Questioning Circumcision

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Male Circumcision and HIV: A Public Health Policy Weblog December 11, 2007

Filed under: Uncategorized — intactivist @ 1:46 am


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  • Circumcision does not affect HIV in U.S. men

Removing foreskin no protection for American men of color, study finds 

December 4, 2007: MSNBC: READ THE STORY  


Circumcision does not affect HIV in US men: study

Washington, Dec 04: Circumcision may reduce a man’s risk of infection with the AIDS virus by up to 60% if he is an African, but it does not appear to help American men of color, US researchers reported on Monday. Black and Latino men were just as likely to become infected with the AIDS virus whether they were circumcised or not, Greg Millett of the US Centers for Disease Control and Prevention found. “We also found no protective benefit for a subset of black MSM (men who have sex with men) who also had recent sex with female partners,” Millett told reporters in a telephone briefing. Doctors believe circumcision protects men because of specialized cells in the foreskin of the penis, which is removed in the procedure. The foreskin is filled with immune cells called Langerhans cells, which are the immune system’s sentinels and attach easily to viruses — including HIV. In addition, sexual intercourse may cause tiny tears in the foreskin, allowing the virus into the bloodstream. The data has been so clear that the World Health Organization now recommends circumcision as one of the ways to prevent HIV infection. But circumcision does not protect men 100 percent — the studies in Africa have suggested it is 50 to 60% protective. Millett’s team studied 1,079 black and 957 Latino bisexual and homosexual men from New York City, Los Angeles, and Philadelphia. They filled out a computer survey and were tested for the AIDS virus. “Overall, we found no association between circumcision status and HIV infection status among black or Latino (men who have sex with men),” said Millett, who presented his findings to the CDC’s National HIV Prevention Conference in Atlanta. Experts knew circumcision would not protect a female sex partner, nor the male sex partner being penetrated. But Millett’s study found no benefit of circumcision to any of the men. “We also found no protective benefit of circumcision among those men reporting recent unprotected sex with a male partner in which they were exclusively the insertive male partner,” he said. HIV is much more common among black and Latino men than whites and this may offset any protection offered by circumcision, Millett said. Black and Latino men are more likely to have sex with other black and Latino men, and thus may be exposed to HIV more often than white men. The CDC is about to release new estimates of how many people become infected with the fatal and incurable human immunodeficiency virus each year in the United States. The CDC estimates that more than 1 million Americans are infected, of the 33 million infected people globally. Bureau Report 

“No one is promoting circumcision as a license for unprotected sex, but inevitably, in Africa and elsewhere, circumcision will be used not in concert with condoms but instead of condoms, potentially wiping out more than two decades’ worth of safer-sex intervention. Also, in an environment where “cut” = “clean,” women, who already constitute the majority of AIDS deaths in Africa, will have far less bargaining power to insist on safer sex with circumcised partners, and may seroconvert in even greater numbers.”LINK 


One Response to “Male Circumcision and HIV: A Public Health Policy Weblog”

  1. Joe Says:

    Jen – I thought I would share with you the mail I sent with regard to this. I started with the one at C&HIV modified and expanded with one paragraph coming from Goldman’s site. I thought it might give others some ideas on what to write so I figured I would share it. Incidentally, the enclosures were the 2 AFOA documents, the Sorrells paper, the news article about the Australian Med Association and Paul Mason, and the excerpt from the Ethical Canary. Good work on your site.

    December 10, 2007
    Julie Louise Gerberding, M.D., M.P.H.
    Director, Centers for Disease Control and Prevention
    Office of the Director
    Centers for Disease Control and Prevention
    1600 Clifton Rd Atlanta, GA 30333
    RE: Recommendations viz neonatal male circumcision and HIV
    Dear Dr. Gerberding:
    It has recently come to my attention that the Centers for Disease Control is considering recommending neonatal circumcision as public health policy in the effort to stem the spread of HIV/AIDS in the United States. I cannot express how strongly I oppose this recommendation.
    Over the past 15 years, research has begun to surface which demonstrates the deleterious effects of circumcision while for at least the last 25 years, neonatal circumcision has run into national grassroots opposition from a sizable and highly active group of people. This opposition on human rights grounds has resulted in the major medical organizations gradually moving away from support of a marginal procedure that damages sexual response and violates the individual human rights of the infants on the receiving end.
    Just this past September, the Australian Federation of AIDS Organizations evaluated the case for circumcision with respect to the three recently released studies and concluded that:

    Male circumcision has no role in the Australian HIV epidemic.
    African data on circumcision is context-specific and cannot be extrapolated to the Australian epidemic in anyway.
    The USA has a growing heterosexual epidemic and very high rates of circumcision.
    A rate of complication of between 2% and 10%.

    The AFAO goes on to point out that:
    “Articles 3 and 6 of UNESCO’s Universal Declaration on Bioethics and Human Rights require consideration in discussion of the implementation of circumcision programs to prevent HIV. Article 3 clause 2 states that: “The interests and welfare of the individual should have priority over the sole interest of science or society” while article 6 clause 1 states that “Any preventive, diagnostic and therapeutic medical intervention is only to be carried out with the prior, free and informed consent of the person concerned, based on adequate information. The consent should, where appropriate, be express and may be withdrawn by the person concerned at any time and for any reason without disadvantage or prejudice.” Given that male circumcision is an invasive HIV prevention method that is expected to have a population effect rather than a direct, measurable individual effect, genuine informed consent that involves a clear understanding of the lack of direct benefits to the individual is therefore ethically required.”
    While the French National Council on Aids (Conseil national du SIDA) issued a statement which concluded: “As the recommendations by the WHO highlight, this strategy is not aimed at countries with low prevalence or where it relates specifically to one part of the population such as in France or the United States.“ Further more, as you are aware, recent research has found that circumcision provided no benefit to highest risks groups in the United States.
    As Dr. Somerville, founding director of the Centre for Medicine, Ethics and Law at McGill University, said in her book The Ethical Canary:
    “The most recent claim of a medical benefit from circumcision is a reduction in the risk of contracting HIV infection or other sexually transmitted diseases. The research on which this claim is based is being challenged, but even if it is correct, it would not justify circumcising infant boys. Even assuming that circumcision gave men additional protection from becoming infected with HIV, baby boys do not immediately need such protection and can choose for themselves, at a later stage, if they want it. To carry out circumcision for such a future health protection reason (assuming for the moment that circumcision is protective) would be analogous to testing a baby girl for the gene for breast cancer and, if it is present, trying to remove all her immature breast tissue in order to eliminate the risk of her developing breast cancer as an adult woman.”

    The Kenya report spotlighted a 53% reduction of HIV acquisition in circumcised men relative to genitally intact men. However, only 47 of the 1,391 (one in 30) genitally intact men in the study contracted HIV, compared to 22 of the 1,393 (one in 63) circumcised men. These figures showed that about 56 circumcisions were needed to prevent one HIV infection, and 55 out of 56 circumcised men received no benefit. In the Uganda study, investigators estimated that 67 circumcisions were needed to prevent one HIV infection while the rate of moderate and severe circumcision complications was about 4%. Therefore, the chance of such a complication was more than 2.5 times greater than the chance of protection from an HIV infection, not including complications that would appear years later. The numbers needed to treat in a develop country such as the US is at least 6 times higher, 6 times as many boys who will gain no benefit and risk moderate to severe complications. Based in part on the aforementioned facts, lack of clear medical benefit, increasing knowledge of deleterious effects, and significant ethical issues surrounding neonatal male circumcision, the Children’s Commissioner of the Australian state of Tasmania, Paul Mason, has called for a ban on male circumcision and has recently gained the support of the Australian Medical Association.
    Whatever marginal gain individuals may receive from male circumcision must be in the context of informed consent and voluntariness. Infants can provide neither. The variables involved in the effectiveness of such a procedure over the longer term are many, including the changing dynamics of the disease, changes in provision of health care impacting cost-effectiveness, the possibility of new treatments, prevention technologies, and eventually a vaccine. Male circumcision has not served the United States well heretofore in comparison with non-circumcising countries and regions where the HIV/AIDS rate is much lower, e.g. Japan, most of Europe, and Latin America.
    For sometime now there has been an increasing awareness of the ethics of neonatal male circumcision which is being recognized by individuals , children’s rights organizations, and medical organizations both nationally and internationally; as such, this kind of intervention cannot be considered in an ethical vacuum when it is clear that there is no individual benefit or that any marginal benefit can be obtained later in life when informed consent is possible. How a man factors the known risk reduction alongside the unknown variables into his sexual decision-making is the important thing. Unless he opts to use condoms with all sexual partners whose HIV status is positive or unknown, he remains at risk of acquiring HIV (and if he does this, there is no need to be circumcised for added protection). I urge you to reject neonatal male circumcision as public health policy in order to safe guard your credibility with the American people and throughout the world. The United States can ill-afford another dubious, ethically questionable, policy with scant input from American stakeholders.
    Very truly yours,

    cc: Timothy Mastro, M.D.
    Division of HIV/AIDS Prevention

    Renée Jenkins, M.D., President, AAP
    Professor and Chair, Department of Pediatrics and Child Health
    Howard University Hospital

    Jay Berkelhamer, MD, FAAP, Past-President, AAP
    Children’s Health Care of Atlanta

    David T. Tayloe, Jr., MD, President-Elect, AAP

    Errol Alden, MD, Executive Director
    American Academy of Pediatrics

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