Wednesday, October 2, 2013
The website 'poz.com', which is about HIV, but from a US point of view, has a recent article on circumcision by Ben Ryan, who is apparently a journalist. The strapline reads "Major studies support circumcision as prevention in Africa but a small yet vocal group argues the science is flawed. Can circumcision lower U.S. HIV rates?" The question is odd, because the article is not primarily about whether the operation can or can not lower transmission in the US (Ryan seems to suggest the answer is 'yes', but in a country where HIV transmission is predominantly among men who have sex with men and intravenous drug users, 'no' seems much more likely to be correct). The article is not really about the science either, but rather how that 'science' is used. (Even the title, 'Cut to Fit', sounds like an ironic reference to the author's journalistic style.)
Ryan gives a selective review of the 'science' as he sees it, listing the major players in circumcision promotion, major in terms of the funding they receive, anyway. But all this is contrasted to an 'ideological war', by what Ryan brands as a small group of 'dissidents'. The fact that many of those who oppose the imposition of mass male circumcision on tens of millions of African men who are not already circumcised, and male infants born to people who would not normally choose circumcision in infancy, are also scientists doesn't seem relevant. The facts that skepticism is not inherently unscientific and that not all those who oppose mass male circumcision can correctly be referred to as 'dissidents' also seem unimportant to Ryan.
Although Ryan enjoys the term 'intactivist' to refer to people who oppose mass male circumcision on the grounds that the 'science' is highly flawed, this is not a widely used term by opponents. Some, like myself, oppose mass male circumcision on human rights grounds, and on the grounds that insisting on every man conforming to what is an American preference is an outrageous instance of cultural imperialism; but I certainly wouldn't call myself an intactivist. According to Ryan, those who oppose mass male circumcision are mainly Americans and Europeans, without pointing out that those who promote it are almost all American, and all their funding is from America.
Part of the pretence of 'giving both sides of the story' involves interviews with people whom Ryan subtly belittles. One of those interviewed is John Potterat, who has carefully outlined the reasons for skepticism about the 'scientific' literature, which is freely available on the Social Science Research Network. According to Ryan and his favored informants, 'dissidents' are 'hampering progress', 'spreading misinformation' and 'creating skeptics among those who stand to benefit', the last referring to African people, whose future is being put in jeopardy because of a handful of unscientific people who are not epidemiologists or health scientists, and therefore should not hold an opinion on human rights or cultural imperialism, or so Ryan wants us to believe.
Ryan also interviews Rachel Baggaley, who has an MD, who reassures us that the three million figure the WHO claims have been circumcised under the program sounds very low beside the 20 million originally hoped to 'benefit' from the operation because 20 million was 'aspirational'; that the WHO had "underestimated the complexities and social sensitivities required to successfully promote the program in certain populations". Could some of these 'social sensitivities' be similar to the views of the people Ryan considers to be a mere fringe of 'dissent? What Baggaley is delicately referring to is a dearth of safe health facilities, experienced health personnel and supplies needed to provide mass male circumcision that doesn't result in a lot of botched operations and a huge increase in hospital transmitted HIV; also, that infuriating barrier to US cultural imperialism: foreigners, non-Americans.
Another 'dissident' cited is David Gisselquist, who has spent years publishing articles showing that unsafe healthcare and cosmetic practices may be making a significant contribution to the most serious HIV epidemics in the world, which are all in sub-Saharan Africa. The evidence for various types of non-sexually transmitted HIV is spread over hundreds of papers, written by people from various backgrounds, including public health, medicine, epidemiology and others. Indeed, one of the most important factors in transmitting HIV in African countries is circumcision itself, not just medical circumcisions carried out in unsafe health facilities, but also circumcisions that are carried out for cultural reasons, generally carried out in unhygienic conditions.
While presenting arguments against mass male circumcision in a context that makes them futile, Ryan lists the arguments for the program as if they were some kind of holy grail of truth, true for all time, in all places, as true for non-Americans as for Americans. Those pushing for the program keep going on about how similar the results of all the randomized controlled trials were, without this being held up to any kind of questioning; were these crusaders really so lucky, that all three trials came up with almost the same results? Why were the trials carried out in those areas, among those people, with those specific (poorly described) methodologies? Were any other trials carried out that may show the opposite effect? And why are the mass male circumcision programs going ahead in areas where HIV prevalence is already higher among circumcised men than uncircumcised men? What about current programs that are currently suggesting that mass male circumcision programs seem to be increasing HIV transmission, in Botswana and Kenya?
Oddly enough, Ryan gives the last word to Baggaley, who now refers to those who oppose the US funded mass circumcision of African men as 'denialists'. She says they are generally not from high HIV prevalence countries, as if those promoting the program are. Seeing herself as having the perspective of a 'young man in South Africa', she finds objections to the operation to be 'paternalistic'. Evidently she doesn't see the paternalism in spending billions of US dollars on persuading people to be circumcised by telling them that there are numerous advantages to be enjoyed. How is that different from the various (also US funded) efforts to persuade poor people to be sterilized? How is that different from various syphilis 'experiments' carried out on African Americans, or similar ones carried out in Guatemala?
In stark contrast to Ryan's stance of appearing to be 'giving both sides of the argument' while achieving no such thing, Brian D Earp has written a very cogent rebuttal of all the bits and bobs that Ryan thinks of as science. Earp does put his cards on the table: he is not undecided about whether mass male circumcision is a good or bad thing. But neither is Ryan, he just pretends to be. If you are interested in reading solid rebuttals of the arguments of those claiming to be 'scientists', and others, it's worth reading Earp's article in full. I can not do it any justice by paraphrasing it.
To conclude, branding people as 'denialists' or as being 'unscientific', even when the point is not a scientific one, or not entirely a matter of science, has a long history. Journalists pretending to be (or thinking that they are?) even handed is also an old trick. So people have to think for themselves: would you do it to someone you love, or would you wait till they were old enough to decide for themselves? And even if your answer is 'yes', and you would circumcise your son when he's still an infant, does that mean tens of millions of African men should be persuaded by the US (and by US funded 'Kofi Annan' type figures) to do the same, using a hotch-potch of scare stories, half baked theories and outright lies, all dressed up as some kind of scientific canon, and that tens of millions of African infants should also be circumcised, their parents having been primed using the same body of 'evidence'?