclusively on sexual risk reduction and condom use”.

The study is in today’s International Journal of STD and AIDS, published by the Royal Society of Medicine. The research team is led by Pennsylvania anthropologist Dr David Gisselquist.

They say HIV cases in Africa have not followed the pattern of most types of sexually transmitted disease. Many studies reported young children infected with HIV even though their mothers were not.

Typically STDs are associated with being poor and uneducated but HIV in Africa is linked with urban living, having a good education and higher income.

Avanova on-line news, Thursday 20 February 2003

3. Unsafe healthcare “drives spread of African HIV”

Since the 1980s most experts have assumed that heterosexual sex transmitted 90% of HIV in Africa. In the March International Journal of STD and AIDS, an international team of HIV specialists presents groundbreaking evidence to challenge this consensus, with “profound implications” for public health in Africa.

In a series of articles, Dr David Gisselquist, Mr John Potterat and colleagues argue that the spread of HIV infections in Africa is closely linked to medical care. In their unique study of existing data from across the continent they estimate that only about a third of HIV infections are sexually transmitted. Their evidence suggests that “health care exposures caused more HIV than sexual transmission”, with contaminated medical injections being the biggest risk.

Sexual behaviour

HIV and STDs: According to the authors’ data, African HIV did not follow the pattern of sexually transmitted disease (STD). In Zimbabwe in the 1990s HIV increased by 12% a year, while overall STDs declined by 25% and condom use actually increased among high-risk groups.

Infection rate: HIV spread very fast in many countries in Africa. For the increase to have been all via heterosexual sex, the study claims, it would have to be as easy to get HIV from sex as from a blood transfusion. In fact, HIV is much more difficult than most STDs to transmit via penile-vaginal sex.

Risky sex?: Several general behaviour surveys suggest that sexual activity in Africa is not much different from that in North America and Europe. In fact, places with the highest level of risky sexual behaviour, such as Yaounde in Cameroon, have low and stable rates of HIV infection. “Information…from the general population shows most HIV in sexually less active adults” .

Did medical care spread HIV?

Children and injections: Many studies report young children infected with HIV with mothers who are not infected. One study in Kinshasa kept track of the injections given to infants under two. In one study, nearly 40% of HIV+ infants had mothers who tested negative. These children averaged 44 injections in their lifetimes compared with only 23 for uninfected children.

Good access to medical care: Countries like Zimbabwe, with the best access to medical care, have the highest rates of HIV transmission. “High rates [of HIV] in South Africa have paralleled aggressive efforts to deliver health care to rural populations”.

Riskier to be rich: Most STDs are associated with being poor and uneducated. HIV in Africa is associated with urban living, having a good education, and having a higher income. In one hospital in 1984, the rate of HIV in the senior administrators was 9.2%, compared with the average employee rate of 6.4%.

“People often see what they wish to see.”

The authors suggest several reasons why evidence has been ignored until now, including the West’s preconceptions about African sexuality, the fear that people might lose trust in healthcare, and simple disbelief that medical practices could be so unsafe.

They conclude: “a growing body of evidence points to unsafe injections and other medical exposures to contaminated blood” as an explanation for the majority of the spread of the epidemic. “This finding has major ramifications for current and future HIV control programmes in Africa”.

4. Further information

These articles are available here.
http://www.cirp.org/library/disease/HIV/

George Denniston and George Hill
HIV and circumcision: new factors to consider
Sexually Transmitted Infections, Vol. 79, 2003, pp. 495-6
http://www.cirp.org/library/disease/HIV/hill-denniston1/

British study finds higher incidence of HIV in circumcised men
If circumcised men are less likely to acquire HIV than men with foreskins, then we should expect fewer of the circumcised men to have tested positive than the men with a foreskin. However, more of the circumcised men had tested positive for HIV (6.1%) than had those with a foreskin (5.0%). This small but significant difference is in the opposite direction than predicted if foreskins are contributing to transmission, and was observed in all ethnic groups and across the age range.

Know the score. Findings from the National Gay Men’s Sex Survey 2001

The full report can be downloaded from http://www.sigmaresearch.org.uk/downloads/report02d.pdf

Comparative studies show that education reduces HIV infection
A recent comparative study in Kenya and Uganda found that in Uganda, where efforts were put into safe sex education, the rate of HIV infection was falling far more significantly than in neighbouring Kenya, where such efforts were much weaker. Circumcision was found not to be a significant influence.

Moore D, and Hogg R, Trends in antenatal human immunodeficiency virus prevalence in western Kenya and eastern Uganda: Evidence of differences in health policies?, International Journal of Epidemiology, Vol. 33, 2004, pp. 542-8

WHY CIRCUMCISION WILLL NOT SAVE THE WORLD FROM AIDS
Introduction
The scare over HIV-AIDS is the main reason why circumcision is on the rise in Australia and elsewhere. Advocates of the operation are making strident and widely reported claims that the destruction of supposedly vulnerable genital tissue provides significant protection against the deadly virus, and some people are frightened enough by the spectre of this terrible and incurable disease to be willing to try anything: doing something, no matter how harmful or ineffective, seems to be better than nothing.

Lies, damned lies and statistics

Table 1: Incidence of HIV infection and male circumcision in selected countries

Voodoo science and primitive magic

References

What if uncut men are more susceptible to HIV-AIDS?

Further information

In the industrial world:
Lies, damned lies and statistics
A glance at the rates of HIV-infection and circumcision in selected western (developed) countries, however, suggests that there is no correlation at all between having a foreskin and greater susceptibility to HIV-AIDS. On the contrary, the country with one of the highest proportions of circumcised males (the USA with 75 per cent) also has the second highest rate of HIV infection (61 cases per 100,000). The countries with the lowest incidence of HIV infection are Finland and Japan, which also have the world’s lowest proportion of circumcised males. In between, patterns are hard to find. Israel, with 95 per cent of the male population circumcised, has a similar rate of HIV infection as that found in Norway, where not more than 2 or 3 per cent of the male population is circumcised.

In other countries with low rates of circumcision the incidence of HIV infection varies wildly, and it is impossible to offer explanations without knowing the proportions represented by homosexual men, heterosexual men and women, intravenous drug users and others. At first sight it seems to be higher in predominantly Catholic countries (Spain, Italy, France, Austria) than in northern Europe (Britain, Germany, Scandinavia), suggesting that opposition to the use of condoms by the Catholic Church could be a more relevant factor than the prepuce. Ireland and Switzerland are puzzling departures from this pattern. Other important reasons may be the speed with which governments took action (since delay gives the virus a head start) and inadequate resources devoted to safe sex education.

Incidence of HIV infection and male circumcision in selected countries

Country Estimated proportion of adult male population(15-49) circumcised (%) HIV prevalence, adult population (M & F, 15-49), cases per 100,000
Industrialised world
Australia
55 15
Austria <5 23
Belgium <5 15
Canada 45 30
Czech Republic <5 4
Denmark <5 17
Finland <2 5
France 10 44
Germany <5 10
Ireland <10 10
Israel 95 8
Italy <5 35
Japan <2 2
Netherlands <5 19
New Zealand 45 6
Norway 2 7
Portugal <5 74
Slovakia <5 1
Spain 10 58
Sweden <2 8
Switzerland <5 46
United Kingdom 15 11
United States 75 61

Developing world: Sub-Saharan Africa 65
857
Botswana
50 3580
Guinea ? 154
Kenya 65 1395
Madagascar ? 15
Nigeria 70 506
South Africa 70 1994
Tanzania 65 809
Zimbabwe 65 2506

Developing world: Other

Bahrain
90 15
China <5 7
Kuwait 90 12
Malaysia 75 42
Mauritius 10 8
Sudan 70 99
Thailand <10 215
United Arab Emirates 90 18

Source: UNAIDS data for 2000. No official statistics on circumcision rates are published; the estimates here are approximate.

Australia has a fairly high proportion of circumcised, sexually active males, but a very low incidence of HIV infection. This is almost certainly a result of the rapidity with which Australian government health authorities acted when the danger first became apparent in the 1980s, and it indicates the great success of the consultative approach, the safe sex education campaign and extensive use of condoms. (This triumph of good sense and rational science in public health has received international acclaim, yet it has been won in the teeth of continual sabotage attempts by assorted moralising reactionaries who seem to think that using a condom when having sex is a greater sin than infecting another person with a fatal and incurable disease).

In South America, where hardly anybody is circumcised, the incidence of HIV infection varies from 10 per 100,000 in Bolivia to 301 in Guyana, strongly suggesting that national differences are far more important than the foreskin. Figures from Asia show that puritanical Muslim societies with a very high rate of circumcision, such as Bahrain, Kuwait and the United Arab Emirates, have much the same rate of HIV infection as a liberal society like Australia, while an authoritarian regime like Malaysia boasts an incidence nearly three times greater. The high rate of HIV infection in Thailand (most males not circumcised) is most probably a consequence of widespread sex-tourism.

The most important point to note is that the main reasons for the spread of AIDS are social and cultural in nature, not anatomical or physiological - which is why the professors’ carry-on about Langerhans cells and all the rest of it is largely irrelevant to the real problem and a distraction from effective action. The strategy followed in places like Germany, Britain, New Zealand and Australia has been effective, and did not involve waging war on the male genitals. The UNAIDS organisation has a sensible discussion of this issue.

The lack of correlation between high proportion of males circumcised and a low rate of HIV infection, and vice versa, suggests that mass circumcision will not be effective as a public health measure. Instead of attacking the innocent foreskin, campaigners for AIDS control would be better advised to direct their impressive polemical talents towards safe sex education and against the opponents of condom use.

In the Third World:
Voodoo science and primitive magic

Whenever the medical profession finds itself confronted with a problem it is unable to solve it seems to respond in the same way as primitive man: sacrifice something valuable to appease the angry gods. The concept of a propitiatory sacrifice to ward off or achieve recovery from illness was common among pre-scientific peoples. In Homer’s Iliad, when plague strikes their camp the Greeks learn that the only way to halt it is by returning the beautiful Chryseis to her father and sacrificing 100 bulls to Apollo. At the height of the Black Death in fourteenth century Germany many people took up vigorous self-flagellation; and when that failed they started murdering Jews, whose relative resistance to the plague (the result of being quarantined in ghettoes) seemed proof of their responsibility for its spread. As soon as AIDS appeared in the USA, long-standing circumcision advocates pushed their favourite surgery as the panacea, a claim requiring some gall in view of the fact that the US then had the highest proportion of circumcised, sexually active men in the developed world.

It is a similar story in Africa today, where the AIDS crisis is fuelling an international push for universal (yes, every boy and man everywhere) circumcision as a preventive health strategy. The leaders of this campaign include a powerful array of US and British professors, supported by an Australian veterinary scientist and expert in reproductive physiology (Dr Roger Short) and a recent medical graduate (Dr Robert Szabo). Professor Short made a big splash in a TV documentary last year, urging universal infant circumcision as an essential part of any strategy to control AIDS. They claim to have evidence that non-circumcising African tribes have a rate of HIV infection two to eight times greater than tribes which cut it off.

Out of Africa
There are many problems with this sort of statistical analysis: as every schoolchild knows, correlation is not causation. One obvious problem is the complexity of African social life. Circumcision is a cultural tradition, performed by most Moslems and about half the non-Moslem tribes, each of which has its own cultural/religious practices and different standards of sexual behaviour. Without far more detailed research than Short, Szabo and Co have done there is no way of knowing whether a lower rate of HIV infection is the result of behavioural rather than anatomical differences, or of other factors that ignorant westerners have never thought about.

Another problem is that Africa already has a very high incidence of circumcision. Out of a total male population of 767 million, about 311 million are Moslems, most of which are probably circumcised as a religious rule. Of the remaining 456 million it is estimated that between 40 and 50 per cent are circumcised as a tribal initiation ritual. Assuming that 90 per cent of the Moslems and 45 per cent of the others are cut, it means that about two thirds of the population is already circumcised. South Africa, with about 70 per cent of the adult male population circumcised, has an HIV infection rate of nearly 20 per cent. If circumcision was such an effective tactic against HIV infection you would expect the AIDS crisis to be less severe, and it is difficult to believe that circumcising the unscathed minority will make much difference.

Why don’t we learn from history?
In the nineteenth century English doctors keen to introduce circumcision assured people that it provided protection against syphilis - then as incurable and deadly as AIDS is now. Instead of innocent Africans they used innocent Jews to prove their case, claiming that Jewish men were highly resistant to syphilis (if not immune) because their foreskins had been removed. A physician named Jonathan Hutchinson recorded the incidence of venereal cases among his Jewish and non-Jewish patients during 1854 and came up with the following table, published in the Medical Times and Gazette in 1855:

Venereal cases Gonorrhoea Syphilis
Non-Jews 272 107 (39.3%) 165 (60.6%)
Jews 58 47 (81%) 11 (19%)

On the basis of these figures he claimed he had demonstrated a conclusion “long entertained by many surgeons of experience”: that “the circumcised Jew is … very much less liable to contract syphilis than an uncircumcised person”, and the reason was obvious: circumcision rendered “the delicate mucous membrane of the glans hard and skin-like”. Hutchinson provided no elaboration of his reasoning as to why a damaged (”hard and skin-like”) glans should provide this protection, nor what non-injurious alternatives might be recommended if it really did, but he showed no reticence at all when it came to the clinical implications, and urged the speedy adoption of routine infant circumcision.

It was a flimsy foundation on which to erect such an ambitious therapeutic edifice. All his observations showed is that, while non-Jewish venereal cases had more syphilis than gonorrhoea (60.6 to 39.3 per cent), Jewish cases had more gonorrhoea than syphilis (81 to 19 per cent). Although Hutchinson insisted that the high level of gonorrhoea among the Jews proved that less promiscuity could not have been the reason for the difference, the statistics revealed nothing about the relative susceptibility of cut and normal men to venereal infection, and could as well be cited to show that circumcision increased the likelihood of getting gonorrhoea. If you compare these figures with the Jewish and non-Jewish populations of London at that time, you actually find that Jews had a higher rate of syphilis than others.

Myths of syphilis
This did not stop doctors from claiming that circumcision could provide immunity to syphilis. For the next century Hutchinson’s shonky stats were regarded as the “hard data” needed to prove the health-giving value of pre-emptive foreskin amputation. In 1900 E. Harding Freeland cited them to prove that “circumcision of every male in infancy” would reduce the incidence of syphilis by 49 per cent. In 1914 Abraham Wolbarst relied on them to support his call for “Universal circumcision as a sanitary measure” in the Journal of the American Medical Association. As late as 1947 Newsweek praised Hutchinson as the first to discover that “syphilis and gonorrhoea were uncommon among Jewish people” and asserted that circumcised men “are not likely to contract venereal disease”. The myth had become a media truth.

Gradually it was realised that any reduced incidence of VD among Jews was the result of cultural and lifestyle factors: the quarantine effect of segregation and a low level of promiscuity and other sexual adventurism. It was also realised (as even Hutchinson had admitted) that the operation, in the days before aseptic surgery, actually infected many babies and children with syphilis, tuberculosis and other diseases, not to mention ordinary gangrene. Circumcision played no role in the eventual conquest of syphilis, which was controlled by growing use of condoms, Metchnikoff’s ointment and Salvarsan, and defeated in the 1940s by penicillin.

The story with AIDS is not likely to be much different. Where it has been controlled, as in Australia, success has been the result of a non-moralistic sex education campaign, and promotion of safe sex and condom use. Little else can be done until a vaccine is developed. But medical researchers don’t like non-medical approaches to disease control because it seems to devalue their expertise; they want a medical and ideally a surgical response in which they, rather than social workers, can play the starring role.

Female circumcision complicates picture
The possibility of a simple link between circumcision and vulnerability to HIV infection is made more remote by the fact that many of the African cultures which practise male circumcision also practise various forms of female circumcision. (This may include excision of the clitoral hood (i.e. prepuce), clitoris, labia minora or more, and sometimes sewing up the vaginal orifice.) How can western researchers know that the reportedly lower incidence of HIV infection among circumcising populations is not the result, or as much the result, of doing it to girls? If, as Szabo and Short assert, the genital mucosa (specialised skin, especially on the inner foreskin) is the Trojan horse, why wouldn’t the mucosa of the clitoral hood, clitoris and labia, not to mention lips, vagina and anus, be just as treacherous? And their amputation just as protective?

It’s difficult to amputate the lips and anus, but if it were shown that excision of the clitoral hood or labia made women two to eight times less likely to contract HIV, would Dr Short and others advocate the universal circumcision of girls?

The limits of scientific neutrality
This is where the researchers’ claim to neutral scientific objectivity breaks down and a cultural double standard asserts itself. The West has no tradition of circumcising women, which most westerners regard with horror as an unacceptable mutilation, whether it offered health benefits or not. Western experts like Dr Short are not interested in amputating part of the female genitals, so it would never occur to them even to research the question. It is a different story in the Islamic and other traditional cultures which practise female circumcision, the defenders of which parrot western medical experts’ claims about the value of male circumcision, but also insist on the many benefits from the equivalent procedure on women, including improved hygiene and reduced susceptibility to STDs, genital warts and AIDS.(1)

An Egyptian cleric who overturned a government ban on female circumcision in 1997 not only thanked God for preserving a religious requirement handed down by mothers and grandmothers for fourteen centuries, but stated that the operation protected the nation from AIDS by reducing promiscuity (Los Angeles Times, 25 June 1997). In explaining the link between circumcision and AIDS control in behavioural rather than anatomical terms, the priest showed a better understanding of the epidemiology of STDs than many medical researchers. Widespread (hetero)sexual promiscuity, especially with prostitutes and without condoms, in conditions of poverty and lack of education, is certainly the main reason for the African AIDS crisis.

Confused messages from the experts
Africans must be getting very confused by the contradictory messages they are receiving from western health experts. One group tells them they must stop circumcising women to improve their health; another group tells them they must circumcise more boys. Either argument might be valid, but it is unlikely that both could be right at the same time. For the reasons mentioned above, reduction of female genital mucosa is likely to be just as effective in combating AIDS as reduction of male genital mucosa - but of course not culturally or ethically acceptable.

Opponents of female circumcision correctly point out that it is harmful as well as cruel and probably spreads AIDS, either via the operation itself (dirty hands, knives, razor blades etc) or because the scars from the operation bleed during intercourse. But these comments are just as applicable to the circumcision of boys. As the New York Times reported last year, “In a country where … 1 in 10 are HIV positive even many boys who emerge seemingly unscathed from [ritual circumcision] face the risk of having contracted the virus … from the surgeons’ use of unsterilized scalpels or spears” (6 August 2001 p. A6)

It is equally true that circumcision scars on the penis can bleed during sex, and it is not unusual for boys who have been cut tightly to suffer splits and tears in the remaining skin when they have erections.

Circumcision also kills African boys
Circumcision, often carried out in unhygienic settings as part of tribal initiation ordeal, is itself a significant cause of death among African boys. According to recent reports:

Boy bleeds to death after ritual circumcision in South Africa (African News Service, 26 June 2001)

Death toll for Northern Provinces initiations reaches eight (http://allafrica.com/stories, 12 July 2001)

Death toll from South African initiations reaches 20, plus 160 boys in hospital with serious injuries (Infobeat, 19 July 2001 - Reporter: Ravi Nessman)

At least 35 South African boys die from circumcision injuries, and many more hospitalised with “horribly injured genitals” (New York Times, 6 August 2001, p. A6).

25 boys admitted to hospital with gangrenous penises following circumcision (South African Press Association, 22 December 2001).

7 boys die after circumcision in Kenya. “It is feared the total could be as high as ten” (The Nation (Nairobi), 27 December 2001).

These reports may only be the tip of the iceberg. Stopping the circumcision of African boys would save more lives than encouraging the practice.

Hard to identify real causes: Infant mortality in the nineteenth century
It is always difficult to establish causality in complex, multi-causal situations and very easy for interested parties, with their own prior agenda, to assume that their particular barrow is the key to a problem. A good example is infant mortality in nineteenth century Britain, which decreased very little as the century advanced, even though adult mortality fell steadily. Several doctors and health officials who happened to believe that women’s place was in the home noticed that infant mortality was particularly high in many places where there was also a high incidence of women working, and they instantly concluded that the problem was maternal neglect. They pressured parliament on the issue, and in 1891 it passed a law restricting employment opportunities for nursing mothers. It was not rigorously enforced and would have made no difference even if it had been. (It might have made the situation worse by reducing household income when it was most needed.)

The largest single cause of infant deaths at that time were diarrhoea-related diseases, which were caught from contaminated food, water, utensils, toys and all the other things babies were always picking up and putting in their mouths. The areas with the highest incidence of working mothers were also the poorest areas and thus the ones with the worst hygiene (dirty and overcrowded living conditions, contaminated food and water, poor drainage, no sewerage etc) and thus offering the most opportunity for contracting the viruses and bacteria, as the babies rolled around in the accumulated filth.(2)

As with HPV and AIDS in Africa, the most important factor in the high rate of infant mortality was poverty, and after that lack of clean water and ignorance of elementary hygiene. In Africa the problem is made worse by the fact that traditional sex practices also discourage condom use. Because western medical experts can’t do anything about Third World poverty they attack Third World penises, the only thing many Africans can call their own.

Why not put more effort into safe sex education?
In countries where AIDS has been controlled (Australia, New Zealand, Germany, Britain), success has been the result of safe sex education and widespread use of condoms. Why don’t Short and Co suggest that more effort be put into an educational strategy to alter adult sexual behaviour? This approach seems to have worked in their own cases: it is reported that neither Professor Short nor Dr Szabo is circumcised, and they are not planning to have it done, yet they feel competent to manage their own sex lives in such a way as to avoid contracting fatal diseases without having to give up their foreskins. Perhaps they feel that dumb and sex-crazed Africans cannot be trusted to modify their behaviour the same extent as smart Europeans. Or perhaps they just lack faith in their own prescriptions or feel the sacrifice would not be worth the advantages they urge for others.

Boys’ foreskins easier target than opponents of condom use
In focusing on anatomical alterations rather than education, Short and his colleagues seem to be saying is that in Third World countries a boy’s foreskin is a softer target than opponents of condom use: traditional tribal custom and male preference, the hostile attitude of many African leaders until very recently and the policy of the Catholic Church have all made it more difficult to educate Africans to use condoms. HIV could be brought under control if condoms were widely used, especially with prostitutes, but it seems to be much harder to make adult men use condoms than to force babies and little boys to be circumcised.

Setting aside the issue of medical ethics and civil rights (amputations performed on non-consenting children showing no signs of injury or disease), what about efficiency and effectiveness? Ensuring that all circumcisions were carried out in proper hygienic conditions and in accordance with the rules of modern surgery would probably be harder and more expensive than educating men to adopt safe sex practices. If a 15-year old boy were shown a condom and a gomco clamp side by side there will not be much doubt as to which he would choose. Whatever he decided, giving him the right to choose is the ethical approach.(3)

Puritanical moral agenda
Those targeting the foreskin rather than advocating education do seem to have an agenda to promote circumcision as an alternative to naughty condoms and the sexual promiscuity inevitably associated with them. That Christian churches in the Philippines have tolerated the Islamic-derived custom whereby mobs of older males set upon boys and circumcise them in the street suggests that they have no dogmatic doctrinal objection to bodily mutilation, despite the judgement of Thomas Aquinas and the decision of the Council of Florence. Non-procreative sex, however, especially if it involves devices associated with contraception, seems to be a different matter.

Despite the pleas of some bishops to relax the ban on condoms (notably Kevin Dowling, Bishop of Rustenburg), the Catholic Church in southern Africa condemns their use as “immoral and misguided” and actually claims that condoms “fuel the AIDS epidemic” by facilitating promiscuity. A conference of bishops in August 2001 stated that the Christian way to overcome AIDS was to “abstain and be faithful” (Age, 1 August 2001). Until recently many African political leaders took much the same line. Conservative politicians and clerics, both Christian and Islamic, can recommend chastity and strict monogamy till the cows come home, but humans are a randy and promiscuous species, and if you want to be scientific (or even practical) there is no point fighting the fact.

Can using a condom when having sex really be a greater sin than infecting another person with a deadly disease? Are the medical experts supporting religious doctrine by promoting circumcision as an alternative to condoms?

Been there, done that
There is a direct historical parallel in the work of the puritanical Jonathan Hutchinson, whose shonky statistics on the protection which circumcision provided against syphilis cost thousands of boys their foreskins and saved nobody from syphilis. He was the principal nineteenth century British crusader for routine circumcision, particularly as a preventive of masturbation, but he also played the syphilis card. In 1900 he wrote: (4)

“Most other measures [to control syphilis], such as the inspection of prostitutes, have a collateral influence prejudicial to morality. Professedly making irregular sexual intercourse less dangerous, they possibly increase its amount to an extent which more than counterbalances their supposed advantages. They are also injurious to the sense of decency, to say nothing of modesty, and detrimental to the moral conscience of a community. It is no so with circumcision. Effected in early infancy, and with other avowed objects [that is, curbing masturbation] it would silently become the means of preventing on a large scale the prevalence of a loathsome and misery-producing disease. The extent to which this diminution of risk might tend to increase sexual folly would probably be infinitesimal.”

In other words, in controlling syphilis circumcision was preferable to condoms or health checks because it would discourage pre- and extra-marital sex. Thus western medical scientists who want male circumcision, Islamic clerics who demand female circumcision and Catholic bishops who favour chastity find they have more in common than anyone suspected.

The medical profession took humanity down this blind alley once before. There’s no need to make the same mistake again.

References
1. David Gollaher, Circumcision: A history of the world’s most controversial surgery, New York, Basic Books, 2000, Chap. 8, esp. p. 199; Sami A. Aldeeb Abu-Sahlieh, Male and female circumcision among Jews, Christians and Muslims: Religious, medical, social and legal debate, (Warren PA, Shangri-La Publications, 2001) pp. 185-7
2. Anthony S. Wohl, Endangered lives: Public health in Victorian Britain (London 1983) pp. 27-32
3. F.M. Hodges, J.S. Svoboda, R.S. van Howe, “Prophylactic interventions in children: Balancing human rights with public health”, Journal of Medical Ethics, Vol. 28, 2002
4. Jonathan Hutchinson, “The advantages of circumcision”, Medical Review, Vol. 3, 1900, p. 641

What if uncut men are more susceptible to HIV-AIDS?
Let’s assume that uncut men are more susceptible to HIV infection. Does that mean all boys should be circumcised long before they are old enough to provide informed consent, and even before they are sexually active? Obviously not.

Even if circumcision did reduce risk, it does not confer anything like immunity; but a slight reduction in risk is not adequate compensation for the loss of a significant genital feature. The comparison between circumcision and vaccination is not valid.

Even if circumcision did reduce risk, the benefit claimed from Short et al’s studies applies only to men taking the active role in heterosexual intercourse without a condom. Circumcision has no impact on the risk of contracting HIV as a result of any other form of exposure, such as intravenous drug use, blood transfusions, injuries, accidents or taking the passive role in homosexual intercourse.

If uncut men are more at risk, they just need to take greater precautions. No boy is at risk at all until he becomes sexually active (late teens), and by then he is sufficiently mature to understand the safe sex message and to modify his behaviour to minimise risk. Doctors should protect boys, not attack their genitals.

If a mature male wishes to embark on a wildly promiscuous sex life and does not want to use condoms he is perfectly at liberty to have himself circumcised if he thinks that will help. That is no reason for doing it to everybody. Others may wish to be monogamous, only practise safe sex, or not engage in sex at all. It’s a person’s right to choose.

Circumcision reduces the options for safe sex by stripping down the penis to a less complex and less responsive member, significantly reducing sensitivity and leaving less to play with. Circumcised men are abandoning condoms because they can’t get no satisfaction through the latex. Uncut men have greater sensitivity and find condoms easier to use and sex more satisfying. Partners agree. Since their penis comes fully equipped with exciting features, they and their partners have more enjoyable options with which to pleasure and amuse themselves.

It is not the proper role of doctors to perform pre-emptive amputations. Their job is to protect the body from harm and that means all parts of the body, not just the parts they consider essential for survival.

If parents and doctors agree that it is not their right to decide who their son marries, what sexual practices he engages in or what his sexual orientation is, how could it be their right to have him circumcised? Compulsory circumcision arose in a period of arranged marriages and sexual repression, when authoritarian adults did claim these rights, but times have changed. Children are no longer their parents’ property.

The cheapest, easiest, least harmful and most effective way of protecting yourself against HIV infection is by using condoms.

–
Regards,

“If you go through life thinking about all the bad things that could happen, you soon talk yourself into doing nothing at all!”