Malawi ‘no’ to circumcision as tool to stop HIV/AIDs: The Church of England Newspaper, Oct 1, 2010 p 8. October 3, 2010
Posted by geoconger in Church of England Newspaper, Church of the Province of Central Africa, Health/HIV-AIDS.trackback
Archbishop Bernard Malango of Central Africa
First published in The Church of England Newspaper.
The government of Malawi has rejected calls to promote circumcision as a prophylactic against HIV/AIDs.
In a Sept 7 address to Malawi’s 2010 HIV & AIDS Research and Best Practices Conference, the chairman of the country’s National Aids Commission, Archbishop Bernard Malango said that a comparison of the rates of infection in Muslim districts, where most men are circumcised, to that of Christian areas of Malawi, where circumcision is not practiced, showed no difference in the rate of infections.
“We have no scientific evidence that circumcision is a sure way of slowing down the spread of AIDS,” Dr. Mary Shaba, the government’s chief HIV/AIDS officer added.
The UNAIDS agency estimates that approximately 930,000 people, or 12 per cent of Malawi’s population, are living with HIV of whom 840,000 are adults aged 15 and above.
However, the archbishop said the 12 per cent prevalence rate of HIV/AIDS does not accurately reflect the incidences of the disease in the country,
Archbishop Malango said that most overseas NGOs look at the overall rate of infection, or the prevalence of the disease, within the population when devising prevention and treatment strategies. However in Malawi, the rate of new infections has been decreasing, while people with HIV/AIDS were living longer, thus keeping the prevalence rate at 12 per cent.
“With the continued scale up of the treatment programme, we will have more and more people alive and therefore considerably contributing to the high prevalence of HIV,” Archbishop Malango said.
“The number of those who were already infected is being maintained and by 2015, we should minimize the new infections by educating people,” the archbishop said.
Dr. Shaba told the conference the number of new cases was estimated to be 90,000 per year. “The difference between incidence and prevalence is that incidence is number of infections that are taking place now while prevalence is the number of people who are considered positive at that time.”
“The prevalence has been 12 per cent for a long time but we need to look at how many infections are taking place. If we are going to move from prevalence from 12 per cent to almost zero, it means the incidences are the ones which have to be zero,” she said.
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Conger 
Circumcision is a dangerous distraction in the fight against AIDS. There are six African countries where men are *more* likely to be HIV+ if they’ve been circumcised: Cameroon, Ghana, Lesotho, Malawi, Rwanda, and Swaziland. Eg in Malawi, the HIV rate is 13.2% among circumcised men, but only 9.5% among intact men. In Rwanda, the HIV rate is 3.5% among circumcised men, but only 2.1% among intact men. If circumcision really worked against AIDS, this just wouldn’t happen. We now have people calling circumcision a “vaccine” or “invisible condom”, and viewing circumcision as an alternative to condoms. The South African National Communication Survey on HIV/AIDS, 2009 found that 15% of adults across age groups “believe that circumcised men do not need to use condoms”.
The one randomized controlled trial into male-to-female transmission showed a 54% higher rate in the group where the men had been circumcised btw.
ABC (Abstinence, Being faithful, and especially Condoms) is the way forward. Promoting genital surgery will cost African lives, not save them.
The above comment is simply not correct. The “intact” shows that he is in the circumcision equals mutilation camp.
Population trials suffer from variation of sexual practice which needs to be controlled for. In 27 studies that went into a large meta-analysis, it is true that 6 showed that circumcision was not helpful. Of course, that means that 21 of the studies showed it was helpful – as did the meta-analysis. But this shows the need for randomized control trials. This is why the two prospective trials in Kenya and Uganda were so important. Both were stopped early because the effect of circumcision was so great – decreasing change of seropositivity by 50%.
And by the way, the above commentator gets it wrong about ABC. The C is not for “especially condoms” but condoms only for sex trade workers and mixed seropositive/seronegative couples.
His criticism of circumcision altering sexual behavior is a problem but epidemilogical studies show it is a MUCH worse problem for condoms.
If male circumcision works so well against HIV, then why are there those six African countries where men are more likely to be HIV+ if they’ve been circumcised? It seems unrealistic to blame it all on “variation of sexual practice”. Many people that circumcise for religious reasons will also have fewer sexual partners, and devout Muslims also abstain completely for Ramadan, which seems to break the cycle of transmission due to variation of viral load.
There have been three RCT’s into male-to-female transmission, but the only RCT into male-to-female transmission showed a 54% higher rate in the group where the men had been circumcised. That’s increasing seroconversion by over 50%. This seems to have been swept under the carpet. It would apparently be considered unethical to have a second RCT into male-to-female transmission, so how can it be considered ethical to promote male circumcision against HIV? More women than men have HIV already, and promoting male circumcision won’t help, especially since HIV+ men will also be circumcised (only 1 in 6 men agree to be tested).
Condoms are not just for sex workers, but for any couple where it is not known that both are HIV- (including couples where both are HIV+!). Risk compensation with condoms is also a problem, but condoms are so effective, it’s less of an issue.
Those same trials also showed an INCREASE in transmission from circumcised men to their female partners. There is evidence that circumcising little girls reduces their risk of contracting HIV too. But we’re all on the bandwagon for eliminating female circumcision while we peddle male-circumcision. It’s a violation regardless of gender and it’s disgusting.
~Huntress
Also,
“Swaziland circumcision program a failure
October 4th, 2010 by ICGI
After years of circumcising young men, the HIV infection rate in Swaziland has gone up, not down as predicted. This data is from a 2007 Swaziland health department report, which the government has had for three years, but continues to circumcise men anyway. Government health officials are only now questioning using circumcision as an AIDS preventative.”
“Female circumcision” is NOT circumcision. That is a euphemism for an atrocious practice that is intended to remove God’s gift of sexual pleasure to women. That is simply a red herring not at all related except for the use of the deceptive term that was created to intentionally blur two very distinct procedures.
Oh blah blah blah… I love it when people try and argue that mutilating women is different somehow than mutilating men. Infibulation (stitching the vaginal opening closed) is performed on only 10% of the girls who are mutilated. The remainder have either their prepuce removed, the tip of their clitoral glans removed or both including the removal of the labia. These women report the same interest in sex, the same arousal, the same number of orgasms and the same frequency of intercourse as their intact counterparts. Regardless, there are studies that show that when you remove a woman’s prepuce and labia, her risk of HIV goes down. That is no better a reason to cut her than it is to cut a boy. Google “circumcision a rose by any other name” to read about the fallacy that mutilating one gender is different than mutilating the other.
~Huntress
Some forms of female circumcision do less damage than the usual form of male circumcision. Sometimes there’s just an incision with nothing actually removed. One form just removes the clitoral hood (the female foreskin), so it’s the exact equivalent of cutting off a boy’s foreskin. In some countries, female circumcision is performed by doctors in operating theatres with anesthesia. Conversely, male circumcision is often performed as a tribal practice. 91 males died of circumcision in just one province of South Africa last year.
Are you aware that the USA also used to practise female circumcision? Fortunately, it never caught on the same way as male circumcision, but there are middle-aged white US American women walking round today with no external clitoris because it was removed. Some of them don’t even realise what has been done to them. There are frequent references to the practice in medical literature up until at least 1959. Most of them point out the similarity with male circumcision, and suggest that it should be performed for the same reasons. Blue Cross/Blue Shield had a code for clitoridectomy till 1977.
One victim wrote a book about it:
Robinett, Patricia (2006). “The rape of innocence: One woman’s story of female genital mutilation in the USA.”
Nowadays, it’s illegal even to make an incision on a girl’s genitals though, even if no tissue is removed. Why don’t boys get the same protection?
Don’t get me wrong. I’m totally against female circumcision, and I probably spend a lot more time and money trying to stop it than most people. If people are serious about stopping female circumcision though, they also have to be against male circumcision. Even if you see a fundamental difference, the people that cut girls don’t (and they get furious if you call it “mutilation”). There are intelligent, educated, articulate women who will passionately defend it, and as well as using the exact same reasons that are used to defend male circumcision in the US, they will also point to male circumcision itself (as well as labiaplasty and breast operations), as evidence of western hypocrisy regarding female circumcision. The sooner boys are protected from genital mutilation in the west, the sooner those peoples that practice FGM will interpret western objections as something more than cultural imperialism.
“If people are serious about stopping female circumcision though, they also have to be against male circumcision.”
A categorical statement that thrown out but is unjustified and simply dishonest.
It is offensive to even equate the two procedures which is what radicals try to do when they talk about “female circumcision” or “male genital mutilation”. Female genital mutilation is done to subjugate women and to make sure that they are “pure” when the man forcibly takes her. In contrast, there is no such reprehensible motive for (male) circumcision.
Also, the health benefits of circumcision are indisputable: Circumcision reduces the rate of penile cancer (basically reduced to zero), all studies show significant decrease in syphilis/chancroid (though not other STDs), infant UTI rate cut dramatically, cervical cancer in female partner, and on and on.
Again, people cite some of the few population studies (in contrast to the majority of studies). Population studies have known problems but metanalysis shows definite protection. All the randomized controlled trials have been terminated early because the protective effect is so great.
“Modeling suggests that MC could avert up to 5.7 million new HIV infections and 3 million deaths over the next 20 years in Sub-Saharan Africa, many
of these among women.” B.G. Williams et al., PLoS Med. 3, e262 (2006).
Thus to oppose male circumcision is to sentence millions to death. For what? Some hippie back to nature argument?
“Also, the health benefits of circumcision are indisputable”
There are studies that say the same thing about women. You suffer from cultural relativism and can’t see past you own bias.
The bulk of female circumcision is very much like the bulk of male circumcision. There are extremes on both sides. In Australia and NZ, the natives not only cut off the foreskin, they put a rod into the penis all the way to the base and they use a blade to slit open the underside of the shaft. This flays the penis open like a vulva and forces the boy to squat to urinate. This isn’t a large percentage of boys, but then the women who are infibulated (stitched closed to ensure chastity) aren’t a large percentage either. More than 85% of female circumcisions involve removing the prepuce alone or the tip of the glans. (The clitoris is actually much larger than the exposed tip and the majority of it remains) It’s important that we compare apples to apples. The mildest fem mutilation with the mildest male mutilations.
They’re all wrong.
As for penile cancer… did you know that a circ’d man has a 0.0000001% chance of developing it? An intact man has a 0.000002% chance. In other words, a circ’d man has a risk one one-hundred thousandth of a percent less than an intact man. WOW that’s impressive. ~rolls eyes~ You need to learn to interpret studies for yourself instead of letting the pro-circers do it for you.
~Huntress
Red herring irrelevancies. Male circumcision is performed everywhere. It is a standard, safe procedure. Someone, somewhere “flays the penis open” and calls it circumcision. Sorry, but that isn’t circumcision (which is removing the foreskin). We could talk about making boys into eunuchs – that also would be as IRRELEVANT to the conversation.
The incidence of penile cancer in the U.S. is very low. Essentially all of the cases in the U.S. are in the uncircumcised. Thus, estimates of relative risk decrease by half are criticized as being very much an underestimate. In residency, I participated in the care of patient with it. He survived (there is a 25% mortality) but only with a penectomy and radiation. It is horribly scarring mentally and physically. I did NOT argue that the salutatory benefits of circumcision with respect to penile cancer ALONE was sufficient to justify circumcision in the U.S.
By the way, your math is wrong. The incidence in uncircumcised men is 1-2 per 100,000 (in the U.S.) which is 0.001-0.002 % Again, the incidence of circumcised males is basically zero.
But penile cancer is NOT rare in Sub-Saharan Africa which is the topic of discussion.
You seem to be some radical feminist ideologue more interested in pushing a political agenda and are willing to sacrifice millions of lives for that agenda.
There has never been a randomized control trial describing benefits of female genital mutilation. Your supposed citations to some health benefits of FGM are junk (just as quoting the few population studies that didn’t show benefit of male circumcision and ignoring the preponderance of positive population studies and much more importantly the randomized controlled trials). Your arguments that some FGM is less barbaric than others are frankly repugnant. Call me “culturally biased”, but I am not interested in faux arguments and more neutral terminology towards female genital mutilation. Attempts by the American Academy of Pediatrics to use more “neutral” terminology was rightly shouted down.
@orthocon: The majority of female mutilation is “true” circumcision and identical to the majority of male circumcision- the removal the prepuce. (foreskin/clitoral hood) More than 80% of the world’s men are intact. They most certainly do NOT circumcise men everywhere.
You really need to do some research so you can speak from a less ignorant place.
Go on and download that study I mentioned above. “A Rose by Any other Name”- and do some actual reading… if your closed mind will let you. Also, look here at what WOMEN in Africa say about their right to cut in a statement from the group African Women Are Free To Choose. http://www.thepatrioticvanguard.com/article.php3?id_article=3752
The Author, a highly educated African woman writes:
“That FC was designed by men to control women’s sexuality is a western feminist myth constructed in a disturbing dismissal of African gender models of male and female complementarity and of our own creativity, power and agency as adult women in the social world. The assertion that FC violates the rights of children falters in the face of WHO’s promotion of routine neonatal male circumcision (MC) to protect against HIV infection in Southern African. Incidentally, circumcised African women also have some of the lowest rates of HIV infection among women in the world, so why the double standard?”
~Huntress
Also-
“1-2 per 100,000 (in the U.S.) which is 0.001-0.002 %”
Perhaps you had issues in grades school math, but the numbers you show would be the equivalent of 1-2 per 1,000. C’mon… a 5th grader knows this.
1-2 in 100,000 translates into 0.000001-0.000002.
5th grade math lesson: To convert fractions to percentages. Take your calculator and divide, then multiply by 100, e.g., 1/10 => 0.1 => times 100 => equals 10 percent.
Now, 1/100,000 => 0.00001 => times 100 => equals 0.001%
Ms Huntress statess are women who advocate and participate in the horrific practice of female genital mutilation. Do I care? Does that make it less barbaric? Do I care about degrees of barbarism?
Sir Charles James Napier on the practice of sati (widows casting themselves on the funeral pyre of their husbands): “You say that it is your custom to burn widows. Very well. We also have a custom: when men burn a woman alive, we tie a rope around their necks and we hang them. Build your funeral pyre; [then] beside it, my carpenters will build a gallows. You may follow your custom. And then we will follow ours.”
Pathetically ignorant statement by Ms Huntress: “Incidentally, circumcised [sic] African women also have some of the lowest rates of HIV infection among women in the world, so why the double standard?”
It takes very little thought to realize that if your vagina is sewn shut, you are probably not very sexually active, hence the low HIV rate. Eunuch males would also have a low HIV rate.
Ayaan Hirsi Ali, herself a victim of FGM: “But the majority of girls are subjected to FGM to ensure their virginity—hence the sewing up of the opening of the vagina—and to curb their libido to guarantee sexual fidelity after marriage—hence the effective removal of the clitoris and scraping of the labia. Think of it as a genital burqa, designed to control female sexuality.”
I am repulsed by your defense of female genital mutilation.
“I am repulsed by your defense of female genital mutilation.”
You are mistaken… I do not defend ANY genital mutilation– including male genital mutilation. It is YOUR defense of male genital mutilation that is disgusting. I show you these references to demonstrate that every culture has their justification for mutilation. You think your justification for mutilating males is somehow better than the African justification for mutilating females? That’s a load of crap.
Cutting another human being’s body without their consent is barbaric. It is ALL mutilation. Get off your high horse… you are not the abiter. Apply the same reasoning to both cultures. Hypocrite.
~Huntress
Also- You clearly didn’t read the link (what are you afraid of? A little education?) I was quoting the author from the link. This group of women don’t infibulate (that is the proper term for sewing the vaginal opening mostly closed- you may wish to learn it) MOST African women don’t infibulate.
You really are a piece of work.
“Also, the health benefits of circumcision are indisputable”
Canadian Paediatric Society
“Recommendation: Circumcision of newborns should not be routinely performed.”
“Circumcision is a ‘non-therapeutic’ procedure, which means it is not medically necessary.”
“After reviewing the scientific evidence for and against circumcision, the CPS does not recommend routine circumcision for newborn boys. Many paediatricians no longer perform circumcisions.”
The Royal Dutch Medical Association
“The official viewpoint of KNMG and other related medical/scientific organisations is that non-therapeutic circumcision of male minors is a violation of children’s rights to autonomy and physical integrity. Contrary to popular belief, circumcision can cause complications – bleeding, infection, urethral stricture and panic attacks are particularly common. KNMG is therefore urging a strong policy of deterrence. KNMG is calling upon doctors to actively and insistently inform parents who are considering the procedure of the absence of medical benefits and the danger of complications.”
“It is YOUR defense of male genital mutilation that is disgusting.”
Saving millions of lives while preserving God given sexual pleasure is my defense.
And what do you offer? Red herrings, false analogies, and straw men. You can’t even do “fith grade math”, so it is not surprising that you don’t understand scientific studies. It is obvious to all but the most radical tree hugging, Birkenstock wearing, feminist radicals, that female genital mutilation is in no way equivalent to circumcision – neither medically, sociologically, nor psychologically. It is simply irrelevant. Ayaan Hirsi Ali in her book, Nomad, deals with the question of whether a just society should give a moral pass on “limited” female genital mutilation pawned off with various euphemisms. Her answer is an emphatic “No” because because of the sociological ramifications but also because of the fact that in the real world, trying to limit FGM to “nicking” doesn’t work.
1/100,000
0.1= one tenth
0.01=one hundredth
0.001=one thousandth
0.0001=one ten thousandth
0.00001=one hundred thousandth
We are both wrong- 1 in 100,000 is one hundred thousandth, or 0.00001
I think this is splitting hairs since even 0.01 would be statistically insignificant- but I’m one for accuracy. ;-]
“We are both wrong.” No. I used this little symbol “%” which we learned (or some of us did) means percent. You are the one who wrote “1-2 in 100,000 translates into 0.000001-0.000002” which is embarrassing nonsense.
“I think this is splitting hairs since even 0.01 would be statistically insignificant- but I’m one for accuracy.”
Well, you are wrong again. This shows an extreme naivete about medical science. We are talking about disease incidence. We would not invest in research in most diseases if we made a cutoff of 0.01 for disease incidence.
Mark Lyndon, firstly, we are talking about sub-Saharan Africa not Canada or the Netherlands. Second, position statements are what we call class C data. The Royal Dutch Medical society is particularly awash in political correctness and is most certainly inapplicable to the present situation because the preponderance of population studies and the subsequent follow-up randomized control trials most definitely show that the procedure IS THERAPEUTIC. The part “bleeding, infection, urethral stricture and panic attacks are particularly common” is particularly disingenuous. The complication rate of circumcision is between 0.2% and 0.6% (Gee WF, Ansell JS. Neonatal circumcision: a ten-year overview: with comparison of the Gomco clamp and the Plastibell device. Pediatrics. 1976; 58:824-827.) Almost all of these were minor bleeding treated with simple pressure or infection treated with topical and/or oral anti-biotics. To mention “urethral stricture” and “common” in the same sentence is simply irresponsible.
There is no medical organization IN THE WORLD that recommends infant circumcision. It doesn’t save lives- any more than female circumcision saves lives. And it DESTROYS 2/3 of a man’s sexual pleasure.
Cultural relativism.
Come back when you’ve read the studies and you have something new to contribute to the discussion.
~Huntress
Are you actually citing a study from 1976? Well no WONDER you’re so confused. ~rolls eyes~
The Swaziland Health Department Report of 2007 shows that “after years of circumcising young men, the HIV infection rate in Swaziland has gone up, not down as predicted. This data is from a 2007 Swaziland health department report, which the government has had for three years, but continues to circumcise men anyway. Government health officials are only now questioning using circumcision as an AIDS preventative.
In 2007, 22% of circumcised Swaziland men were HIV positive compared to 20% of intact men. The report questioned whether confounding factors caused the increase in circumcised men, or if circumcision itself was the cause.”
Oncologists say that penile cancer is one of the rarest cancers and that the median onset age is 64. A man has lots of sexually active years to enjoy his foreskin before he may want to have it cut away in order to prevent a cancer that is 10 times rarer than males breast cancer (we don’t remove male breasts in infancy) and 100 times rarer than female breast cancer (we don’t remove their breasts in infancy either).
I get that you think that you know better than ALL of the medical agencies around the world, but you’d have a tough time selling that BS. I DO believe there are politics involved, but I think they’d outlaw it outright if they weren’t concerned about stepping on people’s freedom of religion. There are NO politics keeping them from recommending it- just sound science.
“It doesn’t save lives”
You don’t like facts to get in the way of your screeds. The RCTs shows male circumcision decreases by about 50% in female to male transmission of HIV. I did not find any studies, population based and certainly not any RCTs for female genital mutilation.
This is simply pathetic: “And it DESTROYS 2/3 of a man’s sexual pleasure.”
In a 2008 study, Krieger et al. stated that “Adult male circumcision was not associated with sexual dysfunction. Circumcised men reported increased penile sensitivity and enhanced ease of reaching orgasm.” In a 2009 study, Cortés-González et al. reported a statistically significant improvement in “perception of sexual events” (p=0.04).
And as far as the female sexual partner, we have a prospective study: “Kigozi et al. reported on a prospective study of 455 female partners of men circumcised as part of a randomized trial. 39.8% reported improved sexual satisfaction following circumcision, 57.3% reported no change, and 2.9% reported reduced sexual satisfaction after their partners were circumcised.”
So you have offered nothing but falsehoods, simple math mistakes, unsubstantiated claims, red herrings, and straw men.
There will probably never be a better study looking at circumcision untoward outcomes than the one I cited because the technique hasn’t changed in 50 years.
Let’s review evidenced base medicine
Level I recommendations are based on results of randomized controlled trials.
Level II recommendations are from non-randomized trials, cohort studies, etc.
Level III are recommendations of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.
The population study in Swaziland, is level II data. Position statements are level III.
But then we have level CCCLXXIX recommendations which are idiotically misapplying position statements of western medical societies to settings that are entirely disconnected.
For a good example of the idiocy, penile cancer is the most common malignancy of males in Uganda, yet Ms Huntress insists on talking from a western perspective.
I would agree that those medical society position statements may not be relevant to Africa, but I quoted them simply to counter your assertion that “the health benefits of circumcision are indisputable”. They are in fact highly contentious.
You’re suggesting that the fact that circumcised men across the whole of Swaziland (and five other African countries) are more likely to have HIV than intact men is of little or no relevance. This is real world data, not a few thousand men in three trials that weren’t finished.
“I did not find any studies, population based and certainly not any RCTs for female genital mutilation.”
If there were three RCT’s into female circumcision and HIV, would you then support the promotion of female circumcision? There aren’t any such RCT’s of course, because female genital cutting is not considered acceptable to westerners who run and fund most (all?) of these trials. There is real world evidence that circumcised women have lower rates of HIV though. The Stallings study 2005 showed that “In the final logistic model, circumcision remained highly significant [OR=0.60; 95% CI 0.41,0.88] while adjusted for region, household wealth, age, lifetime partners, union status, and recent ulcer.”
What about the fact that the only RCT into male-to-female transmission showed a 54% higher rate in the circumcised group? Surely that should have killed dead any thoughts of promoting male circumcision to prevent HIV.
I found a rate of 0.7 per 100,000 per year for penile cancer in Uganda btw. This compares to 2.4 for cancer of the oral cavity, and 0.2 each for vulval cancer, and vaginal cancer.
Mark Lyndon seems to be an “intactivist”. I found numerous comments in just about every news story on circumcision and HIV saying pretty much the same thing by a commentator “ml” or “ml66uk”, etc.
There was a RCT in Lancet (http://tinyurl.com/mq3owu) looking at sero-positive males and sero-negative couples. The male partner was randomized to circumcision or not. The study was designed to show a DECREASE in male to female HIV transmission – which it did not show. It did show an increase of male to female transmission but this was not statistically significant. I am not sure that Mark and other intactivists understand statistical significance and confidence intervals, but the study cites an adjusted hazard ratio 1·49, 95% CI 0·62—3·57; p=0·368. The fact that the CI include 1.00 implies that one CANNOT conclude that circumcision INCREASES male to female transmission. Now, it certainly may. The argument is that circumcised men can cause more microtrauma during intercourse. Thus, the advocacy for condoms in serodiscordant couples in reasonable and pretty much universally accepted.
One certainly can’t conclude something as foolish as the statement, “Surely that should have killed dead any thoughts of promoting male circumcision to prevent HIV.” Here is a proper, rational conclusion from the editors of Lancet (http://tinyurl.com/28ts6wg):
—
Male circumcision provides long-term indirect protection to women by reducing the risk of heterosexual men becoming infected with HIV. In this Review, we summarise the evidence for a direct effect of male circumcision on the risk of women becoming infected with HIV. We identified 19 epidemiological analyses, from 11 study populations, of the association of male circumcision and HIV risk in women. A random-effects meta-analysis of data from the one randomised controlled trial and six longitudinal analyses showed little evidence that male circumcision directly reduces risk of HIV in women (summary relative risk 0·80, 95% CI 0·53—1·36). Definitive data would come from a further randomised controlled trial of circumcision among men infected with HIV in serodiscordant heterosexual relationships, but this would involve enrolling about 10 000 couples and is likely to be logistically unfeasible. As circumcision services for HIV prevention are scaled-up in high HIV prevalence settings, rapid integration with existing prevention strategies would maximise benefits for both men and women. Rigorous monitoring is essential to ensure that any adverse effects on women are detected and minimised.
—
Note the first sentence. If one decreases the pool of sero-positive males, that is good for women in the long term.
Yes I am an intactivist. I would however support male circumcision in Africa (or even minor forms of female circumcision) if I thought it would work against the AIDS epidemic. I think the evidence available suggests that it is more likely to make things worse though, even in the unlikely event that there was no risk compensation, and not one dollar was diverted from ABC.
The Wawer study was indeed too small to show statistical significance. Had it been larger, or had they let it run longer, this may not have been the case. That study was stopped for “futility” btw. Why, when the men in the test group had already been circumcised anyway? One has to wonder if they were afraid that the results might achieve statistical significance, which would indicate researcher bias.
The main problem is that it would not be considered ethical to repeat such an RCT. How then can it be considered ethical to promote mass male circumcision when we don’t know if the increased risk is 0%, 54% or 108%? Since about 19.5% of the intact men in Swaziland will already be HIV+ (compared to 21.8% of circumcised men), this is a very risky strategy, and there is a real chance that the overall rate of HIV infections will go up. Only about one in six men agree to be tested btw, and incredibly, they are being offered circumcision even if they test positive.
There is already a 1993 study which found that “partner circumcision” was “strongly associated with HIV-1 infection [in women] even when simultaneously controlling for other covariates.”
http://ije.oxfordjournals.org/cgi/content/abstract/23/2/371
If male-to-female transmission is increased, it could certainly help to explain those six African countries where men are more likely to be HIV+ if they’ve been circumcised.
The converse of your last sentence is that if we increase the pool of HIV+ women, this is bad for men in the long term. The assumption so far has been that there will be a decreased risk to men, and that this will outweigh any possible increased risk to men.
I was at the AIDS conference in Vienna, and PSI are aiming to raise a billion dollars to circumcise 38 million males. I don’t think we have anything like enough evidence to suggest that this is justified.
I believe the money would be far far better spent on promotion of condoms, more testing, and access to ART.
I’m not the only person questioning the promotion of circumcision btw:
French AIDS Council:
“Even though the WHO insists on the idea that, beyond male circumcision, the use of other forms of prevention remains essential, it is very likely that people who mistakenly believe themselves to be adequately protected will no longer use condoms.”
…
“Implementation of male circumcision as part of a draft of preventative measures could destabilize health care delivery and at the same time confuse existing prevention messages. The addition of a new tool could actually cause a result opposite to that which was originally intended.”
Rozenbaum W, Bourdillon F, Dozon J-P, et al. Report on Male Circumcision: An Arguable Method of Reducing the Risks of HIV Transmission. Conseil National du SIDA, 2007: 1-10.
and as this South African paper puts it:
“Those promoting circumcision argue that circumcision is an additional tool that will ultimately reduce infections more than just relying on condoms, monogamy and abstinence. However, African males are already lining up to be circumcised, thinking they will no longer need to use condoms. Rather than complementing ABC programs, promoting circumcision will undermine the ABC approach by diverting funds and encouraging risk compensation behavior, ultimately leading to an increase in HIV infections.”
http://www.futuremedicine.com/doi/abs/10.2217/17469600.2.3.193
I completely agree with you that circumcision should not be offered to HIV+ men (although it does decrease in syphilis and chancroid).
You repeated bringing up the of the 6 population studies with higher HIV rates in circumcised males and ignoring the 20 or so with lower HIV rates is simply disingenuous. The preponderance of population studies showed lower rates in circumcised males. Population studies have obvious faults which is why we moved on to the RCTs. Three RCTs were done. All showed overwhelming decrease in sero-conversion. The population studies are now basically irrelevant. What is not irrelevant are studies following implementation of population wide circumcision. This is how medicine works.
You also cast doubt about the authors of the lancet study and imply some conspiracy to suppress data. This is what the Lancet editors say, “Definitive data would come from a further randomised controlled trial of circumcision among men infected with HIV in serodiscordant heterosexual relationships, but this would involve enrolling about 10 000 couples and is likely to be logistically unfeasible.”
But they appropriately add: “As circumcision services for HIV prevention are scaled-up in high HIV prevalence settings, rapid integration with existing prevention strategies would maximise benefits for both men and women. Rigorous monitoring is essential to ensure that any adverse effects on women are detected and minimised.”
Why is it “logistically infeasible” to enrol ten thousand serodiscordant heterosexual couples for an RCT into male-to-female transmission, but it’s not considered infeasible to circumcise 38 million African males?
No-one really knows what the effect on male-to-female transmission is, except that there’s likely to be an increase, and it could potentially be a large increase. It looks very much to me like the people promoting circumcision are afraid that a large RCT into male-to-female transmission would give the “wrong” results.
I still don’t understand how you can argue that population studies are irrelevant compared with three unfinished RCT’s, which looked only at female-to-male transmission and were carried out only in countries where circumcised men have lower rates of HIV. Population studies are real world data. If a drug worked well in trials, but not in the real world, we’d stop using it, and maybe try to explain the discrepancy. No-one seems interested in doing that with circumcision and HIV though.
Three of those six countries (where men are more likely to have HIV if they’ve been circumcised) are countries where circumcision is being promoted. How can that make sense, especially in Swaziland, where the male HIV rate is over 20% in circumcised men anyway?
You seem determined to ignore those six countries, despite the fact that if male circumcision really provided a significant protection against HIV, there shouldn’t be more than one or two. I already suggested a plausible reason why some countries should have lower HIV rates amongst circumcised men without circumcision itself being the reason, but I can’t think of a reason why there should be six countries where the rates should be lower in intact men if circumcision does provide significant protection.
Also worth looking at:
http://www.iasociety.org/Default.aspx?pageId=11&abstractId=2197431
“Conclusions: We find a protective effect of circumcision in only one of the eight countries for which there are nationally-representative HIV seroprevalence data. The results are important in considering the development of circumcision-focused interventions within AIDS prevention programs.”
http://apha.confex.com/apha/134am/techprogram/paper_136814.htm
“Results: … No consistent relationship between male circumcision and HIV risk was observed in most countries.”
Something is very wrong here. Even if condoms didn’t exist, mass circumcision to protect against HIV just doesn’t make sense.
This is embarrassing: “I still don’t understand how you can argue that population studies are irrelevant compared with three unfinished RCT’s.”
Unfinished??? This shows incredible ignorance or willful intent to mislead. The studies were NOT unfinished but stopped prematurely because the STATISTICALLY SIGNIFICANT result showing overwhelming data that supported the premise – that HIV seroconversion is much less in circumcised males – had already been attained. In studies that involve mortality or great morbidity, it is unethical to carry the study on when one has already shown statistical significance.
Population studies have a numerous problems. Different populations can show different behavior. RCTs are the gold standard. If you want to rail against best medical practice, go ahead.
@Orthocon:
An international study published the Journal of the American Medical Association this year, of nearly 100 clinical trials found that when they were stopped early due to positive treatment effects, many of those effects were exaggerated.
“Our research shows that in most cases early stopping of clinical trials resulted in misleading estimates of treatment effects. These misleading estimates are likely to result in misguided decisions about the trade-off between risks and benefits of a therapy,” says Victor Montori, M.D., Mayo Clinic endocrinologist and corresponding author of the study. “On average, treatments with no effect would show a reduction in relative risk of almost 30 percent in stopped early trials. Treatments with a true relative risk reduction of 20 percent would show a reduction of over 40 percent.”
So much for the gold standard.
~Huntress
The “randomised control trials” can hardly be called “random,” esp. when biased reseachers who were looking to legitimize male infant circumcision circumcised males that ALREADY WANTED TO BECOME CIRCUMCISED, they were told to ABSTAIN from sex for 6 weeks following their circumcisions, and the studies were cut short early.
Were they stopped because “the effect of circumcision was so great?” Or were they stopped because trends showed the rates evening out and the circumcision advocates wanted to stop the studies before they did?
And yes, female circumcision IS circumcision. It’s just that you don’t want it defined as such because it brings into question the ethic of forcefully circumcising non-consenting infants. “Circumcising” boys is alright, but “circumcising” girls isn’t. Nothing but the name game.
“It is offensive to even equate the two procedures which is what radicals try to do when they talk about “female circumcision” or “male genital mutilation”. Female genital mutilation is done to subjugate women and to make sure that they are “pure” when the man forcibly takes her. In contrast, there is no such reprehensible motive for (male) circumcision.”
It is offensive and sexist to be defending the genital mutilation of one sex using “studies,” but then dismissing the idea that the genital mutilation should ever be “studied.”
Circumcision “studies” put the cart before the bull. Most medical science seeks to AVOID amputation, if not DISPOSE of it altogether. Circumcision “studies” are unique in that they’re the only ones that seek to legitimize the forced amputation of a perfectly normal, healthy body part. You’ll notice that there’s not an overwhelming amount of FEMALE circumcision “studies,” and the ones that DO exist are rightfully dismissed. No medical organization in the right mind would EVER as much as CONSIDER female circumcision “studies,” let alone use them to promote “mass female circumcision” campaigns. But it looks like with circumcision it’s “study it ’till it’s useful.” Sorry, “scientists” are just going to have to find something else. The “study” of ANY genital mutilation is repugnant and disgusting and it needs to stop. We might as well be “studying” the “medical benefits” of skull trephination.
The whole reason circumcision exists in the West today is BECAUSE Victorians wanted to subjugate men and make them “pure.” Circumcision was supposed to stop masturbation. It didn’t, but it continues today. Similarly, yes, I’m sure the “intentions” for female circumcision are to “curb” her sexuality, but science shows us that not even infibulation can prevent orgasm in women.
“Also, the health benefits of circumcision are indisputable: Circumcision reduces the rate of penile cancer (basically reduced to zero), all studies show significant decrease in syphilis/chancroid (though not other STDs), infant UTI rate cut dramatically, cervical cancer in female partner, and on and on.”
HAH HAH HAH HAH!
You MUST be that self-same “infocirc” guy who keeps posting this elsewhere. Here’s what the American Cancer Society has to say about the notionthat circumcision “reduces the rate of penile cancer to zero.”
“In the past, circumcision has been suggested as a way to prevent penile cancer. This was based on studies that reported much lower penile cancer rates among circumcised men than among uncircumcised men. But most researchers now believe those studies were flawed because they failed to consider other risk factors, such as smoking, personal hygiene, and the number of sexual partners.
Most public health researchers believe that the risk of penile cancer is low among uncircumcised men without known risk factors living in the United States. Most experts agree that circumcision should not be recommended solely as a way to prevent penile cancer.”
http://www.cancer.org/Cancer/PenileCancer/DetailedGuide/penile-cancer-prevention
“Again, people cite some of the few population studies (in contrast to the majority of studies). Population studies have known problems but metanalysis shows definite protection. All the randomized controlled trials have been terminated early because the protective effect is so great.”
The “metanalysis” shows the what the supposed “researchers” manipulated them to show, as they happened in a controlled environment. The population studies are more accurate because the people were measuring the status quo, not looking for a desired outcome.
“The incidence of penile cancer in the U.S. is very low. Essentially all of the cases in the U.S. are in the uncircumcised.”
Oh? What’s this you say? All cases of penile cancer in the US are uncircumcised? Really? Where is your “study” for that?
” In residency, I participated in the care of patient with it. He survived (there is a 25% mortality) but only with a penectomy and radiation. It is horribly scarring mentally and physically.”
How do I know that this anecdote wasn’t made up? And even if it were true, how is it relevant? I know plenty of men who survived prostate cancer, only after having it removed etc… Really, what does your little story prove?
“By the way, your math is wrong. The incidence in uncircumcised men is 1-2 per 100,000 (in the U.S.) which is 0.001-0.002 % Again, the incidence of circumcised males is basically zero.”
Need a study please…
“But penile cancer is NOT rare in Sub-Saharan Africa which is the topic of discussion.”
Actually, no, the topic of discussion is the use of circumcision as a means to “prevent AIDS.” Can we stick to it?
“There has never been a randomized control trial describing benefits of female genital mutilation. Your supposed citations to some health benefits of FGM are junk (just as quoting the few population studies that didn’t show benefit of male circumcision and ignoring the preponderance of positive population studies and much more importantly the randomized controlled trials).”
How are the supposed “randomized control trials” different than the population studies? Other than that they were conducted in entirely controlled environments by circumcision advocates with an agenda?
“Your arguments that some FGM is less barbaric than others are frankly repugnant. Call me “culturally biased”, but I am not interested in faux arguments and more neutral terminology towards female genital mutilation. Attempts by the American Academy of Pediatrics to use more “neutral” terminology was rightly shouted down.”
Heh heh… who’s appealing to “emotion” and “opinion” now? Call the fact that some FGM is less barbaric than others “repugnant,” but the fact is that it’s true. If you’re not interested in “faux arguments and more neutral terminology towards female genital mutilation,” only male genital mutilation, right?
“Ms Huntress statess are women who advocate and participate in the horrific practice of female genital mutilation. Do I care? Does that make it less barbaric? Do I care about degrees of barbarism?”
Obviously it matters when you defend male circumcision… female circumcision is more “barbaric” and “repugnant” right?
“Saving millions of lives while preserving God given sexual pleasure is my defense.”
Only, circumcision doesn’t save anybody, and it DOES take away sexual pleasure. That’s what it’s meant to do! Heh heh… SOMEBODY doesn’t know their history…
“And what do you offer? Red herrings, false analogies, and straw men. You can’t even do “fith grade math”, so it is not surprising that you don’t understand scientific studies. It is obvious to all but the most radical tree hugging, Birkenstock wearing, feminist radicals, that female genital mutilation is in no way equivalent to circumcision – neither medically, sociologically, nor psychologically. It is simply irrelevant. Ayaan Hirsi Ali in her book, Nomad, deals with the question of whether a just society should give a moral pass on “limited” female genital mutilation pawned off with various euphemisms. Her answer is an emphatic “No” because because of the sociological ramifications but also because of the fact that in the real world, trying to limit FGM to “nicking” doesn’t work.”
>Yawn< – Quoth the guy who says that all female circumcision are one and the same… quoth the guy who offers false analogies and attacks his own straw men… Pathetic…
Regarding the latest hype regarding the latest circumcision/HIV “studies,“ there are various reasons these studies are flawed.
1. Researcher bias; a lot of these “reseachers” have a conflict of interest in that they belong either to societies, ethnic groups or religious sects where infant circumcision is a requirement. The most prominent people are Robert Bailey and Daniel Halperin. Robert Bailey has been trying to find a way to legitimize infant circumcision since about 1996, a full decade before any of the latest “studies.“ And Daniel Halperin is Jewish, and he is on record saying he wants to continue his grandfather’s legacy (grandpa was a mohel).
2. The “study” was rigged from the beginning. The “reseacrhers” weren’t looking to “find” how circumcision “reduced the risk of HIV by 60%,“ that was already an assumed, forgone conclusion. They were looking to see “how much,“ without ever actually showing any proof that the removal of the foreskin did anything to prevent HIV. Neat huh?
3. Methodology. The circumcised group of men were told to abstain from sexual intercourse for 6 weeks after their circumcision. They were also given full instruction in the use of condoms. A large number of men dropped out of the studies, and, as if this weren’t enough, the “studies” were ended early. The “results” were immediately published, and circumcision advocates were already using them to promote, not adult, but INFANT circumcision.
4. I think this hurts the studies the most, the fact that the hypothesis on which they were based, that the foreskin “reduced the risk of HIV” by eliminating the langerhans cells, which were supposed to be the “prime port of entry” for HIV.
In reality, Langerhans cells are found all over the body; their removal is virtually impossible. Also, deWitte found that “Langerin is a natural barrier to HIV-1 transmission by Langerhans cells” (DeWitte 2009)
As of yet, there hasn’t yet been a single explanation as to how exactly removing the foreskin “reduces the risk” of HIV infection, only assertion that it just “does.“
The langerhans hypothesis has been long forgotten, and researchers tried to sell the lie that “Circumcision ‘reduces the risk of HIV’ because it’s harder for the virus to get through the keratinized glans.“
But in other studies:
“CONCLUSION: We found no difference between the keratinization of the inner and outer aspects of the adult male foreskin. Keratin layers alone are unlikely to explain why uncircumcised men are at higher risk for HIV infection.“
Dinh MH, McRaven MD, Kelley Z, Penugonda S, Hope TJ., Division of Infectious Diseases, Department of Medicine, Chicago, Illinois
5. Realities in other countries with circumcised majorities simply do NOT ADD UP.
According to demographic health studies performed in other countries in Africa, HIV transmission was prevalent in circumcised men in at least 6 different countries:
Cameroon (4.1% v 1.1%)
Ghana (1.6% v 1.4%)
Lesotho (22.8% v 15.2%)
Malawi (13.2% v 9.5%)
Rwanda (3.5% v 2.1%)
Swaziland (21.8% v 19.5%)
The demographic studies for these countries can be found at measuredhs dot com
According to Malaysian AIDS Council vice-president Datuk Zaman Khan, more than 70% of the 87,710 HIV/AIDS sufferers in the country are Muslims (where all men are circumcised). In Malaysia, most, if not all Muslim men are circumcised, whereas circumcision is uncommon in the non-Muslim community. This means that HIV is spreading in the community where most men are circumcised at an even faster rate, than in the community where most men are intact.
Let’s not mention the situation in America, where, despite a circumcised majority (approx. 80% of American men), we still manage higher rates of HIV transmission than other countries who do not circumcise, IE, the UK, Denmark, Germany, and Japan just to name a few.
Before any further promotion of circumcision on the grounds of “HIV” prevention, the failure of circumcision to prevent HIV in the aforementioned countries needs to be explained.
Will the WHO, UNAids, UNICEF, Johns Hopkins etc. please step up to the plate?
Why are these “studies” being used to promote the circumcision of sexually inactive, non-consenting individuals, when the “studies” themselves were conducted in adult, questionably informed men?
But the faulty studies being used to promote circumcision, not to mention the ethical implications of circumcising healthy, non-consenting, sexually INACTIVE children, are only the tip of the iceberg. SCREW what we think about circumcision, promoting it as “HIV prevention” is doing Africa a DISSERVICE. Check it out!
“Boys see circumcision as a licence for unprotected sex”
http://www.postzambia.com/post-read_article.php?articleId=15572
Whatever you think about male infant circumcision, “it’s religion,” “it’s a parent’s choice,” we need to dispose with the fatally dangerous idea that “circumcision prevents AIDS.” Because it DOESN’T. This idea is already hurting men and women in Africa. This isn’t funny. This isn’t cute. It’s people’s lives we’re dealing with. Whatever your reasons for justifying male infant circumcision “the prevention of AIDS” shouldn’t be one of them.
And, just for kicks, another country where circumcision isn’t preventing AIDS: ISRAEL (see links below)
“HIV diagnoses in Israel climb; new cases among gays up sharply”
http://www.haaretz.com/print-edition/news/hiv-diagnoses-in-israel-climb-n…ew-cases-among-gays-up-sharply-1.248651
“Israeli gays shun condoms despite worrying rise in AIDS” (and why shouldn’t they when circumcision ‘protects’?)
http://www.haaretz.com/print-edition/features/israeli-gays-shun-condoms-despite-worrying-rise-in-aids-1.249372
“Failing the AIDS test”
http://www.haaretz.com/print-edition/opinion/failing-the-aids-test-1.249088See More
I want to see “studies” and “researchers” explain the situations in all of these countries. I want to know why the fact that circumcision never worked in the US is never mentioned. (In the 80s, when the AIDS epidemic hit in the US, over 90% of all men were circumcised. So what happened?)
Somewhere along the line, some advocates of male infant circumcision have to make claims to the effect of “well female circumcision is different,” “it’s worse,” or “it minimizes a woman’s sexuality,” without giving any thought to the words that are coming out of their mouths, as if they didn’t have to bear the responsibility of proof. “Female circumcision is worse. Everybody knows this. I don’t have to prove this to you.”
These are all, of course, baseless claims.
Not all female circumcision surpasses male circumcision in severity; the most severe kind of FGM only constitutes about 15% FGM globally.
In Malaysia, baby girls are circumcised all the time. On this Singapore parenting blog, mothers openly talk about circumcising their daughters, almost as non-challantly as American parents talk about circumcising their sons. Here you can see that they remove only the clitoral hood, leaving the clitoris intact. One woman talks about undergoing the procedure as an adult, and it wasn’t all the pain and horror that male circumcision advocates try to make it out to be. Another woman describes the female circumcision she is used to as “less severe” than male circumcision.
http://www.mummysg.com/forums/f40/have-you-sunat-your-girls-29826/
“Studies show” that even women who have undergone full on infibulation (the worst kind of FGM) can orgasm.
http://onlinelibrary.wiley.com/doi/10.1111/j.1743-6109.2007.00620.x/abstract
People seem to forget that the whole reason circumcision even began in the states was as a means to try and curb men’s sexualities.
http://www.stayfreemagazine.org/10/graham.htm
Actually, female genital mutilation (marketed as “labiaplasty” here) is said by some “studies” to actually INCREASE “sexual satisfaction,” for BOTH partners.
http://www.labiaplastysurgeon.com/labiaplasty-clinical-study.html
And just for kicks, here is a link to the Stallings study, which shows a significant reduction in HIV transmission among circumcised women:
http://www.ias-2005.org/planner/Abstracts.aspx?AID=3138
BOTTOM LINE: Pain and/or whether it can be remembered is NOT the issue. Obviously baby girls won’t remember what is done to them either. Adult women can undergo clitoral hood removal and “labiaplasties” in a controlled medical environment. Taking a healthy, non-consenting individual and cutting off his or her genitals, in whole or in part, constitutes the exact same violation of principle, genital integrity, and basic human rights, and it doesn’t matter that you use pain killers.
When an action is morally repugnant, no amount of “study” can ever legitimize it. Medical organizations would NEVER endorse female circumcision as “HIV prevention,” not even if there were “studies” that showed it “reduced” HIV transmission by 100%. Male circumcision “studies” and their use to promote it as “HIV prevention” is a modern medical attrocity in BOYS, as it is in GIRLS. We will look back on these days as the darkest hour in modern medicine, and upon those so-called “researchers” of male circumcision as the Josef Mengeles of their time.
Poor African men and boys; they are but guinea pigs in a failed science experiment…
@Joseph4GI: I have just one word for your posts—
Beautiful. =)
~Huntress
I find it amazing people are justifying circumcision. Nature has designed the genitals for a reason. They are not defective.
If you want to decrease penile cancer to zero, why not cut off the entire penis?
If you want your women to be virgins, instead of circing girls, just cut off the penises of the boys.
If you don’t want to contract an STD make sex impossible.
Your statements are as rediculous as these.
I’ve had it both ways, and intact is better.
Thank goodness the wicked lies of those monstrous individuals advocating the forced genital cutting of children are becoming widely exposed with more and more parents acting to protect their children.
Children deserve to keep all of their bodies, boys deserve to keep all of their penises and those to interfere with and mutilate childrens genitals deserve to be kept in jail.
i believe the best way is to stand on one leg for 3 days after sex – well its no worse than circumcision as a tool to stop hiv
[…] Source: The government of Malawi has rejected calls to promote circumcision as a prophylactic against HIV/AIDs. […]
A rare occasion to praise the Church for its input in Africa.
Education is key, not cutting off part of men’s penises.