The problems with Circumcision & HIV

I'm very worried about a potential public health disaster because In recent years there has been much media publicity that circumcision reduces the risk of HIV infections, however, what has lacked in this media coverage is an in-depth critical analysis of the research and a wider look at other data that exists that refutes this proposition.

Firstly, if we look at the much vaunted African Clinical trials we can find many faults as follows:

The research did not prove life-long protection only partial episodic protection, which is not absolute risk reduction & only relative risk reduction (relative to the trial conditions for only 18months).  The trials were conducted over an 18month period, and in some areas they were highly controlled clinical trials, and in other areas they were poorly controlled clinical trials.  The trials also did not reflect not real world settings, and therefore how can they be applicable to real world settings.

Rarely reported or emphasised, A significant number of circumcised men in the study became infected with HIV.  This fact often gets over-looked in the pro-circ spin.

The participants were not randomly selected, but selected themselves, creating a potential bias or distortion in the generalisability of the results to any general population.  The participants were paid adult male volunteers who wanted to be circumcised and therefore had a bias in favor of it, and could possibly have been in favour of circumcision because they were high risk candidates who had unprotected sex (no condoms) with multiple sex partners. Therefore as the particpants were not randomly selected, and a potentially biased self-selected sample of the population, the results cannot be extrapolated to general populations outside of this population sub-group.  (Van Howe & Storms, 2011)

Inadequate Controls: Participants in the trials were not treated equally with the circumcised group given more education about healing from surgery, advised to not resume sex for 6 to 8 weeks and therefore, abstained from sex longer, and participants were given greater time and emphasis about wearing condoms during the period of healing from surgery. No control was undertaken to examine possible non-sexual blood exposures by participants.  No control was undertaken for dry sex as practised by some african cultures. No control for the sex (gender) of partners, and no control for anal intercourse. (Van Howe & Storms, 2011)

Unexplained and disrtorting the statistics was the finding that in the first three months of the Kenyan trial, five men became HIV-positive who reported no sexual activity in the period before the seroconversion (0.73/100 person-years, 95%CI=0.30-1.76). (Van Howe & Storms, 2011)

Data suggests a percentage of infections were from non-sexual exposures, with 23 infected men reporting no sexual contact without a condom.  No explanations or investigations undertaken for non-sexual exposures to HIV infections. (Van Howe & Storms, 2011)

The African HIV Trial researchers were all pro-circumcision and with a history of activism in the area.


Nearly 10 times as many participants dropped out of the clinical studies as were infected, with HIV status unknown.

The studies were ended early exagerrating effects.

The vast majority of participants in the study were HIV free, therefore, why was no attempt made by researchers to identify the 100% condom users and compare these to the circumcised group, Was 100% condom use more effective than circumcision = Most probably yes!! but researchers did not want to find this and report it. 

No long term follow-up possible with all subjects circumcised at end of trial.

Researchers used speculative hypotheses to explain trial findings, such as Langeran present in the foreskin cells are targeted by HIV, whereas later research found Langeran cells actually kill HIV. (Van Howe & Storms, 2011)

The studies had such high numbers of participants leading to an overpowering of the statistical analysis, inflating the results. (Van Howe & Storms, 2011)

At best the reseach findings are only valid for adult circumcision volunteers, and populations with high prevalence of HIV, not babies or low prevalence nations, at worst the research is so floored the findings only have validity within similar research conditions and virtually zero validity for real world situations.

In another study, Women who had sex with circumcised men were 50% more likely to become infected with HIV. 


Demographic studies in Africa have found many circumcised populations have higher HIV infection rates than non-cirumcised populations. 

Chao et al found Rwandan women who's partners were circumcised at higher risk of HIV.


The USA which circumcises has much higher HIV than western Europe which doesnt circumcise, showing that clinical trials and real world have little in common with each other.

French demographer Garenne demonstrated that interventions with a near 50% clinical trial efficacy had very little population effect.

Anti-viral drugs have shown a 90 to 95% reduction in HIV infections.

HIV infections are caused by behaviours (Unprotected/Unsafe sex with Multiple sex partners) and therefore behavioural interventions are more important than surgical interventions, which may lead to a false sense of security and increase unsafe sex behaviours with multiple sex partners.

The strong message here needs to be safe sex and condoms can only prevent HIV, and a false belief in the protection of circumcision places men and women at greater risk of infection.

Do Pro-Circumcision Propagandists suffer from a Form of Stokholm Syndrome?

There is much evidence that infant circumcision is a traumatic and painful experience causing loss and deprivation, yet we find some or even many males that have been circumcised endlessly and obsessively promoting infant circumcision.  Why is this so?

One explanation may be a form of Stokholm Syndrome (SS). SS refers to a paradoxical psychological phenomenon wherein hostages express adulation and have positive feelings towards their captors that appear irrational in light of the danger or risk endured by the victims, essentially mistaking a lack of abuse from their captors as an act of kindness (Wikipedia).  The captors often feel traumatised by their experience and yet identify with their traumatisers, particularly if they survive unharmed or even experince a form of kindness or even attachment.  In a sense they feel that their traumtisers have spared them death and given them life.  The key psychological ingredients are helplessness, severity of trauma and intensity of emotional involvement.


In the case of infant circumcision, the baby is totally helpless, the circumcison is traumatic and painful, and hopefully in most cases the infant ends up experiencing an intense loving close relationship with the caregivers that made the choice to traumatise them.  The circumcised then not only attach to their parents but identify with their parents customs & practices, and then defend them even though they were severely harmed and deprived by the experience.  Trauma resides in the primitive areas of the brain, predominantly the Limbic system, one expression of this trauma memory is anxiety, which can become an obsession looking for a cause.  Hence the endless pro-circumcision propaganda.!!!! Though in many cases with a deeper understanding and awareness of the cause of the trauma, circumcision trauma's may turn into an obsession to end routine infant circumcision, a cause for good and ending harm, instead of pro-circ's need to forever perpetuate it.

I “Say” to Doctors who perform infant circumcision

I am deeply disturbed that you would dishonour the Hippocratic Oath to perform this  non-therapeutic traumatic surgery on a patient who is unable to consent based on a parental preference for genital appearance or a false medical opinion that infant circumcision is medically necessary for a baby?  Those of you that make the argument circumcision has medical benefits show your total lack of knowledge about normal human male anatomy, your ignorance of the pain trauma and anatomical losses, you demonstrate gender bias,  you show medical illiteracy about epidemiological data which shows the healthiest children come from non-circumcision nations, you show scientific ignorance in your lack of critical analysis of published research, ignorance of health education and healthy human behaviours, a total disregard for individual human autonomy, and a total disrespect for conservative medical practice.  I am ashamed to be a medical colleague because your behaviour demonstrates that medicos are just as biased, self-serving, ignorant and unethical, as any humans at their lowest levels of conduct.

If you are a Doctor who performs infant circumcisions, Ask yourself this question "How have I come to believe that it is medically appropriate for me to circumcise a healthy infant boy when the majority of world medical  opinion sees routine infant circumcision of healthy  babies as medically unnecessary and even unethical?"

The Doctors: Daytime Talk Show Disaster

Circumcision Children and Human Rights

Circumcision Safe Sex and Condoms

I have been involved in health education for over 35yrs , and in that time have I taught the Safe Sex message.  Now, in the desperate attempt to revive the dying practice of infant circumcision, Pro-Circumcision Propaganda is undoing the importannce of that safe sex message!

There is a very dangerous public health message circulating = "that circumcision prevents HIV".  This is a false statement which may lead to an increase in unsafe sex behaviours with less use of condoms.  A circumcised penis is made of human skin, has an exposed meatus, has vulnerabilities around the circumcision scar, and does provide entry for HIV & STI's.  The USA with the highest circumcision rate in the western world also has the highest rates of HIV and STI's in the western world.  Condoms work because they are a barrier method and block viral entry to HIV, circumcision is a reduction method and it fails, it removes some entry points but leaves many other vital entry points for viral entry, you'd have to reduce the whole penis to eliminate all viral entry sites.

Medical professionals such as myself have been educating about safe sex behaviours and the importance of using condoms, for more than 35 years now, and it would be tragic if this message that falsely claims circumcision prevents HIV (Predominantly used by ProCirc Propagandists to revive the dying practice of infant circumcision) led to the undoing of the safe sex behaviours message.

Some History: In the early 1980’s when the HIV AIDS epidemic emerged in Australia it was a disease found predominantly among homosexual men, who came from an era when most Australian men were circumcised.  I then worked for a state health department and some in the medical community wanted to blame anal intercourse and homosexuals for the epidemic (Yes doctors have prejudice too), but some of us pointed out that data from Africa showed it was a heterosexual disease over there.  Further research and investigation and in co-operation with the homo-sexual community, we found that unsafe-sex behaviours were the primary cause of the disease in Australia.  Behavioural analyses found high levels of sexual promiscuity within the community, along with lack of condom use. Given this and a recognition by the homosexual community that the highly promiscuous behavious within the community which included, a culture of a high number of sex partners, virtually non-existant condom use, led to a major behaviour change.  Education campaigns targeted these behaviours within the community, the community began to change its behaviour, and new HIV infections dropped dramatically.  This Australian model has been used for HIV infection control around the world, = education and behavioural solutions work.

Today, some unscrupulous scientists and medical professionals are now blaming the male foreskin for the HIV epidemic and advocating universal circumcision to combat the problem.  The problem with this false claim, as with the earlier biases against homosexual men, is that the cause of the HIV problem is behavioural, too many sex partners and unprotected/unsafe sex.  The other relevant issue is that many circumcised men all over the world are also infected with HIV proving circumcision doesnt work (But that this is minimized by the Procirc propaganda machine).  The solution to the problem today, as with the early 1980’s epidemic = is education and behaviour change.  Solutions include, Educating people, Promoting having sex within a committed relationship with an uninfected partner, and for those that do engage in sex with multiple sex partners, to always practice safe sex behaviours and wear a condom.

The obsession with promoting infant circumcision is undoing 30yrs of safe sex messages, and is dangerous to our public health.  Dont let this Happen!!!!!!!

Has circumcision been successful or a failure in America?

Lets examine whether Infant circumcision has succeeded or failed America?  Americans have claimed they perform infant circumcision because it has health benefits, so lets examine health benefits via examining real life epidemiological outcomes.

Longevity is universally recognised as one of the most important signs of the health of an individual and the individuals of a nation, if we look at Americans Longevity which is 78yrs, you would expect it to be higher than similar nations that do not practice Circumcision, but in fact the opposite is true. Countries that do not circumcise have much higher longevity.  Japan’s  Longevity is 81.4yrs, Sweden’s Longevity is 80.6 yrs, Switzerlands Longevity is 80.6years. In fact most of Europe which does not Circumcise has higher longevity than the USA. Even within the USA it has been reported in Press that American Latino's who generally circumcise the least are the longest lived USA citizens. Therefore it is very clear that Infant Circumcision has failed the USA on the health measure of Longevity.

The Latest OECD report on the medical health of nations lists the the top 30 countries with rankings 1 being best outcomes and 30 the worst reads as follows: Let's start off by considering the health category, since healthcare is very much in the news in the US, and what's happening with it now so richly illustrates the value of Fullbrook's austere marshalling of stubborn facts.  The indicators in this category, along with the United States' ranking, are as follows: life expectancy at birth (24), healthy life expectancy at birth (24 [tied] out of 29), probability of not reaching the age of 60 (25), infant mortality rate (25), obesity (30), practicing physicians per capita (23), acute care hospital beds per capita (25 out of 29), psychiatric care beds per capita (25 out of 29).. On the combined index of health care indicators, the US comes in at 28, just ahead of ... Turkey and Mexico. You would have to agree that if cirumcision is a predictor of health, then it fails miserably in this context, as most nations ranked higher than the USA do not routinely circumcise their males.

Infant mortality is another measure of public health, and the USA does very poorly again compared to its no-circ peers, with much higher infant mortality than the EU nations & Japan.  The USA infant mortality rate is 6.4 deaths per live births, versus Sweden 2.8 deaths per live births  at and Japan at 3.2 deaths per live births. Again most of non-circumcising Europe has lower infant mortality than the USA.  Infant Circumcision has failed the USA on the health measure of Infant Mortality. 

Death from infant circumcision.  Tragically, Babies die unnecessarily every year in the USA from the complications of circumcision.  This is irrefutable evidence, that when babies die from a preventable death, because infant circumcision is an elective procedure, that it is failing America.

Infant circumcision has also failed America on a UN measure of child-well being:

United Nations measure of child well being = look at the table below:

CHILD WELL-BEING TABLE

1. Netherlands

2. Sweden

3. Denmark

4. Finland

5. Spain

6. Switzerland

7. Norway

8. Italy

9. Republic of Ireland

10. Belgium

11. Germany

12. Canada

13. Greece

14. Poland

15. Czech Republic

16. France

17. Portugal

18. Austria

19. Hungary

20. United States**

The 19 Nations ahead of the USA** are all non-circumcising nations.  From this evidence alone it appears than circumcising infants makes zero contribution to child well-being.  This data would suggests there are other factors far more important than circumcision which are involved in child well-being, and that infant circumcision has zero contribution to child well-being.
(http://www.un.org/apps/news/story.asp?NewsID=21566&Cr=unicef&Cr1)

Sexually Transmitted Infections is another measure of Public Health where infant circumcision has failed the USA when compared to Non-Circumcision nations of Europe.  The USA has 1200% higher HIV infections than No-Circ Finland (in Press) has 500% higher HIV infections than No-Circ Germany & 300% higher HIV infections than no-circ Holland.  .  The USA has 2.7 times the Syphillus infections than than no-circ Holland. .  The USA has 33 times the Gonnoreah infections than than no-circ Holland.  .  The USA has 19 times the Chlamydia infections than No-Circ  Holland.  Infant Circumcision has failed the USA on the health measure of STI Infection rates.
 (Advocates for Youth data) http://www.advocatesforyouth.org/storage/advfy/documents/fsest.pdf


Another claim by Circumcision proponents is that circumcison prevents penile cancer. Denmark which doesnt circumcise its male infants has lower penile cancer rates than the USA which does. This epidemiological finding suggests there are more important factors than circumcision to preventing penile cancer. Another fail for infant circumcision.

Male anger at infant circumcision is seen in the foreskin restoration movement and the huge Intactivist movement in the USA.  That men are restoring their foreskins after being involuntarily circumcsed is more evidence of circumcision's failure.

In medical epidemiology we often look to world's best health outcomes, identify the resasons/practices which contribute, and often label this as the gold standard medical practice.  Europe which doesnt circumcise its male infants, has healthier infants, boys, and men, than the USA which does circumcise its infants.  Non-Circumcision of infants would be considered Gold Standard Medical practice, and it could be said that Infant Circumcision as a public health measure, is one big monumental failure in the USA.

In summary, At the very least, and against its own claims "that infant circumcision provides health benefits", infant circumcision has failed America, and if anything one could speculate that the data indicates a correlation with the very opposite (infant circumcision causes poorer health outcomes in first world nations).  However, much further detailed and more expensive research would be required to determine the validity of the correlation between infant circumcision and poorer health outcomes in first world nations.  Non-Circumcising nations would have zero motivation to allocate resources to this research, and circumcision nations would be averse to devoting reseources to find out that their religious & cultural medical practice is actually harmful to male health. In essence as is the case now, it is a grass-roots movement in America where ordinary people through education and a willingness to go against cultural norms, by protecting one baby at a time from infant circumcision, that will eventually see the practice abolished in the USA.

The onus is on the promoters & profilgators of circumcision to prove otherwise, but on these true life medical outcomes infant circumcision has failed America.

The World Health Organisation 2007 is the source of Longevity and Infant Mortality data.  Advocates for youth is the source of STI data:

http://www.advocatesforyouth.org/storage/advfy/documents/fsest.pdf

The Circumcision Lies 1 The Foreskin

In order to continue & promote infant circumcison The Circumcision Promoters must lie about the normal human anatomy.  One prominent lie is about the function of the foreskin.  Circumcisers say the foreskin is obsolete and has no function, but this is a Blatant LIE. The foreskin has over 20,000 pleasure nerves and anatomical structures like the frenar band, the ridged band and frenulum which give enormous pleasure to males.  The gliding mechanism of the foreskin interacts with the glans to provide contrasting and cascading pleasure in masturbation and sexual intercourse.  Many females have reported gentler more enjoyable sex with an intact man.  Circumcised men who have undergone foreskin restoration report improved sex, and their wives also report more enjoyable sex. Most medical organisations in the world recognise the Foreskin as Functional human anatomy.  Please dont believe the lies of the circumcisers that the foreskin has no function, its just their strategy for justifying & perpetuating circumcision.

Why Infant Circumcision is considered Unethical

This is a summary of Gender Across Borders Paper by Joseph Petersen (http://genderacrossborders.com/2009/11/06/the-ethics-of-neonatal-circumcision/) , and also that of Dr Robert Darby, with my additions in bold italics:

1. One of the primary ideas that has evolved in Western law and medical ethics is the strong support of personal autonomy. That individuals have the right to make important decisions about their own lives for themselve, (Which is now becoming understood as a basic human right) .
2. The patient needs to be fully informed, and consent of the patient for treatment is obtained in all but a few, very specific circumstances such as immediate medical need. (The patient here being the infant cannot be fully informed and cannot consent, therefore proxy consent becomes an important issue)
3. The American Academy of Pediatrics (AAP) Committee on Bioethics, for example, said in their 1995 report, Informed Consent, Parental Permission, and Assent in Pediatric Practice, that, “Parents and physicians should not exclude children and adolescents from decision-making without persuasive reasons.” The Academy goes on to say:

Such providers have legal and ethical duties to their child patients to render competent medical care based on what the patient needs, not what someone else expresses. Although impasses regarding the interests of minors and the expressed wishes of their parents or guardians are rare, the pediatrician’s responsibilities to his or her patient exist independent of parental desires or proxy consent. (What a pity American Doctors who perform infant circumcisions do not observe the medical ethics proscribed to them by the AAP)

4. That is the objective needs of the child patient must be the primary focus, not the subjective preferences of his or her parents. (Infant circumcision is carried out on the subjective preferences of the parents and a clear violation of medical ethics)
5. In the context of this doctor/child/parent relationship, the doctor’s responsibility to assess the objective needs of his child patient and then present options to the child’s parents.
6. British Medical Association discussed this in, The Law and Ethics of Male Circumcision – Guidance for Doctors, where they noted:

Unnecessarily invasive procedures should not be used where alternative, less invasive techniques, are equally efficient and available. It is important that doctors keep up to date and ensure that any decisions to undertake an invasive procedure are based on the best available evidence. Therefore, to circumcise for therapeutic reasons where medical research has shown other techniques to be at least as effective and less invasive would be unethical and inappropriate. (Infant circumcision violates this ethical premise in 100% of cases)

7. Dr. Margaret Somerville, a prominent medical ethicist at McGill University, noted in discussing circumcision that, “A medical-benefits or ‘therapeutic’ justification requires that overall the medical benefits should outweigh the risks and harms of the procedure required to obtain them, that this procedure is the only reasonable way to obtain these benefits, and that these benefits are necessary to the well-being of the child.” Does circumcision in the neonatal period:

1. Provide benefits that exceed the risks and harms of the procedure? (the only prophelactic benefit that can be attained by an infant is a very small reduction in the risk of attaining a UTI though this is contested, therefore given UTI's are rare in male infants, the standard treatment is a course of anti-biotics, and the complications of circumcision far exceed the risk and severity of an easily treated UTI, Circumcision causes harm, pain, and loss of functional anatomical tissue, and has rsiks of complications associated with it, circumcision clearly does not meet this criteria)
2. Provide benefits that can not reasonably be realized in some other way? (Breastfeeding, proper intact care, and anti-biotics, are universally recognised as best treatment and preventative care for UTI's in infants)
3. Provide benefits that are necessary to the welfare of the child? (Rare UTI;s are easily treated by conservative medicine, and therefore circumcision is not necessary to the welfare of the child)

8. The potential benefits that American parents cite when justifying infant circumcision pertain to maladies that can be prevented with less invasive, more effective, methods or can be easily treated should they occur.
9.The lack of clear objective medical need makes routine infant circumcision simply unethical.
10. The foreskin is healthy functional anatomy providing protective & errogenous functions & only the owner of this organ should be permitted to make the decision about its non-therapeutic removal.
11. Circumcision comes with risks and complications & to subject a child to this without therapeutic need is a violation of the hippocratic oath.
12. Many adult men resent their infant circumcisions spending many years restoring their foreskins and some are involved in the anti-infant-circumcision movement.
13. Giving primacy to a socio-cultural group to perform infant circumcision on an individual is a violation of that individuals human rights.

A Summary of Dr Robert Darby arguments :
Medical ethics and human rights
Circumcision advocates refer to the objections to circumcision on medical ethics and human rights grounds as "nebulous", but I suggest that these issues are central to the whole question. No matter how great the benefits of circumcision may be, the fact remains that the foreskin belongs to its owner as surely as his fingers, toes, ears, liver and any other organ. The only health-related situation where it can be ethically removed without consent is in a life-threatening emergency, or in order to address a deformity, injury or disease that has not responded to conservative treatments after reasonable efforts.
To be ethically acceptable a medical intervention must pass the five tests proposed by bioethicists Beauchamp and Childress:

1. Beneficence - Does the proposed procedure provide a net therapeutic benefit to the patient, considering the risk, pain, and loss of normal function?
2. Non-maleficence - Does the procedure avoid permanently diminishing the patient in any way that could be avoided?
3. Proportionality - Will the final result provide a significant net benefit to the patient in proportion to the risk undertaken and the losses sustained?
4. Justice - Will the patient be treated as fairly as we would all wish to be treated?
5. Autonomy - Lacking life-threatening urgency, will the procedure honour the patient's right to his or her own likely choice? Could it wait for the patient's assent?

Non-therapeutic circumcision of minors fails all these tests. It is not beneficent because it provides no therapeutic benefit (nor even a relevant prophylactic benefit, since a child is at zero risk of STIs). It is malefic because it diminishes the genitals. It is disproportional because the net gain (if any) is out of proportion to the loss, harm and risk of complications. It is unjust because adult preferences show clearly that if he had a choice in the matter the boy would refuse the operation. And it fails to respect the boy's autonomy and preserve his future options as an adult individual. It has been strongly argued that such unwarranted interventions are unethical, violate the individual's right to physical integrity, and are of borderline legality.

THis is from the Turkish Journal of Psychiatry concluding circumcision is unethical: http://turkpsikiyatri.com/Data/UnpublishedArticles/179rfy.pdf

Circumcision is not a Surgical Vaccine

I have borrowed from the work of Dr Robert Darby of Circinfo.org (my additions are in bold italics)

This blog is to counter the argument that circumcision is like a surgical vaccine, and not a treatise on the pros & cons of vaccinations, that is another argument which I will not deal with here. The argument here establishes that circumcision is very different to the process and protection offered by vaccinations.

Circumcision promoters seem unable to grasp the fundamental difference between amputating body parts to provide limited protection against a rare disease to which the individual is unlikely to be exposed, and giving a person a needle that confers a high level of immunity to common or contagious diseases. The justification for vaccination of non-consenting children is that the diseases to which it confers immunity are common and/or highly contagious. Airborne diseases, such as smallpox, diphtheria, measles and scarlet fever were all major killers before vaccines were developed. Edward Jenner’s vaccine against smallpox was one of the few preventive health success stories of the nineteenth century. Because such diseases are spread by breathing, one person can quickly infect many others: a single child can infect a class or a whole school, just by being there. Vaccination thus protects both the individual who receives the treatment and the people with whom he comes into contact.  Obviously HIV is not spread by being in the same room as others and breathing their air!


Unlike these diseases, HIV is a low-virulence disease. It is very difficult to pass on a disease that is spread by bodily fluids such as blood and sperm, which must enter the bloodstream of the other person before they can do any harm. No matter how much close social interaction with other people there is, there is no risk that an HIV-positive person can pass on the virus to anybody else – unless he or she has unprotected sexual intercourse or otherwise transfers bodily fluids into the other person’s system. Even in cases of unprotected intercourse, the risk of infection is quite low – estimated at rather less than 10 per cent. Quite apart from the vital matter of disfigurement, the justification for vaccination against highly contagious diseases simply does not apply to HIV-AIDS.  Vaccinations do not physically disfigure whereas circumcision does. Even if circumcised one must still wear a condom to avoid infection which doesnt make circumcision much of a vaccine, and you've lost the pleasures and function of the foreskin.


Circumcision is amputation of a prominent, functional body part that causes injury, loss and harm for a merely speculative gain. Vaccination is a harmless pinprick that strengthens the body’s natural defence mechanisms and confers a high level of immunity against contagious diseases.  (There appears to be some evidence that vaccinations are not a harmless pinprick for all babies, with complications evident for some babies, but that is not the argument here)

Vaccinations confer lifelong immunity in all situations to both genders, no matter sexual orientation, whether one is a IV drug user, whereas there is no proof circumcision confers lifelong  protection as trials were halted after 18 to 24 months, there is no evidence of immunity to HIV (At best viral entry points are reduced but not eliminated, but no immunity to HIV is conferred), circumcised males appear to infect female partners at higher rates, gay men have no protection, IV drug users have no protection, young children dont have sex, and you still have to wear a condom if circumcised.............. Not much of a vaccine!!

Circumcision Propaganda Refuted

Recently well known Circumcision Advocates Cooper Morris & Wodek made their case for infant circumcision in the Australian Medical Journal claiming it was like a surgical vaccine, Their case was strongly rebutted as demonstrated by 8 letters of published and found here:
http://www.circinfo.org/MJA_Cooper_letters.html   

The rebuttals clearly indicated that the article by Cooper, Morris, and Wodek was more about circumcision propaganda than it was science.

Cooper et al stung by the letters of rebuttal by Australian Medicine responded by making a wider case for circumcision, and this was suberbly rebutted by Dr Robert Darby, of which I will briefly summarise here:

The most recent comprehensive survey of the benefits of infant circumcision (Perera et al 2010) found the benefits to be minimal or non-existent.  It is perfectly obvious that if Cooper, Wodak and Morris have to adduce all these additional benefits, however dubious, they are all too conscious that their original case for boosting neonatal circumcision as the only possible response to an alleged rising incidence of heterosexual transmission of HIV in Australia is too feeble to stand alone. Their original article was limited to asserting that neonatal circumcision was needed to prevent an AIDS epidemic among the heterosexual population, and that the evidence for the protective effect of circumcision was to be found in the three much-vaunted clinical trials in Africa. The proposal stands or falls on the robustness of the African data; whether its is applicable to Australia; whether there is “rising heterosexual transmission of HIV” in Australia, and if so whether the rise is sufficient to justify and demand such a radical, costly and controversial response; whether the African evidence can be extrapolated to a developed country such as Australia, where AIDS is very rarely found among heterosexuals and is a problem almost entirely confined to homosexual sub-cultures; and whether the African evidence justifies circumcision of infants, as opposed to (sexually active) adult men.
Cooper, Wodak and Morris make no attempt to address these crucial issues. On top of this failure they make any number of unsubstantiated claims, the most serious of which are (1) their assertion that circumcision must be performed in infancy to provide the necessary protection; (2) their blatant misrepresentation of the statistics on heterosexual HIV infection in Australia; and (3) their snide insinuation that opponents of circumcision are also against vaccination.

Why circumcision in infancy?

There is no evidence that circumcision must be performed in infancy to provide a protective effect against HIV. All the evidence for circumcision having a protective effect comes from circumcision of sexually active adult men in the African clinical trials. If the aim is to forestall a heterosexual AIDS epidemic in Australia, it will be sufficient to ensure that sexually active adult men who plan to enjoy a wide variety of partners and are careless about condoms can choose to get themselves circumcised. And in truth, any adult male in Australia who wishes to get himself circumcised, for this or any other reason, can do so without difficulty or trouble, and get the operation subsidised by Medicare. No further action is needed.
Why, then, do our gang of three insist on neonatal circumcision? Quite simply because it is obvious that the vast majority of adult men prefer to hang on to their foreskins and will not be persuaded to submit to circumcision. To force them to do so would be impractical, to bribe them (as in Africa) would be too expensive; and to coerce them (e.g. at gunpoint) would be illegal. But if it is immoral, unethical or illegal to forcibly circumcise an adult male, why is it any less immoral, unethical or illegal to forcibly circumcise an adult-to-be (that is, a child)? Sexual intercourse without consent is rape, and society regards the crime as all the more wicked if the victim is a child; yet it could be argued that circumcision – an irreversible physical disfigurement, as Paix and Chin point out – is a more serious assault than rape. Even if that argument is not accepted, it is clear that if adult men do not wish to get themselves circumcised as a precaution against HIV, it is morally unacceptable to force the operation on children.
Fundamentally, Cooper, Wodak and Morris lack faith in their own prescription. If the argument for circumcision as a precaution against heterosexually transmitted HIV was as cogent as they claim, men would be lining up to get it done. That they do not suggests both that the argument is weak and that men are not convinced. Recognising this reluctance, the gang of three fail to propose what is logically suggested by the evidence (circumcision to be available for men at high risk of heterosexually transmitted HIV ), and instead turn their sights on those too young to defend their own interests – children, who are at zero risk of sexually transmitted infections, and who will not be at risk for the foreseeable future, by which time treatment and prevention options, and the virus itself, may well have changed beyond recognition. It is easy to see that their prescription is driven more by a fanatical desire to promote circumcision than by a sober analysis of the best way to combat AIDS.

Misrepresentation of statistics on HIV infection

For all Cooper et al's assumption of a looming epidemic of heterosexual HIV infection in Australia, the fact is that HIV contracted through unprotected intercourse with an infected female partner (the only avenue of infection of which there is any evidence of circumcision having a protective effect) remains extremely rare here. As the 2010 surveillance report, issued by the very organisation of which Professor Cooper is director, states:

• “the annual number of new HIV diagnoses has remained relatively stable at around 1000 over the past four years”;
• “HIV continues to be transmitted primarily through sexual contact between men”;
• “of 1185 cases of HIV infection newly diagnosed in 2005-2009, 58% were in people from high prevalence countries or their partners” - i.e. were not contracted in Australia unless from a partner.

From 1995 to 2005 fewer than 1000 people a year were diagnosed with HIV in Australia [1] and in no year since the beginning of the HIV epidemic has the number of diagnoses of Australian-born men acquired by heterosexual contact ever approached 100. Of the 1001 people diagnosed in total in 2008, 271 were infected by heterosexual contact, of whom 144 were men, of whom in the vicinity of 60 were Australian-born, of whom only a fraction were intact. It is only to this tiny sub-sub-sub-subgroup that circumcision could have afforded some reduction in risk. Had all 5 million Australian-born males in the susceptible age range been circumcised instead of only two thirds [2, 3] (an additional 1.7 million circumcisions) then, based on the hypothetical assumption that circumcision would have reduced infection in that group by 60%, the total number of diagnoses in Australia would have been cut by a measly 2%.
Life tables for intact men and circumcised men based on age-specific prevalences of circumcision among Australian-born men [2, 3] current age specific incidence rates of HIV infection by heterosexual contact [4], and the hypothetical assumption that circumcision reduces female-to-male transmission of HIV by 60% show that the estimated lifetime risk for an intact Australian-born man of acquiring HIV by heterosexual contact is less than 1 in 1,000 and that the number of circumcisions required to prevent one infection during a lifetime is greater than 1,800.
Contrary to the authors’ contention, circumcising 1,800 babies in 2010, in the hope that it may prevent one HIV infection sometime from 2030 onwards (but only if no progress has been made in reducing the incidence of HIV in the next 20 years, assuming the characteristics of the virus do not change, that it remains as lethal as now, and that treatment methods do not improve), does not make sense.
1. AIDS & HIV statistics by transmission route and gender

2. Smith, A. et al. Australian Study of Health and Relationships Australian and New Zealand Journal of Public Health, Volume 27, Number 2, April 2003
3. Ferris JA, Richters J, Pitts MK, Shelley JM, Simpson JM. Ryall R, Smith AMA. Circumcision in Australia: further evidence on its effects on sexual health and wellbeing, Australian and New Zealand Journal of Public Health, 34:2, pp160-4
4. Australian Public Access Datasets on newly diagnosed HIV infection and AIDS
This is not the only area where Coooper, Wodak and Morris have misrepresented or misunderstood the data. In their original article they also made misleading claims as to the recommendations made by the World Health Organisation on circumcision as a tactic for AIDS control in Africa, and also about the incidence of circumcision in Australia.

Misrepresentation of WHO recommendations on circumcision

In their original paper Cooper et al state: “The protection conferred to heterosexual males by circumcision is similar in hyperendemic and low-prevalence settings (refs. 3-5).” This is untrue, and shown to be untrue by their own references.
Reference 3 states: “Male circumcision, together with other prevention interventions, could play an important role in HIV prevention in settings similar to those of the clinical trials.” (http://www.cdc.gov/hiv/resources/factsheets/circumcision.htm) That is, it is not recommended in countries with low HIV prevalence such as Australia.
Reference 4 states: “Together, these three trials provided strong evidence that MC can significantly reduce men’s risk of acquiring HIV infection in the contexts in which the trials were conducted.”  (Public Health Rep 2010; 125 Suppl 1: 72-82)
Reference 5 is to Morris BJ. Why circumcision is a biomedical imperative for the 21st century. Bioessays 2007; 29: 1147-1158. This is simply an opinion piece by one of the authors of the article under consideration. The one reference in this that might bear on the issue proves to be to yet another opinion piece by the same author.
No researchers have published any results of clinical trials of male circumcision outside Africa, and very limited observational data exist on the association between circumcision status and HIV infection among men – but much of what does exist shows that circumcision is of no benefit at all. Mor et al.’s study of nearly 58,000 men attending San Francisco's STD clinics found “no significant differences between circumcision status and the risk of HIV or syphilis infection” in either men who have sex with men or heterosexual men. [5]
The claim that circumcision prevents heterosexual HIV transmission from women to men is based on three non-double-blinded, non-placebo-controlled Randomised Controlled Trials in Africa [6,7,8] in which a total of 5,400 men were circumcised, all called off after less than two years, at which time a total of 64 of the men in the circumcised experimental groups had HIV, compared to 137 in the non-circumcised control groups. 673 men in total were lost from those trials, their HIV status unknown. But even granting that those trials proved that circumcision grants “60% reduction” in female-to-male heterosexual HIV transmission (the most widely quoted figure, even though the Cochrane Review estimates it as between 38 and 64 per cent, and we have no idea as to that the risk reduction in Australia, if any, might be), a case for widespread neonatal circumcision does not follow.
5. Mor Z, Kent CK, Kohn RP, Klausner JD (2007) Declining Rates in Male Circumcision amidst Increasing Evidence of its Public Health Benefit. PLoS ONE 2(9): e861. doi:10.1371/journal.pone.0000861
6. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, et al. 2005. Randomized, controlled intervention trial of male Circumcision for reduction of HIV infection risk: The ANRS 1265 Trial. PLoS Med 2:e298.
7. Bailey RC, Moses S, Parker CB, Agot K, Maclean I, et al. 2007. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet 369:643-656.
8. Gray RH, Kigozi G, Serwadda D, Makumbi F, Watya S, et al. 2007. Male ircumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet 369:657-666.

Misrepresentation of statistics on the incidence of circumcision in Australia

Cooper, Wodak and Morris claim: “Despite official discouragement, Medicare statistics show a rise in the rate of infant male circumcision in Australia from 13% in 1998 to 19% in 2009.”
In fact, the national rate of infant male circumcision, based on Medicare claims statistics [9] and births data published by the Australian Bureau of Statistics [10], has not exceeded 13% at any time during the period for which Medicare statistics are available on-line (July 1993 to the present). Since public hospitals in most states do not provide non-therapeutic circumcisions, the total number of infant circumcisions has probably gone down, but this would not have been reflected in Medicare statistics (except perhaps by a rise in the number of claims on Medicare). It is therefore likely that the decline in the real rate of infant circumcision that began some 40 years ago has continued in recent years. Certainly, the rate fell sharply in Tasmania and Northern Territory several years ago, has recently fallen substantially in Queensland, and is well below 10% in the majority of states and territories. A charitable explanation is not that Cooper et al are statistically illiterate, but that they have confused figures for New South Wales with figures for the nation as a whole. It is apparent that there is a gaggle of circumcision promoters centred around Professor Morris in Sydney, and that they are having an effect on the incidence of circumcision in that state. Elsewhere, however, respect for the principles of evidence-based medicine and medical ethics take precedence over their emotion-driven hatred of normal human anatomy.
9. https://www.medicareaustralia.gov.au/statistics/mbs_item.shtml
10. Australian Bureau of Statistics

Circumcision and vaccination

Perhaps the most scandalous gambit in the Cooper et al reply to critics is their insinuation that opponents of circumcision as a tactic against HIV control in Australia are also against vaccination. This allegation is unfounded and untrue: no prominent critic of circumcision has ever attacked vaccination, nor did any of the letters to which Cooper et al were responding. There may be some individuals among the general public who are opposed to both circumcision and vaccination, but most critics of circumcision, both within the medical profession (such as the Royal Australasian College of Physicians in its recent policy statement) and among the informed public (such as this website) are not merely not opposed to vaccination, but fully support it as a valid instance of preventive, evidence-based medicine.
Circumcision promoters seem unable to grasp the fundamental difference between amputating body parts to provide limited protection against a rare disease to which the individual is unlikely to be exposed, and giving a person a needle that confers a high level of immunity to common or contagious diseases. The justification for vaccination of non-consenting children is that the diseases to which it confers immunity are common and/or highly contagious. Airborne diseases, such as smallpox, diphtheria, measles and scarlet fever were all major killers before vaccines were developed. Edward Jenner’s vaccine against smallpox was one of the few preventive health success stories of the nineteenth century. Because such diseases are spread by breathing, one person can quickly infect many others: a single child can infect a class or a whole school, just by being there. Vaccination thus protects both the individual who receives the treatment and the people with whom he comes into contact.
Unlike these diseases, HIV is a low-virulence disease. It is very difficult to pass on a disease that is spread by bodily fluids such as blood and sperm, which must enter the bloodstream of the other person before they can do any harm. No matter how much close social interaction with other people there is, there is no risk that an HIV-positive person can pass on the virus to anybody else – unless he or she has unprotected sexual intercourse or otherwise transfers bodily fluids into the other person’s system. Even in cases of unprotected intercourse, the risk of infection is quite low – estimated at rather less than 10 per cent. Quite apart from the vital matter of disfigurement, the justification for vaccination against highly contagious diseases simply does not apply to HIV-AIDS.
It is actually quite hypocritical for Cooper, Wodak and Morris to attack critics of circumcision by suggesting that they are anti-vaccination. Morris himself is on record as disparaging the vaccine (Gardasil) recently developed to protect women against varieties of human papilloma virus that cause cervical cancer.
So let’s have no more of this anti-scientific nonsense. Circumcision is amputation of a prominent, functional body part that causes injury, loss and harm for a merely speculative gain. Vaccination is a harmless pinprick that strengthens the body’s natural defence mechanisms and confers a high level of immunity against contagious diseases.