Saturday, June 16, 2018

RACP Medical Journal of Australia response to push for routine infant circumcision in Australia

In a recent editorial, Cooper and colleagues recommend increasing infant circumcision to combat increasing rates of heterosexual transmission of HIV infection, and contend that the major obstacle to increasing male circumcision in Australia is a Royal Australasian College of Physicians (RACP) policy. [1]

“The case for boosting infant male circumcision in the face of rising heterosexual transmission of HIV” . . . and now the case against

David A Forbes, John W Travis, Sarah J Buckley, Paul Mason, Ken McGrath, Robert S Van Howe, George Williams, Anthony N Lyons, Marian Pitts, Anthony Smith, Jeffrey Grierson, Niall Conroy, Gregory J Boyle, George Hill, Robert J L Darby, Bruce R Paix, Jeremy J Chin, David A Cooper, Alex D Wodak and Brian J Morris

Med J Aust 2011; 194 (2): 97.
Published online: 17 January 2011

In September, after a literature review and analysis, the RACP released a revised policy on infant male circumcision, concluding that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand. [2] While evidence of HIV prevention by circumcision is strong in high-prevalence settings with predominantly heterosexual transmission, [3] this is not so in low-prevalence environments where homosexual transmission is more important. [4] Evidence of the protective effect of circumcision against other sexually transmitted infections in Australia is limited. [5]
Cooper et al’s comparison of circumcision with vaccines is misleading. Protection against HIV by circumcision is predominantly for males, and the risk for females may increase. [6] There is minimal protection against homosexual acquisition of HIV. [4]
The RACP acknowledges the strong and differing opinions on this topic, ranging from the strong pro-circumcision views of Cooper et al to the equally strong diametrically opposed views of the Royal Dutch Medical Association, which believes that (for reasons of ethics and medical risks) legal prohibition of infant circumcision is warranted. [7]
The RACP recognises the important role of parents in decision making, and recommends that parents contemplating circumcision of their newborn sons be carefully apprised of the risks and benefits. If they elect to proceed with circumcision, the procedure should be undertaken in a safe child-friendly environment, with appropriate analgesia, and by an appropriately trained, competent practitioner who is capable of dealing with complications. We believe that this approach safeguards the social and community interests of children, and offers protection from unnecessary surgical risks. [2]
The RACP does not accept that its policy on circumcision of infant males represents an obstacle to effective public health policy — it believes that, at present, the evidence does not allow a recommendation for widespread infant male circumcision and that Cooper et al have misrepresented this evidence. In the interests of children, and of public health more generally, it is important that this evidence be kept under review and decisions that could lead to increased morbidity and mortality of children only be made when it is clear that the benefits very clearly outweigh any risks.
David A Forbes, Chair, Policy and Advocacy Committee Paediatrics and Child Health Division, Royal Australasian College of Physicians, Sydney.
1. Cooper DA, Wodak AD, Morris BJ. The case for boosting infant male circumcision in the face of rising heterosexual transmission of HIV [editorial]. Med J Aust 2010; 193: 318-319.
2. Royal Australasian College of Physicians. Circumcision of infant males. Sydney: RACP, 2010.
3. Siegfried N, Muller M, Deeks JJ, Volmink J. Male circumcision for prevention of heterosexual acquisition of HIV in men. Cochrane Database Syst Rev 2009; (2): CD003362. 
4. Templeton DJ, Jin F, Mao L, et al. Circumcision and risk of HIV infection in Australian homosexual men. AIDS 2009; 23: 2347-2351. 
5. Templeton DJ, Jin F, Prestage GP, et al. Circumcision and risk of sexually transmissible infections in a community-based cohort of HIV-negative homosexual men in Sydney, Australia. J Infect Dis 2009; 200: 1813-1819. 
6. Wawer MJ, Makumbi F, Kigozi G, et al. Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial. Lancet 2009; 374: 229-237. 
7. Royal Dutch Medical Association. Non-therapeutic circumcision of male minors. Utrecht: KNMG, 2010. 

Link to Intact America =

Tuesday, June 5, 2018

The mindset difference of American Medical Scientists when it comes to Female circumcision vs Male circumcision Research

Below I have cut and paste the research presentation "Female Circumcision and HIV Infection in Tanzania:
for Better or for Worse?" by Rebecca Y. Stallings, from Missouri State University.

The research was conducted to try and gather data to validate the hypothesis by K.E. Kun that female circumcision caused an elevated risk for HIV infection.  

Note the political/medical discussions of that time, that epidemic levels of HIV infections in Africa were being blamed on lack of circumcision in males, and a positive incidence of circumcision in females.  A bit of opposing logic here.  Cut genitals on one gender, the females, will increase the likelihood of HIV infection, versus uncut genitals in the male gender, being the cause of 
increased likelihood of HIV infections in men?  Logical?

The question needs to be posed, as to how much the culture of the American researchers influences such logic?  Americans support and practice male circumcision, but abhor the practice of female circumcision.  Could this have influenced such an a priori hypotheses?

The results of the research showed that female circumcision reduced HIV infections by a significant margin, and the researchers were not happy, as per following "The surprising and perplexing significant inverse association between reported female circumcision and HIV seropositivity remained highly statistically significant in the final logistic regression model, despite the presence of other significant potential confounders, namely, geographic zone, household wealth index, woman´s age, lifetime sex partners, and current/past union status".  Rather than be happy for the women that they were protected from HIV they were palpably disappointed.

Further Findings "The couples analysis also suggests a protective effect, real or not, of female
circumcision" "The surprising and perplexing significant inverse association between reported female circumcision and HIV seropositivity has not been explained by other variables available and examined in these analyses"

This next statement is telling for their lack of curiosity or unwillingness to speculate, as seems to be so common with male circumcision research.   "As no biological mechanism seems plausible, we conclude that it is due to irreducible confounding".  If American researchers are willing to speculate or hypothesise that male genitals have virus entry points, why isn't it permissable to speculate that female genitals have viral entry points also?  Cultural bias?

Female Circumcision and
HIV Infection in Tanzania:
for Better or for Worse?
Rebecca Y. Stallings,
Statisticus Consultoris, USA and
Emilian Karugendo,
National Bureau of Statistics,
Data Source
This analysis and its findings are
derived from the 2003-04 Tanzania
HIV/AIDS Indicator Survey (the THIS),
which is currently available for public
use. The first author received
permission from the National Bureau of
Statistics in Tanzania to conduct this
work prior to the official release of the
data set to the public.
Female circumcision, also referred to
as female genital cutting (FGC) and
female genital mutilation (FGM), is
most prevalent in Africa. The practice
has been linked to obstetrical and
gynecological problems in addition to
mental and physical trauma that may
result from the more severe forms of
the procedure and has hence been
widely condemned for both ethical and
health reasons by the World Health
Organization and other entities
involved with Human Rights.
WHO has defined 4 types of circumcision:
I. Clitoridectomy
II. Excision (cutting of both the clitoris and
part or all of the labia minora)
III. Infibulation (cutting of all external
genitalia with stitching of the vaginal
IV. Other less radical forms including
pricking and piercing
It has been estimated that 80-85% of female
circumcision is either type I or II.
K.E.Kun proposed 4 hypothetical
mechanisms by which female
circumcision could result in an
elevated risk of HIV infection
(ref. K.E.Kun, 1997, Intl J Gynecology
and Obstetrics)
Female circumcision
Partial/complete occlusion of the vagina
Greater risk of inflammation/bleeding during
Disruption of the genital epithelium/exposure
to blood/penile abrasions which have been
reported to enhance risk of HIV infection
Female circumcision
Painful/difficult vaginal penetration
Increased practice of anal
intercourse, which has been
shown to enhance the efficiency
of HIV transmission
Female circumcision
Higher incidence of obstructed
labor and tearing
Higher risk of blood transfusion;
blood supply may not be optimally
screened for HIV
Use of unsterilized instruments to
perform the female circumcision
Exposure to blood contaminated by
the virus
While WHO and the International Federation
of Gynecology and Obstetrics publicly
postulated that female circumcision might be
a risk factor for HIV infection as long ago as
1992, very little research has been published
to date examining this relationship.
In light of the alarming spread of HIV among
females in a number of African countries
where female circumcision continues to be
practiced, the dearth of work on this question
is somewhat perplexing.
Prior Studies
3 published studies were identified which
looked at the association between female
circumcision and HIV infection;
All 3 studies were conducted in the
Kilimanjaro region of Tanzania
•S.E.Msuya et al, 2002, Tropical Medicine
and Intl Health
0.64 [95% CI = 0.26<RR<1.57]; N=379
•S.H.Kapiga et al, 2002, JAIDS
1.29 [95% CI =0.88<RR<1.90];N=312
•E.Klouman et al, 2005, Tropical Medicine
and Intl Health
1.19 [95% CI=0.45<RR<3.16];N=392
Tanzania HIV/AIDS Indicator Survey
All protocols were reviewed and given ethical
clearance by the National Institute for Medical
Research (NIMR)
A nationally representative probability sample
of households was selected, excluding
Zanzibar, which had recently been similarly
Data collection took place from December
2003-March 2004 and was conducted by
trained interviewers, all of whom were nurses
from the Ministry of Health
Participants aged 15-49 were
interviewed and asked to give informed
consent for the collection of capillary
blood by finger-prick for HIV testing
All participants were offered free VCT at
their closest center regardless of their
For participants consenting to the
procedure, a set of unique barcoded
labels was used to provide an
anonymous link
HIV testing was conducted at the
national reference laboratory at
Muhimbili University College of Health
Cleaned questionnaire data was
anonymously linked to results from the
HIV testing using the barcodes after the
destruction of the end pages of the
Response Rates
Households selected: 6901
…interviewed 6499
…response rate 98.5%
Eligible women 7154
…interviewed 6863
…response rate 95.9%
…interview & HIV test result 6061
…response rate for both 84.7%
Distribution of reported female
The highest reported rates of female
circumcision were found in the Northern
regions of Tanzania bordering Kenya, and in
the regions directly south of those, ranging
from 20% in Iringa to 73% in Manyara. These
adjacent regions hence form a central belt
from North to South.
Other than in the capital city of Dar es
Salaam (7%), the rate did not exceed 3%
elsewhere in the country
Ethnicity was not collected but may explain
the regional clustering wrt female
circumcision rates.
Age at time of circumcison, type of
procedure, and practitioner
Age at time of circumcision, type of procedure,
and practitioner were not collected in the 2003-
04 THIS, but were included in the 1996 DHS
74% of women in 1996 who self-reported
having been circumcised said that the
procedure was performed by a “circumcision
practitioner” (91% in Lake zone)
Doctors or trained nurses/midwives were most
frequently reported by women in the Northern
Highlands (6.9%)
The next 2 slides show distributions of age and
type by zone
Age at circumcision by zone
0-5 yrs 6-10 yrs 11-15 yrs 16+ yrs miss/dk
Coastal N Highlands Lake Central S Highlands
Type of procedure by zone
Coastal N Highlands Lake Central S Highlands
Distribution of female HIV infection
HIV infection among women aged 15-44
ranged from 2.0-15.2% by region
Among the 10 (of 21) regions with the highest
reported female circumcision rates (>=20%),
only 4 were among the 10 regions with the
highest female HIV infection rates
The regions with female HIV infection rates
>10% were Mbeya, Iringa, Dar es Salaam,
and Pwani
Potential confounders available and
Demographic characteristics
Household wealth index
Educational attainment
• Occupation
Time in current residence
• Religion
Marriage and sexual activity
Age at sexual debut
Age when began cohabiting
Currently married or living with partner
Number of wives of husband/partner
Lifetime sex partners
Sex partners in last 12 months
Use of alcohol during recent sexual liasons
Ability to say “no” to having sex with recent
Symptoms of sexually transmitted
Genital sore or ulcer in last 12 months
Bad smelling abnormal discharge in last
12 months
Potential exposure to contaminated blood
Any injection in last 12 months
Any blood transfusion in last 12 months
•The χ
test of association was used to
examine the bivariate relationships between
potential HIV risk factors with both
circumcision and HIV serostatus
Logistic regression was used to reduce the
model to those factors remaining statistically
significantly associated with HIV serostatus
and to adjust circumcision status for those
All analyses were performed using the latest
version of the Statistical Analysis System
The crude relative risk of HIV
infection among women reporting
to have been circumcised versus
not circumcised was
0.51 [95% CI =0.38<RR<0.70]
The power (1 – ß) to detect this
difference is 99%
Logistic Regression Models
Each variable that was statistically significant in the
simple bivariate analyses was added to a separate
simple logistic regression model to predict HIV
serostatus, together with circumcision status
Additional logistic models were run which
combined those variables which remained
significant in their individual models, together with
circumcision status
Models were further restricted to include only those
women who had ever been sexually active
A final model was selected in which all variables
remain statistically significant
Final Logistic Regression Model
n=5284 ever sexually active women
(continued on following slides)
3.771.282.20Genital ulcer
in last 12
UL 95% CILL 95% CIOR estimateEffect
UL 95% CILL 95% CIOR estimateEffect
1.00Central (ref).
UL 95% CILL 95% CIOR estimateEffect
HH wealth
UL 95% CILL 95% CIOR estimateEffect
1.0015-19 (ref.)
Age (years)
UL 95% CILL 95% CIOR estimateEffect
1.001 (ref.)
Lifetime sex
UL 95% CILL 95% CIOR estimateEffect 2+ prior
4.812.653.57In 1 prior
2.501.331.82In 2+
union in
1.00In 1st
union (ref.)
The surprising and perplexing significant
inverse association between reported female
circumcision and HIV seropositivity remained
highly statistically significant in the final
logistic regression model, despite the
presence of other significant potential
confounders, namely, geographic zone,
household wealth index, woman´s age,
lifetime sex partners, and current/past union
Some additional analyses were undertaken
using those women for whom a male partner
was interviewed and could be linked (n=2305)
Couples analysis (male x female)
UL 95% CILL 95% CIRR estimate
that both
partners are
+ for the
Muslim women are more likely
than other women to be married
to a partner of the same religion
90.5 82 75.2 68.4
Muslim Catholic Protestant None
Percent of women married to partner of
same religion
Relative Risk of HIV infection for the
Female Partner by circumcision status
UL 95% CILL 95% CIRR estimateComparison
1.420.660.97Male circ
vs neither
0.960.310.55Both circ
vs neither
0.970.330.56Both circ
vs male
Discussion continued
The couples analysis also suggests a
protective effect, real or not, of female
There are several important risk factors which
were not collected in the 2003-04 THIS which
might be explanatory confounders of this
perplexing conundrum, including ethnic
group, age at time of circumcision and type of
In 6 of the 10 regions with the highest female
circumcision rates, the HIV seroprevalence
among males is <5%, and is <3% in 3 of
them. In such cases, a lower transmission
risk may be an explanatory confounder.
The surprising and perplexing
significant inverse association between
reported female circumcision and HIV
seropositivity has not been explained by
other variables available and examined
in these analyses
As no biological mechanism seems
plausible, we conclude that it is due to
irreducible confounding
Anthropological insights on female
circumcision as practiced in Tanzania
may shed light on this conundrum
Similar analyses are needed
from other countries to
determine if this association
holds elsewhere.
It is an understatement to say
that further research is
Thank you for your attention !

This research doesn't cite any other publications.
October 2015
    This study compares the residential outcomes of affluent black and affluent white households using data from the 1990 and 2000 censuses and pooled data from the 2005–2009 American Community Survey. Results indicate that affluent black households are highly segregated from their white economic peers. Furthermore, affluent black households live in neighborhoods of lower average quality compared... [Show full abstract]

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