Wednesday, December 12, 2012

Mass Male Circumcision Recommended Even Where it Increases HIV Transmission

I commend The Guardian (UK) for covering the issue of circumcision from the point of view of those who are opposed to it. It's in their Science section, though it is also an important issue for development, given that it is being marketed aggressively in developing countries as a HIV intervention, and given the billions of dollars of 'aid' money that have been earmarked for these idiotic campaigns. However, the development section in The Guardian is sponsored by the Gates Foundation, which funds circumcision in high HIV prevalence countries and doesn't appreciate dissenting views. Anyhow, the fact that serious opposition to circumcision is being raised in a relatively open-minded newspaper is very heartening.

The campaigns in African countries are doing a lot of damage in the sense that hundreds of thousands of people have already agreed to be circumcised and many people seem to believe the pro-circumcision propaganda. But nowhere near the number expected are agreeing to the operation. And the majority of those being circumcised are not adults, the very people who are most at risk from sexual transmission of HIV, if the propagandists are to be believed. It's mostly teenagers that have been persuaded that the operation will be more difficult or more painful if they wait till they are adults. I'm not sure if that's what they have been told or if it is what they are allowed to believe; either way, what does it mean? Cutting off a healthy piece of flesh is the same whether you are an infant, child, teenager or adult.

Adverse events may be less frequent during infant circumcisions, but that is not a reason to make a decision that could easily be left to the person when they are an adult. After all, the majority of men will probably decide not to be circumcised, which is the best way of eliminating adverse events altogether. It may be objected that circumcision is said to give some protection against some fairly easily avoidable conditions, many of which will not be a risk till adulthood anyway. But this still doesn't make circumcision sound like something that obviously needs to be carried out universally. There doesn't seem to be anything about circumcision that makes it urgent, something that needs to be done to infants or children, or people who have not reached a stage where they can make up their own minds.

One of the most pathetic arguments is that the child should 'look like their father', which doesn't hold much sway in countries where the operation is not yet common. But I've never heard of anyone refusing to circumcise a child whose father was not circumcised just so the child can look like their father. Their father may have a tattoo or a pierced penis, but this would not be permitted on an infant just so he could resemble his father. The argument about resemblance may be more popular in Western countries anyway. But what about the claim that circumcision is 'cleaner'? Dirty finger nails are unhygienic but we don't remove finger nails. Instead, we wash our hands and use a nailbrush. Not that I'm suggesting people use a nailbrush on their penis, but if they have difficulty washing themselves, it's hard to see circumcision alone helping them much.

Of course, there is nothing that could be called debate in countries where people are simply bombarded with publicity; campaigns exhort men to 'stand proud' and that 'wise men make smart choices' (even though the main targets are teenagers; men tend to choose not to be circumcised), etc. The effectiveness of circumcision, and not just against HIV, is presented to people in Kenya and other African countries as if there is no room for doubt, as if it is just another aspect of modern healthcare, like vaccination, giving birth in health facilities and going to a hospital when you are sick. But with infant circumcision there isn't even the pretense of making a choice; the choice is made for you by a parent or by both parents.

The vast majority of males, even in high HIV prevalence countries, do not face much risk of being infected until they are well into their twenties. So there is no excuse for circumcising infants and claiming that it reduces sexual transmission of HIV and other sexually transmitted infections. Even if it can do so in theory, it will not prevent infections among those who are not sexually active. The fact that the majority of men may choose to remain uncircumcised may worry those who think public health is something that should be imposed on Africans whether they agree or not. But most of us would claim to be against imposing 'public health' measures, whether through lies, trickery, force or by any other means. We would expect informed choice to be involved, even where the intervention has been shown to be beneficial.

So much for the pretense of legitimacy. But what about the 'science'. HIV prevalence is higher among uncircumcised men in some countries (such as Kenya) and higher among circumcised men in other countries (such as Zimbabwe). If HIV is 'scientifically proven', does that mean it should only be introduced in Kenya and other countries where HIV prevalence is lower among circumcised men? And in countries like Zimbabwe, where HIV prevalence is higher among circumcised men, what would the public health experts recommend? They seem to be recommending circumcision, and hence increased HIV transmission. Imposing a public health measure for which there is weak evidence of benefit, without informed consent, is bad enough, but what about imposing a public health measure which the evidence suggests will do harm?

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



Anonymous said...

It is concerning that you imply that infant circumcision has fewer adverse effects without there being any proof of such a statement. Babies die from circumcision, and yet I have never seen documented a single case of a death in an adult or even a teenager from circumcision. Babies feel more pain (that has been proven), they receive inadequate anesthesia, they can easily bleed to death, there are so many complications documented in the medical literature it is mind-boggling. Many of these complications are related to inadequate pre-op screening and grossly inadequate anesthesia during and after the procedure, and inadequate post-op care, all of which are usually dealt with for adults and teenagers. Please refrain from perpetuating the myth that circumcision is easier and less traumatic on infants. It is just easier to get infants circumcised because they can be forcibly restrained. The procedure is more likely to have greater adverse effects on infants, not fewer.

Simon said...

Thank you for clarifying that but I think I make it quite clear that I am opposed to infant circumcision, regardless of any claimed benefits and regardless of whether adverse events are higher or lower. If you have data on levels of adverse events for infants, adults and any other age groups, I'd love to see it, but it would not make me change my mind. I am opposed to infant circumcision because possible future benefits does not make it the right choice when people can choose it as adults. And even if it were in some way 'easier' or otherwise preferable in infants, this would not change my mind either, because they can still choose later. But only if their parents don't choose for them, of course! I believe such claims about ease, less pain, etc, to be not so much lies as senseless as I don't believe you can compare the level of pain in infants and adults. But either way, there is no public health reason for circumcising infants, generally, and none for circumcising adults either.

Petit Poulet said...

Great posting. An interesting trend in the HIV-circumcision data that are available is that the association between circumcision and HIV infection is not present in data taken from general populations. It only shows up in "high-risk" populations. That means that circumcision should not be recommended for the general population.

Those in "high-risk" populations have a number of choices that are more effective, less expensive, and less invasive than circumcision, such as condoms, abstinence, ART, PreP, and timely treatment of STDs. If given the available options in a factual, balanced fashion, few would choose circumcision.

At the most recent HIV industry junket (your appropriate appellation) in Washington, DC, the circumcision roll-out, which to date has been a colossal failure, has been rebranded to "Reshape Your Relationship!" with the false claims that circumcision will improve your sex life. The efforts to circumcise will focus on younger and younger males as the the older, wiser males will know that something doesn't smell right about circumcision preventing HIV.

Simon said...

Thank you for your comments. I agree to some extent but the problem is that HIV and circumcision status are sometimes negatively correlated and sometimes positively correlated, not that circumcision is never associated with lower HIV prevalence; it is in some populations but not in others. That should be perplexing to those implementing the programs because it means they should only be implementing them in certain places. But any intelligent person would want to know that it is really circumcision, or circumcision on its own, that accounts for differences in prevalence and why it only appears to be beneficial (or harmful) in some places.

A bigger problem is that HIV is not always closely correlated with sexual behavior, so there's no reason to even expect it to be correlated with circumcision, which is not directly relevant to non-sexual transmission. In fact, your use of the term 'high-risk' is quite tenuous as it is generally used to mean 'high sexual risk', as if all HIV risk is sexual risk. Not only is high HIV prevalence not particularly associated with general populations, but rather with clusters in certain areas and/or circumstances, such as some towns in Nyanza, some cities, etc, but also, it tends to cluster around things like roads and health facilities. Careful analysis of these phenomena could reveal some level of non-sexual transmission, but even a cursory glance should make one wonder. Evidently not, in the case of UNAIDS, WHO, Harvard Medical School, London School of Hygiene and Tropical Medicine and the other big players in the industry.

So what you identify as 'high-risk' populations are, in fact, HIV positive people or people in places where HIV prevalence is high. Their risk has not been assessed, not beyond their sexual risks, anyhow, which may only be assumed rather than clearly demonstrated. So the more effective choices for reducing HIV transmission that you list are of little use when it comes to non-sexually transmitted HIV; some of them have even been shown to be of little use, such as abstinence and treatment of STIs (though these activities may have other benefits). How ART and PrEP are employed is very important, but it is still necessary to assess non-sexual risks because they are both expensive and ineffective remedies for risks that arise from unsafe healthcare.

You mentioned the "Reshape Your Relationship!" slogan before but I wasn't able to find out much about it; aside from a mention in an FHI booklet I can't find out who is behind it, what it involves, whether it's been implemented, etc, so I can't really say much about it. I totally agree that claims that circumcision improves sexual pleasure or even hygiene are rubbish, there is simply no way of testing them and no evidence for them, but I wonder if they have really adopted these claims as part of their publicity. I think they just allow people to think such things and allow such rumors to spread, without actually saying they believe it.

I'm not sure if older, sexually active males are necessarily 'wiser' and thereby refusing to be circumcised, but they are clearly not being swayed, whereas younger people are. Many of them may be in the care of their mothers or of other female relatives. Circumcision has been miss-sold to women as being hygienic and better and more aesthetic and various other unproven and often untestable claims. Men don't seem that bothered, they wouldn't do it themselves but they don't appear to be warning younger men of this.

Simon said...

Here are some interesting figures about the aim to circumcise 20 million men by 2015; they've only managed 1.5 million so far, and many of them are probably not sexually active men.

It's no wonder they are concentrating on infants and younger men and boys, they will never come close to their targets otherwise. It remains to be seen whether they will adjust their targets when they change their target population, though. Those figures, by the way, come from extremely biased sources, AVAC, a front group for the pharmaceutical industry and PEPFAR, the main source of funding for mass male circumcision.

FredR said...

Frederick Rhodes says.... Circumcision has been used subversively for millenia as a weapon against the sons of unwanted races and religions. After the prepuce is excised, a little extra snip of the frenulum nerves at infancy will cause the boy to grow up and commit suicide or turn into a warrior from painful erections/erectile dysfunction. It is a form of eugenics that only works on weak minded, superstitious, ignorant races that can be fooled into fearing an invisible heavenly godfather. You'd better become educated in the prepuce's physiological functions from birth through adulthood, and its proper and safe use, care, and hygiene, or they will fool you into letting them cut it off.

Simon said...

Hi Fred, thank you for your comment. I certainly agree that circumcision is far more subversive than those promoting it, even some of those opposing it, would admit. I also agree that there is often a covert religious or moral agenda behind it, which feeds nicely into the prejudice that HIV is generally an indication of illicit sexual behavior in African countries. It is harder to see it as a form of eugenics, though I think it fits in well with a eugenic agenda.

Petit Poulet said...

The term "high risk" is taken from the "HIV is spread through sexual contact only" paradigm, so when I use this term it is within this context, primarily men who are long-distance truck drivers, clients of STD clinics, and patrons of female sex workers. Those who are high risk of HIV infections from other methods of transmission have not been properly identified because these "anomalous" don't fit within their narrow paradigm, so this has not been well studied.

The conventional terminology is not appropriate because the conventional knowledge on HIV in Africa is incomplete and inaccurate.

Simon said...

Petit Poulet, I'm not sure how much recent data really shows that long-distance truck drivers really do have a higher risk of being infected sexually with HIV. There may be evidence that they are more promiscuous, I don't know, that that would also increase their non-sexual risks. If they are more promiscuous, they face a higher risk of being infected with some STI and regular visits to STI clinics may pose a higher risk than sexual behavior. So it might make the sexual behavior of truck drivers appear to be associated with higher risk of sexually transmitted HIV; this clearly needs to be investigated in such a way that non-sexual risk in STI clinics (amongst others) is also assessed. The same applies to clients of STI clinics; being a client of an STI clinic may also be a HIV risk. The mere fact that they may be identified as promiscuous does not clearly and indisputably identify their HIV infection as sexual. It may seem 'obvious' that they face sexual risks, and they do, but are the sexual risks higher than the non-sexual risks? It's the STI clinics that need to be investigated. If these are risky places, that should be easy enough to spot, if the right kind of investigation is carried out. That could rule out non-sexual risks, but I have never heard of such investigations being carried out in African countries. Same applies to sex workers and their clients; they also face non-sexual risks because of their sexual behavior, not just sexual risks. For any HIV positive truck driver, sex worker, client, etc, can non-sexual risks be ruled out, and if so, how? These are the questions I would like answered.