Australian Doctors reject push for circumcision of infants in Australia

Medical Journal of Australia publishes replies to Cooper et al

“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

"An article in the 20 September issue of the Journal that suggested circumcision of infant boys could be considered a “surgical vaccine” against future heterosexually transmitted HIV has attracted strong criticism from many of our readers."

[Contrary to policy of responsible medical authorities]

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]
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.

[Circumcision ineffective, risky and cruel]

In their recent editorial, Cooper and colleagues propose newborn circumcision as primary prevention for heterosexual HIV transmission in Australia. [1] However, they cite no evidence for its effectiveness as a primary prevention measure, and their editorial references few high-quality studies, offering instead opinions from like-minded individuals.
Experience in the United States suggests that circumcision is unlikely to be effective in preventing heterosexual HIV transmission. While having a high infant circumcision rate for the past 60 years, the US has had one of the highest rates of heterosexually transmitted HIV infection among developed nations. African Americans have the highest rates of both circumcision [2] and heterosexually transmitted HIV infection. [3] Circumcision removes the most sensitive tissue of the penis [4] and serious complications include death (about 0.9 deaths per 10 000 circumcisions). [5] If two-thirds of Australian newborn boys were circumcised at birth, around nine would die every year from complications.
Cooper et al sidestep the ethical issues raised by non-therapeutic circumcision. Infants and children lack the legal capacity to grant consent but have human rights. The High Court of Australia holds that parents may grant consent only when surgery to the genital organs is therapeutic, [6] which does not include neonatal circumcision. Without valid consent, circumcision constitutes legal battery. It is far preferable legally and ethically for circumcision decisions to be deferred until the child is competent to make a fully informed decision for himself. Cooper et al state that infant circumcision is cost-effective, but the cost analysis that they reference does not directly assess cost effectiveness. [7] In fact, the data suggest that infant circumcision costs more than it saves. Another cost analysis showed that a circumcision program would be five times more costly in preventing HIV than providing free condoms, and that condoms are 95 times more effective than circumcision. [8]
In summary, newborn circumcision for primary prevention of HIV remains unsupported by evidence of efficacy or cost-effectiveness, introduces potentially serious risks, and raises complex ethical and medico-legal issues. New 2010 Royal Australasian College of Physicians guidelines [9] continue to not recommend circumcision, despite pressure from a well funded, international, pro-circumcision lobby group. [10] Instead of adopting a circumcision experiment that has failed in the US, Australia should take its lead from the Royal Dutch Medical Association and condemn non-therapeutic circumcision in boys. [11]
John W Travis, Adjunct Professor, School of Health Sciences, RMIT, Melbourne; Sarah J Buckley, General Practitioner, Brisbane; Paul Mason, Former Commissioner for Children, Tasmania; Ken McGrath, Senior Lecturer in Pathology, Auckland University of Technology; Robert S Van Howe, Clinical Professor, Department of Pediatrics and Human Development, Michigan State University; George Williams, Former Director, Newborn Intensive Care Unit, Sydney Children’s Hospital.
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. Mor Z, Kent CK, Kohn RP, Klausner JD. Declining rates in male circumcision amidst increasing evidence of its public health benefit. PLoS ONE 2007; 2: e861.
3. Centers for Disease Control and Prevention. Racial/ ethnic disparities in diagnoses of HIV/AIDS — 33 states, 2001–2005. MMWR Morb Mortal Wkly Rep 2007; 56: 189-193.
4. Sorrells ML, Snyder JL, Reiss MD, et al. Fine-touch pressure thresholds in the adult penis. BJU Int 2007; 99: 864-869.
5. Bollinger D. Lost boys: an estimate of US circumcision-related infant deaths. Thymos 2010; 4: 78-90.
6. Secretary, Department of Health and Community Services v JWB and SMB (Marion’s case) (1992) 175 CLR 218, FC 92/010.
7. Schoen EJ, Colby CJ, To TT. Cost analysis of neonatal circumcision in a large health maintenance organization. J Urol 2006; 175: 1111-1115.
8. McAllister RG, Travis JW, Bollinger D, et al. The cost to circumcise Africa. Int J Men’s Health 2008; 7: 307- 316.
9. Royal Australasian College of Physicians. Circumcision of infant males. Sydney: RACP, 2010.
10. Llewellyn DJ. The circumcision lobby. The 11th International Symposium on Circumcision, Genital Integrity, and Human Rights. Genital Autonomy. Program and Syllabus of Abstracts; 2010 Jul 29–31; University of California, Berkeley.
11. Royal Dutch Medical Association. Non-therapeutic circumcision of male minors. Utrecht: KNMG, 2010.

[Circumcision irrelevant to Australian conditions]

We refer to a recent editorial in which Cooper and colleagues made a case for boosting infant male circumcision in Australia to reduce female-to-male HIV transmission. [1] The case is strong for hyperendemic countries, such as those in sub-Saharan Africa, given the evidence for circumcision reducing the prevalence of HIV when infections are primarily from heterosexual contact. [2] However, the epidemiology of the HIV epidemic in Australia paints a radically different picture from these countries. Most striking is that men who have sex with men (MSM) still comprise the largest group — around 83% — of people living with HIV. [3] Prevalence of HIV among men and women who report a history of heterosexual contact only remains at less than 0.5%4 while MSM continue to have the majority of new infections. [4] In short, efforts to reduce Australia’s HIV epidemic still require a primary focus on MSM.
With this in mind, a recent meta-analysis of 18 international studies and a combined pool of 53 567 MSM5 showed only a small, statistically non-significant trend toward a protective benefit from circumcision with regard to HIV and other sexually transmitted infections. Hypothesised benefits are limited to the insertive partner; however, circumcised MSM who engaged primarily in insertive anal intercourse (IAI) were not significantly less likely to be HIV-positive than other MSM.
The sexual repertoire of many MSM suggests that interventions designed specifically to protect those who engage in IAI are unlikely to be successful at a population level. Data from a national survey of 856 homosexual men, conducted recently by the Australian Research Centre in Sex, Health and Society, show that only 9% of those who had anal intercourse in the past 12 months reported taking an exclusively insertive role. Of the remainder, 8% were exclusively receptive and 83% were versatile, adopting each role at least once over the preceding 12 months. Uncircumcised men who engaged exclusively in IAI were just as likely to be HIV-negative as their circumcised counterparts (P=0.90).
As infant male circumcision programs are rolled out in some hyperendemic countries, we encourage policymakers to tread carefully when considering such a move in Australia. Boosting education campaigns that promote HIV awareness and safer sex may prove to be more cost-effective and successful than largescale infant male circumcision programs which seem likely to offer, at most, a marginal benefit to the extremely small proportion of the Australian male population who are exclusively insertive partners in homosexual anal intercourse.
Anthony N Lyons, Research Fellow; Marian Pitts, Director; Anthony Smith; Professor Jeffrey Grierson, Senior Research Fellow, Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne.
1. Cooper DA, Wodak AD, Morris BJ. The case for boosting infant male circumcision in the face of rising heterosexual transmission of HIV. Med J Aust 2010; 193: 318-319.
2. Doyle SM, Kahn JG, Hosang N, et al. The impact of male circumcision on HIV transmission. J Urol 2010; 183: 21-26.
3. Grierson J, Power J, Croy S, et al. HIV futures six: making positive lives count. Melbourne: La Trobe University, 2009.
4. National Centre in HIV Epidemiology and Clinical Research. HIV/AIDS, viral hepatitis and sexually transmissible infections in Australia: annual surveillance report 2009.
5. Millett GA, Flores SA, Marks G, et al. Circumcision status and risk of HIV and sexually transmitted infections among men who have sex with men: a meta-analysis. J Am Med Assoc 2008; 300: 1674- 1684.

[Circumcision: Not enough evidence of efficacy]

In their recent editorial, Cooper and colleagues argue for a shift in Australian policy to boost neonatal male circumcision levels, in an effort to prevent future heterosexual acquisition of HIV. [1] There is very strong evidence for a protective effect of male circumcision against HIV acquisition in high-prevalence settings, where heterosexual intercourse is the most common mode of transmission and access to antiretroviral therapy is poor. However, Australia is a low-prevalence setting with an HIV epidemic that largely affects the homosexual population and excellent access to condoms and antiretroviral therapy.
There have been very few studies on the protective effect of male circumcision in settings similar to Australia, and those that have been reported have produced variable results. [2] The publications cited by Cooper et al do not strongly support the notion that male circumcision confers similar protection in both high- and low-prevalence settings — the conclusions are based on expert opinion or other inconclusive, low-quality evidence. [2-4] There are also other issues to consider when discussing a population-based intervention strategy for a low-prevalence disease. Given that rates of male circumcision in Australia are currently low,1 compliance could be an issue, as parents may be unwilling to accept a surgical procedure for their newborns on the basis of predictions about future HIV protection.
Is circumcision cost-effective compared with other modalities used to prevent or treat heterosexually transmitted HIV? Cost effectiveness studies have been carried out in the United States, where health care costs are likely to be significantly different to those in Australia. The Centers for Disease Control and Prevention consultation report cited by the authors acknowledges that the available cost and cost-effectiveness research on male circumcision is subject to a variety of “methodological limitations and data insufficiencies”. [3] Further, the case needs to be made that neonatal male circumcision is a more cost-effective option in preventing heterosexual HIV transmission than the current response — targeted education campaigns, antiretroviral therapy, and medical advice regarding safe sex practices.
In conclusion, the jury is still out with regard to the role of male circumcision in HIV prevention in Australia on two counts: efficacy and cost-effectiveness. To justify a shift in policy towards actively encouraging routine neonatal circumcision at a national level, we should have access to high-quality, relevant data. Until such information is available, the environment doesn’t exist for parents or policymakers to make a truly informed decision about this issue.
Niall Conroy, Public Health Registrar, Sir Albert Sakzewski Virus Research Centre, Queensland Paediatric Infectious Diseases Laboratory, Brisbane.
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. Smith DK, Taylor A, Kilmarx PH, et al. Male circumcision in the United States for the prevention of HIV infection and other adverse health outcomes: a report from a CDC consultation. Public Health Rep 2010; 125 Suppl 1: 72-82.
3. Centers for Disease Control and Prevention. Male circumcision and risk for HIV transmission and other health conditions: implications for the United States [CDC HIV/AIDS science facts]. Atlanta: CDC, 2008.
4. Morris BJ. Why circumcision is a biomedical imperative for the 21st century. Bioessays 2007; 29: 1147- 1158.

[Circumcision violates principles of medical ethics and human rights]

In a recent editorial, Cooper and colleagues asserted that infant male circumcision reduces heterosexual (female-to-male) transmission of HIV. [1] However, they failed to acknowledge the serious methodological flaws of the three African randomised controlled trials (RCTs) on which the claim is based, including early termination and loss of participants to follow-up. These RCTs reported on circumcision of adults in Africa and, therefore, are not relevant to children in Australia. In a major oversight, the editorial did not cite contradictory RCT evidence that male circumcision increases heterosexual (male-to-female) HIV transmission by 61.4%. [2] Therefore increased male-to-female transmission of HIV would negate any reduction in female-to-male HIV transmission.
Common law recognises the right of bodily integrity. International human rights law enshrines the right to security of the person. The High Court of Australia opines that parents may grant surrogate consent only when a surgical intervention is therapeutic. As male circumcision amputates healthy, functional, protective, erogenous tissue, imposing male circumcision on unconsenting minors violates these rights. It has been strongly argued that non-therapeutic infant circumcision is tantamount to criminal assault. [3]
Unlike America, which has a high incidence of male circumcision and a high prevalence of HIV infection (0.6%),4 in the Australian context there is a low incidence of male circumcision among men aged under 35 years combined with a very low prevalence of HIV (0.1%). [4, 5] HIV infection in Australia occurs mostly among homosexual men. [6] It has been reported that any prophylactic value of male circumcision in preventing homosexual transmission of HIV is not statistically significant, [7] so male circumcision would be of little value in reducing future Australian HIV infection rates.
Despite calling for increased non-therapeutic infant male circumcision, Cooper et al unequivocally stated “Condom use remains essential”. Since this is the case, what is the purpose of inflicting lifelong bodily and psychosexual harm [8] on defenceless children, contrary to ethical or moral principles? Furthermore, circumcision of unconsenting minors may amount to criminal assault.
Gregory J Boyle, Professor of Psychology, Bond University, Queensland; George Hill, Independent Consultant, Port Allen, La, USA.
1. Cooper DA, Wodak AD, Morris BJ. The case for boosting infant male circumcision in the face of rising heterosexual transmission of HIV. Med J Aust 2010; 193: 318-319.
2. 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.
3. Boyle GJ, Svoboda JS, Price CP, Turner JN. Circumcision of healthy boys: criminal assault? J Law Med 2000; 7: 301-310.
4. UNAIDS. Country factsheets. Geneva: UNAIDS, 2010. http://cfs.unaids.org/ (accessed Dec 2010).
5. National Centre in HIV Epidemiology and Clinical Research. HIV/AIDS, viral hepatitis and sexually transmissible infections in Australia: annual surveillance report 2009. Sydney: NCHECR, 2009.
6. Richters J, Smith AMA, de Visser RO, et al. Circumcision in Australia: prevalence and effects on sexual health. Int J STD AIDS 2006; 17: 547-554.
7. Millett GA, Flores SA, Marks G, et al. Circumcision status and risk of HIV and sexually transmitted infections among men who have sex with men: a meta-analysis. JAMA 2008; 300: 1674-1684.
8. Boyle GJ, Goldman R, Svoboda JS, Fernandez E. Male circumcision: pain, trauma and psychosexual sequelae. J Health Psych 2002; 7: 329-343.

[Violates principles of evidence-based medicine]

Cooper and colleagues propose circumcision of male infants in Australia as a strategy for reducing the incidence of heterosexually transmitted HIV infection. [1] They base this suggestion on evidence, from three clinical trials in Africa, that circumcision of adult men can reduce the risk of men acquiring HIV during unprotected sexual intercourse with an infected female partner. The proposal must be rejected because it is irrelevant to the Australian situation and departs from the principles of evidence-based medicine.
The proposal is irrelevant because it targets infants, who are not at risk of infection by sexual contact and will not be at risk until they become sexually active in 16–20 years time, by which time treatment and prevention options, and the virus itself, may have altered beyond recognition. Evidence-based medicine requires that recommendations for treatment or prophylaxis follow logically and directly from the evidence. In this case, there is a radical disconnect between the evidence and the recommendation. Even assuming the African evidence is reliable and applicable (and ignoring the many critiques), [2, 3] the logical prescription arising from these data is that sexually active adult men who have regular intercourse with numerous different female partners and who do not always use condoms should consider circumcision for themselves as a means of lowering their risk of infection.
This is not what Cooper et al propose. What they prescribe is that parents be advised to circumcise their boys in infancy as a precaution against a risk they will not face until they are adults, and against a disease that is very rare among heterosexually active adult men in Australia. Even if circumcised, they would still have to use a condom to be sure of avoiding infection, as the risk reduction promised by the African data is only partial — between 38 and 66 per cent. [4] We have no data at all on what the risk reduction in Australia might be. If it is still necessary to wear a condom there seems little point in getting circumcised.
As others point out, [5] moreover, the African trials on which Cooper et al rely involved sexually active adult men, not infants, and there is no hard evidence that neonatal circumcision has any protective effect against acquiring HIV. Arguments concerning other possible, non-HIV-related benefits of circumcision (all contested in the literature and rejected in the policy statement on circumcision recently issued by the Royal Australasian College of Physicians [6]) are irrelevant to HIV infection itself. In sum, the prescription offered has so little connection with the evidence on which it relies that it cannot be taken seriously.
Robert J L Darby, Independent Researcher, Canberra, ACT.
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. Green LW, McAlister RG, Peterson KW, Travis JW. Male circumcision is not the surgical vaccine we have been waiting for. Futur HIV Ther 2008; 2: 193- 199.
3. Myers A, Myers JE. Rolling out male circumcision as a mass HIV/AIDS intervention seems neither justified nor practicable [editorial]. S Afr Med J 2008; 98: 781-782.
4. 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.
5. Perera CL, Bridgewater FHG, Thavaneswaran P, Maddern GJ. Safety and efficacy of nontherapeutic male circumcision: a systematic review. Ann Fam Med 2010; 8: 64-72.
6. Royal Australasian College of Physicians. Circumcision of infant males. Sydney: RACP, 2010.

[Proposed cure worse than the disease]

I write in response to the editorial by Cooper and colleagues, which advocates an increase in male infant circumcision as an anti-HIV strategy. [1] The authors claim that male circumcision is effectively a surgical vaccine for preventing female-to-male HIV transmission and, while the authors do present evidence in favour of this, they fail to canvass the serious and inevitable long-term adverse effects of the procedure. Far from being an inconsequential snip, male circumcision is a highly mutilating operation which seriously impairs penile function.
Glibly quoting four articles which “prove” that circumcised and uncircumcised males are equally satisfied sexually, the authors totally ignore a large and expanding body of evidence to the contrary, [2-4] and indeed growing popular movements against circumcision and for restoration of the foreskin. Circumcision typically removes nearly half the skin of the penis [3] — including its most sensitive areas — and, by exposing the glans to the elements, induces keratinisation of its formerly moist mucosal surface — making it rougher, dryer and less sensitive. It also destroys the “sliding” or “rolling” action of the shaft in the skin tube and most certainly impairs both male and female sexual satisfaction. [4,5]
It is totally inappropriate to suggest that circumcision is akin to vaccination: needle vaccination generally confers high-level immunity to the majority of its recipients with few, if any, long-term sequelae. In contrast, circumcision confers moderate immunity at best, and does so at the cost of mutilating and de-functioning every penis so treated. I strongly urge my colleagues who still believe that male circumcision is a trivial operation to type “foreskin restoration” into a search engine and see what they find. Finally, I implore us all to refrain from removing body parts from our unconsenting children without immediate and direct surgical need.
Bruce R Paix, Anaesthetist, Department of Anaesthesia, Flinders Medical Centre, Adelaide.
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. Zoossmann-Diskin A, Blustein R. Challenges to circumcision in Israel. In: Denniston GC, Mansfield Hodges F, Milos MF, editors. Male and female circumcision: medical, legal and ethical considerations in pediatric practice. New York: Kluwer Academic/ Plenum Publishers, 1999: 343-350.
3. Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996; 77: 291-295.
4. Fleiss PM, Hodges FM, Van Howe RS. Immunological functions of the human prepuce. Sex Transm Infect 1998; 74: 364-367.
5. Cold CJ, Taylor JR. The prepuce. Br J Urol 1999; 83 Suppl 1: 41.

[Circumcision for HIV prevention not relevant to children]

I read with interest the editorial by Cooper and colleagues in which the authors argue for infant male circumcision as a population-wide strategy to reduce HIV transmission. Circumcision is an irreversible body-altering procedure and, therefore, as far as possible, individuals should participate in the decision of whether or not to be circumcised. Male circumcision in infancy removes an individual’s ability to participate in the decision-making process. Further, the protective benefits of infant circumcision with regard to reduction of HIV transmission are not conferred until an individual becomes sexually active and is capable of understanding the risks and benefits. Deferment of circumcision to a later age would allow individuals to fully appreciate the magnitude of the procedure and participate in the decision-making process, and it would not necessarily negate the protective benefits. This should be considered by anyone who advocates infant male circumcision as a strategy to reduce HIV transmission.
Jeremy J Chin, Intern, Northern Health, Melbourne.
Source: Medical Journal of Australia, Vol. 194 (2), 17 January 2011, 97-101. Headings to the letters have been added by Circumcision Information Australia.
Click here for Cooper et al's reply to their critics and our response to their reply

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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.

Circumcision & poor health outcomes in 1st world nations

There is much evidence that infant circumcision contributes to poorer health outcomes in first world nations.

Health Outcomes in Children

Firstly, A recent Australian (2009) research found that present day Australian Children had far superior health outcomes to when routine infant circumcision was common, read as follows:

"The health of Australia’s children continues to improve, according to the latest report on child health from the Australian Institute of Health and Welfare, A Picture of Australia's Children 2009. During the period 1986-2006 there was a dramatic decline in infant and child deaths (which fell by half), improved survival in cases of cancer, and a reduction in the incidence of asthma.
These are significant findings, given that the period 1986 to 2006 witnessed a huge decline in the incidence of circumcision, from about 40 per cent of boys in the early 1980s to about 10 per cent in 2006. It is thus good empirical proof that “lack of circumcision” does not increase child health problems. Even more significantly, it is a decisive refutation of “scientific” predictions by Terry Russell, Brian Morris and other diehard promoters of routine circumcision that the fall in the circumcision rate would lead to an explosion of genito-urinary problems in boys and an ever-increasing death toll from urinary tract and bladder infections. No such problems are identified in this report, which does not even mention any health problems affecting the genito-urinary area.
On the contrary, the halving of the death rate among infants and children suggests that leaving the foreskin in place could even have significantly improved child health outcomes and contributed to the decline in infant and child mortality. It is, after all, quite illogical to claim that a boy with wound on his penis is somehow healthier than a boy who has not been injured there. As the British child health expert N.R.C. Roberton points out, “it is fundamentally illogical that mutilating someone might be beneficial.” *
Problems identified by the AIHW report include an increasing incidence or diabetes and obesity, more, tooth decay, too much television, not enough vegetables, and persistent poor health among indigenous Australians. It is hard to see how even a fanatic like Brian Morris could blame “lack of circumcision” for children not eating their vegetables.
The Australian Institute of Health and Welfare is the Australian Government’s premier health research foundation.
The full report and press release can be downloaded from the AIHW website.
Reference
N.R.C. Roberton, “Care of the Normal Term Newborn Baby,” in Textbook of Neonatology, eds. Janet M. Rennie, N.R.C. Roberton, 3rd edn. (Edinburgh: Churchill Livingston, 1999), 378-379.

Longevity

When we look at longecity of first world nations an interesting story emerges.  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 (Circumcision Culture) 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 dont circumcise are the longest lived USA citizens. Therefore it is very clear that Infant Circumcision fails 1st world nations on the health measure of Longevity.

Infant Mortality

Infant mortality is another measure of public health, and the USA (The largest circumcising 1st world nation) 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 first world circumcising nation of USA on the health measure of Infant Mortality.


UN Child Well-Being Measure
Infant circumcision has also failed circumcising 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)

STI's & HIV

Sexually Transmitted Infections is another measure of Public Health where infant circumcision has failed the Circumcision USA when compared to Non-Circumcision nations of Europe.  The USA has 6 times the HIV infections than No-Circ Germany & 3 times the 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.

Penile Cancer

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.

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 & Japan which dont circumcise their male infants, have healthier infants, boys, and men, than the USA which does circumcise its infants.  On these 5 measures alone 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 first world medicine nation of the USA.

In summary, At the very least, and against its own claims "that infant circumcision provides health benefits", infant circumcision has failed the first world nation of America, and Non-Circumcision Cultures do better. 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 limited health resources to do this research, and circumcision nations would be averse to devoting limited health resources 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 first world nations like America where ordinary people through education and a willingness to go against cultural norms, and by protecting one baby at a time from infant circumcision, that will eventually see the practice abolished in all first world nations.

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

Why does the foreskin become more impt as men age?

Direct Sexual Nerve stimulation and its response becomes more important for men as they age because sex hormone levels of testosterone gradually diminish and vascular circulation becomes less efficient. Robbing men of 20,000 pleasure nerves and anatomical pleasure structures like the frenar band and frenulum deprives them of much needed nerve stimulation as they age.  The loss of testosterone and vascular efficeincy can be in part compensated by direct stimulation of pleasure nerves, if these are lost to circumcision then men are deprived of this potential sexual compensation.

Why does infant circumcision still exist?

Culture is the one word that encapsulates why this practice still exists.  Culture covering the whole spectrum of social life including: religion, community, tribal practices, belief systems, Scientific values, Cultural Myth making, Cultural taboos, & Cultural shaming practice.  These cultural reasons are reinforced by the practice iteslf which has components of trauma, pain and anxiety, which can manifest as obsessiveness in individuals. Look at the obsessive lengths people go to, including scientists and medico's to promote the practice.

1Culture Non-Religious = In this instance we have a cultural set of beliefs and practices, including institutions, high profile individuals from media to medicine, Friends, Family, & Community leaders who are Saying "circumcision is good and that natural anatomy (the foreskin) is bad."  Very difficult issue to deal with but predominantly extensive education is required, and a variety of persuasion strategies from predominantly gentle coaxing & education, to "rarely as a last resort" aggressive shaming tactics (Giving the Pro-Circers a smell and taste of their own medicine), Knowing your audience is important, in which persuasion strategy to use.

Cultural Belief Systems = "The foreskin is of no value, it is a useless flap of skin."  "Circumcision is a harmless procedure and the baby won’t feel a thing."  The new one: "Circumcision is like a surgical vaccine, and circumcision is the only way I can achieve these health benefits for my child."  While clearly false with strong evidence that disputes these cultural beliefs, many people still believe these strongly contested circumcision myths. The answer here, is to challenge these beliefs with education, such as healthiest longest lived people with lowest STI's/HIV are non-circumcision people.

2.       Obedience to Medical Authority = Medical personal have an esteemed position in most cultures and strongly influence people.  "If my doctor says I need to do it, then it must be right."  Some people have been bought up to defer to medical authority, and that the Doctor always knows best.  Doctors are human beings and are susceptible to personal bias, prejudice, errors, false beliefs, greed, ignorance, incompetence, medical negligence, unethical behaviour, and cultural conditioning.  In many ways doctors can be cultural ambassadors.  This belief in the infallibility of the medical profession needs to be challenged with opinions from the world-wide consesus of respected medical authorities that recommend against infant circumcision.

3.      Cultural Religious obligation = This is the most difficult one to deal with.  Ultimately it is from within the religious community that change needs to occur.  Some Jews have created an alternate ceremony that does not involve circumcision (Brit Shalom). Even a small minority of muslims are rejecting the practice.  Respect and dignity is required here no matter how much or how strongly we disagree.  When we go too hard on religion we usually get a severe backlash, however, I believe Scofield's San Francisco legislation proposal is a great way to highlight the ethical and legal issues of infant circumcision, and its connotations for religious circumcision.  Dont fall for or buy the anti-semetic tag, refer to the increasing numbers of Jews and Jewish groups that are anti-circumcision as well.

4.      Tribalism = The father who says “ I want him to look like me” is not really thinking about his son at this very moment, but instead his own need for his son to belong to the no-foreskin tribe.  Take a deep breath, and slowly educate and persuade.  What the father is not thinking about and needs to be reminded of, is that circumcision is harmful, there are risks in the procedure, the foreskin is functional anatomy and it is a human rights violation of his son. Tribalism constructs its own social reality and can be deconstructed and reconstructed to a higher moral level of functioning, particularly as we know more and know better.

5.       6.       Investment in the procedure = Some parents, having already circumcised feel very invested and defensive about the procedure, very difficult to change or persuade in this case, all of the above suggestions apply.     Many in the medical profession who have circumcised 100's if not 1,000's of babies are also very invested in the procedure and also very defensive.  Not easy to persuade here.
7. Scientific research = "The research from Africa says that circumcision will prevent males from getting HIV." This false belief arises out of the supposed infallibility of Scientific Research.  WE need to educate that All scientific research is culturally value laden, and not infallible.  The researcher can interpret data, & emphasise what he/she wants to find or publish, & ommisions can made of what the researcher doesnt want known about his/her research.  Again education is critical here.  Hints when discussing African Research = The research did not prove life-long protection only partial episodic protection. It is not absolute risk reduction only relative risk reduction.  A significant number of circumcised men in the study became infected with HIV, Participants were not treated equally with the circumcised group given more education about healing from surgery, abstained from sex longer, and were given greater time and emphasis about wearing condoms during the period of healing from surgery.  Nearly 10 times as many participants dropped out of the study 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.  In another study, Women who had sex with circumcised men were 50% more likely to become infected with HIV.  The reseach is valid only for adult circumcision volunteers, and populations with high prevalence of HIV, not babies or low prevalence nations. Demographic studies in Africa have found many circumcised populations have higher HIV infection rates than non-cirumcised populations.  The USA which circumcises has much higher HIV than western Europe which doesnt circumcise. 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.

There are many other reasons and I would invite comments and discussion on the blog.

Busting Circumcision Myths: Babies Sleep through Circumcision

Having watched the recent interview with Lloyd Schofiled (SF MGM Bill) where CNN;s Kelly stated (In trying to minimize the harms of the procedure) "Some babies sleep through their circumcision........." Since millions of people hear this sort of bullshit......I thought this pro-circ myth needs to be challenged once again.

Firstly why does such a myth even exist? One reason is that it probably developed to give some comfort to the Parents, particularly the mother who has just given birth, because the truth that the baby screamed in agony gasping for breath, would probably cause too much stress to the mother.  Another reason is to perpetuate the practice. Possibly another is self-protection by the medical profession?

The truth is that the studies that have examined pain response have found that babies feel severe and intense pain.  One study was stopped early once the severity of pain in circumcised babies was recognised. Taddio's studies found circumcised babies demonstrated greater pain behaviours at 6 month immunisations, and another study found even with the use of EMLA topical anaesthetic cream, circumcised babies had elevated cortisol levels (the human stress hormone).  So the truth is that  babies feel intense & severe pain during circumcision, and that if babies lose consciousness it is not that they are sleeping but that they have a traumatic shock or dissociative unconsciousness.

Lets bust the myth that babies sleep through circumcision.

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.