Tuesday, August 14, 2012

Circumcision Enthusiasts; Up Have You Screwed, and Badly

An article by Charlene N Muzyka and others looks at Kenyan newspaper 'analysis' of the limitations of mass male circumcision and the importance of sustained condom use in the online Daily Nation. That there is any analysis involved may be in question; are these newspaper reports merely paraphrasing press releases? Or do they represent a genuine attempt to make sense of what scientists and other circumcision enthusiasts tell us about circumcision and HIV and try to get that across to their readers?

It's worth pointing out straight away that the researchers do not even mention the most significant finding relating to circumcision, something established by one of the three randomized controlled trials that is so often held up as 'proof' that circumcision protects against HIV: it was found that those who waited for 10 minutes after coitus and then wiped their genitals with a dry cloth were far less likely to be infected even than those who were circumcised!

In other words, the best option is penile hygiene, not circumcision. Yet the enthusiasts recommend the less effective, more expensive, riskier and less culturally sensitive option of mass male circumcision. If your first question was always 'why is cleaning a circumcised penis so much more difficult than cleaning an uncircumcised penis?', the answer is 'it is not more difficult; appropriate penile hygiene protects against HIV transmission, regardless of circumcision status'.

Anyhow, the researchers wished "to determine how the limitations of male circumcision are represented, and whether condom use is still being promoted" and to "gain insight into popular understandings of the limitations of this new procedure through newspaper reader comments". This approach highlights a serious problem for anyone who wishes to advocate for circumcision, yet continue to recommend the use of condoms; if they manage to get their point across well, people will immediately wish to know why there is any need to circumcise.

One of the limitations of circumcision is that it is nowhere near as good as condoms when it comes to protecting against STIs, including sexually transmitted HIV (for men only), and it does not protect against unplanned pregnancy (which is a particular for pro-circumcision people like Gates, who is also a eugenicist). All in all, the disadvantages of circumcision, such as the increased risk of transmitting HIV to female partners, highly prevalent myths and misinformation about circumcision held by men and women and the fact that 85% of Kenyan men are already circumcised and are therefore quite uninterested any public health messages relating to being circumcised, seem to outweigh any claimed advantages.

But the propaganda keeps coming out. Flippant apologists say it's a 'once off' operation, unlike using condoms or other prevention measures. But it is clearly not a strategy that finishes once the scar has healed. The authors of the article recommend regular news releases to the media that include clear and accurate information about sexual behavior and condom use. However, the operation is 'once off' in the sense that once it has been carried out, it is irreversable. Once the 2 million or so Kenyans targeted for the operation have been circumcised, who will be listening to any circumcision related advice, however skewed? Will there even still be a budget for follow-up interventions? Pro-circumcision proselytizing suggests not.

Clear messages about condom use should be clear enough to raise doubts about the necessity for circumcision. But continued calls for 'abstinence' should erase any remaining doubts; if abstinence is a useful strategy to anyone (is it?), they certainly don't need circumcision. Genuinely safe sex obviates the need for circumcision. Non-sexually transmitted HIV, on the other hand, will continue to be a risk. Even brains dulled to complete idiocy by the constant misinformation about circumcision will realize that unsafe healthcare will still pose considerable risk of HIV infection, especially in a country like Kenya, given current conditions in health facilities.

The 15% (and declining, but not as fast as the enthusiasts would like) of Kenyans who are not yet circumcised are being misinformed about the virtues of circumcision and they are being left entirely uninformed about non-sexual risks. The 85% may face even higher risks if they believe the propaganda. Certainly, the female partners of circumcised men face an increased risk of being infected with HIV if they and their partners internalize any of the misconceptions about the protective value of the operation that they are being fed with.

But what about the more effective, cheaper and safer option of penile hygiene? Why are those pushing their randomized trials so coy about their absolutely stunning finding; that uncircumcised "men who cleaned their penises after coitus but waited at least 10 minutes to do so got HIV at the rate of 0.39% per year", compared to circumcised men, who got HIV at the rate of 0.66% per year? Why are Muzyka and friends apparently uninterested in this finding, which is surely in far greater need of being reported? Why are newspapers not interested, even if they are just aping press releases?

It's not clear why the researchers who discovered that penile hygiene gives far better protection against HIV transmission than circumcision do not promote this discovery, nor why papers citing the original research don't mention this excellent intervention. They can hardly claim that teaching appropriate penile hygiene is a more mixed message than recommending circumcision, but only in conjunction with condom use, can they? Circumcised or uncircumcised, penile hygiene is best; even the circumcision enthusiasts have demonstrated that.

As for newspaper coverage, it is clearly not informed directly by the paper based on the trial. If it were, the astounding finding would be too sensational to ignore. Which means that it is not the media that the government needs to have 'information sessions' with, it is the researchers themselves and the scientific community that releases the bits of 'science' that it wants the public to hear. The Government of Kenya and other African governments need to ensure that research findings are clearly reported to the public and that the policies that are subsequently based on the findings are appropriate. The plan to circumcise millions of African adults (and children) is not an appropriate reaction to what has been published on the subject.

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



Anonymous said...

There is a big difference between legitimate research and the advertising/public relations industry.

Simon said...

Quite true! But sometimes it's hard to tell the difference. This article is an ad for a 'bloodless' circumcision device but it is presented as if it is an article:


Lyn said...

I was with you up to the eugenicist part.

Simon said...

Thank you for your comment, Lyn, 'eugenicist' is very impolite. Perhaps I should have said 'neo-Malthusian'. It's rude of me to attempt to interpret his annual letters, his obsession with control and technology in food and agriculture, reproduction, health, education, the environment (geoengineering) and elsewhere, his creative use of population and birth control statistics, his attempts to set the global development agenda, etc, as suggesting that he is a eugenicist. But perhaps someone would like to supply an alternative term?

Martin said...

But note that the group at highest risk of seroconverting was among intact men who cleaned their penis within the first 3 minutes after coitus. So, intact men had both the highest and the lowest rate of HIV uptake, but it depended on the difference between <3 minutes and >10 minutes before cleaning up. (No meaningful data on the 7 minutes in-between.) That information absolutely has to be part of the message, so men are sufficiently informed to avoid the riskiest choice.

People have already begun to spread the meme "Cuddling, not cutting, reduces HIV".

Simon said...

Thanks Martin, absolutely, I've been using the term 'appropriate' penile hygiene because it's not straightforward. Personally I wouldn't jump out of bed for a quick wash after sex but apparently some counselors have been advising that and some women seem to think they need to wash frequently, with serious adverse consequences. But this research underlines the fact that if we don't what mechanism may be involved and the figures for any protective effect are variable as well as underwhelming, it seems premature to recommend the operation, and for millions of people. The research is confused and confusing, so how can it be used to support such a categorical strategy as mass circumcision? It's as if the researchers are dying to circumcise all and sundry but they have to produce the right evidence before they are allowed to do so. It's disturbing.

Dick Scalper said...

They brand men like a herd of cows. "Neonatal post-traumatic stress disorder" -- the recurrent American nightmare for boys. American men are such wimps to let their sons be subjected to this absurd surgery. If it were women tied down & cut, the Feminists would be howling all over the world. The male genitals are a cheap commodity. There is no
argument too absurd for the circumcisers. They insult the appearance of the intact penis, claim that circumcision heals everything from body warts to HIV, and draw an illogical distinction between female & male genitals. It will be up to merciful mothers to spare their sons this humiliation. With a few exceptions, most circumcised men are so defensive they’ll never own up to their loss. Circumcision is the mark of a slave, not a free man.

Top Ten Tortures Less Painful Than Circumcision

10. Get waterboarded.
9. Pull out your fingernails.
8. Eat a pile of steaming bear crap.
7. Skin yourself alive.
6. Fall into a vat of molten iron.
5. Get run over by a train.
4. Go through a sausage grinder.
3. Saw off your legs.
2. Poke out your eyes.
1. Go To Hell