Why The Caribbean Must Reject Circumcision As A Method For HIV Prevention

Category: Health Created on Saturday, 07 January 2012 14:06 Written by Terri Henry

condoms prevent hiv There is news in the medical world that one of the new ways to fight the HIV/AIDS pandemic is male circumcision. Proponents of this method point to three studies conducted in Africa arguing that the HIV infection rate was reduced for circumcised males. However more accurate and objective findings show the research methods and results to be at best flawed[i] and at worst a calculated misinformation campaign designed to promote the genital mutilation of males in Africa and other susceptible countries. With its relatively high rates of HIV infection, the Caribbean population needs to be aware of the facts and equipped to reject the use of circumcision as a tactic in the prevention of the HIV/AIDS virus.

Circumcision is the practice of removing the male foreskin. The foreskin is a delicate prepuce of skin designed to protect the glans of the penis from abrasions and infections. With over 20,000 nerve endings, the foreskin increases sexual sensitivity and pleasure. Women also report increased sexual pleasure from an uncircumcised male.[ii] The foreskin also offers valuable immunological protection from urinary tract infections[iii] and many sexually transmitted diseases[iv]. There are many other functions of the foreskin[v] and besides all males are born with a foreskin so they were obviously intended by nature to be there. The non-religious origin of circumcision is believed to have started as a method to discourage sexual activity and over the years the procedure has been touted as a way to prevent male masturbation and cure diseases such as penile cancer and epilepsy[vi] (none of which have been proven under rigorous scientific tests and medical peer reviews)[vii]. It continues largely because of cultural stereotypes, tradition and myths[viii]. As many informed doctors insist, circumcision is an unnecessary, painful, cruel practice[ix] that causes long term physical and psychological damage[x] and is essentially a solution in search of a problem – meaning that there is very rarely any medical reason to ever circumcise. Unfortunately ignorance abounds and circumcision is still one of the most widely non-medical surgical procedures performed in the USA.

Since most circumcision is conducted on babies, it is a human rights issue. An uninformed parental choice will affect a boy for the rest of his life, altering his genital integrity forever. Intactivists (someone who believes in keeping a penis intact) insist that a child’s body is his own and infringing on these rights is abuse. A recent article in the Guardian newspaper states that ‘Just as we call sex without consent 'rape', circumcision without consent or reasonable justification should be called 'mutilation'.’[xi] Rates of circumcision for non-religious reasons are declining all over the world[xii] except now in countries where the propaganda linking circumcision & reduced HIV is widespread. Circumcision is one of the latest trends to be foisted upon the African continent with an almost evangelistic zeal and needs to be examined in the harsh light of real science and neo-colonialist critique.

Campaigns across Africa have already resulted in thousands of males getting circumcised to reduce their likelihood of being infected with HIV but the results of such an initiative are not proving successful for two main reasons. The first is that the original studies were far from conclusive that circumcision really is effective and secondly when it circumcision is performed it affects sexual behaviour to the extent that disease transmission becomes more likely.

Let’s start with the studies. Three separate studies were conducted - in South Africa, Uganda and Kenya. All involved a group of men who signed up wishing to be circumcised.

In South Africa a total of 3,274 men were divided into two groups where 1,582 were left intact while 1,546 were circumcised. At the end of the trial, 45 of the intact men had HIV while 20 of the uncircumcised group were HIV+.
In Uganda, researchers randomly divided a total of 4,996 men into two groups. 2,474 men were circumcised while the other group of 2,522 men was left intact. After 24 months, both groups were tested for HIV infection. Of the circumcised men, 22 tested positive, while 45 in the uncircumcised group tested positive.
A similar scenario took place in Kenya where studies began with 2,784 men with 1,391 undergoing circumcision and 1,391 left intact. Two years later there were 22 new infections in the group of circumcised men and 47 among those left intact.

On face value the studies do appear to show that circumcision has a slightly positive effect on reducing HIV infections. However some of the flaws of the study include:

No in-depth questioning was done in either of the groups as to the HIV status of their partners, their sexual behaviour, or other lifestyle circumstances.
The short length of the trial means that the circumcised men were unable to have sex for a significant portion also reducing their risk. (At the end of the trial the uncircumcised group was offered circumcisions and thus no long term follow-ups can be completed.)
The studies ignored the fact that the main way in which HIV is transmitted in Africa is not through heterosexual intercourse but via contaminated injections and surgical procedures. Some of those who registered HIV+ during the study had declared not to have had sex at all thus showing that their infection was not the result of intercourse and circumcision had made no difference but these variables were not taken into consideration.
The studies are in no way consistent with other evidence from the general population. The Circumcision Resource Centre reports that ‘African national population surveys in eight countries found a higher rate of HIV infection among circumcised men compared to men who were not circumcised. There are at least 17 other observational studies that have not found any benefit from male circumcision in reducing HIV transmission. Among developed countries, the United States has the highest circumcision rate and the highest rate of heterosexually transmitted HIV. Other countries have lower rates of HIV infection than the United States and do not practice circumcision.’[xiii]
The studies did not take into consideration the drop-outs from the study which represented 6.4% of all participants[xiv]
The circumcised men received more exposure to safe-sex information during their time in medical hands, waiting for and recovering from, their operations. They were specifically told to use condoms in the post operative healing period and were more likely to have had condoms available after that time frame.
The studies also showed that circumcision ONLY protects the male from viral transmission from the female during heterosexual intercourse and offers no protection for a woman in this intercourse and offers no protection for a homosexual male receiving anal penetration. Women have been shown to be at increased risk from HIV infection from circumcised men.[xv]

In their in depth critique of the research methods and findings of the research in Africa, Robert S. Van Howe, and Michelle R. Storms of College of Human Medicine, Michigan State University present a clear response to show ‘How the circumcision solution in Africa will increase HIV infections.’ The full article is definitely worth reading in entirety as they clearly articulate how the entire study was biased, lacking in scientific rigor, had a skewed selection process and demonstrates a lack of biological plausibility that circumcision could ever be effective in preventing HIV. They also highlight that diverting funding from other proven methods of HIV reduction to circumcision, which is barely effective in comparison, will cause an increase in infections.[xvi]

The report on ‘Sub Saharan African randomized clinical trials into circumcision and HIV: Methodological, legal and ethical concerns’[xvii] also details and references meticulously the numerous flaws in the studies and the ethics involved.

The other major problem with promoting circumcision as a way to prevent HIV is that many men and women think that they are immune to catching HIV once the male is circumcised leading to decreased condom use and increased risky sexual behaviour.[xviii] In truth the new findings of growing HIV prevalence among circumcised males indicates that accurate information is not being effectively conveyed. Some men have signed up for the operations saying ‘When I am circumcised I don’t need a condom.’ In truth, circumcision cannot protect an individual from HIV infection unless it is combined with other safe sex measures including using condoms, being faithful to one partner, or abstaining from sex. Of course if one practices the aforementioned behaviour the circumcision is not even a necessary part of the equation! As the Circumcision Resource Centre states ‘If you were an adult male and had the option of using a condom and getting virtually assured protection or having part of your penis cut off to get a one in 60 chance of protection, the choice is clear.’[xix] Since many circumcised males also experience a significant decrease in the sensitivity of their penis due the cutting of the erogenous tissue and nerves of the foreskin and keratinisation of the glans, there is even less desire to wear condoms and thus the infection rate increases.

The confusion on whether or not circumcision relieves men of the necessity to wear condoms is cleared up by Marilyn Milos, founder of the National Organization of Circumcision Information Resource Centers (NOCIRC) who states: "Circumcision cannot prevent the spread of HIV; circumcised men contract HIV, transmit HIV, and die from AIDS. Transmission of HIV infection is caused by risky behaviors, such as multiple sex partners, failure to use condoms, and contaminated instruments or needles. Anyone who engages in high-risk behavior, whether circumcised or intact, is in danger of contracting HIV and other sexually transmitted diseases."[xx] However it is unlikely that this information is reaching the masses signing up for circumcision in the hope of a magic bullet protection.

When condoms are used properly they are 95-99% effective in the prevention of HIV, other sexually transmitted diseases and pregnancy. It would therefore be logical that continued promotion of their use would be in the highest interests of the entire society. The cost of one circumcision in Africa can pay for 3000 condoms, and it is far more cost effective to continue advocating, educating and distributing condoms as well as promoting other safe sex measures. Condoms also have the advantage of protecting women and present no surgical risks and complications (the rate of post operation infections in areas without properly sterilized equipment can be as high as 35%)[xxi]According to the World Health Organization ‘Circumcision can be risky if it is performed in unsterile conditions. It can lead to infection, bleeding and permanent injury, or HIV infection from non-sterilized “instruments”, and possible death if appropriate treatment is not provided.’ Yet still they advocate it. Also the money being diverted to circumcision could be better spent in upgrading both medical services and treatments that present a high risk for HIV transmission as, in Africa, this is where many new infections occur.

In a report for the journal ‘Future Medicine’ entitled ‘Male circumcision is not the HIV ‘vaccine’ we have been waiting for’, authors Green, McAllister, Peterson & Travis caution strongly against promoting circumcision for HIV reduction writing that:

“Campaigns to promote safe-sex behaviors have been shown to accomplish a high rate of infection reduction, without the surgical risks and complications of circumcision, and at a much lower cost. For the health community to rush to recommend a program based on incomplete evidence is both premature and ill-advised. It misleads the public by promoting false hope from uncertain conclusions and might ultimately aggravate the problem by altering people’s behavioral patterns and exposing them and their partners to new or expanded risks. Given these problems, circumcision of adults, and especially of children, by coercion or by false hope, raises human rights concerns.”[xxii]

Increasing the incidence of a surgical procedure that needs sterile instruments, leaves an open wound in sometimes unsanitary conditions and in areas where HIV is primarily transmitted through medical operations and unclean needles is foolish indeed. Advocating a procedure that is highly invasive, leaves physical and psychological wounds, has a low protection rate against HIV and still needs to be used in conjunction with other protective methods seems to buck common-sense entirely. The current plan based on the inconsistent and inaccurate research is to now roll out up to 28 million circumcisions in Africa. It doesn’t take much to dig a little deeper, join the dots and realize that HIV prevention through circumcision is misleading notion used to disguise other disturbing agendas.

To begin with, it is more than a tragic irony that the research in Africa was conducted largely by American circumcised males who are actively involved in pro-circumcision research (and who’s funding depends on reporting findings agreeable to the donor). Ronald Goldman, PhD, executive director of the Circumcision Resource Center and author of Circumcision: The Hidden Trauma, has stated:

"We have seen such claims about the 'preventive benefits' of circumcision for over 100 years. They have all been refuted. No other normal, healthy body part is cut off for supposed 'preventive benefits.' From our psychological work, we know that there is a compulsion on the part of some circumcised men to have others circumcised. Unfortunately, it appears that this compulsion continues to drive some professionals and authorities to promote circumcision without proper critical analysis. They also ignore the serious sexual and psychological harm caused by circumcision."[xxiii]

By advocating high rates of circumcision for adult males, it is predicted that rates of neonatal circumcision will also rise as parents are duped into believing the benefits and feel they may as well get it done sooner rather than later (completely ridiculous of course as babies cannot get HIV until they are sexually active and then it will be their choice to cut or not to cut). BUT the foreskins of young babies are far more valuable to the foreskin industry than those from adults. Yes you read it right – there is an entire industry built around the amputation and re-use of foreskins.

Firstly there are the instruments used for foreskin removal which include circumstraint board, clamps, circumcision kits, anesthesia etc. Manufactures of these products and their company shareholders are profiting as rates of circumcision increase. Some companies have even been advertising on prime news outlets showing their equipment and positioning themselves as modern health saviours rather than the vultures that they are; cashing in on the more than dubious links being made between HIV and Circumcision. One of the inventors of the ‘AccuCirc’ device which is being used on male infant circumcision campaigns in Africa is David R. Tomlinson. He has also been at the helm of improving other circumcision devices and making profits from their sales. A serious conflict of interest is apparent in his position as a "chief expert on circumcision" at the World Health Organization.[xxiv] Does it get any more obvious than this?

Individual pro-circumcising doctors are also keen for any ‘medical’ excuse to continue circumcision even though no medical board in the world supports non-medical, routine circumcision. Doctors in the US are paid anywhere between $100 and $3000 for a circumcision and thus some doctors are all too keen to a promote and engage in research that shows any reason however tentative, ambiguous or downright false to continue with a trade that pays their bills, sends their kids to college and sets up their retirement fund.

Also, far from being discarded as bio-hazardous waste after the procedure, neonatal foreskins are resold to scientific research or pharmaceutical companies who then use them for cosmetic products, stem cell research and even creating breathable bandages. Foreskin material has even been found in a high-end skin cream that was promoted by Oprah Winfrey no less.[xxv] One German factory has now produced a machine that can grow new skin from the cells in the foreskin and are using it for a variety of clinical studies.[xxvi] It is estimated that the re-growth of skin that is possible from just one foreskin could make the final value as high as US$100,000.

Some countries, reviewing the evidence and facts, are not getting involved in the ‘circumcision charade’. In 2010 the African country of Malawi with a 12% infection rate, decided that it will not promote male circumcision as an HIV-prevention strategy. Dr. Mary Shaba, a top HIV/AIDS official in Malawi stated "We have no scientific evidence that circumcision is a way of slowing down the spread of AIDS"[xxvii]

In the South Africa Medical Journal Vol 101, No 11 (2011) the editor Daniel J Ncayiyana has offered a critique of the research on the circumcision/HIV link and argues that circumcision is an ‘illusive promise’ and ‘not the way to go for South Africa’[xxviii]

The Australian Federation of AIDS Organizations has also issued a statement which rejects circumcision for Australia, reiterating that ‘correct and consistent condom use, not circumcision, is the most effective means of reducing female-to-male transmission, and vice-versa.’[xxix]

In 2009, the Royal Dutch Medical Association released a position statement discouraging the practice of male circumcision.[xxx]

The British Medical Association's guidelines say, ‘It is important that doctors keep up to date and ensure that any decisions to undertake an invasive procedure are based on the best available evidence. Therefore, to circumcise for therapeutic reasons where medical research has shown other techniques to be at least as effective and less invasive would be unethical and inappropriate.’[xxxi]

The many other countries around the world that do not routinely practice or advocate circumcision will no doubt continue to ignore or refute the attempts by pro-circumcisers to promote their foreskin cutting agenda with links to HIV prevention and leave their males perfectly intact as the day they were born.

The report in Future Medicine Journal sums up by saying ‘In short, given the large number of unknowns, confounding factors and lack of long-term follow-up in the three RCTs, it is premature to recommend circumcision as an HIV-prevention strategy. Much more evidence must be gathered on real-world efficacy of male circumcision as a prevention tool before mass surgeries are implemented.’[xxxii]

The Caribbean has a traditionally low rate of circumcision but there is no reason to be complacent or feel that this procedure will not soon be advocated for the health of our nations. In fact the West Indies Medical Journal recently published an article[xxxiii] which unquestioningly went along with the pro-circumcision arguments citing the supposed health benefits (as mentioned previously none of these have withstood the test of rigorous duplication or medical peer reviews). The journal article also viewed the African studies in a positive light and although the author eventually concludes that the high cost of circumcision in the region would be a prohibitive factor to it being utilized, he still felt that males should be sensitized to this as an option. Given what has been discussed above, we should be vigilant that even this ‘discussion of circumcision as an option’ is monitored and doesn’t slip into mainstream sex-education classes or barber shop banter without being clearly balanced and countered with the more objective scientific data and effectiveness of superior HIV protective methods.

The Global Aids Program website recently published an article ‘To cut or not to cut: should the Caribbean region adopt male circumcision as an HIV prevention tool...or not’ by Dr. Pauline Russell Brown, a researcher and public health consultant based in Jamaica who has done extensive work in HIV and AIDS in the Caribbean region. After carefully weighing up the evidence on the reported benefits of circumcision, Brown feels that ‘for us in the Caribbean to go down the road of male circumcision will, in the short term, do more harm than good.’[xxxiv]

The Caribbean population should also beware that the circumcision/HIV misinformation campaign is not only being spread by white-coated scientists or medical professionals but high profile NGO’s also. The Bill Gates foundation recently funded the recording and air-play of a song promoting circumcision in Africa.[xxxv] The recording which features many of the top musicians in Africa, advocates circumcision as a preventative for many types of illness (again, none of which have stood up to rigorous and objective scientific studies – but heck let’s just sing about it anyway). So if in the Caribbean we hear a song by top reggae artists with lyrics promoting that males cut off valuable parts of their penis all sung to a catchy dancehall beat – beware! Be sure to arm yourself with enough information to keep the scalpels away from your foreskin and cover it with a condom instead.

Editor-in-Chief’s Note: Terri Henry is freelance contributor to MNI Alive. She is a writer & wellness consultant with a focus on natural health, ecological awareness, and sustainability. She is also a mother of two and blogs on the subject of natural parenting at ‘Child of the Nature Isle’ (www.childofnatureblog.com)

[i] Circumcision and HIV: Harm Outweighs "Benefit" http://www.circumcision.org/hiv.htm

[ii] The New Zealand Medical Journal ‘Effects of Male Circumcision on Female Arousal and Orgasm’http://journal.nzma.org.nz/journal/116-1181/595/content.pdf

Sex as Nature Intended - http://www.sexasnatureintendedit.com/

[iii] How the foreskin protects against UTI http://www.drmomma.org/2009/12/how-foreskin-protects-against-uti.html

[iv] See the section on ‘Lack of Biological Plausibility’ in this articlewww.publichealthinafrica.org/index.php/jphia/article/view/jphia.2011.e4/html_9

[v] Functions of the Foreskin: Purposes of the Prepuce http://www.drmomma.org/2009/09/functions-of-foreskin-purposes-of.html

[vi] Frederick Hodges, DPhil. a medical historian who has collected approximately 6,000 articles on circumcision which detail its history in the U.S. "In this country," he explains, "there is a common thread running throughout circumcision advocacy. It turns out that whatever disease is the focus of national attention, in whatever given time period, the circumcision advocates will use that disease as an excuse for circumcision. In the 1940's, when venereal disease was the focus of national attention, circumcision advocates said that circumcision would prevent and cure venereal disease. In the 1950's and '60's, when cancer was the great fear of the American public, naturally circumcision was used as a cure and a preventative of cancer. In the late 1980's and the 1990's, when AIDS and HIV has become a tremendous problem, the circumcision advocates have advocated circumcision as a way to reduce the risks."

[vii] The medicalization of Circumcision http://www.youtube.com/watch?v=IZpU_1OSppc

[viii] Psychology Today. ‘Myths about circumcision you likely believe’ http://www.psychologytoday.com/blog/moral-landscapes/201109/myths-about-circumcision-you-likely-believe

[ix] Circumcision Trauma http://www.youtube.com/watch?v=UAGNnqyNidY

[x] MRI Studies Show That the Brain Is Permanently Altered From Infant Circumcision

http://birthofanewearth.blogspot.com/2011/12/mri-studies-show-that-brain-is.html

[xi] Infant male circumcision is genital mutilation http://www.guardian.co.uk/science/the-lay-scientist/2011/dec/06/1?INTCMP=SRCH

[xii] Steep Drop Seen in Circumcisions in the US http://www.nytimes.com/2010/08/17/health/research/17circ.html?ref=health

[xiii] Circumcision and HIV: Harm Outweighs "Benefit" http://www.circumcision.org/hiv.htm

[xiv] See the study comparison table in Circumcision and HIV - the Randomised Controlled Trialshttp://www.circumstitions.com/HIV-SA.html#3

[xv] BBC News – HIV Circumcision study ends too early - http://news.bbc.co.uk/2/hi/health/8154134.stm

[xvi] Journal of Public Health in Africa ‘How the circumcision solution in Africa will increase HIV infections’www.publichealthinafrica.org/index.php/jphia/article/view/jphia.2011.e4/html_9

[xvii] ‘Sub Saharan African randomized clinical trials into circumcision and HIV: Methodological, legal and ethical concerns’http://xa.yimg.com/kq/groups/23477339/1441224426/name/JLM_boyle_hill.pdf

[xviii] Doctors Opposing Circumcision http://www.doctorsopposingcircumcision.org/DOC/pressrelease07-31-05.html

[xix] Circumcision and HIV: Harm Outweighs "Benefit" http://www.circumcision.org/hiv.htm

[xx] No Circ Pamphlet on HIV & Circumcision http://www.nocirc.org/publish/11-HIV.pdf

[xxi] The Circumcision Resource Centre http://www.circumcision.org/hiv.htm

[xxii] Male circumcision is not the HIV ‘vaccine’ we have been waiting for!http://www.futuremedicine.com/doi/full/10.2217/17469600.2.3.193?prevSearch=authorsfield%25A%2528Green%252C%2BLawrence%2BW%2529&searchHistoryKey=&&&

[xxiii] Flawed Studies Used to Claim Circumcision Reduces HIV Infection http://www.salem-news.com/articles/december112011/circumcision-hiv-rg.php

[xxiv] CircLeaks http://www.circleaks.org/index.php?title=David_R._Tomlinson

[xxv] The Foreskins in Oprah's Facecream - http://www.drmomma.org/2009/10/foreskins-in-oprahs-facecream.html

[xxvi] German Factory Uses Infant Foreskin to Grow Human Skin http://www.drmomma.org/2011/12/german-factory-uses-infant-foreskin-to.html

[xxvii] Malawi rules out circumcision for AIDS prevention http://intaction.org/wp/?p=63

[xxviii]South African Medical Journal, Vol 101, No 11 (2011) ‘The illusive promise of circumcision to prevent female-to-male HIV infection – not the way to go for South Africa’ http://samj.org.za/index.php/samj/article/view/5384/3655

[xxix] Male circumcision has no role in the Australian HIV epidemichttp://www.afao.org.au/__data/assets/pdf_file/0019/4528/BP0709_Circumcision.pdf

[xxx] Royal Dutch Medical Association Launches Anti-Circumcision Campaignhttp://www.intactnews.org/node/128/1316026077/royal-dutch-medical-association-launches-anti-circumcision-campaign

[xxxi] The law and ethics of male circumcision - guidance for doctorshttp://www.bma.org.uk/ethics/consent_and_capacity/malecircumcision2006.jsp

[xxxii] Male circumcision is not the HIV ‘vaccine’ we have been waiting for!http://www.futuremedicine.com/doi/full/10.2217/17469600.2.3.193?prevSearch=authorsfield%25A%2528Green%252C%2BLawrence%2BW%2529&searchHistoryKey=&&&

[xxxiii] West Indian Medical Journal - Male circumcision and the Caribbean HIV epidemic. July 2010

http://caribbean.scielo.org/scielo.php?script=sci_arttext&pid=S0043-31442010000400002&lng=en&nrm=iso

[xxxiv] Global Aids Program: ‘To cut or not to cut: should the Caribbean region adopt male circumcision as an HIV prevention tool...or not’http://www.panosaids.org/2010/blog/showBlog.asp?bid=13&eid=20

[xxxv] Circumcision song hits the airwaves across Africa http://www.drmomma.org/2011/12/circumcision-song-hits-airwaves-across.html

Other notable resources used that are not cited in Endnotes:

Dr Dean Edell on Circumcision http://www.youtube.com/watch?v=bk8bfpCADcA

The Circumcision Channel - http://www.youtube.com/watch?v=FlzdPBymQeQ

Effects of Male Circumcision on Female Arousal and Orgasm - http://www.drmomma.org/2009/10/effects-of-male-circumcision-on-female.html

Mothering Magazine September/October 2005 ‘The Truth about Circumcision and HIV.’ http://mothering.com/health/the-truth-about-circumcision-and-hiv?page=0,0

No Circ of Pennsylvania. Ignore the Myths Get the Facts - http://www.nocircpa.org/4642.html Circumcision and HIV -http://www.circumstitions.com/HIV.html

Circumcision Decision Maker - http://circumcisiondecisionmaker.com/

Christianity and Circumcision http://circumcisiondecisionmaker.com/decide/infant-circumcision/religion/christian/

Male Circumcision & Women's Health - http://www.drmomma.org/2009/07/how-male-circumcision-impacts-women.html

The Whole Baby Network - http://www.wholebabyrevolution.com/default.html

Intactivist Facebook Pages:
Saving Our Sons
Intact America
The Whole Network
The Intact Network
Stop Infant Circumcision Society
End Routine Infant Circumcision