Circumcision: Never Mind the Evidence, Just Feel the Sentiment

What has circumcision got to do with public health? You might be surprised to hear that it hasn't got very much to do with public health at all. There is a huge amount of pro-circumcision sentiment, and probably just as much anti-circumcision sentiment. But evidence for and against the operation on public health grounds doesn't differ very much. In other words, the evidence for and against doesn't suggest that the operation does any more harm than any other unnecessary operation, nor does it do a great deal of good. Those in favor use that to impose their circumcision programs and those against use pretty much the same evidence to oppose them.

But this is a serious problem for Kenya, Uganda, Zimbabwe and a lot of other countries with medium or high HIV prevalence; because there is an enormous amount of money behind the pro-circumcision sentiment, and none behind those opposing it. This means that the evidence for the effectiveness of circumcision in reducing HIV transmission, and in reducing all sorts of other conditions, is used exclusively to push circumcision on populations that are desperate to address numerous health problems, HIV being just one of them, and often not even the most urgent.

Evidence that would count against the wisdom of circumcising millions of African men, at great expense, is either dismissed as being insignificant or ignored altogether. Most of the evidence for and against voluntary medical male circumcision programs is collected by the same teams, handfuls of extremely well funded Americans and a few Africans thrown in to make it look like a collaboration. They have data showing that circumcised men in some countries are less likely to be HIV positive than uncircumcised men, but they also have evidence that in other countries, circumcised men are more likely to be HIV positive. They have evidence that even where circumcision 'works', it doesn't always work very well. And those opposing circumcision also have this evidence.

These circumcision enthusiasts (positively messianic, one might say) even have evidence for the damage that can be done when circumcision is carried out by badly trained, underpaid, poorly equipped medical staff who have many other things they could be spending their time and resources on, but don't, because there is a lot of financial and political pressure to carry out circumcisions. They have data on genital hygiene that suggests the whole thing might be better addressed without carrying out an invasive operation, but such data is likely to remain as inconclusive at it is now. You might think, to balance things out, that those who oppose circumcision would attend to everything else, but you'd be wrong. Infants and children die from acute respiratory infections and water based diseases, assisted by poor nutrition and numerous endemic conditions, such as intestinal parasites. There is no money in 'everything else'.

Mothers frequently die giving birth, or quite soon after. People going to hospitals with one illness often leave with another, which may only be discovered much later, or not discovered until it is too late. Many die in hospital, not always because they had an incurable disease (though you could say that most diseases people go to hospital with in Sub-Saharan Africa are incurable), but because they received such poor quality treatment or because they were infected with something else while there. Most people suffer from, and many people die of, preventable and treatable diseases. It's one of the few things preventing more people from dying of lifestyle diseases. There may be sentiment behind maternal and infant morbidity and mortality, but there is not much money behind them.

The obvious question is, why are we even discussing circumcision, let alone pouring millions of dollars into it, when money is so scarce? I can accept that we don't discuss possible HIV interventions that we don't have any evidence for whatsoever, but not ones for which there is little evidence, but may prove fruitful, given some further investigation. And I can accept that we don't (often) discuss interventions that may work well, but are just too terrible to contemplate, because they are inhumane, unethical or simply wholly underdetermined, as yet, by the evidence.

But wait, doesn't circumcision fall into all three of those categories (and probably a good many others)? We strongly oppose the one child rule in China. We would oppose the removal of one testicle in men on the grounds that it might substantially reduce incidence of testicular cancer (men would still be fertile with one testicle), but this is just not being discussed, thankfully. So why is circumcision? It is inhumane, it is unnecessary  it is painful, it involves the removal of a piece of healthy flesh, it seriously influences a person's interaction with their immediate environment, it costs a lot of money that could be better spent in other ways, it ignores some far more urgent issues that it addresses, if you even accept that it addresses any issues.

The fact is that we are not just discussing male circumcision programs, it is claimed that millions of Africans have already been circumcised on the grounds that it will reduce transmission of HIV from women to men. Kenya claims to have circumcised 450,000 men under the current program. An article in the English Guardian claims that 380,000 Ugandans have been circumcised under a similar program, called Safe Male Circumcision (SMC) there. However, the article finds that progress is mixed in Uganda. This is despite the fact that Uganda are circumcising men at a faster rate than in Kenya and they hope to circumcise one million a year for the next few years.

Uganda's HIV epidemic is curious in the sense that it has probably had more money thrown at it per head than any other African country, yet prevalence remained flat for many years and is now said to be rising. Flat prevalence is very bad news in a country with a rapidly rising population because it can mask the fact that many people are being newly infected, even though many are dying and quite a few are only surviving because they are receiving antiretroviral drugs. It's one of the best examples of the futility of throwing money at an epidemic without being clear about how the virus is being spread, as long as current sentiment is behind the main interventions, which, we must bear in mind, used to be abstinence and a few other buzzwords thrown in for good measure.

Antiretroviral treatment programs in Uganda have also not always been as successful as some would like us to believe. HIV transmission in discordant couples, where only one partner is infected, has not always been substantially reduced among those who are receiving treatment. Also, fewer than half those who need treatment are receiving it. There have even been many interruptions in treatment where drug supplies have been unreliable and where programs are not consistent or sustainable. Throwing drugs at people can be about as ineffective as throwing money at them.

We were always told that abstinence and related programs were examples of 'evidence-based' public health, but they were not. They were what could best be called 'sentiment-based'; those with the money felt that people (Africans, of course) should not be having so much sex (however much they may have been having), that they shouldn't be having so many children, that they should use contraception more, that they should do, not what Westerners do, but what it was felt Africans clearly weren't doing, whatever that might be. Yes, it's a bit cryptic, but it appears that sentiment was on the side of abstinence. People still appear quite comfortable with the views that HIV is almost always transmitted sexually, that Africans have a lot of illicit sex, and that therefore it's no wonder HIV prevalence is so high in some parts of some African countries.

Or, to put it another way, HIV prevalence is only high in some parts of some African countries, and even though we know that HIV is not generally transmitted through heterosexual sex, don't Africans have loads of illicit sex, multiple, concurrent partnerships, underage marriages, widow inheritance, polygyny and whatever else? Yes? Well, then the answer is obvious. But circumcision is supposed to prevent the very kind of HIV transmission that should hardly ever happen, female to male transmission during penile-vaginal sex.

HIV is sexually transmitted (among other ways), but it is very rarely transmitted from the receptive to the passive partner in penile-vaginal sex. Heterosexual or homosexual, HIV is generally transmitted from the penetrative partner (generally male) to the receptive partner (male or female). That means women face a very high risk of being infected if they have unprotected sex, anal or vaginal, with a HIV positive man. And men face a very high risk if the have unprotected receptive anal sex. But it is very difficult for a woman to infect a man. The fact that so many men in Africa are infected when their only known risk is penile-vaginal sex with women doesn't just pour cold water on mass male circumcision, it raises the question of why non-receptive sex should be so risky only in some parts of some African countries.

You may find UNAIDS and other 'official' figures, and certainly plenty of published rhetoric, claiming that 'we' or 'everyone' or 'all promiscuous people' or something like that are at risk; but *we* are not, unless we are the receptive partner, and the penetrative partner is not using some kind of barrier method, such as a condom.

This is a crucial distinction that various institutions which receive copious quantities of money for public health programs fail to make clear. Many HIV positive men may claim to have been infected because they had sex with a sex worker, or something like that. But in the days when further investigations would be carried out, this was generally found to be untrue; men who are not intravenous drug users and who are not engaging in unprotected receptive anal sex are very rarely HIV positive. And very few men indeed (if any) have been demonstrated to have been infected by a woman as a result of having penile-vaginal sex with them.

If women don't pose a high risk to men, why are millions of African men infected, even though they have only had penile-vaginal sex with women? If women were not able to infect men easily, this epidemic would never have got off the ground; no sexually transmitted virus could become an epidemic if it can't be transmitted in both directions. It would have been confined to a few high risk groups, as it currently is in most Western countries (men who have (receptive) sex with men, intravenous drug users, but not, generally, sex workers). Huge numbers of heterosexual men should not be infected when they don't face serious risks. This is the question that needs to be answered in order to decide what is the best intervention. And the answer to this question is unlikely to be 'circumcise all the men'.

What's 'different' about Africa is that it is not clear how women infect men with HIV, because they hardly ever do outside of Africa. Of course, many women were probably not infected through heterosexual sex either, and that's also a problem to which mass male circumcision is not going to be a solution. If you are asking the right questions about HIV, and UNAIDS, WHO, CDC, the World Bank and others know that these questions are the right ones, mass male circumcision will not even be on the agenda. So why is it the entire agenda (for the moment)?

HIV is not, and has never been a 'gay plague', but it is a 'receptive partner' disease. This is not a new discovery, it is what has been known from the earliest years of the pandemic. So why have they spent so many years and so much effort telling us that it is sexually transmitted, that we are all at risk and that Africans are most at risk because they [fill in with your favorite prejudice]? Originally, HIV wasn't even a sexually transmitted disease because it was so infrequently transmitted to people who might infect someone else, and those they infected sexually were unlikely to have infected anyone else (generally being women). To avoid transmission, people need to know what the risks are and how to protect themselves; telling them lies will not help, something international health institutions should have noticed by now, if reducing transmission is one of their aims.

So why am I angry? Because this has been known all along, that it is receptive sexual partners who are at risk, not all and sundry. It has also been known all along that HIV could be transmitted most efficiently through unsafe healthcare and, while healthcare practices changed in Western countries, it went off the agenda in African countries due to a combination of structural adjustment policies and general lack of interest. It was known that about half the HIV positive infants were not infected by their mothers, they were infected through unsafe healthcare, and the same people who found that are out are the very people promoting circumcision and who promoted abstinence and whatever 'evidence-based' initiatives that attracted popular sentiment (and funding).

We knew all along, when there were only a few million HIV positive people in the world; we knew how people were being infected and we didn't raise a hand to protect them. We knew that it wasn't 'all about sex', but we allowed HIV to become a 'gay plague' in the West and then a matter of African sexuality, with consequent levels of prejudice and stigma (to say nothing of sentiment, positive and negative). We know, at least, UNAIDS, WHO and the rest know, that a significant proportion of HIV transmission is not through sex, but this is not currently being investigated. Male circumcision programs are not driven by public health considerations, but by massive amounts of money, attracted by current pro-circumcision sentiment. Meanwhile, HIV continues to spread. We know how to avert many new infections, but we prefer, it seems, to allow the virus to spread, as long as we can continue to exercise our prejudices.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]