Monday, August 27, 2012
Two recent publications discuss medical male circumcision. The first is a technical report from the 'Task Force on Circumcision' of the American Academy of Pediatrics (AAP). The second is an article entitled 'Costs and Effectiveness of Neonatal Male Circumcision', published by the Archives of Pediatrics and Adolescent Medicine (APAM). The first concludes that "the health benefits of newborn male circumcision outweigh the risks". The second concludes that, based on a mathematical model, "[c]ontinued decreases in MC rates are associated with increased infection prevalence, thereby increasing medical expenditures for men and women".
Firstly, the AAP report is about circumcision for infants, whereas the randomised controlled trials (RCT), so often referred to in defence of circumcision, are about adult circumcision. Research has not shown that the same results are equally applicable to adults and infants. Also, the RCTs were carried out in African countries, for the specific reason that HIV prevalence in some areas is very high. It is not credible that the same results for African countries are equally applicable to the US; the majority of infections in the US are a result of men having sex with men, followed by intravenous drug use, whereas the majority in African countries are not.
In the APAM article, most of the cost savings from increasing levels of male circumcision assume the ability to avert increases in transmission of various diseases. But if the results from the RTCs are not applicable in the US, the model could end up showing very little indeed. But how applicable are the African RCTs in Africa? They did not investigate how people were infected, whether sexually or otherwise; it was just assumed that all transmissions were a result of heterosexual sex. Had some of the transmissions not been a result of heterosexual sex, this could have enhanced their findings considerably. However, there may be other reasons for discounting the relative contribution of non-sexual transmission; it might be difficult to attract volunteers to be circumcised, for a start.
One of the RCTs found that appropriate penile hygiene gave far better protection than circumcision, but this finding is not widely reported. Clearly, penile hygiene is important for the circumcised and the uncircumcised, the sexually active and those who are not, etc. Some research has even shown that circumcision may increase transmission from males to females, which makes up the greater proportion of transmission in African countries (though not in the US or in Western countries).
On the other hand, the reported 'low risks' involved in circumcision would appear to be more applicable to the US. The AAP report says: "Male circumcision should be performed by trained and competent practitioners, by using sterile techniques and effective pain management". None of these are guaranteed in high prevalence African countries. In fact, some studies suggest extremely high rates of adverse events where the operation is carried out in clinical settings, and far higher rates when the operation is carried out in a non-clinical setting; the majority of circumcisions are currently carried out in non-clinical settings in African countries (the article is by Robert Bailey, a pro-circumcision fundamentalist).
So, highly suspect data from three places in Africa are being used to sell the idea of circumcision; OK, ostensibly it's being sold to Americans, but the mass male circumcision programs in African countries are being pushed by American institutions, using American money. The claimed low risks involved apply to the US, if they apply anywhere. But the evidence for any protective effects from mass male circumcision in African countries is still too slight to support a program that proposes to circumcise tens of millions of men and perhaps tens of millions of infants. And conditions in health facilities are not adequate for such a program to be carried out safely.
It all seems so reasonable: the more we circumcise, the better; and the costs of doing this will far outweigh the levels of disease and sickness that would result if we don't do it. But we seem to have been here before: the claimed benefits bestowed on us by Big Pharma may be outweighed by costly adverse drug reactions. Using carefully selected bits of data from RCTs is bad enough, but using them to support circumcision in the US, while using data pertinent to the US to argue for the operation in African countries, is surely an insult to the intelligence.
If individuals wish to be circumcised, fine, although I'm at a loss to know what to say to people in the US who wish their infants to be circumcised. But neither infant nor adult mass male circumcision should be foisted on African countries where it will do little good, nay, is likely to do a lot of damage.
[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]