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Is circumcision child abuse?
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Posted 5/14/12 , edited 5/14/12

longfenglim wrote:


Morbidhanson wrote:

^That white stuff is called smegma. If you have any experience, you will know that women tend to produce a LOT more than men, but few are willing to accept removal of lady parts. Clean regularly and it will hardly bother you.

I have a 'cancer' analogy. I know it is not 100% relevant, but you seem intelligent enough to get the gist of it:
An 80-year old man discovers that he has a good chance of having prostate cancer. He goes to the doctor and the doctor tells him that he does, indeed, show early signs of developing the cancer. If he opts for treatment, his health will worsen and his quality of life will decrease for a while (he may even die due to the treatment), but the cancer will probably be fully eradicated. If he does not opt for treatment, he can live his next 20 years of life largely unaffected by the cancer.


It is not analogous, because Circumcision does not deteriorate the quality of life of any person, nor does it adversely affert anyone's health. In addition, to use your analogy, it is certainly better for the eighty year old to undergo this process, for it eliminates the potential for cancer, and even if it does temporarily worsen his health and his quality of life, it allows him to live cancer free, while if he does not, he has a great chance of developing it, and slowly and painfully die from it, therefore, should a man be greedy of life, and wanting in health, he should opt for what is best, and, in this case, the best is that he should undergo this treatment rather than take the chance that this cancer will be harmless or will not develop at all.




longfenglim wrote:


Morbidhanson wrote:


longfenglim wrote:


Morbidhanson wrote:

I think it IS abuse. It doesn't help boys function any better. When it comes down to it, it's a flap of skin. If you're okay with circumcision, why aren't you okay with girls having their labia removed? The only reason it is more 'socially-acceptable' is that it's been going on for a while, covered by the shroud of religion. Clean properly and there will be no problems. All the supposed 'health benefits' are either negligible or outright false. If it ain't broke or about to break, don't fix it, especially if you're not clear about what the 'fix' actually does.


I refer you to several pages of my previous argument with ShintoMale, who has made almost exactly the same points you have, which, I think, I have done well in debunking.


Actually, I only typed this because I don't think any of the points have been effectively refuted. No offense intended, but I still see circumcision as an unnecessary and potentially-damaging procedure. Even if it isn't 'abuse,' it certainly is not a procedure that I'd recommend that all parents have their boys go through.


Its the parent's choice in the end- people like ShintoMale are all in favour of banning it outright for no better reason than they don't like it.


The foreskin helps protect the head of the organ and helps it retain sensitivity. It is also a natural 'lubricant' that allows better movement and less discomfort for both parties during intercourse. Germ trap? Just clean it properly. Sure, removing it helps reduce the chance of disease transmission, but proper precautions (such as condoms) are less intrusive than circumcision, as well as more effective. A permanent physical loss shouldn't be discounted so easily.


All nice explaination, but no major studies have corrolated such speculations as loss in sensitivity, or decrease in sexual pleasure in either partner.
http://en.wikipedia.org/wiki/Sexual_effects_of_circumcision#Summary_of_research_findings


I'm not saying circumcision ought to be banned. I am saying there are better alternatives than snipping off a body part. Once removed, it is not easily restored.



I have never stated that you believe that infant circumcision should be banned, but that people like Mr Shintomale believes so.


Are you so sure that it will not affect quality of health? Studies certainly don't say for certain whether it does or does not. Why undergo a dubious procedure? IMO, the man should NOT get treatment because it will cost a lot, and 20 years of quality life (until he expires naturally) is, in my eyes, better than a period of suffering (and possibly premature death) that does not guarantee that his lifestyle will improve. Chances are, he will not reach 100, anyway. Also, there is a chance of relapse, even with treatment. I've lost a few friends to cancer relapses and I have had chances to speak with them before they died. Cancer is not an ailment that strikes you with suffering the instant you have it. Cancer can grow for years (often decades) before any discomfort is experienced by the the person who has it.

Anyway, the point I am trying to make is that this issue is not black-and-white. The choice may seem obvious to you, but others have their valid reasons to believe otherwise. Surely, you do not believe that ALL boys should be circumcised?
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Posted 5/14/12 , edited 5/14/12

Morbidhanson wrote:


Are you so sure that it will not affect quality of health? Studies certainly don't say for certain whether it does or does not. Why undergo a dubious procedure? IMO, the man should NOT get treatment because it will cost a lot, and 20 years of quality life (until he expires naturally) is, in my eyes, better than a period of suffering (and possibly premature death) that does not guarantee that his lifestyle will improve. Chances are, he will not reach 100, anyway. Also, there is a chance of relapse, even with treatment. I've lost a few friends to cancer relapses and I have had chances to speak with them before they died. Cancer is not an ailment that strikes you with suffering the instant you have it. Cancer can grow for years (often decades) before any discomfort is experienced by the the person who has it.

Anyway, the point I am trying to make is that this issue is not black-and-white. The choice may seem obvious to you, but others have their valid reasons to believe otherwise. Surely, you do not believe that ALL boys should be circumcised?


There is no studies which shows any difference in the lifestyle or the quality of health between circumcised and uncircumcised men, and, while it is possible to say that it might adversely affect his life, such logic can be applied to the foreskin, for there are various diseases which Uncircumcised people suffer from more than circumcised people, and there is no studies, either way, that show keeping the foreskin is better than snipping, thus, is it not better to be safe than sorry, for, what have you to lose in circumcision? Weighing these two, you have, on one side, evidence that circumcision is possibly effective against certain diseases, without any damage to the quality of life or sex, on the other, you have the possiblity of attaining several diseases, without any improvement to the quality of life or sex. You call the procedure dubious? How is it any more dubious than cutting open a man's stomach? Indeed, as common as surgery in the abdomen is, it is probably less safe than circumcision.

To answer your hypothetical, if he should have Prostate Cancer, and, even if he has not long to live, should he not be able to live out the rest of his life in the best of all condition? Why shorten your life, even if you are nearing the end? For one, he will not have a quality life, as cancer, as it grows, is usually painful, and, of the 130,000 people diagnosed with prostate cancer, 30,000 become diagnosed with acute prostate cancer, meaning that over twenty percent of people who attain prostate cancer will undergo the most painful variation of it, with symptoms such as trouble urinating, erectile dysfunction, etc. This life, certainly, can in no way be quanified as 'quality', and, even if he will not develop it, it is certainly better to suffer shortly, and live the rest of his life in the primest condition, than to suffer immensely until premature death. You are saying that this man, hypothetically, should lead himself to a drawn out death, premature as it will be, rather than let himself live as long as possible, in the best possible condition. Therefore, where improvement can be found, it should be sought. Relapses are possible, sure, but they occur latter, and his life still is extended beyond what not healing would do for the man, and, so, as life is extended, and his condition is better than being left untreated, the choice is an obvious one.

In addition, you ask if I would like for all boys to be circumcised- I have made my position on it clear enough, it is a choice left to the parents, and it is a valid choice, and an extremely sensible choice. I am not circumcised myself, but I will not hinder any parent from their choice in either circumcising or not circumcising their child.
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Posted 5/14/12 , edited 5/14/12

longfenglim wrote:


Morbidhanson wrote:


Are you so sure that it will not affect quality of health? Studies certainly don't say for certain whether it does or does not. Why undergo a dubious procedure? IMO, the man should NOT get treatment because it will cost a lot, and 20 years of quality life (until he expires naturally) is, in my eyes, better than a period of suffering (and possibly premature death) that does not guarantee that his lifestyle will improve. Chances are, he will not reach 100, anyway. Also, there is a chance of relapse, even with treatment. I've lost a few friends to cancer relapses and I have had chances to speak with them before they died. Cancer is not an ailment that strikes you with suffering the instant you have it. Cancer can grow for years (often decades) before any discomfort is experienced by the the person who has it.

Anyway, the point I am trying to make is that this issue is not black-and-white. The choice may seem obvious to you, but others have their valid reasons to believe otherwise. Surely, you do not believe that ALL boys should be circumcised?


There is no studies which shows any difference in the lifestyle or the quality of health between circumcised and uncircumcised men, and, while it is possible to say that it might adversely affect his life, such logic can be applied to the foreskin, for there are various diseases which Uncircumcised people suffer from more than circumcised people, and there is no studies, either way, that show keeping the foreskin is better than snipping, thus, is it not better to be safe than sorry, for, what have you to lose in circumcision? Weighing these two, you have, on one side, evidence that circumcision is possibly effective against certain diseases, without any damage to the quality of life or sex, on the other, you have the possiblity of attaining several diseases, without any improvement to the quality of life or sex. You call the procedure dubious? How is it any more dubious than cutting open a man's stomach? Indeed, as common as surgery in the abdomen is, it is probably less safe than circumcision.

To answer your hypothetical, if he should have Prostate Cancer, and, even if he has not long to live, should he not be able to live out the rest of his life in the best of all condition? Why shorten your life, even if you are nearing the end? For one, he will not have a quality life, as cancer, as it grows, is usually painful, and, of the 130,000 people diagnosed with prostate cancer, 30,000 become diagnosed with acute prostate cancer, meaning that over twenty percent of people who attain prostate cancer will undergo the most painful variation of it, with symptoms such as trouble urinating, erectile dysfunction, etc. This life, certainly, can in no way be quanified as 'quality', and, even if he will not develop it, it is certainly better to suffer shortly, and live the rest of his life in the primest condition, than to suffer immensely until premature death. You are saying that this man, hypothetically, should lead himself to a drawn out death, premature as it will be, rather than let himself live as long as possible, in the best possible condition. Therefore, where improvement can be found, it should be sought. Relapses are possible, sure, but they occur latter, and his life still is extended beyond what not healing would do for the man, and, so, as life is extended, and his condition is better than being left untreated, the choice is an obvious one.

In addition, you ask if I would like for all boys to be circumcised- I have made my position on it clear enough, it is a choice left to the parents, and it is a valid choice, and an extremely sensible choice. I am not circumcised myself, but I will not hinder any parent from their choice in either circumcising or not circumcising their child.


You have a BODY PART to lose, that's what. Until studies are clear, there is no solid reason to get circumcised without completely understanding the pros and cons unless there is an existing medical condition that prompts you to get it. Dealing with the intangible specter of 'possible' diseases is, IMO, not worth losing a body part over, because things that are removed tend to be harder to restore than to remove. People get to choose between losing a potentially valuable body part or falling victim to a potentially bad disease. I don't ever hear of people who choose to have their hearts replaced by artificial ones when they are young and healthy because their ancestry makes them prone to suffering from heart attacks and they are planning to not exercise, their minds set on consuming unhealthy foods (not taking care of their hearts). Like heart surgery, stomach surgery is gotten when it needs to be. The functions of a stomach and the consequences of certain things being inside it are pretty clear. You don't split a person's stomach when there is nothing wrong with him. You lay open the stomach to fix what's wrong with it, not to remove the healthy organ it before it causes complications or because stomach cancer is 'possible.' Not so with the foreskin. That seems to be the difference. Nearly all, if not all, surgical procedures come with a set of risks. Why take those risks if you don't have to? Speculative preventative treatments of this degree are impractical as well as possibly dangerous.

Do I think subjecting a healthy person (who can't give consent) to the unnecessary perils of the scalpel is abuse? You bet.

There is not much of a reason to deal with a condition if it does not severely affect your quality of life. For instance, would it be wise to treat a minor joint ache that will affect you for the next 20 years if the procedure is potentially crippling, expensive, not guaranteed to make you better, and risky? Of course, some think so. However, I believe that many people, especially the elderly, are better off NOT treating their terminal diseases because the treatments' benefits are outweighed by the risks. A balance between longevity and life quality must be found. This will vary from person to person.

That being said, I am actually enjoying this debate. It is always interesting to see what other people think when they present their points in a rational way.
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Posted 5/16/12 , edited 5/16/12

Morbidhanson wrote:


longfenglim wrote:


Morbidhanson wrote:


Are you so sure that it will not affect quality of health? Studies certainly don't say for certain whether it does or does not. Why undergo a dubious procedure? IMO, the man should NOT get treatment because it will cost a lot, and 20 years of quality life (until he expires naturally) is, in my eyes, better than a period of suffering (and possibly premature death) that does not guarantee that his lifestyle will improve. Chances are, he will not reach 100, anyway. Also, there is a chance of relapse, even with treatment. I've lost a few friends to cancer relapses and I have had chances to speak with them before they died. Cancer is not an ailment that strikes you with suffering the instant you have it. Cancer can grow for years (often decades) before any discomfort is experienced by the the person who has it.

Anyway, the point I am trying to make is that this issue is not black-and-white. The choice may seem obvious to you, but others have their valid reasons to believe otherwise. Surely, you do not believe that ALL boys should be circumcised?


There is no studies which shows any difference in the lifestyle or the quality of health between circumcised and uncircumcised men, and, while it is possible to say that it might adversely affect his life, such logic can be applied to the foreskin, for there are various diseases which Uncircumcised people suffer from more than circumcised people, and there is no studies, either way, that show keeping the foreskin is better than snipping, thus, is it not better to be safe than sorry, for, what have you to lose in circumcision? Weighing these two, you have, on one side, evidence that circumcision is possibly effective against certain diseases, without any damage to the quality of life or sex, on the other, you have the possiblity of attaining several diseases, without any improvement to the quality of life or sex. You call the procedure dubious? How is it any more dubious than cutting open a man's stomach? Indeed, as common as surgery in the abdomen is, it is probably less safe than circumcision.

To answer your hypothetical, if he should have Prostate Cancer, and, even if he has not long to live, should he not be able to live out the rest of his life in the best of all condition? Why shorten your life, even if you are nearing the end? For one, he will not have a quality life, as cancer, as it grows, is usually painful, and, of the 130,000 people diagnosed with prostate cancer, 30,000 become diagnosed with acute prostate cancer, meaning that over twenty percent of people who attain prostate cancer will undergo the most painful variation of it, with symptoms such as trouble urinating, erectile dysfunction, etc. This life, certainly, can in no way be quanified as 'quality', and, even if he will not develop it, it is certainly better to suffer shortly, and live the rest of his life in the primest condition, than to suffer immensely until premature death. You are saying that this man, hypothetically, should lead himself to a drawn out death, premature as it will be, rather than let himself live as long as possible, in the best possible condition. Therefore, where improvement can be found, it should be sought. Relapses are possible, sure, but they occur latter, and his life still is extended beyond what not healing would do for the man, and, so, as life is extended, and his condition is better than being left untreated, the choice is an obvious one.

In addition, you ask if I would like for all boys to be circumcised- I have made my position on it clear enough, it is a choice left to the parents, and it is a valid choice, and an extremely sensible choice. I am not circumcised myself, but I will not hinder any parent from their choice in either circumcising or not circumcising their child.


You have a BODY PART to lose, that's what. Until studies are clear, there is no solid reason to get circumcised without completely understanding the pros and cons unless there is an existing medical condition that prompts you to get it. Dealing with the intangible specter of 'possible' diseases is, IMO, not worth losing a body part over, because things that are removed tend to be harder to restore than to remove. People get to choose between losing a potentially valuable body part or falling victim to a potentially bad disease. I don't ever hear of people who choose to have their hearts replaced by artificial ones when they are young and healthy because their ancestry makes them prone to suffering from heart attacks and they are planning to not exercise, their minds set on consuming unhealthy foods (not taking care of their hearts). Like heart surgery, stomach surgery is gotten when it needs to be. The functions of a stomach and the consequences of certain things being inside it are pretty clear. You don't split a person's stomach when there is nothing wrong with him. You lay open the stomach to fix what's wrong with it, not to remove the healthy organ it before it causes complications or because stomach cancer is 'possible.' Not so with the foreskin. That seems to be the difference. Nearly all, if not all, surgical procedures come with a set of risks. Why take those risks if you don't have to? Speculative preventative treatments of this degree are impractical as well as possibly dangerous.


Your first objection, it seems to me, is that there is something of a stigma in losing a body part- granted we remove body parts all the time, such as the wisdom teeth, and I highly doubt that you would find the practice of removing that body part objectionable. Like the wisdom tooth, which are removed routinely, there is no reason to remove it in a good portion of the population, which may even die without the realisation of the various perils associated with the wisdom teeth, but we remove it all the same because it poses a threat. So too does this apply to the foreskin, for we should have the right to remove it if we feel that is would prevent future perils. It is a body part, but not so vital that we can be without it, and with multitudious benefits. The stomach, the heart, the lungs, etc. are vital to the function of our body, and the removal of them cause a noticable decrease in the standard of living, not so the foreskin, circumcised people do not suffer any more than uncircumcised people, and, indeed, are protected against certain diseases. If you object to this practice because it fends off the phantoms of diseases people may never come in contact with, consider the vaccine, that we allow a weaker form of the disease to invade the body so that our immune system should be better able to protect ourselves against the stronger version, despite the fact that many may not even see the diseases they are vaccinated for. We accept various precautionary measure, as the removal of the wisdom tooth or vaccination of our children, and we accept them as necessary, yet, there seems to be something about the foreskin, which no studies have been able to show that the retention of is any better than the removal of, and, indeed, many to the contrary, that sickens people. I would say that, based upon my initial experience upon hearing of such procedure, that it is mostly from a disgust at people doing things differently than ourselves, which constitute a form of xenophobia. I am certain that this is the case with Shinto-Male, and, while I would never say that this is true for you, I would say that this feeling of disgust towards such thing arises from such in most people from this.



Do I think subjecting a healthy person (who can't give consent) to the unnecessary perils of the scalpel is abuse? You bet.


The duty of the parents is to make informed choices on what they think is best for their child, and, as the child cannot give consent, and there is no practical way of finding an age where they are really able to consent to anything, this duty is borne upon them by necessity. There are greater perils to which a child is subjected, such as where his parents live, or where and how he is to take his education, etc., things that, while undoubtably greater, the child has just as much consent in. To return to the example of the vaccine, a child has no consent in being vaccinated, which, in my state, is necessary to start school, and yet, no one would object to it, despite the relative rarity of catching the smallpox in this age, because it is a preventative measure. In this case, however, it is not the parent, but the government, that makes a decision to subject an healthy person, who is unable to consent, to undergo an 'unnecessary peril', and we do not call it abuse.



There is not much of a reason to deal with a condition if it does not severely affect your quality of life. For instance, would it be wise to treat a minor joint ache that will affect you for the next 20 years if the procedure is potentially crippling, expensive, not guaranteed to make you better, and risky? Of course, some think so. However, I believe that many people, especially the elderly, are better off NOT treating their terminal diseases because the treatments' benefits are outweighed by the risks. A balance between longevity and life quality must be found. This will vary from person to person.


If it were for something minor as occassional aches, then, yes, no doubt many people will agree with you, but when it does severly affect the quality of life, like prostate cancer, and it does make it painful, drawn out, and shorten it, then, should a man be greedy of life, he should do what he can to prolong it. The elderly should not give up a full decade on the basis that he would die soon anyways, for an extended life with moderate discomfort is indefinately better than a sharp decline into death. Elderly people, they may be struck by the various infirmies of age, they, however, should not wish death simply because of it, and let themselves waste away from a preventable disease, to died in agony, pain, and prematurely. Longevity is indeed quality, and premature death from diseases are rarely worse in quality than preservation.In diseases, no man wants to endure it, and should a man find his life too inconvinent or terrible under treatments, he does not wish for the disease to take him, to be swiftly put out.


That being said, I am actually enjoying this debate. It is always interesting to see what other people think when they present their points in a rational way.




I am glad of it.
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25 / M / California
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Posted 5/16/12 , edited 5/16/12

longfenglim wrote:


Morbidhanson wrote:


longfenglim wrote:


Morbidhanson wrote:


Are you so sure that it will not affect quality of health? Studies certainly don't say for certain whether it does or does not. Why undergo a dubious procedure? IMO, the man should NOT get treatment because it will cost a lot, and 20 years of quality life (until he expires naturally) is, in my eyes, better than a period of suffering (and possibly premature death) that does not guarantee that his lifestyle will improve. Chances are, he will not reach 100, anyway. Also, there is a chance of relapse, even with treatment. I've lost a few friends to cancer relapses and I have had chances to speak with them before they died. Cancer is not an ailment that strikes you with suffering the instant you have it. Cancer can grow for years (often decades) before any discomfort is experienced by the the person who has it.

Anyway, the point I am trying to make is that this issue is not black-and-white. The choice may seem obvious to you, but others have their valid reasons to believe otherwise. Surely, you do not believe that ALL boys should be circumcised?


There is no studies which shows any difference in the lifestyle or the quality of health between circumcised and uncircumcised men, and, while it is possible to say that it might adversely affect his life, such logic can be applied to the foreskin, for there are various diseases which Uncircumcised people suffer from more than circumcised people, and there is no studies, either way, that show keeping the foreskin is better than snipping, thus, is it not better to be safe than sorry, for, what have you to lose in circumcision? Weighing these two, you have, on one side, evidence that circumcision is possibly effective against certain diseases, without any damage to the quality of life or sex, on the other, you have the possiblity of attaining several diseases, without any improvement to the quality of life or sex. You call the procedure dubious? How is it any more dubious than cutting open a man's stomach? Indeed, as common as surgery in the abdomen is, it is probably less safe than circumcision.

To answer your hypothetical, if he should have Prostate Cancer, and, even if he has not long to live, should he not be able to live out the rest of his life in the best of all condition? Why shorten your life, even if you are nearing the end? For one, he will not have a quality life, as cancer, as it grows, is usually painful, and, of the 130,000 people diagnosed with prostate cancer, 30,000 become diagnosed with acute prostate cancer, meaning that over twenty percent of people who attain prostate cancer will undergo the most painful variation of it, with symptoms such as trouble urinating, erectile dysfunction, etc. This life, certainly, can in no way be quanified as 'quality', and, even if he will not develop it, it is certainly better to suffer shortly, and live the rest of his life in the primest condition, than to suffer immensely until premature death. You are saying that this man, hypothetically, should lead himself to a drawn out death, premature as it will be, rather than let himself live as long as possible, in the best possible condition. Therefore, where improvement can be found, it should be sought. Relapses are possible, sure, but they occur latter, and his life still is extended beyond what not healing would do for the man, and, so, as life is extended, and his condition is better than being left untreated, the choice is an obvious one.

In addition, you ask if I would like for all boys to be circumcised- I have made my position on it clear enough, it is a choice left to the parents, and it is a valid choice, and an extremely sensible choice. I am not circumcised myself, but I will not hinder any parent from their choice in either circumcising or not circumcising their child.


You have a BODY PART to lose, that's what. Until studies are clear, there is no solid reason to get circumcised without completely understanding the pros and cons unless there is an existing medical condition that prompts you to get it. Dealing with the intangible specter of 'possible' diseases is, IMO, not worth losing a body part over, because things that are removed tend to be harder to restore than to remove. People get to choose between losing a potentially valuable body part or falling victim to a potentially bad disease. I don't ever hear of people who choose to have their hearts replaced by artificial ones when they are young and healthy because their ancestry makes them prone to suffering from heart attacks and they are planning to not exercise, their minds set on consuming unhealthy foods (not taking care of their hearts). Like heart surgery, stomach surgery is gotten when it needs to be. The functions of a stomach and the consequences of certain things being inside it are pretty clear. You don't split a person's stomach when there is nothing wrong with him. You lay open the stomach to fix what's wrong with it, not to remove the healthy organ it before it causes complications or because stomach cancer is 'possible.' Not so with the foreskin. That seems to be the difference. Nearly all, if not all, surgical procedures come with a set of risks. Why take those risks if you don't have to? Speculative preventative treatments of this degree are impractical as well as possibly dangerous.


Your first objection, it seems to me, is that there is something of a stigma in losing a body part- granted we remove body parts all the time, such as the wisdom teeth, and I highly doubt that you would find the practice of removing that body part objectionable. Like the wisdom tooth, which are removed routinely, there is no reason to remove it in a good portion of the population, which may even die without the realisation of the various perils associated with the wisdom teeth, but we remove it all the same because it poses a threat. So too does this apply to the foreskin, for we should have the right to remove it if we feel that is would prevent future perils. It is a body part, but not so vital that we can be without it, and with multitudious benefits. The stomach, the heart, the lungs, etc. are vital to the function of our body, and the removal of them cause a noticable decrease in the standard of living, not so the foreskin, circumcised people do not suffer any more than uncircumcised people, and, indeed, are protected against certain diseases. If you object to this practice because it fends off the phantoms of diseases people may never come in contact with, consider the vaccine, that we allow a weaker form of the disease to invade the body so that our immune system should be better able to protect ourselves against the stronger version, despite the fact that many may not even see the diseases they are vaccinated for. We accept various precautionary measure, as the removal of the wisdom tooth or vaccination of our children, and we accept them as necessary, yet, there seems to be something about the foreskin, which no studies have been able to show that the retention of is any better than the removal of, and, indeed, many to the contrary, that sickens people. I would say that, based upon my initial experience upon hearing of such procedure, that it is mostly from a disgust at people doing things differently than ourselves, which constitute a form of xenophobia. I am certain that this is the case with Shinto-Male, and, while I would never say that this is true for you, I would say that this feeling of disgust towards such thing arises from such in most people from this.



Do I think subjecting a healthy person (who can't give consent) to the unnecessary perils of the scalpel is abuse? You bet.


The duty of the parents is to make informed choices on what they think is best for their child, and, as the child cannot give consent, and there is no practical way of finding an age where they are really able to consent to anything, this duty is borne upon them by necessity. There are greater perils to which a child is subjected, such as where his parents live, or where and how he is to take his education, etc., things that, while undoubtably greater, the child has just as much consent in. To return to the example of the vaccine, a child has no consent in being vaccinated, which, in my state, is necessary to start school, and yet, no one would object to it, despite the relative rarity of catching the smallpox in this age, because it is a preventative measure. In this case, however, it is not the parent, but the government, that makes a decision to subject an healthy person, who is unable to consent, to undergo an 'unnecessary peril', and we do not call it abuse.



There is not much of a reason to deal with a condition if it does not severely affect your quality of life. For instance, would it be wise to treat a minor joint ache that will affect you for the next 20 years if the procedure is potentially crippling, expensive, not guaranteed to make you better, and risky? Of course, some think so. However, I believe that many people, especially the elderly, are better off NOT treating their terminal diseases because the treatments' benefits are outweighed by the risks. A balance between longevity and life quality must be found. This will vary from person to person.


If it were for something minor as occassional aches, then, yes, no doubt many people will agree with you, but when it does severly affect the quality of life, like prostate cancer, and it does make it painful, drawn out, and shorten it, then, should a man be greedy of life, he should do what he can to prolong it. The elderly should not give up a full decade on the basis that he would die soon anyways, for an extended life with moderate discomfort is indefinately better than a sharp decline into death. Elderly people, they may be struck by the various infirmies of age, they, however, should not wish death simply because of it, and let themselves waste away from a preventable disease, to died in agony, pain, and prematurely. Longevity is indeed quality, and premature death from diseases are rarely worse in quality than preservation.In diseases, no man wants to endure it, and should a man find his life too inconvinent or terrible under treatments, he does not wish for the disease to take him, to be swiftly put out.


That being said, I am actually enjoying this debate. It is always interesting to see what other people think when they present their points in a rational way.




I am glad of it.


Well, perhaps we believe in different degrees of balance between health and longevity.

Indeed, there is a stigma against unnecessarily losing body parts. Vaccines, I'd like to point out, are not very intrusive. A shot and you're done. There is virtually no risk involved in getting a vaccine, and the diseases they are meant to protect us against are very common. Thus, the risks are outweighed by the benefits. Tuberculosis, for example, is very common. It is also a nasty disease. I'd get a TB shot even if it wasn't required. While I do not deny that some preventative treatments are effective, I do not believe that circumcision provides us with the same degree of protection that vaccines do. Circumcision does not do anything close to preventing diseases. There is no correlation between circumcision and disease prevention that is strong enough to make me think it is effective. A lot of things are murky and unclear, so I believe risky decisions that involve health should not be brushed aside or hastily made. When it comes to losing things that are much harder to restore than to destroy, even things like earlobes, teeth, or the appendix, I'd rather not attempt to fix what isn't broken.

Wisdom tooth removal is done when dentists discover that the tooth will cause problems or if the tooth is already a problem. People will often leave their wisdom teeth intact if the teeth are not causing discomfort. Unnecessary removal only exposes a person to unnecessary risk. People have died when the surgical sites became infected and bacterial infection set in the jaw. Similarly, some baby boys have died due to infections stemming from circumcision. Some have survived such complications but have to live with their shafts removed. I don't see the removal of the wisdom teeth as a preventative treatment. I would not remove my wisdom teeth if I did not have to. I'd even tolerate slight discomfort before considering their removal. On the other hand, if my foot was already wracked with rot and the infection was threatening to spread, I'd cut off my foot.
Posted 5/16/12
i think they should wait until they're old enough to have a choice in the matter. things like "it looks better" or "it's better for the sexual partner" are lame excuses to make someone involuntarily undergo the procedure and it actually does decrease sexual pleasure. if we deem unnecessary genital surgery on girls to be terrible, it should be considered bad for boys too.
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renfort wrote:

i think they should wait until they're old enough to have a choice in the matter. things like "it looks better" or "it's better for the sexual partner" are lame excuses to make someone involuntarily undergo the procedure and it actually does decrease sexual pleasure. if we deem unnecessary genital surgery on girls to be terrible, it should be considered bad for boys too.


You know what pisses me off, comparing FGM with Male Circumcision. They are nothing alike, and are created for different purposes- one involves the severing of the clitorus, the libia major and minor, and sewing the vagina shut (depending on its severity), and causing a lifetime of pain in sex and even in urinating, made to subjugate females and hold their libido in check, a practice most people are rightly appalled by, and the other a relatively harmless procedure, with no noticable difference in sexual pleasure, etc., practiced, usually, by male dominated cultures such as the Moslems and the Jews. Comparing the snipping of a small bit of male skin with the outright destruction of the female genital shows either a lack of empathy for females and femalekind, or a complete ignorance which deems one unfit to talk of a subject.
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Morbidhanson wrote:


longfenglim wrote:


Morbidhanson wrote:


longfenglim wrote:


Morbidhanson wrote:


Are you so sure that it will not affect quality of health? Studies certainly don't say for certain whether it does or does not. Why undergo a dubious procedure? IMO, the man should NOT get treatment because it will cost a lot, and 20 years of quality life (until he expires naturally) is, in my eyes, better than a period of suffering (and possibly premature death) that does not guarantee that his lifestyle will improve. Chances are, he will not reach 100, anyway. Also, there is a chance of relapse, even with treatment. I've lost a few friends to cancer relapses and I have had chances to speak with them before they died. Cancer is not an ailment that strikes you with suffering the instant you have it. Cancer can grow for years (often decades) before any discomfort is experienced by the the person who has it.

Anyway, the point I am trying to make is that this issue is not black-and-white. The choice may seem obvious to you, but others have their valid reasons to believe otherwise. Surely, you do not believe that ALL boys should be circumcised?


There is no studies which shows any difference in the lifestyle or the quality of health between circumcised and uncircumcised men, and, while it is possible to say that it might adversely affect his life, such logic can be applied to the foreskin, for there are various diseases which Uncircumcised people suffer from more than circumcised people, and there is no studies, either way, that show keeping the foreskin is better than snipping, thus, is it not better to be safe than sorry, for, what have you to lose in circumcision? Weighing these two, you have, on one side, evidence that circumcision is possibly effective against certain diseases, without any damage to the quality of life or sex, on the other, you have the possiblity of attaining several diseases, without any improvement to the quality of life or sex. You call the procedure dubious? How is it any more dubious than cutting open a man's stomach? Indeed, as common as surgery in the abdomen is, it is probably less safe than circumcision.

To answer your hypothetical, if he should have Prostate Cancer, and, even if he has not long to live, should he not be able to live out the rest of his life in the best of all condition? Why shorten your life, even if you are nearing the end? For one, he will not have a quality life, as cancer, as it grows, is usually painful, and, of the 130,000 people diagnosed with prostate cancer, 30,000 become diagnosed with acute prostate cancer, meaning that over twenty percent of people who attain prostate cancer will undergo the most painful variation of it, with symptoms such as trouble urinating, erectile dysfunction, etc. This life, certainly, can in no way be quanified as 'quality', and, even if he will not develop it, it is certainly better to suffer shortly, and live the rest of his life in the primest condition, than to suffer immensely until premature death. You are saying that this man, hypothetically, should lead himself to a drawn out death, premature as it will be, rather than let himself live as long as possible, in the best possible condition. Therefore, where improvement can be found, it should be sought. Relapses are possible, sure, but they occur latter, and his life still is extended beyond what not healing would do for the man, and, so, as life is extended, and his condition is better than being left untreated, the choice is an obvious one.

In addition, you ask if I would like for all boys to be circumcised- I have made my position on it clear enough, it is a choice left to the parents, and it is a valid choice, and an extremely sensible choice. I am not circumcised myself, but I will not hinder any parent from their choice in either circumcising or not circumcising their child.


You have a BODY PART to lose, that's what. Until studies are clear, there is no solid reason to get circumcised without completely understanding the pros and cons unless there is an existing medical condition that prompts you to get it. Dealing with the intangible specter of 'possible' diseases is, IMO, not worth losing a body part over, because things that are removed tend to be harder to restore than to remove. People get to choose between losing a potentially valuable body part or falling victim to a potentially bad disease. I don't ever hear of people who choose to have their hearts replaced by artificial ones when they are young and healthy because their ancestry makes them prone to suffering from heart attacks and they are planning to not exercise, their minds set on consuming unhealthy foods (not taking care of their hearts). Like heart surgery, stomach surgery is gotten when it needs to be. The functions of a stomach and the consequences of certain things being inside it are pretty clear. You don't split a person's stomach when there is nothing wrong with him. You lay open the stomach to fix what's wrong with it, not to remove the healthy organ it before it causes complications or because stomach cancer is 'possible.' Not so with the foreskin. That seems to be the difference. Nearly all, if not all, surgical procedures come with a set of risks. Why take those risks if you don't have to? Speculative preventative treatments of this degree are impractical as well as possibly dangerous.


Your first objection, it seems to me, is that there is something of a stigma in losing a body part- granted we remove body parts all the time, such as the wisdom teeth, and I highly doubt that you would find the practice of removing that body part objectionable. Like the wisdom tooth, which are removed routinely, there is no reason to remove it in a good portion of the population, which may even die without the realisation of the various perils associated with the wisdom teeth, but we remove it all the same because it poses a threat. So too does this apply to the foreskin, for we should have the right to remove it if we feel that is would prevent future perils. It is a body part, but not so vital that we can be without it, and with multitudious benefits. The stomach, the heart, the lungs, etc. are vital to the function of our body, and the removal of them cause a noticable decrease in the standard of living, not so the foreskin, circumcised people do not suffer any more than uncircumcised people, and, indeed, are protected against certain diseases. If you object to this practice because it fends off the phantoms of diseases people may never come in contact with, consider the vaccine, that we allow a weaker form of the disease to invade the body so that our immune system should be better able to protect ourselves against the stronger version, despite the fact that many may not even see the diseases they are vaccinated for. We accept various precautionary measure, as the removal of the wisdom tooth or vaccination of our children, and we accept them as necessary, yet, there seems to be something about the foreskin, which no studies have been able to show that the retention of is any better than the removal of, and, indeed, many to the contrary, that sickens people. I would say that, based upon my initial experience upon hearing of such procedure, that it is mostly from a disgust at people doing things differently than ourselves, which constitute a form of xenophobia. I am certain that this is the case with Shinto-Male, and, while I would never say that this is true for you, I would say that this feeling of disgust towards such thing arises from such in most people from this.



Do I think subjecting a healthy person (who can't give consent) to the unnecessary perils of the scalpel is abuse? You bet.


The duty of the parents is to make informed choices on what they think is best for their child, and, as the child cannot give consent, and there is no practical way of finding an age where they are really able to consent to anything, this duty is borne upon them by necessity. There are greater perils to which a child is subjected, such as where his parents live, or where and how he is to take his education, etc., things that, while undoubtably greater, the child has just as much consent in. To return to the example of the vaccine, a child has no consent in being vaccinated, which, in my state, is necessary to start school, and yet, no one would object to it, despite the relative rarity of catching the smallpox in this age, because it is a preventative measure. In this case, however, it is not the parent, but the government, that makes a decision to subject an healthy person, who is unable to consent, to undergo an 'unnecessary peril', and we do not call it abuse.



There is not much of a reason to deal with a condition if it does not severely affect your quality of life. For instance, would it be wise to treat a minor joint ache that will affect you for the next 20 years if the procedure is potentially crippling, expensive, not guaranteed to make you better, and risky? Of course, some think so. However, I believe that many people, especially the elderly, are better off NOT treating their terminal diseases because the treatments' benefits are outweighed by the risks. A balance between longevity and life quality must be found. This will vary from person to person.


If it were for something minor as occassional aches, then, yes, no doubt many people will agree with you, but when it does severly affect the quality of life, like prostate cancer, and it does make it painful, drawn out, and shorten it, then, should a man be greedy of life, he should do what he can to prolong it. The elderly should not give up a full decade on the basis that he would die soon anyways, for an extended life with moderate discomfort is indefinately better than a sharp decline into death. Elderly people, they may be struck by the various infirmies of age, they, however, should not wish death simply because of it, and let themselves waste away from a preventable disease, to died in agony, pain, and prematurely. Longevity is indeed quality, and premature death from diseases are rarely worse in quality than preservation.In diseases, no man wants to endure it, and should a man find his life too inconvinent or terrible under treatments, he does not wish for the disease to take him, to be swiftly put out.


That being said, I am actually enjoying this debate. It is always interesting to see what other people think when they present their points in a rational way.




I am glad of it.


Well, perhaps we believe in different degrees of balance between health and longevity.

Indeed, there is a stigma against unnecessarily losing body parts. Vaccines, I'd like to point out, are not very intrusive. A shot and you're done. There is virtually no risk involved in getting a vaccine, and the diseases they are meant to protect us against are very common. Thus, the risks are outweighed by the benefits. Tuberculosis, for example, is very common. It is also a nasty disease. I'd get a TB shot even if it wasn't required. While I do not deny that some preventative treatments are effective, I do not believe that circumcision provides us with the same degree of protection that vaccines do. Circumcision does not do anything close to preventing diseases. There is no correlation between circumcision and disease prevention that is strong enough to make me think it is effective. A lot of things are murky and unclear, so I believe risky decisions that involve health should not be brushed aside or hastily made. When it comes to losing things that are much harder to restore than to destroy, even things like earlobes, teeth, or the appendix, I'd rather not attempt to fix what isn't broken.

Wisdom tooth removal is done when dentists discover that the tooth will cause problems or if the tooth is already a problem. People will often leave their wisdom teeth intact if the teeth are not causing discomfort. Unnecessary removal only exposes a person to unnecessary risk. People have died when the surgical sites became infected and bacterial infection set in the jaw. Similarly, some baby boys have died due to infections stemming from circumcision. Some have survived such complications but have to live with their shafts removed. I don't see the removal of the wisdom teeth as a preventative treatment. I would not remove my wisdom teeth if I did not have to. I'd even tolerate slight discomfort before considering their removal. On the other hand, if my foot was already wracked with rot and the infection was threatening to spread, I'd cut off my foot.


To introduce a potentially dangerous substance into a child, albiet in a weakened form, is still intrusive, and death from vaccination, though rare, is not entirely unheard of. However, as dangerous as this may sound, it is usually done for the benefit of the child, and, in the mind of most people, whatever the potential risks are, when weighed and meted, and judged, it incomparible to the potential benefit. Therefore, most people, even the most suspicious, would concede that vaccinations are a necessary intrusion for the sake of preventing an uncertain possibility.

So, the benefit outweigh the risk. Circumcision is only slightly more dangerous than a vaccination, not known to cause any significant decrease or increase in pleasure, in life, or anything, and is shown to be potentially useful in fighting against various penile diseases (with the WHO recommending the procedure as part of their programme to combat HIV in Africa). I can go through various studies, which I have, at one point or another, posted up, which shows that it is strongly linked with the prevention of various diseases, but very strongly with HIV, also a common and deadly disease. Thus, weighing the risk, which have been shown to be negiliable, with the potential benefits, which are consiberable, we would find that the benefit far outweighs any risk- and even if the supposed benefit are not really there, there is still nothing to lose in losing a peice of skin.

http://www.telegraph.co.uk/news/uknews/3336455/Secret-report-reveals-18-child-deaths-following-vaccinations.html
http://www.ncbi.nlm.nih.gov/pubmed/16581731
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UGANDA: Free male circumcision gets priority over life-saving obstetrics and gynaecology

National Post (Toronto)
May 14, 2012
Jean Chamberlain Froese on Ugandan health care: Women and children last

By Jean Chamberlain Froese

As a Canadian obstetrician working in the developing world, I’m reminded daily of the superior health care available to men here compared to the health care available to women. Sadly, this discrepancy is often supported and perpetuated by well-meaning international donors.

The profound injustice hit me when I was visiting a local health-care facility in Uganda — I hesitate to call it a hospital, but it does offer obstetrical care for pregnant mothers and can, when strained to do so, perform cesarean sections for mothers who need them.

I met Helen in the delivery room at this facility. She was a Ugandan mother-to-be who had been in labour for nearly two days with no progress or chance to deliver naturally. After careful assessment by the local midwife and doctor, the obvious decision to do a C-section was made. Now the only thing that stood between Helen and a safe delivery was the $60 that this government health facility required from her — after all, she needed to pay for the gloves, medicine and anesthesia required to surgically deliver her baby. Her alternative was to hop on public transit — in this case an overcrowded minivan — and risk a two-hour drive followed by numerous hours of waiting at the national referral hospital, where she would queue up behind the many other mothers trying to access free services.

As director of the Save the Mothers program and a qualified doctor, I couldn’t just stand by and watch. The delay in moving to another facility would mean certain death for the unborn baby and probably significant injury, if not death, for the mother. I reached into my pocket and pulled out the Ugandan cash; Helen could now receive the medical care she urgently needed.

I was relieved to see that within an hour, Helen was operated upon and a healthy baby boy was born. But as I approached the operating room, I was shocked at the commotion outside. There were 10 men waiting — all lined up in a row, clutching their medical files with sheepish looks on their faces. They were scheduled for male circumcision — an approach to reducing HIV/AIDS transmission that [perhaps] shows some benefit in decreasing men’s susceptibility to infection. It was a procedure the men could access for free and one that was advertised nationally with billboards and radio campaigns. These operations took up nearly all the space in the operating theatre and the attention of the medical staff — at least three times more of whom were assigned to one man’s care than were assigned to Helen’s. This injustice stung me.

There really is a distinct difference in the care available for men versus women in the developing world. Male procedures that potentially reduce HIV/AIDS receive unlimited and sustained international support, while health interventions to categorically save mothers’ (and their babies’) lives still take a back seat — or a small corner of an operating room in Helen’s case.

Shouldn’t the women who are risking their lives to deliver the next generation at least receive the same free health care as the men who want to reduce their personal chances of HIV/AIDS acquisition? Don’t their lives count as much as those of men? If that operating room in Uganda was any indicator, the current answer is no.



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Clean-Cut: Study Finds Circumcision Helps Prevent HIV and Other Infections
The first microbiome study of the penis offers some clues as to why removing foreskin cuts the risk of HIV infection in circumcised men

The World Health Organization declared three years ago that circumcision should be part of any strategy to prevent HIV infection in men. The organization based its recommendation on three randomized clinical trials in Africa that found the incidence of HIV was 60 percent lower in men who were circumcised. Although this "research evidence is compelling," wrote the WHO panel assigned to the topic, there was little evidence explaining how circumcision might reduce a man's risk of acquiring HIV.

Now comes an answer in a new study, published in the January 6 issue of PLoS ONE, which found that there are gross changes in the penis's microbiome following circumcision, suggesting that shifts in the bacterial environment could account, in part, for the differences in HIV infection. Families of anaerobic bacteria, which are unable to grow in the presence of oxygen, are abundant before circumcision but nearly disappear after the procedure. The researchers suspect that in uncircumcised men, these bacteria may provoke inflammation in the genitalia, thereby improving the chances that immune cells will be in the vicinity for HIV viruses to infect.

"We never knew that there were that many anaerobic bacteria on the uncircumcised penis before [this study]," says Ronald Gray, a reproductive epidemiologist at Johns Hopkins Bloomberg School of Public Health and one of the lead authors on the current study. According to a 2006 survey, 56.1 percent of boys in the U.S. are circumcised. In its recommendation, the WHO panel stated that circumcision efforts would be most beneficial in parts of the world where less than 20 percent of boys are circumcised.

Gray, who is also working with one of the three randomized clinical trials on which WHO based its recommendation, adds that, "If we can show that these anaerobic bacteria are associated with HIV, then one could develop microbicides—antiseptics or targeted antibiotics —that might provide protection."

In the current study Gray and his colleagues compared the microbiota of 12 HIV-negative Ugandan men ages 15 to 49 before and after they were circumcised. It was important to limit the study to HIV-negative participants because infection itself can throw off the bacterial environment of the penis, says Lance Price, a research director at the Translational Genomics Research Institute in Flagstaff, Ariz., and co-author on the study. The team collected swabs from an area between the head and shaft of the men's penises before and one year after circumcision. Then the researchers performed polymerase chain reaction analysis of a gene that is shared by, although not identical in, numerous bacterial families. The analysis allowed for identification of different bacterial families as well as abundance counts.

At 12 months after circumcision, the microbiome's predominant bacterial population had shifted fromanaerobic to aerobic, which require oxygen to grow. Whereas the researchers detected similar number of bacteria belonging to aerobic families in circumcised and uncircumcised samples, they found that the abundance of anaerobic family members plummeted after circumcision. As the authors wrote, this decrease makes sense because there is an oxygen-deprived area under the foreskin that is lost after circumcision.


Whereas the current analysis could only detect gene sequences that were specific to bacterial families, the researchers are now working to identify the specific species that presumably cannot survive on circumcised penises. Price says that the researchers should begin this PCR-based analysis in the next six months, as soon as they finish improving the databases of bacterial sequences and developing new PCR tools.

Once the researchers identify the anaerobic species, the plan is to determine which can create an inflammatory environment that favors HIV infection, Gray says. Certain species of bacteria, both anaerobic and aerobic, can cause the release of inflammatory cytokines (immunoregulatory proteins) from cells present in the skin and body surfaces, such as the foreskin and vagina. These cytokines then activate a type of immune cell, called Langerhans cells. Scientists think that HIV transmission requires that the virus first infect activated Langerhans cells, which then pass the virus to T cells.

Even if the researchers demonstrate that specific species of anaerobic bacteria on the uncircumcised penis are potent activators of Langerhans cells, the microbiome is probably only one aspect of the environment that affects HIV infection. As Gray points out, anatomical changes following circumcision also "almost certainly" account for part of the protection against HIV infection. Specifically, the authors wrote, after the foreskin is removed the penis head develops extra layers of skin, which reduces the abundance of Langerhans cells.

In any case, changes that occur to the penis microbiome following circumcision could hamper the transmission of other sexually transmitted diseases. Similar to HIV reduction, Gray's clinical trial in Uganda found that the incidence of genital herpes and human papillomavirus were about 27 and 35 percent lower, respectively, in circumcised men.

Moreover, the current study found that two of the most abundant anaerobic organisms present on uncircumcised penises, Clostridiales and Prevotellaceae, have been associated with bacterial vaginosis, an uncomfortable condition in which the vagina's bacterial balance is upset. This finding could help explain why there are reduced rates of bacterial vaginosis in the wives of circumcised men, Gray says. He adds that the microbiome study will help doctors understand the extent of the potential health benefits of circumcision.



http://www.scientificamerican.com/article.cfm?id=circumcision-penis-microbiome-hiv-infection&page=2
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http://www.circinfo.org/AIDSnews.html




Soaring incidence of AIDS among circumcised populations …
… shows that foreskin not the problem and circumcision not the answer


Reports from the United States and several African countries show that, despite the WHO push for circumcision as the key strategy against AIDS in underdeveloped countries, HIV infection rates are increasing rapidly among circumcised populations. The most recent evidence to undermine the hypothesis that circumcision is the most effective preventive intervention against AIDS is a report in the New England Journal of Medicine, which reveals an HIV epidemic in the (largely circumcised) USA that rivals the problem in (largely circumcised) regions of Africa.

The NEJM reports that more than 1 in 30 adults in Washington, D.C., are HIV-positive — a prevalence higher than that found in Ethiopia, Nigeria, or Rwanda. Among men who have sex with men, the study reveals that in some parts of the USA as many as 30 per cent of active men are infected. With the overwhelming majority of adult males in the USA circumcised in infancy, these figures cast serious doubt the case that circumcision is a useful strategy against AIDS.

In other news, we find that 6 out of 10 new HIV cases in British Africans are among Muslims (almost all circumcised), and that in Uganda “confused” young Muslim men are having to be reminded that circumcision is not an adequate protection against sexual diseases. In Kenya, where mass circumcision of young men has been funded by the WHO and touted as the solution to the AIDS problem, it has been revealed that in two areas of almost universal male circumcision, HIV infections are rising rapidly – reaching 8.3 percent in Kenya’s coastal province. On top of that, women are complaining that circumcision is giving promiscuous men a false sense of security, and discouraging condom use.

The authors of the NEJM report suggest that ideology is hampering America’s approach to HIV prevention and point out that “Preventive interventions must be rooted in science, not driven by ideological concerns.” They mention homophobia as one of these ideologies, but we would suggest that posthephobia (irrational hatred of the foreskin) should also be listed among the ideological obsessions that hamper the fight against AIDS.

Most recently, a study of 4,889 men published in the journal AIDS has shown that circumcised gay men are not less likely to become infected with HIV. Headlined in the press as “Circumcision may not cut HIV spread among gay men”, the study in fact showed that HIV infection was higher among circumcised men than among the uncut After controlling for sexual behaviours and demographic factors the report concluded there was no difference between the two groups.

1. HIV and circumcision in United States
Social disadvantage and sexual networks to blame for AIDS spread, not foreskins

Despite Americans’ faith in circumcision as the most reliable form of health insurance known to man, and the high incidence of circumcision among American males, the prevalence of AIDS in some part of the United States now exceeds the infection rate in several hard-hit African countries. An article in the New England Journal of Medicine reports (18 March 2010) that the incidence of HIV infection in New York is 1 in 40 among Blacks, 1 in 10 among men who have sex with men, and 1 in 8 among injection drug users. In Washington DC the prevalence is 1 in 30 adults. In some urban areas the HIV prevalence among men who have sex with men is as high as 30 per cent – many times higher than the over all incidence of 7.8 per cent in Kenya and 16.9 per cent in South Africa.

The authors of the report attribute the high incidence of AIDS to promiscuity within specific communities, associated with interlocking sexual networks; social disadvantage, meaning poor education, less access to safe sex information, and greater probability of spending time in prison (where unsafe sex is the rule); and various health or moral ideologies that generate inappropriate control strategies.

The following extracts from the article make clear that the authors do not consider that “lack of circumcision” (i.e. normal male anatomy) is part of the problem, and hence do not believe that yet more circumcision is part of the solution.

1. Promiscuity and sexual networks

“Unlike the generalized HIV epidemics in sub-Saharan Africa, the U.S. epidemic primarily affects certain discrete geographic areas — especially urban areas of the Northeast and West Coast and cities and small towns in the South (see U.S. map). Within these areas, specific neighborhoods are often disproportionately affected (see New York City map), in part because of residents’ engagement in unprotected sex within relatively insular social– sexual networks. Many of the populations most affected tend to have limited social mobility; thus, partner selection tends to concentrate transmission patterns and amplify spread within defined geographic areas. …

“The extent of the risk of acquiring HIV in the United States today is largely defined by a person’s sexual network rather than his or her individual behaviors. Understanding the context and settings in which risk is increased may lead to more robust and effective preventive interventions. For example, black men who have sex with men are at increased risk for HIV infection in part because of its high prevalence in their sexual networks and their likelihood of choosing racially similar partners; they have also been shown to be less likely than their white counterparts to be aware of their HIV status and thus are more likely to unknowingly transmit HIV.”

2. Social disadvantage

“Most glaringly, HIV disproportionately affects poor black Americans who have substandard education, unstable housing, and limited social mobility. This confluence of factors may result in high rates of incarceration, which threaten a community’s social fabric. Such vulnerable populations must be engaged in research, program development, and interventions that are culturally relevant and address the socioeconomic milieu in which HIV transmission occurs. …

The situation is similar for black and Hispanic women, whose increased risk of HIV acquisition is attributable in greater part to their vulnerable social and economic situations and their sexual networks than to their own risky behaviors. Socioeconomic disadvantage and instability of partnerships due to high rates of incarceration among men in their communities may lead women to engage in concurrent relationships or serial monogamy. In addition, they may be unaware of their partners’ HIV status or may be involved in abusive or economically dependent relationships and thus be unable to negotiate safer sex with their partners.”

Prison = unsafe sex

As the authors of the report acknowledge, the large number of Blacks and Hispanics in American prisons is a significant factor in the high and increasing incidence of AIDS among the Black and Hispanic population. A recent article in the New York Review of Books on the problem of rape and other sexual abuse in American gaols and juvenile detention centres points out that sexual contact, both forced and otherwise, is rife in such institutions, and that authorities, in their anxiety not to “condone” such practices, refuse to make condoms available. They thus ensure that most of the sexual contact that occurs is of the unsafe variety. The authors of the review quote the Report of the National Prison Rape Elimination Commission as suggesting that the increasing incidence of HIV among American Blacks is the result of rape and other unsafe sex in prisons:

“In 2005–2006, 21,980 State and Federal prisoners were HIV positive or living with AIDS. Researchers believe the prevalence of hepatitis C in correctional facilities is dramatically higher, based on [the] number of prisoners with a history of injecting illegal drugs prior to incarceration. … The incidence of HIV in certain populations outside correctional systems is likely attributable in part to [sexual] activity within correctional systems. Because of the disproportionate representation of minority men and women in correctional settings it is likely that the spread of these diseases in confinement will have an even greater impact on minority men, women, and children and their communities.” (National Prison Rape Elimination Commission Report, pp. 129–130).

The commissioners seem to be saying here, as delicately as they can, that they suspect prisoner rape has contributed to the way HIV infection in this country has shifted demographically: i.e., to the way in which AIDS has changed from being a predominantly gay disease to a predominantly black one.

David Kaiser and Lovisa Stannow, The rape of American prisoners, New York Review of Books, 11 March 2010.

3. Ideology

"Preventive interventions must be rooted in science, not driven by ideological concerns. Homophobia may have impeded the development of sexually appropriate prevention studies among men who have sex with men. Reluctance to fund studies of needle exchange or conditional cash transfer (providing financial incentives for healthy behavior) or to support work in high-risk venues, such as bathhouses, has hampered progress."

The authors of the article discuss homophobia (hostility to men who have sex with men) and moralistic objections to people who take injecting drugs as obstacles to the development of effective strategies to control the spread of AIDS. They might also have mentioned the moralistic objections to sex education that have hindered instruction in safe sex and distribution of condoms, and the diversion of funds to laughably ineffective “abstinence education"; and the posthephobia (irrational hatred of the foreskin) that has caused medical bureaucrats to focus on lack of circumcision as the most important factor in susceptibility to HIV infection, and thus on yet more circumcision as the most promising intervention.

But as officials in Africa have finally admitted (see below), circumcision is not sufficient to give immunity to AIDS. Only consistent use of condoms and practice of other forms of safe sex and the avoidance of promiscuity can guarantee that a person will remain uninfected; and if he is doing all that, there is no need for circumcision at all. He might as well hang on to his foreskin and exploit its vast potential for safe sex.

Source: Wafaa M. El-Sadr, Kenneth H. Meyer and Sally L. Hodder, AIDS in America: Forgotten but not gone, New England Journal of Medicine, Vol. 362, 18 March 2010, 967-970
2. Britain: 60 per cent of new AIDS cases among Africans are among African Muslims

Meanwhile in Britain, the British Broadcasting Corporation reports that six out of ten new AIDS cases among British African men are among Muslims. Since the vast majority of these men were circumcised as infants or children in accordance with Islamic custom, it is evident that circumcision has done nothing to protect them from the disease.

The BBC reports: According to Dr Shima Tariq, who has studied the transmission of HIV, more than half of newly diagnosed patients caught HIV through heterosexual sex, and two-thirds of them are of black African origin or descent. But most of this group are not Christian: six out of 10 are Muslim. Ibrahim, a Muslim who came to Britain from the Ivory Coast, is HIV positive. “It’s quite difficult for me because the thing is I can’t tell anybody. Because my family...nobody knows. None of my friends know. Nobody. Because if I tell them they will leave me alone and I will have to live alone and it will be a hard life for me.”

Along with a conservative African culture, religion has played a significant role in creating this taboo. Ismael is 40 and originally from Sudan. “The imams don’t talk too much about it, but they start off by saying ‘this is a taboo, this is a sin, a punishment from Allah’. When you disclose it, straight away they think you are gay, or maybe you got it from a prostitute or you did something bad and Allah is punishing you. That is why it has to be kept secret.”

The African HIV Policy Network has asked imams to break the taboo by talking openly about HIV. One of them, Mohamed Bashir of the North Brixton mosque in London, says imams need to acknowledge “that not everyone practises their religion to the letter”. There are Muslims who go to the mosque, who pray. They do everything similarly nicely and they suffer moments of lapse in judgement. They have extra-marital relations that they will not speak about, and engage in risky behaviour. Some imams might not want to admit that.”

Mohamed Bashir has agreed to train other imams on how to tackle the taboo. He accepts that in the face of HIV, condoms may be the lesser of two evils, but says communicating that to a congregation is a sensitive issue. “It won’t be considered responsible for an imam to say ‘when you’re making a mistake make sure you use a condom’, because that could be misunderstood as condoning that particular activity. In our awareness programme, literature is presented to members of the Muslim community. They can go to GM clinics, they can anonymously stock up on condoms. But to actively share them out, that wouldn’t be proper for an Islamic centre or an imam probably to do that.”

BBC World News, 1 December 2009
3. Kenya: Rapid rise in AIDS cases in areas of universal circumcision

And in Kenya, where circumcision is already practised on most boys as a matter of tribal custom or adherence to Islam, and uncircumcised men have been assaulted in the streets and forcibly circumcised by angry mobs, the incidence of AIDS is rising rapidly in regions where circumcision is near universal.

All Africa News reports

Nairobi: As thousands of young men in Nyanza Province troop to health centres to be circumcised in hopes of fending off HIV, new studies show it might be too early to claim victory. Although circumcision has been touted as one of the ways to prevent HIV infection, recent findings show an increase in HIV infection in regions where most males are circumcised. According to findings of the Kenya Aids Indicator Survey (Kais) released last week, North Eastern and Coast provinces, where 97 per cent of males are circumcised, registered an increase in HIV prevalence.

Within a span of five years, HIV prevalence in North Eastern and Coast provinces increased from 0 to 1.0 per cent and from 5.8 per cent to 8.3 per cent respectively. In the same period, HIV prevalence in Nyanza Province, where about 48 per cent of males are circumcised, stood at 15 per cent, the highest in the country.

These are sobering statistics for young men who have rushed to get circumcised in he belief that doing so would provide complete protection from HIV infection. The new findings of growing HIV prevalence among circumcised males indicates the practice cannot completely protect an individual from HIV infection unless it is combined with other practices including using condoms, being faithful to one partner, or abstaining from sex.

[In fact, using condoms, being faithful to one’s partner or consistently practising safe sex would provide near total protection from AIDS without the need for circumcision and all the risks, cost and loss that this surgery entails. The versatility, sensitivity and mobility of the foreskin provide greatly enlarged scope for safe sex practices.]

Health officials acknowledge that getting people to look at circumcision in the larger context of other factors and strategies can be challenging. “The figures from these two provinces are sending a warning that circumcision alone is not the magic bullet to controlling the disease. Other methods have to be used in combination,” said Dr Ibrahim Mohammed, Head of National Aids and STD Control Programmes in the Ministry of Medical Services.

The increase in prevalence in communities that circumcise indicates there are other factors that contribute to the spread of the disease among males in addition to being uncircumcised. Multiple sexual partners, low condom use and alcohol and drug abuse are some of the factors. “Unless we address all the reasons predisposing people to HIV infection, we might not make much headway,” said Judy Adero, who has lived with the virus for nine years. But scientists still believe circumcision will result in the lowering of HIV prevalence in provinces such as Nyanza.

[No real scientist would continue to believe something if the evidence against it started to pile up, or if a hypothesis was not consistently confirmed by subsequent experience. Belief in the superior effectiveness of circumcision against AIDS is actually concentrated more among public health and medical bureaucrats who are under pressure to produce quick fixes. Their continuing faith in circumcision is a typical prejudice, driven more by religious belief, tribal custom and American cultural commitment to circumcision than by genuine scientific open-mindedness.]

Women complain that circumcised men believe they are immune to AIDS and do not need to use condoms

Following the World Health Organisation’s policy decision to pour billions of medical aid money into circumcision, clinics offering free operations have been opened in many African countries. Vigorous propaganda campaigns urge uncircumcised men to get themselves done at these centres.

In Kenya, more than 30,000 men have been circumcised since the call first went out; the target of 100,000 circumcised men is expected to be reached by year’s end. Female activists, however, have criticised the way the whole operation is being carried out, arguing that it is making women more vulnerable as men engage in more frequent sex with multiple partners in the belief that their recent circumcision has made them immune to infection with HIV.

Circumcision not enough to stop AIDS, experts warn, All Africa News, 26 September 2009
4. Uganda: Muslim youth reminded that circumcision does not stop AIDS

In Uganda, to, circumcised Muslim men are having to be reminded that circumcision does not give them immunity to HIV infection. As East Africa News and Entertainment reports:

The Muslim Youth League has launched a campaign to fight against the spread of HIV among Muslims in the country. The Chairperson of the Youth League, Abdalla Karim Musitwa says the campaign will mainly target preventing HIV infection amongst the Muslim youths. Musitwa says recent researches showing circumcision helps to protect men from HIV infection has confused some Muslims to go on rampage having multiple sexual relationships without any protection hoping that they are safe because of being circumcised.

He says the campaign will among others convince Muslims that circumcision is not a guaranteed protection against HIV infection. Musitwa says the Muslim Youth League will be promoting abstinence and being faithful as the major means of protection against HIV infection. He says without a HIV cure in place, prevention of infections remains the key intervention against the spread of HIV/AIDS.

Uganda Health News: Muslim youth launch campaign against HIV/AIDS

Ugpulse: East Africa News and Entertainment, 7 June 2009
5. Circumcised gay men at greater risk of AIDS

A study of 4,889 men published in the journal AIDS has shown that circumcised gay men are not less likely to become infected with HIV. Headlined in the press as “Circumcision may not cut HIV spread among gay men”, the study in fact showed that HIV infection was higher among circumcised men than among the uncut After controlling for sexual behaviours and demographic factors the report concluded there was no difference between the two groups.

See abstract of article below.

This result is similar to a British study of 12,433 gay men published in 2001 by Sigma Research, which indicated a significantly higher risk of HIV among circumcised men. After controlling for factors likely to influence circumcision status – such as age and living in London – the authors found no association between circumcision status and HIV.

David Reid, Peter Weatherburn, Ford Hickson, Michael Stephens, Know the score: Findings from the National Gay Men’s Sex Survey 2001 (Sigma Research: University of Portsmouth, 2002) Full text available here.

Later report here: Hickson F, Weatherburn P, Reid D, et al, Consuming passions: Findings from the United Kingdom Gay Men’s Sex Survey 2005. London: Sigma Research, 2007. PDF available from Sigma research

See below for letter from Sigma researchers to Sexually Transmitted Infections criticising the current foreskin obsession.
Circumcised men may be at greater risk of AIDS

Gust, Deborah A; Wiegand, Ryan E; Kretsinger, Katrina; Sansom, Stephanie; Kilmarx, Peter H; Bartholow, Brad N; Chen, Robert T

Circumcision status and HIV infection among MSM: Reanalysis of a Phase III HIV vaccine clinical trial

AIDS (Official Journal of the International AIDS Society), On-line publication, 17 February 2010

Abstract

OBJECTIVE: Determine whether male circumcision would be effective in reducing HIV transmission among men who have sex with men (MSM).

DESIGN: Retrospective analysis of the VAXGen VAX004 HIV vaccine clinical trial data.

METHODS: Survival analysis was used to associate time to HIV infection with multiple predictors. Unprotected insertive and receptive anal sex predictors were highly correlated, thus separate models were run.

RESULTS: Four thousand eight hundred and eighty-nine participants were included in this reanalysis; 86.1% were circumcised. Three hundred and forty-two (7.0%) men became infected during the study; 87.4% were circumcised. Controlling for demographic characteristics and risk behaviors, in the model that included unprotected insertive anal sex, being uncircumcised was not associated with incident HIV infection [adjusted hazards ratio (AHR) = 0.97, confidence interval (CI) = 0.56-1.68]. Furthermore, while having unprotected insertive (AHR = 2.25, CI = 1.72-2.93) or receptive (AHR = 3.45, CI = 2.58-4.61) anal sex with an HIV-positive partner were associated with HIV infection, the associations between HIV incidence and the interaction between being uncircumcised and reporting unprotected insertive (AHR = 1.78, CI = 0.90-3.53) or receptive (AHR = 1.26, CI = 0.62-2.57) anal sex with an HIV-positive partner were not statistically significant. Of the study visits when a participant reported unprotected insertive anal sex with an HIV-positive partner, HIV infection among circumcised men was reported in 3.16% of the visits (80/2532) and among uncircumcised men in 3.93% of the visits (14/356) [relative risk (RR) = 0.80, CI = 0.46-1.39].

CONCLUSIONS: Among men who reported unprotected insertive anal sex with HIV-positive partners, being uncircumcised did not confer a statistically significant increase in HIV infection risk. Additional studies with more incident HIV infections or that include a larger proportion of uncircumcised men may provide a more definitive result.

Real conclusion

The real conclusion is that circumcision probably makes no difference to the risk of contracting HIV during male/male sex, but may increase the risk. Being Americans, these researchers are determined to go on wasting public money until they have manufactured enough verbiage to get the foreskin convicted.
6. Sigma researchers attack obsession with foreskin

The authors of the Sigma Research study are critical of the current obsession with circumcision as the magic bullet against AIDS. In 2008 they pointed out he flaws in an editorial in the British journal Sexually Transmitted Infections that called for circumcision of men who have sex with men as a means of reducing their risk of infection with HIV. The editorial was just the sort of opinion piece – long on rhetoric and short on evidence – that newspapers love to headline, and blithely oblivious to the fact that most men who have sex with men find the presence of their foreskin an important component of their sexual experience. The Sigma researchers expressed concern at the medical researchers’ focus on the innocent foreskin at the expense of “much more promising interventions than circumcision”.

Their letter was not published in the print edition of the journal, but only in the on-line edition, accessible only to subscribers. It is reproduced in full here in order to make it more readily available.

The editorial to which Hickson et al replied was Abigail MacDonald, Joanna Humphreys, Harold W. Jaffe, Prevention of HIV transmission in the UK: What is the role of male circumcision?, Sexually Transmitted Infections, Vol. 84 (3), 2008, 158-160.

Dear editor, If MacDonald, Humphreys and Jaffe (2008, STI, 84) are correct in their contention that circumcising men who have sex with men will result in a reduction in HIV incidence among this population, then we would expect circumcised MSM in the UK have a lower incidence of HIV than uncircumcised MSM. This should be reflected in HIV prevalence and since there is no reason to think that circumcision promotes diagnoses of HIV, this difference should be reflected in the prevalence of diagnosed HIV.

In 2001 we carried out a short, community-based, self-completion survey among 12,433 White British men aged 16 and over, living in the UK, who had sex with another man in the last year and/or identify as gay or bisexual. Fieldwork was conducted over the summer at Gay Pride events (52.1% of respondents), on-line through commercial gay web sites (31.6%) and through community based HIV prevention organisations (16.3%). Self report is a valid measure of circumcision in MSM (Termpleton et al., 2008, STI, 84).

Overall, 0.5% (n=64) indicated they did not know whether they had been circumcised or not. Excluding these men, 18.6% (2438/13,127) of respondents said they had been circumcised.

Circumcised men were as a group, older than un-circumcised men (mean age 36.5 years, sd 12.0, median 35, range 16-82 compared with mean 32.3, sd 10.2, median 31, range 16-79). The proportion of men who were circumcised increased step-wise with increasing age (11.9% of teens, 14.7% among those in their 20s, 16.8% in the 30s, 21.7% in the 40s and 38.1% among those 50 and older). More of the circumcised men lived in London (24.8% compare with 19.6% of un-circumcised men ).

Overall, 4.6% of respondents indicated they were living with diagnosed HIV infection. Circumcised men were not more or less likely to be living with diagnosed HIV (5.2% compared with 4.5% in un-circumcised men: chi squared = 1.84, p=0.175). In a multiple logistic regression controlling for age and living in London, the odds ratio of a circumcised man living with diagnosed HIV to an un-circumcised man doing so was 1.01 (95% confidence interval 0.81-1.25).

This suggests that circumcising MSM will make no difference to HIV incidence in this population. Since HIV acquisition in the UK is highly concentrated in MSM (HPA, 2008) and since identification of future MSM pre -puberty is not feasible, this suggest circumcision has little part to play in the UK HIV epidemic. Those concerned with the UK epidemic should be looking elsewhere for solutions. We have no doubt that a multi-pronged approach to minimising HIV infections is required. We also have little doubt that maximising circumcision is not one of them among MSM in the UK. Minimising nitrite inhalant use during unsafe sex might, on the other hand, have a very real effect (McDonald et al. 2008, STI, 84). We support MacDonald, Humphreys and Jaffe's call for more experimental research about HIV among MSM in the UK but stress that these have yet to be done for much more promising interventions than circumcision.

Source: Ford C.I. Hickson, David Reid, Peter Weatherburn, Michael Stephens, Circumcised MSM in the UK no less likely to be living with HIV, e-letter, Sexually Transmitted Infections, 5 August 2008.

Sexually Transmitted Infections can be searched here. Articles published pre-2006 are freely available; after that, a subscription is required.
7. Malawi bucks the WHO witchdoctors

Malawi is a small country in east central Africa, sandwiched between Mozambique, Zambia and Tanzania. The Secretary to the Office of the President, responsible for HIV/AIDS and Nutrition, Dr. Mary Shaba, has said Malawi cannot follow World Health Organisations recommendations to adopt widespread circumcision of men as a weapon to reduce the spread of HIV through heterosexual contact.

Although the WHO claims that circumcised males are 60 percent less likely to contract HIV through sexual intercourse, Shaba points out that Malawi is not a circumcised country and that those cutting off their children’s foreskin are doing it for religious and cultural reasons. “So it is mainly the Moslems and the Yaos who are doing circumcisions and some of the Lhomwe group,” she said in Capital Radio interview. “Malawi the way it is when you look at the statistics, you find that the majority would already be asking “Are we all becoming Moslems?” if you go that line.”

Shaba said Malawi has no policy and guidelines on circumcision. She said she has been asking for a report to study what condition circumcisions are done in countries doing it and what practices were followed after circumcision. “I have been asking for a report from all those people who have claimed that people are being protected, nobody has been able to give me the report. I want the report. I need to look at the methodology. I need to look at the cultural practices surrounding circumcision," said the free-speaking Shaba.

She pointed out that in Malawi HIV is most prevalent in areas where circumcision is practiced, and that many have died of AIDS in those particular districts.

“We are not a circumcised country as a nation. Circumcision is mainly practiced on a religious basis, and very few of the tribes practice circumcision. You can’t take what is done elsewhere and say we are going to do in Malawi.” She also pointed out that male circumcision will not be effective to fight HIV/AIDS because the new infection rate is highest among women.

Shaba also noted that circumcision can cause some problems for the penis.

Shaba says Malawi cannot follow Rwanda on circumcision to fight Aids, Nyasa Times, 26 January 2010
Officials annoyed by local reluctance, as private clinics try to take advantage of foreign health aid money

LILONGWE, 13 April 2010 (PlusNews): Circumcision is controversial in Malawi and the government has yet to implement a program. But a chain of private clinics run by Banja La Mtsogolo (BLM) – Future Family in the local Chichewa language – has rolled out the procedure at its network of 30 national clinics in 2009. It is the only organization offering circumcision as part of an HIV prevention package.

Following WHO directives, Malawi’s National HIV Prevention Strategy 2009-2013 acknowledges the role of circumcision, but it falls short of outlining a clear policy, and Brendan Hayes, the head of BLM, has admitted that circumcision has been a hard sell. “In Malawi, you’ve got very big differences in the HIV epidemic from north to south, and those differences don’t correlate to differences in circumcision prevalence. High HIV prevalence rates are in the southern part of the country, which is also where we have the most circumcision,” he told IRIN/PlusNews. “These differences aren’t totally inexplicable but I think it’s made people more cautious about moving forward with male circumcision.”

Confusion and controversy

Southern Malawi has a large migrant labour population and an HIV prevalence of about 18 percent, accounting for almost 70 percent of the country’s HIV infections, according to government figures. Circumcision is culturally less prominent in northern Malawi, where the prevalence of HIV is also lower.

The mismatch between HIV prevalence and circumcision incidence has raised doubts among some high-level health officials, particularly Principal Secretary for HIV and AIDS within the Presidency, Dr Mary Shawa [or Shaba]. Earlier this year, Shawa argued that she had not yet been presented with enough clinical evidence on circumcision, and that its efficacy was questionable given the high HIV prevalence among traditionally circumcising populations in the south. Shawa also questioned the acceptability of the practice among ethnic groups that did not traditionally perform the procedure.

Source: PlusNews
8. Malaysia: AIDS most prevalent among (circumcised) Muslims

In Malaysia, the local AIDS Council reports that 72 per cent cent of AIDS/HIV Sufferers in Malaysia are Muslims. In view of the facts that only 60 per cent of the Malaysian population is Muslim, and that nearly all Muslim malls are circumcised when young boys, this figure must mean that the majority of AIDS cases there are found in circumcised men.

KUALA TERENGGANU, June 9 (Bernama) -- More than 70 per cent of the 87,710 HIV/AIDS sufferers in the country are Muslims, Malaysian AIDS Council vice-president Datuk Zaman Khan said on Wednesday. Therefore, he said, the celebration for this year's World AIDS Day would emphasise efforts to enhance the participation of and awareness on AIDS among Muslims. He said what was more worrying a report by the United Nations General Assembly Special Session (UNGASS)on AIDS which stated that nine Malaysians were infected with the disease everyday. Also of concern was the spread of the disease among women, from 9.5 per cent in 2000 to 20 per cent last year, he said when speaking at a function to commemorate World AIDS Day here Tuesday night.

He said that in 2000 the main cause of women being infected with HIV/AIDS was drug addiction, but lately, it had been attributed to heterosexual sex (30 per cent). This happened because of lack of concern and cooperation from the society to protect women from the disease, he added. On HIV/AIDS sufferers in Terengganu, he said, a total of 315 new cases were reported last year. Kelantan recorded the highest number of HIV/AIDS cases at 596, followed by Pahang (431) and Selangor (378), he added.

Bernama: Malaysian National News Agency, 9 June 2010
Further information

Studies casting doubts on wild claims of African "circumcision to stop AIDS" experiments
9. Swaziland: Circumcised men more likely to have AIDS

Despite the hype about circumcision as the magic bullet against HIV infection, new figures from Africa show that AIDS is more common among circumcised men.

Australian circumcision promoters are hitting the headlines with demands for mass circumcision of baby boys in Australia as a precaution against HIV acquired from unprotected heterosexual intercourse. In support of this proposal they refer to old evidence from Africa as to the protective effect of circumcision against heterosexually acquired HIV infection, as shown in three clinical trials. While the World Health Organisation rolled out circumcision programs with funds provided by Bill Gates and President Bush, sceptics warned that the trials were riddled with scientific flaws and that it was far too early to tell whether circumcision would have a significant protective effect in the real world - quite part from the vast cost and serious ethnical doubts. Recent news from Africa is proving the sceptics correct, as the incidence of AIDS in many Africa countries continues to rise among circumcised populations.

In Swaziland, a small nation in south central Africa, where the government is planning particularly ambitious programs, it was recently revealed that the incidence of HIV infection was significantly higher among circumcised men. According to government figures, the incidence of HIV among circumcised men is currently at 22 per cent, but among uncircumcised men at only 20 percent. These are both astronomical figures (nothing like the situation in Australia), but they do not show any evidence of circumcision having a protective effect against HIV; on the contrary, looking at these figures, you would have to conclude that circumcision increased the risk of infection with AIDS.

What is even more scandalous is that the Swaziland government was perfectly aware of these figures when it decided to roll out the circumcision programs. Makes you wonder how some of the Gates/Bush billions have been spent.
Swaziland: Incidence of AIDS higher among circumcised men

Times of Swaziland, 19 September 2010

MBABANE – Even though male circumcision is considered to have a protective effect for HIV infection, circumcised men have a slightly higher HIV infection than those who are not. The Times SUNDAY can today reveal that government has known this for close to three years. It is contained in the Swaziland Demographic and Health Survey (SDHS) of 2007 which still prevails. This report summarises findings of the 2006 survey carried out by the Swaziland Central Statistical Office (SCO). The report places the infection rate for circumcised males at 22 per cent while for those uncircumcised stands at 20 per cent.

The report states that the protective aspect of male circumcision is based in part because of the physiological differences that increase the susceptibility to HIV infection among uncircumcised men. However, the relationship between HIV prevalence and circumcision is not in the expected direction. "It is worth noting that the relationship between male circumcision and HIV infection may be confounded by the fact that the circumcision may not involve the full removal of the foreskin, which provides partial protection," stated the report.

But additional analysis is needed to determine if this lack of a relationship between male circumcision and HIV infection is a result of confounding factors or represents the true situation. In 2007 government introduced a policy on male circumcision, which has a goal of halting the spread of HIV infection to achieve an HIV-free generation. Cited in the report is that to meet this objective, male circumcision services, as part of the national comprehensive HIV prevention package, would have to be availed to men of all ages. To maximise the health benefit for HIV prevention, the primary targets of the services are men who are HIV-negative, in the age bracket of 15-24 and also newborn babies.

Value of circumcision questioned

Meanwhile, the belief that circumcision can provide a considerable measure of protection against HIV infection has been questioned by academicians and medical professionals of repute. Last week Occupational Health Specialist Dr Cleopas Sibanda questioned the rationale of circumcision to justify it being adopted as part of the national HIV and AIDS prevention strategy.

"What exactly happened in Uganda as far as HIV and AIDS and population demographics are concerned to correctly attribute the observed previous decline in their national HIV and AIDS statistics to wholesale male circumcision?" Sibanda was quoted as having asked. But he noted that circumcision for the wrong reasons can be very dangerous, in fact it has increased episodes of diminished consistent use of condoms and increased incidences of HIV and AIDS affected populations. [As shown in an earlier report, printed below.]

More circumcised men are HIV positive
By MUSA SIMELANE

Times of Swaziland, 19 September 2010
After circumcision, men stop using condoms

Times of Swaziland, 8 September 2010

MBELEBELENI – A traditional healer has related how he treats many men who have STIs due to their belief that after circumcision they will not contract HIV. The healer, who wished to be identified only as Nkambule, said he had been receiving an influx of male clients who wanted to be treated for sexually transmitted infections. He said when he questioned them on why they do not use condoms, the response was that they were of the view that since they were circumcised, they did not need to use one. "Most of them then require me to treat them with my traditional medicine," he said.

Nkambule explained that in one instance his client asked him to prepare a concoction that would enhance his manhood as he would not be required to use a condom since he had undergone circumcision. "I always advise them to follow the laid-down procedures a person is expected to undergo after circumcision, but most of them insist that they be given traditional medicine. As a traditional healer, I support circumcision but it is now clear that people have different understandings of it," he said.

Nkambule disclosed that he always advised his clients to test for HIV before opting for traditional treatment. "After observing the condition of my clients, I always advise them to check their status so that the necessary treatment can be administered," he explained.Judging from the number of people who came to him after circumcision, it was clear that people have this strong belief that circumcision prevented one from getting a sexually transmitted disease. "I treat people for different ailments, but the number of those who come with problems of sexually related diseases is increasing," he said.

Inyanga's warning about circumcision
By MBONGISENI NDZIMANDZE

Times of Swaziland, 8 September 2010
Kenya: Circumcised men just as likely to be HIV-positive

A recent study (yet another one) in Kenya has found no association between being uncircumcised and being at greater risk of infection with HIV. To put it another way, the study found that circumcision had no protective effect against HIV-AIDS.

The study, by Matthew Westercamp et al and published by PlosOne, examined “the behaviors, beliefs, and HIV/HSV-2 serostatus of men and women in the traditionally non-circumcising community of Kisumu, Kenya prior to establishment of voluntary medical male circumcision services. A total of 749 men and 906 women participated. Circumcision status was not associated with HIV/HSV-2 infection nor increased high risk sexual behaviors. In males, preference for being or becoming circumcised was associated with inconsistent condom use and increased lifetime number of sexual partners. Preference for circumcision was increased with understanding that circumcised men are less likely to become infected with HIV.”

That is, although there was no difference in HIV incidence between the circumcised and uncircumcised, the people in the survey believed the intensive American propaganda that circumcision gave significant protection against HIV infection.

It is thus not surprising that there was a high level of acceptance of and interest in circumcision among the sample, many of whom stated their intention to get circumcised. The study found that those planning to get circumcised were more likely to have a history of high risk behaviour, involving numerous casual partners and inconsistent condom use.

Matthew Westercamp et al, Male circumcision in the general population of Kisumu, Kenya: Beliefs about protection, risk behaviors, HIV, and STIs, PlosOne, December 2010; Full text of study at PlosOne
Belief in witchcraft and burning of witches also common in Kenya

Before we marvel at the readiness with which Kenyans accept the latest in proven scientific wisdom, we should bear in mind that Kenya is also a country in which there is a strong (and apparently rising) belief in witchcraft, and that burnings of suspected witches are becoming more common. Only last year a Kenyan correspondent for the BBC reported:

I was witnessing a horrific practice which appears to be on the increase in Kenya - the lynching of people accused of being witches. I personally saw the burning alive of five elderly men and women in Itii village. I had been visiting relatives in a nearby town, when I heard what was happening. I dashed to the scene, accompanied by a village elder. He reacted as if what we were watching was quite normal, which was shocking for me. As a stranger I felt I had no choice but to stand by and watch. My fear was that if I showed any sign of disapproval, or made any false move, the angry mob could turn on me. Not one person was protesting or trying to stop the killing. Hours later, the police came and removed the charred bodies. Village youths who took part in the killings told me that the five victims had to die because they had bewitched a young boy. “Of course some people have been burned. But there is proof of witchcraft,” said one youth.

Odhiambo Joseph, Horror of Kenya’s witch lynchings, BBC News, Kenya, 26 June 2009

Other reports at James Randi's skeptic site

Persecution of witches also in Nigeria, Angola and the Congo

In Nigeria, Angola and the Congo anti-witch hysteria targets children rather than old men or women. Hundreds of boys and girls are reported to have been blinded, injected with battery acid, and otherwise tortured in an effort to purge them of the demons thought to be possessing them. Many more have been cast out by their families and left to roam the streets. Especially in Nigeria, the campaign against witches is led by the Evangelical churches, as reported in the Daily Telegraph (Sydney):

In Nigeria as many as 1000 children may have been accused of witchcraft by pastors of evangelical Christian churches, many of whom have subsequently been tortured and burnt.

The idea of witchcraft is hardly new, but it has taken on new life recently partly because of a rapid growth in evangelical Christianity. Campaigners against the practice say around 15,000 children have been accused in two of Nigeria's 36 states over the past decade and around 1,000 have been murdered. In the past month alone, three Nigerian children accused of witchcraft were killed and another three were set on fire. Some of the churches involved are renegade local branches of international franchises. Their parishioners take literally the Biblical exhortation, “Thou shalt not suffer a witch to live” [Exodus, 22:18].

Katharine Houreld, Church burns witchcraft children
Daily Telegraph (Sydney), 20 October 2009
Twin superstitions: Burn the witches; destroy the foreskins

The justification traditionally given for burning witches is remarkably similar to the reasons commonly given for circumcising boys. A passing remark in the Old Testament is not the real reason or cause, but a post-hoc rationalisation: poor and ignorant people want to burn witches for their own traditional reasons, and the biblical text provides no more than a justification after the event, to be brought out when they are required to explain themselves. It is rather similar with circumcision: the circumcision promoters just want to do it for their own superstitious reasons (usually no more than habit), and when challenged to produce reasons they reach into the vast grab-bag of the medical literature and pull out a few choice quotes or stats.

Just like the witch-burners leant on the Book of Exodus to justify the murder of innocent people, circumcision promoters deploy questionable or irrelevant statistics from medical journals to justify the genital mutilation of innocent and unwilling children. And for much the same reasons: because their own or their community’s health, in the opinion of the circumcision promoters, demands and requires such a measure. Like the witch-burners, they are convinced that a crisis situation, with disease (or the devil) rampaging through society is no time for sentimentality (or mercy) if society is not to be engulfed in epidemics, plagues and assorted other disastrous evils. As in ancient times, the best way to appease the angry gods is by sacrificing something precious.
Uganda: Circumcision campaign increases HIV infections

Recent news reports from Africa reveal that circumcision as a tactic for stopping the spread of HIV is having the opposite effect, as men who have consented to be circumcised believe that they are now completely immune to infection and can have as much unsafe sex as they like, with as many partners as they can find, and don’t need to use condoms. In Uganda a report has found that “new HIV/AIDS messages meant to reduce the prevalence of the disease are instead facilitating its spread”, while in Swaziland a poster campaign is generally interpreted by men as meaning “that after circumcision, they would be safe from sexually transmitted illnesses”. This is exactly the result that critics of the circumcision solution have consistently predicted and warned against from the start. Suggesting that circumcision is a “surgical vaccine” against HIV, as many irresponsible researchers, circumcision promoters and journalists have done, gives people a false sense of security and encourages them to engage in unsafe sex - with inevitably tragic results.
Uganda: New HIV/AIDS Messages Worsening HIV Situation

A new report by PANOS Eastern Africa has shown that new HIV/AIDS messages meant to reduce the prevalence of the disease are instead facilitating its spread as they have created false impressions, especially with regard to multiple concurrent partnerships and male circumcision. The report, "Communication challenges in HIV Prevention: Multiple Concurrent Partnerships and Medical Male Circumcision", shows that majority of rural population believed that circumcision gives a complete protection to HIV/AIDS, while more than 88 per cent did not know what the sexual network was.

The report also notes that most of these messages are urban-based with little or no translation for the rural people, while younger people are no longer scared of the HIV pandemic because it is no longer as scary as it used to be. These communications include the "Be a man" campaign, "Go together Know together", "Go Red" campaign and the "Fidelity" campaign. "Current Multiple Concurrent Partnership (MCP) policies, programmes and communication initiatives in Uganda are not addressing the social, cultural and economic issues that underline why people engage in MCP. Future attempts should incorporate an analysis of the social drivers of HIV," the report released last month reads in part.

Speaking at the launch of the report in Kampala, the Director PANOS Eastern Africa, Peter Okubal, said the report was prompted by the increasing number of infections every year. Last year alone, 120,000 new infections were recorded. One of the lead researchers, Daudi Ochieng, from the Uganda Health Marketing Group, said that the messages have lost authority and have become cliché. "People are tired of the same old messages, campaigns are vague and boring, there is nothing shocking about them and they lack coherence as everyone gives a different message," Mr Ochieng said.

Flavia Lanyero, New HIV/Aids Messages Worsening HIV Situation, All Africa News, 5 May 2011
Swaziland: Circumcision campaign targets women

A similar report from Swaziland reveals that a government campaign to encourage women to pressure their partners into getting circumcised has been interpreted as advice that circumcision gives complete protection agains HIV and means that a man can then give up condoms and have more partners. Although the Swazi government has launched a ferocious circumcision campaign, figures show that there is higher incidence of HIV among the circumcised than among: cut men - 21.8%, uncut men - 19.5%.

The report in a Swazi newspaper reads: THE ministry of health has engaged on a campaign to encourage women to support their partners to circumcise. In an effort to publicise the campaign, billboards and public transport have been branded with posters of women who are supporting the campaign. The campaign is about the involvement of women in the male circumcision programme.

However, this campaign has been misinterpreted by some people who thought that the message being sent out was that they were safe from contracting sexually transmitted infections when they were circumcised and therefore, could have more than one sexual partner. The posters on the public transport display pictures of a man and four women accompanied by the word; “ngingumancoba” (I am a conqueror). To some, this has implied that after circumcision, they would be safe from sexually transmitted illnesses, hence the decision to have multiple concurrent partners.

Winile Masinga , New male circumcision campaign targets women, Observer (Swaziland) 21 April 2011
Zambia: Another study fails to find that foreskins increase risk of HIV …
… but still recommends circumcision

A study of the possible link between genital herpes and increased risk of HIV in Zambia did find that men with herpes were more likely to be HIV-positive, but also found that lack of circumcision did not increase the risk of HIV infection. Quite the contrary, the study found that uncircumcised men were less likely to contract HIV. In their discussion of the results, however, the authors of the study failed to mention this vital fact, and concluded by recommending that circumcision be promoted as an AIDS control strategy – thus violating the most basic principles of evidence-based medicine.

The Zambian study was conducted by researchers from the United States Centers for Disease Control – well known for its pro-circumcision agenda. They recruited 1062 male farm workers at a sugar estate in Zambia to participate in an experiment known as a prospective cohort study.** The researchers were looking for a link between genital herpes (herpes simplex type-2 or HSV-2) infections and developing an infection with HIV-1. The study had two outcomes of interest.

First, they looked at factors that affect the prevalence of HIV-1 infection (whether the men were infected at the time of recruitment). Second, they measured the incidence of HIV-1 infection (new infections detected during the follow-up period). At the time of recruitment 20.7% of the men were HIV-positive. Men with a positive blood test for past herpes were five times more likely to be HIV-positive at the time recruitment. Other factors significantly associated with being HIV-positive were self-reported genital ulcers in the past year, and being widowers (i.e. their wife had died). Rates of HIV-1 infection at the time of recruitment were the same in circumcised men and uncircumcised men (20.71% versus 20.76%). When adjusted for other factors, there was no significant association between circumcision status and HIV-1 prevalence.

The second half of the study involved following 731 participants who started off as HIV-negative and who made at least one follow-up visit. Becoming HIV-positive during the follow-up period was independently associated with a positive blood test for herpes at the beginning of the study, and 18 times more likely in men who developed a first-time HSV-2 (herpes) infection during the follow-up period. During the follow-up period uncircumcised men developed 23 infections in 5686 months of patient follow-up (4.04 per 1000 months), while circumcised men developed four infections in 817 months of follow-up (4.89 per 1000 months). This means that uncircumcised men had a slightly lower (but probably not statistically significant) risk of HIV infection. When adjusted for other factors, circumcision status made no difference to the risk of infection with HIV.

A significant weakness of the study is its reliance on self-reported circumcision status – something about which men are surprisingly uncertain. While the investigators assumed that all the HIV infections were transmitted sexually, it is also possible (even likely) that men with genital herpes would seek medical care, and in doing so placed themselves at greater risk of HIV infection through non-sterile medical treatment (iatrogenic infection) – notoriously common in the over-stretched health services of underdeveloped countries.

This is yet another study that fails to confirm the “60% reduction in risk of HIV infection” claimed for circumcision in the three famous randomized clinical trials. Such a reduction is outside the 95% confidence intervals of this and several other studies, indicating serious doubts about the clinical trials. Despite this, the researchers in the Zambia study recommend that company health centres should “promote and provide medical male circumcisions” as a part of the effort to decrease infection rates: yet their own data that shows that circumcision would either have no impact, or might even increase the risk of HIV infection. It would appear that the authors, even in light of their own negative findings, are unwilling to stray from the CDC’s pro-circumcision agenda, and thus fail to observe the basic principles of evidence-based medicine: that recommendations for treatment must follow logically and directly from the evidence. According to the data in this study, to recommend circumcision as a preventive strategy in Zambia is ideological and plainly anti-scientific.

Source: The article is: Heffron R, Chao A, Mwinga A, Sylvester Sinyangwe S, Sinyama A, Ginwalla R, Shields M, Kafwembe M Kaetano L, Mulenga C, Kasongo W, Mukonka V, Bulterys M. High prevalent and incident HIV-1 and herpes simplex virus 2 infection among male migrant and non-migrant sugar farm workers in Zambia. Sex Transm Infect 2011; 87: 283-8.

** A prospective cohort study is a cohort study that follows over time a group of similar individuals (cohorts) who differ with respect to certain factors under study, to determine how these factors affect rates of a certain outcome.





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This fact sheet summarizes information in four areas of male circumcision: 1) male circumcision and risk for HIV transmission; 2) male circumcision and other health conditions; 3) risks associated with male circumcision; and 4) status of HIV infection and male circumcision in the United States.

What is Male Circumcision?
Male circumcision is the surgical removal of some or all of the foreskin (or prepuce) from the penis [1].

Male Circumcision and Risk for HIV Transmission
Several types of research have documented that male circumcision significantly reduces the risk of HIV acquisition by men during penile-vaginal sex.

Biologic Plausibility

Compared with the dry external skin surface, the inner mucosa of the foreskin has less keratinization (deposition of fibrous protein), a higher density of target cells for HIV infection (Langerhans cells), and is more susceptible to HIV infection than other penile tissue in laboratory studies [2]. The foreskin may also have greater susceptibility to traumatic epithelial disruptions (tears) during intercourse, providing a portal of entry for pathogens, including HIV [3]. In addition, the microenvironment in the preputial sac between the unretracted foreskin and the glans penis may be conducive to viral survival [1]. Finally, the higher rates of sexually transmitted genital ulcerative disease, such as syphilis, observed in uncircumcised men may also increase susceptibility to HIV infection [4].

International Observational Studies

A systematic review and meta-analysis that focused on male circumcision and heterosexual transmission of HIV in Africa was published in 2000 [5]. It included 19 cross-sectional studies, 5 case-control studies, 3 cohort studies, and 1 partner study. A substantial protective effect of male circumcision on risk for HIV infection was noted, along with a reduced risk for genital ulcer disease. After adjustment for confounding factors in the population-based studies, the relative risk for HIV infection was 44% lower in circumcised men. The strongest association was seen in men at high risk, such as patients at sexually transmitted disease (STD) clinics, for whom the adjusted relative risk was 71% lower for circumcised men.

Another review that included stringent assessment of 10 potential confounding factors and was stratified by study type or study population was published in 2003 [6]. Most of the studies were from Africa. Of the 35 observational studies in the review, the 16 in the general population had inconsistent results. The one large prospective cohort study in this group showed a significant protective effect: the odds of infection were 42% lower for circumcised men [7]. The remaining 19 studies were conducted in populations at high risk. These studies found a consistent, substantial protective effect, which increased with adjustment for confounding. Four of these were cohort studies: all demonstrated a protective effect, with two being statistically significant.

Ecologic studies also indicate a strong association between lack of male circumcision and HIV infection at the population level. Although links between circumcision, culture, religion, and risk behavior may account for some of the differences in HIV infection prevalence, the countries in Africa and Asia with prevalence of male circumcision of less than 20% have HIV infection prevalences several times higher than those in countries in these regions where more than 80% of men are circumcised [8].

International Clinical Trials

Three randomized controlled clinical trials were conducted in Africa to determine whether circumcision of adult males will reduce their risk for HIV infection. The study conducted in South Africa [9] was stopped in 2005, and those in Kenya [10] and Uganda [11] were stopped in 2006 after interim analyses found a statistically significant reduction in male participants’ risk for HIV infection from medical circumcision.

In these studies, men who had been randomly assigned to the circumcision group had a 60% (South Africa), 53% (Kenya), and 51% (Uganda) lower incidence of HIV infection compared with men assigned to the wait-list group to be circumcised at the end of the study. In all three studies, a few men who had been assigned to be circumcised did not undergo the procedure, and vice versa. When the data were reanalyzed to account for these occurrences, men who had been circumcised had a 76% (South Africa), 60% (Kenya), and 55% (Uganda) reduction in risk for HIV infection compared with those who were not circumcised. The Uganda study investigators are also examining the following in an ongoing study: 1) safety and acceptability of male circumcision in HIV-infected men and men of unknown HIV infection status, 2) safety and acceptability of male circumcision in the men’s female sex partners, and 3) effect of male circumcision on male-to-female transmission of HIV and other STDs.

Male Circumcision and Male-to-Female Transmission of HIV

In an earlier study of couples in Uganda in which the male partner was HIV infected and the female partner was initially HIV-seronegative, the infection rates of the female partners differed by the circumcision status and viral load of the male partners. If the male’s HIV viral load was <50,000 copies/mL, there was no HIV transmission if the man was circumcised, compared with a transmission rate of 9.6 per 100 person-years if the man was uncircumcised [7]. When viral load was not controlled for, there was a nonsignificant trend toward a reduction in the male-to-female transmission rate from circumcised men compared with uncircumcised men. Such an effect may be due to decreased viral shedding from circumcised men or to a reduction in ulcerative STDs acquired by female partners of circumcised men [12]. A clinical trial in Uganda to assess the impact of circumcision on male-to-female transmission reported that its first interim safety analysis showed a nonsignificant trend toward a higher rate of HIV acquisition in women partners of HIV-seropositive men in couples who had resumed sex prior to certified postsurgical wound healing and did not detect a reduction in HIV acquisition by female partners engaging in sex after wound healing was complete [13].

Male Circumcision and Other Health Conditions
Lack of male circumcision has also been associated with sexually transmitted genital ulcer disease and chlamydia, infant urinary tract infections, penile cancer, and cervical cancer in female partners of uncircumcised men [1]. The latter two conditions are related to human papillomavirus (HPV) infection. Transmission of this virus is also associated with lack of male circumcision. A recent meta-analysis included 26 studies that assessed the association between male circumcision and risk for genital ulcer disease. The analysis concluded that there was a significantly lower risk for syphilis and chancroid among circumcised men, whereas the reduced risk of herpes simplex virus type 2 infection had a borderline statistical significance [4].

Risks Associated with Male Circumcision
Reported complication rates depend on the type of study (e.g., chart review vs. prospective study), setting (medical vs. nonmedical facility), person operating (traditional vs. medical practitioner), patient age (infant vs. adult), and surgical technique or instrument used. In large studies of infant circumcision in the United States, reported inpatient complication rates range from 0.2% to 2.0% [1, 14, 15]. The most common complications in the United States are minor bleeding and local infection. In the recently completed African trials of adult circumcision, the rates of adverse events possibly, probably, or definitely attributable to circumcision ranged from 2% to 8%. The most commonly reported complications were pain or mild bleeding. There were no reported deaths or long-term sequelae documented [9, 10, 11, 16]. A recent case-control study of two outbreaks of methicillin-resistant Staphylococcus aureus (MRSA) in otherwise healthy male infants at one hospital identified circumcision as a potential risk factor. However, in no case did MRSA infections involve the circumcision site, anesthesia injection site, or the penis, and MRSA was not found on any of the circumcision equipment or anesthesia vials tested [17].

Effects of Male Circumcision on Penile Sensation and Sexual Function
Well-designed studies of sexual sensation and function in relation to male circumcision are few, and the results present a mixed picture. Taken as a whole, the studies suggest that some decrease in sensitivity of the glans to fine touch can occur following circumcision [18]. However, several studies conducted among men after adult circumcision suggest that few men report their sexual functioning is worse after circumcision; most report either improvement or no change [19–22]. The three African trials found high levels of satisfaction among the men after circumcision [9, 10, 11, 16]; however, cultural differences limit extrapolation of their findings to U.S. men.

HIV Infection and Male Circumcision in the United States
In 2005, men who have sex with men (MSM) (48%), MSM who also inject drugs (4%), and men (11%) and women (21%) exposed through high-risk heterosexual contact accounted for an estimated 84% of all HIV/AIDS cases diagnosed in U.S. areas with confidential name-based HIV infection reporting. Blacks accounted for 49% of cases and Hispanics for 18%. Infection rates for both groups were several-fold higher than the rate for whites. An overall prevalence of 0.5% was estimated for the general population [23]. Although data on HIV infection rates since the beginning of the epidemic are available, data on circumcision and risk for HIV infection in the United States are limited. In one crosssectional survey of MSM, lack of circumcision was associated with a 2-fold increase in the odds of prevalent HIV infection [24]. In another, prospective study of MSM, lack of circumcision was also associated with a 2-fold increase in risk for HIV seroconversion [25]. In both studies, the results were statistically significant, and the data had been controlled statistically for other possible risk factors. However, in another prospective cohort study of MSM, there was no association between circumcision status and incident HIV infection, even among men who reported no unprotected anal receptive intercourse [26]. And in a recent cross-sectional study of African American and Latino MSM, male circumcision was not associated with previously known or newly diagnosed HIV infection [27]. In one prospective study of heterosexual men attending an urban STD clinic, when other risk factors were controlled, uncircumcised men had a 3.5-fold higher risk for HIV infection than men who were circumcised. However, this association was not statistically significant [28]. And in an analysis of clinic records for African American men attending an STD clinic, circumcision was not associated with HIV status overall, but among men with known HIV exposure, circumcision was associated with a statistically significant 58% reduction in risk for HIV infection [29].

Status of Male Circumcision in the United States

In national probability samples of adults surveyed during 1999–2004, the National Health and Nutrition Examination Surveys (NHANES) found that 79% of men reported being circumcised, including 88% of non-Hispanic white men, 73% of non-Hispanic black men, 42% of Mexican American men, and 50% of men of other races/ ethnicities [30]. It is important to note that reported circumcision status may be subject to misclassification. In a study of adolescents¸ only 69% of circumcised and 65% of uncircumcised young men correctly identified their circumcision status as verified by physical exam [31].

According to the National Hospital Discharge Survey (NHDS), 65% of newborns were circumcised in 1999, and the overall proportion of newborns circumcised was stable from 1979 through 1999 [32]. Notably, the proportion of black newborns circumcised increased during this reporting period (58% to 64%); the proportion of white newborns circumcised remained stable (66%). In addition, the proportion of newborns who were circumcised in the Midwest increased during the 20-year period—from 74% in 1979 to 81% in 1999; the proportion of infants born in the West who were circumcised decreased from 64% in 1979 to 37% in 1999. In another survey, the National Inpatient Sample (NIS), circumcision rates increased from 48% during 1988–1991 to 61% during 1997–2000. Circumcision was more common among newborns who were born to families of higher socioeconomic status, born in the Northeast or Midwest, and who were black [33].

In 1999, the American Academy of Pediatrics (AAP) changed from a neutral stance on circumcision to a position that the data then available were insufficient to recommend routine neonatal male circumcision. The Academy also stated, “It is legitimate for the parents to take into account cultural, religious, and ethnic traditions, in addition to medical factors, when making this choice” [34]. This position was reaffirmed by the Academy in 2005. This change in policy may have influenced reimbursement for, and the practice of, neonatal circumcision. In a 1995 review, 61% of circumcisions were paid for by private insurance, 36% were paid for by Medicaid, and 3% were self-paid by the parents of the infant. Compared with infants of self-pay parents, those covered by private insurance were 2.5 times as likely to be circumcised [35]. Since 1999, 16 states have eliminated Medicaid payments for circumcisions that were not deemed medically necessary [36]. However, AAP has recently (2007) convened a panel to reconsider its circumcision policy in light of additional data now available.

Cost-Benefits and Ethical Issues for Neonatal Circumcision in the United States

A large retrospective study of circumcision in nearly 15,000 infants found neonatal circumcision to be highly cost-effective, considering the estimated number of averted cases of infant urinary tract infection and lifetime incidence of HIV infection, penile cancer, balanoposthitis, and phimosis. The cost of postneonatal circumcision was 10-fold the cost of neonatal circumcision [37]. Many parents now make decisions about infant circumcision based on cultural, religious, or parental desires rather than health concerns [38].

Some persons have raised ethical objections to asking parents to make decisions about elective surgery during infancy, particularly when it is done primarily to protect against risks of HIV and STDs that don’t occur until young adulthood, but other ethicists have found it an appropriate parental proxy decision [39].

Considerations for the United States

A number of important differences from sub- Saharan African settings where the three male circumcision trials were conducted must be considered in determining the possible role for male circumcision in HIV prevention in the United States. Notably, the overall risk of HIV infection is considerably lower in the United States, changing risk-benefit and cost-effectiveness considerations. Also, studies to date have demonstrated efficacy only for penile-vaginal sex, the predominant mode of HIV transmission in Africa, whereas the predominant mode of sexual HIV transmission in the United States is by penile-anal sex among MSM. There are as yet no convincing data to help determine whether male circumcision will have any effect on HIV risk for men who engage in anal sex with either a female or male partner, as either the insertive or receptive partner. Receptive anal sex is associated with a substantially greater risk of HIV acquisition than is insertive anal sex. It is more biologically plausible that male circumcision would reduce HIV acquisition risk for the insertive partner rather than for the receptive partner, but few MSM engage solely in insertive anal sex [40].

In addition, although the prevalence of circumcision may be somewhat lower in U.S. racial and ethnic groups with higher rates of HIV infection, most American men are already circumcised, and it is not known whether men at higher risk for HIV infection would be willing to be circumcised or whether parents would be willing to have their infants circumcised to reduce possible future HIV infection risk. Lastly, whether the effect of male circumcision differs by HIV-1 subtype, predominately subtype B in the United States and subtypes A, C, and D in circulation at the three clinical trial sites in Africa, is also unknown.

Summary
Male circumcision has been associated with a lower risk for HIV infection in international observational studies and in three randomized controlled clinical trials. It is possible, but not yet adequately assessed, that male circumcision could reduce male-to-female transmission of HIV, although probably to a lesser extent than female-to-male transmission. Male circumcision has also been associated with a number of other health benefits. Although there are risks to male circumcision, serious complications are rare. Accordingly, male circumcision, together with other prevention interventions, could play an important role in HIV prevention in settings similar to those of the clinical trials [41, 42].

Male circumcision may also have a role in the prevention of HIV transmission in the United States. CDC consulted with external experts in April 2007 to receive input on the potential value, risks, and feasibility of circumcision as an HIV prevention intervention in the United States and to discuss considerations for the possible development of guidelines.

As CDC proceeds with the development of public health recommendations for the United States, individual men may wish to consider circumcision as an additional HIV prevention measure, but they must recognize that circumcision 1) does carry risks and costs that must be considered in addition to potential benefits; 2) has only proven effective in reducing the risk of infection through insertive vaginal sex; and 3) confers only partial protection and should be considered only in conjunction with other proven prevention measures (abstinence, mutual monogamy, reduced number of sex partners, and correct and consistent condom use).

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Buchbinder SP, Vittinghoff E, Heagerty PJ, et al. Sexual risk, nitrite inhalant use, and lack of circumcision associated with HIV seroconversion in men who have sex with men in the United States. J Acquir Immune Defic Syndr. 2005 May 1;39(1):82-9.
Templeton DJ, Jin F, Prestage GP, et al. Circumcision status and risk of HIV seroconversion in the HIM cohort of homosexual men in Sydney [Abstract WEAC103]. Presented at: 4th IAS Conference on HIV Pathogenesis, Treatment, and Prevention; Jul 22-25, 2007; Sydney, Australia. Accessed Jan 23, 2008.
Millett GA, Ding H, Lauby J, et al. Circumcision status and HIV infection among black and Latino men who have sex with men in 3 US cities. J Acquir Immune Defic Syndr. 2007 Dec;46(5):643-50.
Telzak EE, Chiasson MA, Bevier PJ, Stoneburner RL, Castro KG, Jaffe HW. HIV-1 seroconversion in patients with and without genital ulcer disease: a prospective study. Ann Intern Med. 1993 Dec 15;119(12):1181-6.
Warner L, Ghanem KG, Newman D, et al. Male circumcision and risk of HIV infection among heterosexual men attending Baltimore STD clinics: an evaluation of clinic-based data [Abstract 326]. Presented at: National STD Prevention Conference; May 8-11, 2006; Jacksonville, FL. Accessed Jan 23, 2008.
Xu F, Markowitz LE, Sternberg MR, Aral SO. Prevalence of circumcision and herpes simplex virus type 2 infection in men in the United States: the National Health and Nutrition Examination Survey (NHANES), 1999–2004. Sex Transm Dis. 2007 July; 34(7):479-84.
Risser JM, Risser WL, Eissa MA, Cromwell PF, Barratt MS, Bortot A. Self-assessment of circumcision status by adolescents. Am J Epidemiol. 2004 Jun 1;159(11):1095-7.
Centers for Disease Control and Prevention. Trends in circumcisions among newborns. Accessed Jan 24, 2008.
Nelson CP, Dunn R, Wan J, Wei JT. The increasing incidence of newborn circumcision: data from the nationwide inpatient sample. J Urol. 2005 Mar;173(3):978-81.
American Academy of Pediatrics, Task Force on Circumcision. Circumcision policy statement. Pediatrics. 1999 Mar;103(3):686-93.
Mansfield CJ, Hueston WJ, Rudy M. Neonatal circumcision: associated factors and length of hospital stay. J Fam Pract. 1995 Oct;41(4):370-6.
National Conference of State Legislatures. State Health Notes: Circumcision and infection.
Schoen EJ, Oehrli M, Colby CJ, Machin G. The highly protective effect of newborn circumcision against invasive penile cancer. Pediatrics. 2000 Mar;105(3):e36. Accessed Jan 24, 2008.
Adler R, Ottaway S, Gould S. Circumcision: we have heard from the experts; now let’s hear from the parents. Pediatrics. 2001:107:e20. Accessed Jan 24, 2008.
Benatar M, Benatar D. Between prophylaxis and child abuse: the ethics of neonatal male circumcision. Am J Bioeth. 2003 Spring;3(2):35-48.
Koblin BA, Chesney MA, Husnik MJ, et al. High-risk behaviors among men who have sex with men in 6 US cities: baseline data from the EXPLORE study. Am J Public Health. 2003 Jun;93(6):926-32. Erratum in: Am J Public Health 2003 Aug;93(8):1203.
World Health Organization and UNAIDS. New data on male circumcision and HIV prevention: policy and programme implications. 2007 Mar. Accessed Jan 24, 2008.
Williams BG, Lloyd-Smith JO, Gouws E, et al. The potential impact of male circumcision on HIV in sub-Saharan Africa. PLoS Med. 2006;3(7):e262. Accessed Jan 24, 2008.
http://www.cdc.gov/hiv/resources/factsheets/circumcision.htm

Larger foreskin size increases HIV infection risk
Transmission and prevention >
Michael Carter
Published: 14 October 2009
Larger foreskin size is associated with an increased risk of becoming infected with HIV, investigators from the Rakai circumcision study report in the October edition of AIDS.

“Larger foreskin size is a risk factor for HIV acquisition in uncircumcised men,” comment the investigators.

Several African studies have shown that circumcised men have a lower risk of becoming infected with HIV than uncircumcised men. The Rakai study was one of these studies, and showed that men who underwent circumcision at the beginning of the study had a 48% lower risk of infection than men randomised to remain uncircumcised.

Investigators from the Rakai circumcision study hypothesised that the size of an individual's foreskin may be associated with an increased risk of HIV infection, due to the larger surface area containing cells vulnerable to HIV infection.

They therefore analysed men in the clinical trial who had previously taken part in a cohort study to see if they could find an association between the size of the foreskin measured at the time of circumcision and the risk of HIV acquisition in uncircumcised men prior to the removal of their foreskin.

They conducted the retrospective analysis in men who had initially been recruited to the Rakai community cohort study, tested for HIV at baseline and followed for a median of four years prior to enrolling in the clinical trial and undergoing medical circumcision.

A total of 965 men were included in the study. In the clinical trial they were randomised to be circumcised immediately or to have circumcision delayed for two years.

Foreskin area was measured in centimetres squared (cm2) by multiplying the length of the foreskin by the width.

In addition, the foreskin surface areas were categorised into quartiles:


Lowest 25% in surface area (7 to 26.3 cm2).
26 to 50% (26.4 to 35 cm2).
51 to 75% (35.1 to 45.5 cm2).
Above 75% (45.6 to 99.8cm2).

There were 48 new HIV infections. The median foreskin area was larger in those who became infected with HIV compared with those who did not (41.5 vs 35 cm2).

Furthermore, the mean foreskin area was significantly higher among those who seroconverted than those who did not (43.3 vs 36.8 cm2).

The investigators also noticed than men aged 24 and younger had smaller foreskin areas compared to both men in their late 20s and those in their 30s and 40s.

HIV incidence was lowest amongst men with foreskin surface areas in the lowest quartile (0.8 per 100 person years), and incidence increased with foreskin surface area, being 2.48 per 100 person years amongst individuals in the upper quartile (p < 0.01 for the trend).

After adjustment for possible confounding factors, the investigators found that individuals with a foreskin area above 45.6 cm2 had a significantly increased risk of becoming infected with HIV compared to men with the smallest foreskin surface area (adjusted risk ratio, 2.37, 95% CI: 1.05 to 5.31, p = 0.04).

Men aged 25 and older (p = 0.01), those with a lower level of education (p = 0.03), and Catholics (p = 0.01) also had a higher risk of HIV seroconversion.

“We found that the mean foreskin surface area among men who seroconverted to HIV was significantly larger than among men who remained uninfected, and that the risk of HIV acquisition was significantly increased among men with foreskins in the upper quartile of surface area compared with men in the lowest quartile of foreskin area,” write the authors.

They conclude, “a larger foreskin area was associated with an increased risk of HIV acquisition”, a finding which they suggest has implications for circumcision providers who “should avoid leaving excess residual foreskin tissue after circumcision”. Although this is a particular problem with the forceps-guided procedure used in the study, because it leaves a margin of mucosal skin of up to 1cm, the investigators also note that this remaining mucosal surface is still substantially smaller than that measured in the lowest-risk group in this study.
Reference
Kigozi G et al. Foreskin surface area and HIV acquisition in Rakai, Uganda (size matters). AIDS 23: 2209-13, 2009.

http://www.aidsmap.com/Larger-foreskin-size-increases-HIV-infection-risk/page/1436434/

Foreskin surface area and HIV acquisition in Rakai, Uganda (size matters).
Kigozi G, Wawer M, Ssettuba A, Kagaayi J, Nalugoda F, Watya S, Mangen FW, Kiwanuka N, Bacon MC, Lutalo T, Serwadda D, Gray RH.
SourceRakai Health Sciences Program, Entebbe, Uganda. gkigozi@rhsp.org

Abstract
INTRODUCTION: Male circumcision reduces HIV acquisition in men. We assessed whether foreskin surface area was associated with HIV acquisition prior to circumcision.

METHODS: In two randomized trials of male circumcision, the surface area of the foreskin was measured after surgery using standardized procedures. Nine hundred and sixty-five initially HIV-negative men were enrolled in a community cohort who subsequently enrolled in the male circumcision trials, provided 3920.8 person-years of observation prior to circumcision. We estimated HIV incidence per 100 person-years prior to circumcision, associated with foreskin surface area categorized into quartiles.

RESULTS: Mean foreskin surface area was significantly higher among men who acquired HIV (43.3 cm2, standard error 2.1) compared with men who remained uninfected (36.8 cm, standard error 0.5, P = 0.01). HIV incidence was 0.80/100 person-years (8/994.9 person-years) for men with foreskin surface areas in the lowest quartile (< or =26.3 cm2), 0.92/100 person-years (9/975.3 person-years) with foreskin areas in the second quartile (26.4-35.0 cm2), 0.90/100 person-years (8/888.5 person-years) with foreskin area in the third quartile (35.2-45.5 cm2) and 2.48/100 person-years (23/926.8 person-years) in men with foreskin surfaces areas in the highest quartile (>45.6 cm2). Compared with men with foreskin surface areas in the lowest quartile, the adjusted incidence rate ratio of HIV acquisition was 2.37 (95% confidence interval 1.05-5.31) in men with the largest quartile of foreskin surface area.

CONCLUSION: The risk of male HIV acquisition is increased among men with larger foreskin surface areas.

http://www.ncbi.nlm.nih.gov/pubmed/19770623

Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial
Original Text
Prof Robert C Bailey PhD a , Prof Stephen Moses MD c, Corette B Parker DrPh e, Kawango Agot PhD d, Ian Maclean PhD b, Prof John N Krieger MD f, Carolyn FM Williams PhD g, Prof Richard T Campbell PhD a, Prof Jeckoniah O Ndinya-Achola MBchB h
Summary
Background
Male circumcision could provide substantial protection against acquisition of HIV-1 infection. Our aim was to determine whether male circumcision had a protective effect against HIV infection, and to assess safety and changes in sexual behaviour related to this intervention.
Methods
We did a randomised controlled trial of 2784 men aged 18—24 years in Kisumu, Kenya. Men were randomly assigned to an intervention group (circumcision; n=1391) or a control group (delayed circumcision, 1393), and assessed by HIV testing, medical examinations, and behavioural interviews during follow-ups at 1, 3, 6, 12, 18, and 24 months. HIV seroincidence was estimated in an intention-to-treat analysis. This trial is registered with ClinicalTrials.gov, with the number NCT00059371.
Findings
The trial was stopped early on December 12, 2006, after a third interim analysis reviewed by the data and safety monitoring board. The median length of follow-up was 24 months. Follow-up for HIV status was incomplete for 240 (8·6%) participants. 22 men in the intervention group and 47 in the control group had tested positive for HIV when the study was stopped. The 2-year HIV incidence was 2·1% (95% CI 1·2—3·0) in the circumcision group and 4·2% (3·0—5·4) in the control group (p=0·0065); the relative risk of HIV infection in circumcised men was 0·47 (0·28—0·78), which corresponds to a reduction in the risk of acquiring an HIV infection of 53% (22—72). Adjusting for non-adherence to treatment and excluding four men found to be seropositive at enrolment, the protective effect of circumcision was 60% (32—77). Adverse events related to the intervention (21 events in 1·5% of those circumcised) resolved quickly. No behavioural risk compensation after circumcision was observed.
Interpretation
Male circumcision significantly reduces the risk of HIV acquisition in young men in Africa. Where appropriate, voluntary, safe, and affordable circumcision services should be integrated with other HIV preventive interventions and provided as expeditiously as possible.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)60312-2/abstract?refuid=S1571-8913(07)00109-4&refissn=1571-8913

Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial
Original Text
Prof Ronald H Gray MD a , Godfrey Kigozi MBChB b, David Serwadda MBChB c, Frederick Makumbi PhD c, Stephen Watya MBChB d, Fred Nalugoda MHS b, Noah Kiwanuka MBChB b, Prof Lawrence H Moulton PhD a, Mohammad A Chaudhary PhD a, Michael Z Chen MSc a, Nelson K Sewankambo MBChB e, Fred Wabwire-Mangen PhD c, Melanie C Bacon MPH f, Carolyn FM Williams PhD f, Pius Opendi MBChB b, Steven J Reynolds MD f g, Oliver Laeyendecker MSc f g, Prof Thomas C Quinn MD f g, Prof Maria J Wawer MD a
Summary
Background
Ecological and observational studies suggest that male circumcision reduces the risk of HIV acquisition in men. Our aim was to investigate the effect of male circumcision on HIV incidence in men.
Methods
4996 uncircumcised, HIV-negative men aged 15—49 years who agreed to HIV testing and counselling were enrolled in this randomised trial in rural Rakai district, Uganda. Men were randomly assigned to receive immediate circumcision (n=2474) or circumcision delayed for 24 months (2522). HIV testing, physical examination, and interviews were repeated at 6, 12, and 24 month follow-up visits. The primary outcome was HIV incidence. Analyses were done on a modified intention-to-treat basis. This trial is registered with ClinicalTrials.gov, with the number NCT00425984.
Findings
Baseline characteristics of the men in the intervention and control groups were much the same at enrolment. Retention rates were much the same in the two groups, with 90—92% of participants retained at all time points. In the modified intention-to-treat analysis, HIV incidence over 24 months was 0·66 cases per 100 person-years in the intervention group and 1·33 cases per 100 person-years in the control group (estimated efficacy of intervention 51%, 95% CI 16—72; p=0·006). The as-treated efficacy was 55% (95% CI 22—75; p=0·002); efficacy from the Kaplan-Meier time-to-HIV-detection as-treated analysis was 60% (30—77; p=0·003). HIV incidence was lower in the intervention group than it was in the control group in all sociodemographic, behavioural, and sexually transmitted disease symptom subgroups. Moderate or severe adverse events occurred in 84 (3·6%) circumcisions; all resolved with treatment. Behaviours were much the same in both groups during follow-up.
Interpretation
Male circumcision reduced HIV incidence in men without behavioural disinhibition. Circumcision can be recommended for HIV prevention in men.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)60313-4/abstract?refuid=S0749-3797(09)00491-7&refissn=0749-3797

Effect of circumcision of HIV-negative men on transmission of human papillomavirus to HIV-negative women: a randomised trial in Rakai, Uganda
Original Text
Prof Maria J Wawer MD a f †, Dr Aaron AR Tobian MD a c †, Godfrey Kigozi MBChB f, Xiangrong Kong PhD a d, Patti E Gravitt PhD e, David Serwadda MMed f g, Fred Nalugoda MHS f g, Frederick Makumbi PhD f g, Victor Ssempiija ScM f, Nelson Sewankambo MMed f h, Stephen Watya MMed i, Kevin P Eaton BS b, Amy E. Oliver BA b, Michael Z Chen MSc a, Steven J Reynolds MD b j, Prof Thomas C Quinn MD b j, Prof Ronald H Gray MD a f
Summary
Background
Randomised trials show that male circumcision reduces the prevalence and incidence of high-risk human papillomavirus (HPV) infection in men. We assessed the efficacy of male circumcision to reduce prevalence and incidence of high-risk HPV in female partners of circumcised men.
Methods
In two parallel but independent randomised controlled trials of male circumcision, we enrolled HIV-negative men and their female partners between 2003 and 2006, in Rakai, Uganda. With a computer-generated random number sequence in blocks of 20, men were assigned to undergo circumcision immediately (intervention) or after 24 months (control). HIV-uninfected female partners (648 of men from the intervention group, and 597 of men in the control group) were simultaneously enrolled and provided interview information and self-collected vaginal swabs at baseline, 12 months, and 24 months. Vaginal swabs were tested for high-risk HPV by Roche HPV Linear Array. Female HPV infection was a secondary endpoint of the trials, assessed as the prevalence of high-risk HPV infection 24 months after intervention and the incidence of new infections during the trial. Analysis was by intention-to-treat. An as-treated analysis was also done to account for study-group crossovers. The trials were registered, numbers NCT00425984 and NCT00124878.
Findings
During the trial, 18 men in the control group underwent circumcision elsewhere, and 31 in the intervention group did not undergo circumcision. At 24-month follow-up, data were available for 544 women in the intervention group and 488 in the control group; 151 (27·8%) women in the intervention group and 189 (38·7%) in the control group had high-risk HPV infection (prevalence risk ratio=0·72, 95% CI 0·60—0·85, p=0·001). During the trial, incidence of high-risk HPV infection in women was lower in the intervention group than in the control group (20·7 infections vs 26·9 infections per 100 person-years; incidence rate ratio=0·77, 0·63—0·93, p=0·008).
Interpretation
Our findings indicate that male circumcision should now be accepted as an efficacious intervention for reducing the prevalence and incidence of HPV infections in female partners. However, protection is only partial; the promotion of safe sex practices is also important.
Funding
The Bill & Melinda Gates Foundation, National Institutes of Health, and Fogarty International Center.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61967-8/abstract
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http://www.circinfo.org/JAMA_censorship.html



JAMA censors circumcision critics:

Circumcision promoters given open slather

An extraordinary feature of the United States today is the widening gulf between popular and professional medical attitudes towards routine circumcision, and the sharp divisions of opinion among medical and health professionals themselves. On one side we can see a flood of attacks on circumcision on blogs, websites, Youtube and in the mass media; more and more young parents deciding not to circumcise their boys; increasing numbers of circumcised men voicing their anger and resentment at having been circumcised, and taking up the onerous task of foreskin restoration; and if that was not a sufficient indication of the way the wind is blowing, it appears that a significant number of Jewish Americans are also abandoning circumcision in favour of peaceful naming ceremonies. Given the swelling flood of critical comment, it looks as though the "tipping point" predicted by Geoffrey Miller is rapidly approaching.

Within professional circles there is obviously no consensus on the issue and probably bitter argument behind closed doors. Both the Centers for Disease Control and the American Academy of Pediatrics have been “working on” new circumcision policy statements for years; every few months they announce that it is just about ready to be released, yet nothing emerges. It would appear either that they cannot find the evidence they need to justify a recommendation of infant circumcision in the United States, or that the members of the various task forces cannot reach agreement on the content or wording of the policy. In the meantime, medical authorities in both Australia and the Netherlands have issued policies that firmly reject routine circumcision, making it far more difficult for those who want to restore the old days. The problem for the CDC is that all the evidence for circumcision having a protective effect against HIV and human papilloma virus comes from experiments on adult men in African countries with extremely high levels of heterosexual HIV infection. These conditions simply do not apply in the USA (or any other developed country); since there are no American studies showing that circumcision has any protective effect against these problems, it becomes very difficult to “recommend” it as a routine health precaution. Quite apart from the bioethical and human rights issues, the so called “medical benefits” are simply not there.

These developments clearly have some sectors of the American medical industry deeply worried, including, the editors of many US medical journals, who seem to think that the African AIDS crisis presents a heaven-sent opportunity to stop the rot. Over the past few years we have seen any number of scaremongering articles, with titles such as “Declining rate of circumcision despite increasing evidence of health benefits”, and numerous opinion pieces by diehard believers in circumcision, who paint lurid scenarios of the public health catastrophe that is sure to unfold if American parents stop circumcising their baby boys. (Indeed, according to one imaginative American senator, the omission could even lead to epidemics of spina bifida and "neurogenic bladder" - whatever that is.)

A recent effusion along these lines was produced by Aaron Tobian and Ronald Gray, both seasoned pro-circumcision warhorses with a long record of such advocacy. [1] Taking time off from their well-funded day job (circumcising ill-informed but trusting Africans), they penned a short opinion piece, published in the Journal of the American Medical Association, in which they asserted that what was good for Swaziland and Zimbabwe was also good for the United States. Now you might well feel that America’s desperate debt situation, unemployment crisis and general social dislocation means that it does have much in common with the less developed parts of darkest Africa, in which case it would perhaps follow that a tribal rite such as circumcision is entirely appropriate. Indeed, by asserting that parental power to circumcise children should not be in any way limited because this would be an affront to religious freedom, Tobian and Gray suggest as much. But their principal argument is to do with that other American dream – health. Because three clinical trials in South Africa, Kenya and Uganda appeared to show that circumcision of sexually active adult men could lower their risk of acquiring HIV in an environment of high heterosexual prevalence, baby boys in America should be circumcised as a precaution.

We have heard this tired old argument so often from circumcision advocates that we must wonder why the editor of JAMA bothered to publish such a poorly-argued rehash of the same old stuff. But not only did he publish it, he also censored or refused to print letters criticizing the obvious flaws in this prescription. To our knowledge, at least 8 letters were submitted to the journal, only 2 of which were published, and one of these was so severely cut that the author complained that he had been censored rather than edited. Not content with suppressing contrary opinion, JAMA also published 2 letters in support of the Tobian and Gray’s position and, on top of that, gave them generous space for a “response” that allowed them to repeat their case all over again. What else could the editor do: if there are no good arguments or relevant evidence for a course of action he wishes to follow, the only thing to do is to keep asserting its necessity in the hope that if it is done often enough, people will come to believe it by sheer dint of repetition.

In an attempt to overcome this blatant censorship, and to restore some semblance of decency and fairness to the medico-scientific debate about circumcision (a debate in which the negative is gagged most of the time), we publish a selection of the letters that JAMA refused to publish. We are not publishing Tobian and Gray’s original article because it was made freely available at the time, and heralded with a media release that was picked up all over the world, thus giving it massive exposure. You can easily get hold of it if you want it through the JAMA website. The letters published here focus on different objections to the circumcision solution, and one theme is indignation and wonderment that one of the world’s leading medical journals should publish such a poorly-argued case, particularly one that ignores the cardinal principle of evidence-based medicine: that treatments should follow directly from the evidence. Tobian and Gray need to go back to school and relearn their geography; contrary to what they seem to think, the United States is not Africa.

We invite readers to compare the Tobian and Gray’s proposals with the arguments of their critics and make their own assessment of the who has the better case.

[1] Tobian AAR, Gray RH. The medical benefits of male circumcision. JAMA 2011; 306: 1479-80.
The letters JAMA refused to publish
Ignores ethical and human rights issues

Tobian and Gray ignore the substantial ethical and human rights implications of male circumcision as an HIV preventive. While they acknowledge that the best interests of the child are a primary consideration, they claim that banning neonatal male circumcision denies religious freedoms to Jewish and Muslim parents, which would be potentially unconstitutional. The opposite is true. Permitting parents to irreversibly mark their religion on the bodies of their children by amputating functional tissue is contrary to the law. After all, upon reaching adulthood, the child might choose to follow a different religion.

In 1891, the United States Supreme Court recognized the right of all citizens to bodily integrity and self-determination. No right is held more sacred or is more carefully guarded by common law than the right of every individual to the possession and control of his own person free from all restraints or interference of others. [1] Joel Feinberg argues for the child’s right to an open future, [2] and the British Medical Association recommends prioritizing options that maximize the patient’s future opportunities and choices. [3]

When children are incapable of consenting, parents possess temporary authority to make health care decisions on their behalf if the procedure is in the child's best interests. Parents do not possess unrestricted authority to make decisions on behalf of their children. Moreover, parents are not permitted to make martyrs of their children. [4] According to the American Academy of Pediatrics, parental permission for medical intervention is authorized only in situations of clear and immediate medical necessity, such as disease, trauma, or deformity. [5] Because parents lack the power to give permission for prophylactic amputation from their children of healthy tissue, and because neonatal circumcision has no universally recognized medical benefit, parental permission for the procedure is not effective.

Where parents request a procedure that is not medically indicated, courts have required strong evidence that the procedure is in the patient-child's interests and does not entail parents injecting their own preferences into the decision-making process. The benefits of the proposed procedure must clearly outweigh short- and long-term disadvantages, and spiritual considerations may not be incorporated into this analysis. For non-essential treatments—such as neonatal circumcision--that can be deferred without loss of efficacy, the physician and family must wait until the child is old enough to consent. Judging by the low adult circumcision rates, most will hang onto what they have.

References

1. Feigenbaum MS. Minors, medical treatment, and interspousal disagreement: Should Solomon split the child? De Paul L Rev 1992; 41:841-884.

2. Feinberg J. 2007. The Child’s Right to an Open Future. In Curren R, ed. Philosophy of Education: An Anthology. Malden, Massachusetts: Wiley-Blackwell: 112-123.

3. Medical Ethics Committee, British Medical Association. 2006. The Law & Ethics of Male Circumcision. London: British Medical Association.

4. Prince v. Massachusetts, 321 U.S. 158 (1944).

5. American Academy of Pediatrics Committee on Bioethics. Informed consent, parental permission, and assent in pediatric practice. Pediatrics 1995; 95: 314-317.

J. Steven Svoboda, JD Hons (Harvard), MS (Berkeley)
Executive Director, Attorneys for the Rights of the Child
Better methods of HIV control available

Looking past the statistical sleights-of-hand that characterize the African RCTs upon which Gray and Tobian rely so heavily (and forgiving the Tuskegee redux situation which sent HIV infected African men back home untreated), both bioethical and practical issues intrude on their scheme. The fundamental bioethics of surgery generally – and epidemiology in particular – require that the least intrusive methods of disease control be systematically applied before more drastic measures are adopted.

Gray and Tobian fail to mention that ART therapy reduces to near zero the likelihood of sero-conversion between discordant partners. Nor do they mention that barrier methods are themselves much more effective (and affordable) than male circumcision (MC). Neither has been widely available to Africans even while the funding for a massive campaign for MC appears available. Nor do Gray and Tobian discuss the morbidity and mortality (or iatrogenic transmission of HIV itself) such a campaign, whether in Africa or the USA, would entail.

Gray and Tobian concede that the African RCTs may not be directly applicable to the situation in the USA, and admit there is a racial and social-class correlation accounting for the incidence of STIs. But in the USA, at least, this experiment has already been conducted, longitudinally no less, and failed miserably. The United States has the highest rate of HIV among Western countries, and also the highest rate of MC, around 70%. Circumcising American infants in 2011 is not going to shift those numbers significantly, even in the long term. Moreover, Gray and Tobian appear to be recommending a situation in which over-confidence in the prophylactic properties of MC will produce males who “risk compensate” by unprotected sex, thus over-balancing any claimed prophylaxis. We have already seen evidence of this in Sub-Saharan Africa. Mathematical models do not reflect that risk, which should be of great concern to vulnerable female partners, whether in Africa or the US.

American children – circumcised in 2011 as a putative preventative of a disease of which they are not at risk until they become sexually active, and very careless – will have every right to demand in 2031 why less intrusive measures of disease control were not exhausted before they were ensnared in the Gray–Tobian scheme. They might point to Western Europe or New Zealand, where HIV rates are much lower than the USA, and circumcision is rare or non-existent Finally, we have been here before. A similar massive MC campaign, featuring similar tortured reasoning, was proposed to control the American black population in 1914. [1] Mercifully, the proposal failed.

George C. Denniston, MD, MPH,
President
John V. Geisheker, JD, LLM,
Executive Director, Doctors Opposing Circumcision, Seattle

1. Hazen HH. Syphilis in the American Negro. JAMA 1914; 63(6): 463-8.
Violates child’s right to physical integrity and Christian religious teaching

Tobian and Gray suggested that Medicaid should pay for non-therapeutic circumcisions, including religious circumcisions of Jews and Muslims. By law, Medicaid tax dollars are to be used for medically necessary (not religious) services, and not wasted fraudulently on unnecessary surgeries. All fifty states should instead defund all unnecessary circumcisions.

No national medical association in the world recommends routine circumcision, despite the opinions and questionable research of pro-circumcision advocates. Amputating (and selling) healthy body parts from children may be financially profitable for some, but it is unethical and violates Christian teaching. Father Edwin F. Healy, S.J. wrote, “Some physicians, it seems, circumcise all male infants, and their motive appears to be mercenary. Such physicians act in a manner unworthy of their high calling. ” [1] Tobian’s and Gray’s commentary was just the latest high-pressure sales pitch.

Catholics (and other Christians) should not be forced to pay for non-therapeutic circumcisions. Catholic Catechism teaching (# 2297) states, “Except when performed for strictly therapeutic medical reasons, directly intended amputations, mutilations, and sterilizations are against the moral law.” [2] In 1999, the American Academy of Pediatrics described circumcision as “amputation of the foreskin." In 2000, the American Medical Association described elective circumcisions as “non-therapeutic.” [3]

Fr Peter A. Clark, SJ, PhD summarized the problem with circumcision. “God created us in God's image and likeness” (Gen 1:27-28). It follows then that God created males with normal, healthy foreskins for the purpose of protecting the glans, providing natural lubrication to prevent dryness, and contributing significantly to the sexual response of the intact male. To surgically remove the foreskin for hygienic reasons, and/or to obtain other questionable benefits that absorb medical resources costing over $200 million a year is not only ethically unjustifiable but morally irresponsible, especially when such procedures can lead to serious injury and even death. Besides the possible harm the procedure can inflict on a child — which violates the basic tenet of … treating every person with dignity and respect — it also violates Medicaid’s mandate to be responsible stewards of medical resources. When millions of people in the United States and around the world lack basic health care, the provision of a non-therapeutic procedure — especially one that is unnecessary, costly, and in some cases fatal — is irresponsible and a violation of the moral law.” [4]

References

1. Healy EF. Problems connected with surgery. In Medical ethics. Chicago, IL: Loyola University Press; 1956: 129.

2. Catechism of the Catholic Church. Mahwah, New Jersey: Paulist Press; 1994: 553.

3. Fadel P. Respect for bodily integrity: a Catholic perspective on circumcision in Catholic hospitals. Am J Bioethics 2003; 3(2): 1f-3f.

4. Clark PA. To circumcise or not to circumcise? A Catholic ethicist argues that the practice is not in the best interest of male infants. Health Prog 2006; 87(5): 30-9.

Petrina Fadel
Director, Catholics Against Circumcision
Ignores African evidence: No consistency in relation between circumcision and HIV status

Tobian and Gray advocate male circumcision (MC) for preventing the transmission of HIV and other sexually transmitted infections (STI’s). Their arguments are serious, but hide counter evidence much displayed in the past 20 years. There is no doubt that male circumcision has an effect on HIV and STI transmission during sexual intercourse. However, this does not guarantee a large population impact, which would be the only rationale for recommending its large scale use. In Africa, groups practicing and not practicing male circumcision have basically the same level of HIV seroprevalence some 25 years after the onset of the epidemic. This has been shown from well conducted large scale Demographic and Health Surveys (DHS), as well as from numerous studies based on selective groups. [1,2] MC has no long term impact because of repeated exposure, and does not confer any “protection” per se. The effect found in clinical trials is similar to that of a low-efficacy vaccine (as cholera vaccine), or that of a low efficacy contraceptive (as rhythm method), none of which being recommended on a large scale because there are much more efficient alternatives. Note that in the Uganda and South-Africa trials, the incidence of HIV in the circumcised groups was about 1% per year, which would lead to massive levels of infection after 30 to 40 years of sexual life.

The argument about potential demographic impact or cost-effectiveness measured by mathematical models seems fallacious. Mathematical models are good as long as they predict the real world. This is the case for highly efficacious vaccines (measles), or highly efficacious contraceptives (pill, IUD), where mathematical models predict accurately the observed population impact. But in the case of MC, where is the mathematical model explaining the situation observed in Lesotho, Malawi or Tanzania, where the HIV seroprevalence is higher in the circumcised groups than in others? Where is the model explaining why the dynamics of the HIV epidemics is the same in circumcised ethnic groups than in others in South Africa?

Likewise, the argument about the long term effect of newborn circumcision does not match what has been found in a long term study in Australia. [3] Condom use and safe behaviour are the only efficacious strategies to protect individuals and to control STI’s at population level. This policy can be implemented on a large scale, as exemplified by the case of Japan.

References

1. Garenne M. Long-term population effect of male circumcision in generalized HIV epidemics in sub-Saharan Africa. African Journal of AIDS Research 2008; 7(1):1-8.

2. Van Howe, RS. Circumcision and HIV infection: review of the literature and meta-analysis. Int J STD&AIDS 1999; 10:8-16.

3. Millett GA, Flores SA, Marks G, Reed JB, Herbst JH. Circumcision status and risk of HIV and sexually transmitted infections among men who have sex with men: a meta-analysis. JAMA 2008; 300(14):1674-84.

Michel Garenne
Institut Pasteur, Epidemiologie des Maladies Emergentes, Paris
Claims not supported by evidence from African circumcision trials

Tobian and Gray [1] recommend that people making decisions about male circumcision in the US consider evidence from three randomized controlled trials (RCTs) in South Africa, Kenya, and Uganda, which reported that circumcision reduced men’s HIV incidence by 51% to 60%. This communication requests additional information from the Ugandan trial, [2] which was funded by the National Institutes for Health (NIH), and from a parallel trial of circumcision to protect men in Uganda, funded by the Bill and Melinda Gates Foundation (BMGF). [3]

Tobian and Gray state “the protective efficacy of circumcision increases with time.” In fact, the evidence shows that the opposite. The NIH-funded Ugandan trial collected data relevant to that statement during follow-up visits after the RCT was stopped in late 2006. [4] To my knowledge, these data have not been reported separately, nor have data from the BMGF-funded trial been reported separately. However, all infections and person-years (PYs) of follow-up in both trials (the NIH trial to December 2006; the NIH trial after December 2006; and the BMGF trial) have been reported in combined form. [4] Subtracting date reported from the NIH trial to December 2006 [2] shows a net of 38 infections in 2,927 PYs during late follow-up in the NIH trial and in the BMGF trial. From these net data, circumcision reduced men’s risk for HIV by 42% – showing that protection waned over time among men in the NIH trial and/or less protection for men in the BMGF trial than in the other three trials.

Other unreported evidence could inform continuing debates about circumcision’s impact on HIV transmission. Data reported from the Ugandan NIH trial to December 2006 suggest that non-sexual transmission was important: 16 of 67 men with incident HIV reported no partners (6 men) or 100% condom use (10 men). [2] Similar data are not available from later follow-up in the NIH trial or from the BMGF trial. The HIV-status of men’s partners is relevant to assess men’s risks. The BMGF protocol reports following more than 3,700 wives, including wives of men in the NIH trial. [3] But neither trial has reported the partner’s HIV-status for any man. Study teams have reported no information about blood exposures. Full report of collected evidence from these studies might improve our understanding of circumcision’s impact on men’s and women’s health, as well as adults’ risks for HIV infection in Africa. [5]

References

1. Tobian AAR, Gray RH. The medical benefits of male circumcision. JAMA 2011; 306: 1479-1480.

2. Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomized trial. Lancet 2007; 369: 657-666.

3. ClinicalTrials.gov. Trial of male circumcision: HIV, sexually transmitted disease (STD) and behavioral effects in men, women and the community. ClinicalTrials.gov identifier: NCT00124878, last updated on 9 August 2007. Washington DC: NIH, 2007. Available at: http://clinicaltrials.gov/show/NCT00124878 (accessed 25 June 2011).

4. Gray RH, Serwadda D, Tobian AAR, et al. Effects of genital ulcer disease and herpes simplex virus type 2 on the efficacy of male circumcision for HIV prevention: analyses from the Rakai trials. PLoS Med 2009; e1000187.

5. Gisselquist D. Randomized controlled trials for HIV/AIDS prevention among men and women in Africa: untraced infections, unasked questions, and unreported data. Social Science Research Network 2011. Available at: http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1940999 (accessed 11 October 2011); and at http://dontgetstuck.wordpress.com/downloads/ (accessed 11 October 2011).

David Gisselquist, independent consultant
Claims about Human Papilloma Virus untrue

Why did JAMA publish the recent commentary by Tobian and Gray when there is good reason to ignore their studies? When studying the impact of circumcision on human papillomavirus (HPV) infections, Tobian and Gray found a 35% reduction in the incidence of HPV in those randomized to early circumcision. [1] Unfortunately, the entire treatment effect can be attributed to sampling bias, as the researchers failed to sample the penile shaft where circumcised men are more likely to harbor the virus. [2] Similarly, the reduction in genital herpes infections, when properly adjusted for lead-time bias, is not statistically significant. [2] Their study found no association between circumcision and gonorrhea and a slight, non-significant increased risk of syphilis in those randomized to early circumcision.

Their study on HPV transmission to women, whose husbands had been randomized to early or delayed circumcision, also has methodological flaws. The researchers made no attempt to determine the source of the infections, half of the women were infected at the beginning of the trial, infections were determined using an insensitive method, and 17% were lost to follow-up. Interestingly, condom use was associated with increased HPV incidence. For HPV 16 and 18, which account for 70% of cervical cancers, no difference was found based on the partner’s circumcision status. Consequently, their positive findings apply to viruses responsible for only 30% of cervical cancers.

Studies from the United States have failed to confirm these flawed African studies. A prospective study of 603 female university students found no association between new HPV infections and circumcision status of the partner. [3] Similarly, in 477 male university students, there was no association between the incidence of HPV and circumcision status. [4] A national survey using a complex, stratified, multistage probability sampling design found that circumcision was not associated with herpes simplex virus type 2. [5] Fortunately, some of this discussion is moot, as effective HPV vaccines are currently available. It appears that JAMA is allowing well-financed zealots to promote their own unethical, poorly designed research. In the future commentaries should be also be carefully vetted for factual accuracy.

References

1. Tobian AAR, Serwadda D, Quinn TC, Kigozi G, Gravitt PE, Laeyendecker O, et al. Male circumcision for the prevention of HSV-2 and HPV infections and syphilis. N Engl J Med 2009; 360: 1298-309.

2. Storms MR. Male circumcision for the prevention of HSV-2 and HPV infections. N Engl J Med 2009; 361: 307.

3. Winer RL, Lee S-K, Hughes JP, Adam DE, Kiviat NB, Koutsky LA. Genital human papillomavirus infection: incidence and risk factors in a cohort of female university students. Am J Epidemiol 2003; 157: 218-26. Erratta 2003; 157: 858.

4. VanBuskirk K, Winer RL, Hughes JP, Feng Q, Arima Y, Lee S-K, et al. Circumcision and the acquisition of human papillomavirus infection in young men. Sex Transm Dis 2011 (December); e-pub ahead of print. See summary on this site.

5. Xu F, Markowitz LE, Sternberg MR, Aral SO. Prevalence of circumcision and herpes simplex type 2 infection in men in the United States: the National Health and Nutrition Examination Survey (NHANES), 1999-2004. Sex Transm Dis 2007; 34: 479-84.

Robert S. Van Howe, MD, MS, FAAP
Clinical Professor, Department of Pediatrics and Human Development
Michigan State College of Human Medicine
Marquette, Michigan
Ignores harm to women

Imagine my surprise to see JAMA allow Tobian and Gray a commentary promoting the benefits of male circumcision while ignoring how their own research showed a 50% increase in HIV transmission to the partners of circumcised males. [1] Why would any ethical physician promote a procedure that will ultimately infect a greater number of females who will then infect their babies? Furthermore, infant circumcision has been shown to negatively impact the primal period by decreasing bonding and breastfeeding, [2] causing increased pain to the newborn because they lack inhibitory pathways, and imprinting violence onto their brains. [3] It is barbaric and unethical to cut off healthy, normal body parts on people without their consent. Parental rights do not trump basic human rights in such situations. Saying that infant circumcision prevents some unforeseen adult disease is like promoting mastectomies for infant females. It is ludicrous. The only thing circumcision prevents is normal sexual function. [4]

What is particularly galling is that their studies are not only flawed with multiple biases, but they would never have been allowed in the U.S. because of the ethical red flags. [5] Tobian and Gray have moved Tuskegee to Africa, and Johns Hopkins continues to make millions off these unethical experiments using American taxpayers’ money. Tobian and Gray’s professional careers depend on promulgating the myth that male circumcision prevents HIV. Yet, they state they have no conflict of interest. Their impassioned pleas can only undermine their credibility, which can only be rescued by making their data public. Any reluctance to do so should be suspect.

Michelle R. Storms, MD
Northern Michigan University

References

1. Wawer MJ, Makumbi K, Kigozi G, Serwadda D, Watya S, Nalugoda F, Buwembo D, Ssempijja V, Kiwanuka N, Moulton LH, Sewankambo NK, Reynolds SJ, Quinn TC, Opendi P, Iga B, Ridzon R, Laeyendecker O, Gray RH. Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial. Lancet 2009; 374: 229-37.

2. Howard CR, Howard FM, Weitzman ML. Acetaminophen analgesia in neonatal circumcision: the effect on pain. Pediatrics 1994; 93: 641-6.

3. Fitzgerald M. The birth of pain. MRC News 1998; (Summer): 20-3.

4. Frisch M, Lindholm M, Grønbæk. Male circumcision and sexual function in men and women: a survey-based, cross-sectional study in Denmark. Int J Epidemiol 40.5 (October 2011): 1367-1381. See news item at Science Nordic.

5. Van Howe RS, Storms MR. How the circumcision solution will increase HIV infections. J Publ Health Afr 2011; 2(e4):11-5.
Ignores flaws and limitations of African studies

The commentary by Tobian and Gray placed too much importance on the results of their own and other randomized clinical trials (RCTs), which have serious problems with both internal and external validity. Internal validity problems include selection bias (only men willing to be circumcised were recruited), expectation bias, lead-time bias, duration bias (one of the studies found the protective effect began to disappear at 18 months and valid long-term follow-up was not possible), and attrition bias (205 men became infected, yet 703 were lost to follow-up). The studies were halted early, which, in studies with a small percentage having the outcome of interest, can result in marked overestimates of treatment effect and exaggeration of lead-time bias. There were also unexplained anomalies. Men who reported no unprotected sex accounted for 23 of 69 infections in the South African study and 16 of 67 infections in the Ugandan study. In the Ugandan study, men who consistently used condoms had a higher frequency of HIV infection than men who never used condoms (1.03 versus 0.91 per 100 person-years). The researchers made no attempt to determine the source of new HIV infections, so the number of sexually transmitted infections is unclear.

The studies also lack external validity. [1] In African national surveys, HIV rates are higher in circumcised males for 10 of the 18 countries. [2] Subsequent African studies have failed to find an association between circumcision status and HIV. [3] There is a major problem when extrapolating the RCT results, conducted under highly sterile conditions with research-supported and supervised personnel, to the scale-up for African health care at large, in which shortages of personnel, sterile conditions, and equipment, would likely produce more infections. The men in the trials received continuous counselling, extensive education, free condoms, free health care, and high levels of compensation not available to other Africans.

Extrapolating these results to infants in the United States is an even further unjustified leap. There are no studies of infant circumcision or of heterosexual males in the United States that support circumcision as a preventative for reducing HIV infection. With nearly 50 million Americans lacking health insurance, and poor children going without many basic services, it is ethically and morally inappropriate that Medicaid fund an unproven procedure. The focus should be on interventions that work. Abstinence, limiting the number of sexual partners, condom use, and testing for and treating HIV, are much better options to be pursued. [4]

References

1. Green LW, Travis JW, McAllister RG, Peterson KW, Vardanyan AN, Craig A. Male circumcision and HIV prevention: Insufficient evidence and neglected external validity. Am J Prev Med. 2010; 39: 479-82.

2. Vinod M, Medley A, Hong R, Gu Y, Robey R. Levels and spread of HIV seroprevalence and associated factors: evidence from national household surveys. DHS Comparative Reports No. 2. 2009:209.

3. Heffron R, Chao A, Mwinga A, et al. High prevalent and incident HIV-1 and herpes simplex virus 2 infection among male migrant and non-migrant sugar farm workers in Zambia. Sex Transm Infect 2011; 87: 283-8.

4. Lima V, Anema A, Wood R, et al. The combined impact of male circumcision, condom use and HAART coverage on the HIV-1 epidemic in South Africa: a mathematical model. 5th IAS Conference on HIV Treatment, Pathogenesis and Prevention, Cape Town, abstract WECA105, 2009.

John W. Travis, MD, MPH
RMIT University, Melbourne, Australia
Ignores principles of evidence-based medicine

Tobian and Gray have cherry picked the medical evidence in favour of neonatal circumcision and ignored both arguments and evidence to the contrary. A similar exercise was performed in Australia last year by Cooper et al, [1] which received an immediate rebuttal in the circumcision policy statement released by the Royal Australasian College of Physicians, and so much additional criticism that the journal published eight letters in reply. [2] After an exhaustive review of the evidence the RACP found that “in low prevalence populations … circumcision does not provide significant protection against STIs and HIV,” and concluded that there was no medical case for neonatal circumcision. [3] A longer critique argued that the proposal was flawed because it ignored doubts about the African clinical trials and the interpretation of the WHO recommendations arising from them; was irrelevant to the specifics of Australia’s HIV problem; departed from the principles of evidence-based medicine; underplayed the harm and risks of circumcision; ignored basic principles of medical ethics and human rights; and was marred by unscientific thinking in describing circumcision as a “surgical vaccine.” [4]

Tobian and Gray’s appeal suffers from the same flaws, the most serious of which is its violation of the principles of evidence-based medicine. Evidence of circumcision as an acceptable tactic from underdeveloped countries with high sero-prevalence and predominantly female to male transmission cannot be transposed to developed countries with low sero-prevalence and transmission predominantly in MSM or injecting drug users. Where is the United States evidence that uncircumcised men are at greater risk of HIV, and that circumcision without consent is an effective and ethically acceptable response? Evidence that circumcision of adult men has a protective effect against HIV cannot be extrapolated to children [5], and the same is true of the claim that the Africans experienced no loss of sexual sensation; circumcision in infancy may well have a different impact from circumcision after sexual maturity.

Tobian and Gray assert that surrogate consent from parents overcomes the ethical and human rights problem because they can consent to vaccination. This hackneyed analogy fails because children are vaccinated against diseases that affect them as children and, unlike circumcision, it does not entail the amputation of a functional body part that the individual may appreciate. Children are not at risk of HIV or any other STIs: since there is no urgency to intervene we can safely wait until they are old enough to provide their own informed consent.

References

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. “The case for boosting infant male circumcision in the face of rising heterosexual transmission of HIV” ... and now the case against. Med J Aust 2011;194(1)97-101.

3. Royal Australasian College of Physicians. Circumcision – RACP Position Statement. Sydney (AUST): RACP; 2010 September.

4. Darby R, Van Howe R. Not a surgical vaccine: There is no case for boosting infant male circumcision to combat heterosexual transmission of HIV in Australia. Aust N Z J Public Health 2011;35(5):459-465.

5. Perera CL, Bridgewater FHG, Thavaneswaran P, Maddern GJ. Safety and efficacy of nontherapeutic male circumcision: A systematic review. Ann Fam Med 2010; 8 (1): 64-72. See summary on this site.

Robert Darby
Canberra, Australia

NOTE: JAMA did publish an “edited” (i.e. censored) version of this letter; we publish the original, full version here.
Circumcision commentary ignores risks

In making their case for more explicit promotion of neonatal circumcision in the United States, Tobian and Gray cursorily dismiss or simply ignore the arguments against it, including such fundamentally crucial factors as the true range and incidence of risks. The claimed 0.2% to 0.6% neonatal complication rate is a falsely minimized representation of potential harm, already suspect due to the retrospective, short-term design of the source studies. Data exists to show, for example, at least a 1% risk of circumcised boys needing some kind of repeat surgery,(1) and up to a 20% incidence of meatal stenosis (found virtually only in circumcised males, and often requiring painful surgical correction).(2) Other real concerns left unacknowledged include the risk of circumcision-related MRSA infection,(3) and underreporting of rarer but catastrophic complications.(4)

The United States does not, in fact, have in place any comprehensive system of prospective surveillance for adverse events following circumcision. The truth is that no one actually knows how many circumcised boys need to be rehospitalized, how many require specialist follow-up, IV antibiotics, or blood transfusions, how many lose part or all of their glans or penile shaft, or die due to circumcision complications, nor is there precise prospective data on the incidence of a host of other documented problems. But our lack of understanding of the scope of circumcision’s risks is not limited only to those problems directly associated with surgical outcomes. There is, in addition, little scientific knowledge of or attention paid to the possible harmful effects of genital cutting of children on later sexual functionality or emotional health.(5)

Without such information, flatly, no valid risk-benefit comparison, cost-benefit analysis, or policy pronouncements can be made. Nor indeed, when deprived of such risk information, can any parent be said to be giving valid informed consent. Promoting circumcision for its potential benefits, yet with such a limited and inadequate analysis of it potential risks and harms – let alone its ethical problems – is scientifically unsupportable and ethically improper.

References

1. Van Howe RS. A cost-utility analysis of neonatal circumcision. Med Decis Making 2004;24:584-601.

2. Joudi M, Fathi M, Hiradfar M. Incidence of asymptomatic meatal stenosis in children following neonatal circumcision. J Ped Urol 2011;7(5):526-8. Epub 2010 Sep 18.

3. Nguyen DM, Bancroft E, Mascola L et al. Risk factors for neonatal methicillin-resistant staphylococcus aureus infection in a well-infant nursery. Infect Control Hosp Epidemiol 2007;28(4):406-11.

4. Pediatric Death Review Committee: Office of the Chief Coroner of Ontario. Circumcision: A minor procedure? Paediatr Child Health. 2007;12(4);311-312.

5. Bollinger D, Van Howe RS. Alexithymia and circumcision trauma: A preliminary investigation. Int J Mens Health 2011;10(2):184-195.

Gillian Longley RN,

Colorado, USA
Further objections to the circumcision solution
Full of factual errors

The new editor of JAMA needs to find a competent fact checker to assure that the commentaries published by the journal are factually accurate. A case in point is the recent commentary on the need for more infant circumcision by Tobian and Gray. Contrary to their article:

1. The California ballot initiative did not propose a “ban” on circumcision.

2. There are no observational studies in the United States (let alone a large number) which found that male circumcision reduces the risk of HIV infection in men. On the contrary, American studies show either that circumcision makes no difference, or that circumcised men (especially if Black) are at greater risk of HIV. A study by Sansom et al, actually cited by Tobian and Gray as though it supported their case, actually showed the lifetime risk of HIV among Black men to be 6.23% with 73% circumcised, yet a lifetime risk to Hispanics of only 2.88% and a circumcision rate of 42%. [1] This would suggest either that there is no connection between circumcision and reduced susceptibility to HIV; that circumcision increases the risk of HIV; or that being Black in the USA is a far greater risk factor for HIV than “lack of circumcision”.

3. Very few of the observational studies document the age at which the participants were circumcised.

4. Blacks in the United States do not have “the lowest rates of male circumcision” but have circumcision rates which are similar to or greater than the circumcision rates in whites.

5. Circumcision has not been shown to reduce the risk of cervical cancer. Even if it did, that is not a valid reason to circumcise infant boys.

6. The American Academy of Pediatrics recommends that decisions be delayed until the child is competent enough to provide fully informed consent. The age of this depends on the child, but is usually around 14 years of age.

7. Meatitis has repeatedly been shown to be more common in circumcised males. Two studies have shown that balanitis is more common in circumcised boys, especially in the first three years of life. There have been three studies that compared the rates of phimosis based on circumcision status: none of which found a significant difference.

8. The complication rate of 0.2% given by the commentators is from a typographical error in the abstract of a study that found a 2% risk of complications. [2] The 0.6% figure is from a letter to the editor [3] . Based on actual studies, the rate of immediate complications is 2% to 10%. The rate of meatal stenosis, which is a delayed complication, is between 5% and 20%. [4]

9. There is no evidence that complication rate of neonatal male circumcision is substantially lower than the complication rates of adult male circumcision. Two studies have directly compared neonatal circumcision to later circumcision. One found no difference in complications, one found a higher rate of complications for the neonate.

10. Sexual dysfunction has been documented in a national survey in Denmark and multiple other studies. These are not anecdotal reports.

11. Vaccines with only 30% to 60% effectiveness are rarely if ever promoted or used, especially when other less expensive, more effective, less invasive options are available.

References

1. Sansom SL, Prabhu VS, Hutchinson AB, An Q, Hall HI, et al. Cost-effectiveness of newborn circumcision in reducing lifetime hiv risk among U.S. males. PLoS ONE 2010:5(1): e8723. doi:10.1371/journal.pone.0008723. Informative comment by Hanabi at http://www.plosone.org/article/comments/info%3Adoi/10.1371/journal.pone.0008723. See also comment on this site.

2. Gee WF, Ansell JS. Neonatal circumcision: a ten-year overview: with comparison of the Gomco clamp and the Plastibell device. Pediatrics 1976; 58: 824-7.

3. Harkavy KL. The circumcision debate. Pediatrics 1987; 79: 649-50.

4. Joudi M, Fathi M, Hiradfar M. Incidence of asymptomatic meatal stenosis in children following neonatal circumcision. J Pediatr Urol 2011; 7: 526-8.
Ignores functions of the foreskin

Before recommending unlimited government funding of infant male circumcision, Tobian and Gray should at least make a good will effort to acknowledge the impact of amputating the prepuce. The prepuce is a specialized, pentalaminar, junctional tissue, similar to lips and eyelids, that has skin on the outer surface and a mucosal membrane on the inner surface. Near the transition of the inner and outer surface is a pleated region with an extremely high concentration of fine-touch neuroreceptors. This region, which contains nearly all of the penis’s fine-touch neuroreceptors, is removed in virtually all circumcisions. [1] By contrast, the glans is a neurologically dumb organ and contains primarily free nerve endings that transmit only deep pressure and pain. [2] When tested for fine-touch thresholds, the foreskin was found to be the most sensitive portion of the penis, which was more sensitive that the most sensitive portion of the circumcised penis, which was the circumcision scar. The glans in circumcised adult men was significantly less sensitive than the glans in men not circumcised. [3] Similarly, the vibrotactile thresholds of the glans increase significantly following circumcision. [4]

Circumcision also severs the frenular artery and interrupts the blood supply to the ventral aspect of the urinary meatus. This results in scarring and narrowing meatus. Consequently, between 5% and 10% of males circumcised as infants will require a meatotomy to correct their acquired meatal stenosis. [5, 6] In absolute contrast to what is stated by Tobian and Gray, meatitis has been documented almost exclusively in circumcised males.

In the nineteenth century the medical community adopted circumcision as a cure for masturbation. Physicians at the time recognized that if the most sensitive portion of the penis were removed, this might help decrease the temptation to masturbate. Circumcision has been failing to deliver the promises of its promoters ever since.

References

1. Cold CJ, Taylor J. The prepuce. BJU Int 1999; 83 (suppl 1): 34-44.

2. Halata Z. Munger BL. The neuroanatomical basis for the protopathic sensibility of the human glans penis. Brain Res 1986; 371: 205-30.

3. Sorrells ML, Snyder JL, Reiss MD, Eden C, Milos MF, Wilcox N, Van Howe RS. Fine-touch pressure thresholds in the adult penis. BJU Int 2007; 99: 864-9.

4. Yang DM, Lin H, Zhang B, Guo W. [Circumcision affects glans penis vibration perception threshold]. Zhonghua Nan Ke Xue 2008; 14: 328-30.

5. Van Howe RS. Incidence of meatal stenosis following neonatal circumcision in a primary care setting. Clin Pediatr (Phila) 2006; 45; 49-54.

6. Joudi M, Fathi M, Hiradfar M. Incidence of asymptomatic meatal stenosis in children following neonatal circumcision. J Pediatr Urol 2011; 7: 526-8.
Smacks of racism and sexism

The commentary by Tobian and Gray suggests an underlying racism and sexism. Studies of circumcision were performed in Africa because they were not ethically permissible in the United States. HIV investigators in Africa have uniformly accepted the theory that the African epidemic is fuelled by frequent sexual contacts with multiple partners because it fits an unsubstantiated racial stereotype rather than the facts. This theory requires African men to have sexual contact with each of their partners on a daily basis to generate the current infection rates. [1] African men and women have been used as guinea pigs to fortify the American cultural practice of circumcision. In the most egregious of these studies, HIV infected men were randomized to circumcision or not. The HIV status of the participants was not disclosed to the participants or their female sexual partners. The female sexual partners were followed to determine how long it took for them to become HIV infected. Eighteen per cent of the women with circumcised partners became HIV infected and 12% of women with uncircumcised partners became HIV infected before the study was terminated. Amazingly, the researchers concluded that it was more important to circumcise HIV infected men so they could avoid stigmatization than to protect their female partners from the 50% increase in HIV infection risk. [2] In other words, they believe African women are dispensable. At least in Tuskegee, the men were no longer contagious.

In 2009 Gray and colleagues suggested promoting circumcision primarily to blacks and Hispanics. [3] While HIV infections are concentrated in the economically deprived, Hispanics have a much lower prevalence of HIV and a much lower circumcision rate than blacks. This would suggest that circumcision in the economically deprived may increase HIV infection rates. Blacks actually have the highest circumcision rates in the U.S. and yet also have the highest HIV rates.

Blacks have circumcision rates between 81% and 91%, depending on the decade of birth, which are similar or higher than the rates seen in whites. [4,5] Rather than admit circumcision has failed to protect black males from heterosexually transmitted HIV infection and focusing on more effective means of preventing HIV infection (such as condoms and anti-retroviral therapy), the commentators appear to think that some benefit may come from increasing an already high circumcision rate. This defies logic and suggests that there is a lingering fear of black sexuality.

References

1. Sawers L, Stillwaggon E. Concurrent sexual partnerships do not explain the HIV epidemics in Africa: a systematic review of the evidence. J Int AIDS Soc 2010; 13: 34.

2. Wawer MJ, Makumbi K, Kigozi G, Serwadda D, Watya S, Nalugoda F, Buwembo D, Ssempijja V, Kiwanuka N, Moulton LH, Sewankambo NK, Reynolds SJ, Quinn TC, Opendi P, Iga B, Ridzon R, Laeyendecker O, Gray RH. Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial. Lancet 2009; 374: 229-37.

3. Gray RH, Wawer MJ, Serwadda D, Kigozi G. The role of male circumcision in the prevention of human papillomavirus and HIV infection. J Infect Dis 2009; 199: 1-3.

4. Xu F, Markowitz LE, Sternberg MR, Aral SO. Prevalence of circumcision and herpes simplex type 2 infection in men in the United States: the National Health and Nutrition Examination Survey (NHANES), 1999-2004. Sex Transm Dis 2007; 34: 479-84.

5. 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(9): e861.
Discriminates in favour of minority religions

Tobian and Gray have suggested that Medicaid pay for the religious circumcisions of Jewish and Muslim boys. This clearly violates the separation between church and state as set up in the First Amendment of the Constitution. While the commentators use a selective bibliography to espouse their beliefs about the medical benefits of circumcision, parents do not circumcise their sons for some imaginary medical benefits, they circumcise them for cultural, cosmetic, and religious reasons.

One could more easily argue that marriage is associated with improved health, including lower rates of STIs, and lower rates of HIV infections. If Medicaid is asked to pay for circumcisions for religious reasons, Medicaid should also be expected to pay for religious weddings. Why should Jews and Muslims get a benefit from the state that is not available to people of other religions? The commentators obviously did not think this through. It is not the role of the state to favor those with one set of religious beliefs over another.

This is also a slap in the face of those from cultural or religious backgrounds who believe that they are required to have the genitals of their daughters cut. Over the past five years there has been increasing evidence in medical literature that cutting of female genitals may have medical benefits and minimal risks. [1-4] So, why focus only on boys, when girls could benefit as well?

References

1. Stallings RY, Karugendo E. Female circumcision and HIV infection in Tanzania: for better or for worse?[abstract] Third International AIDS Society Conference on HIV Pathogenesis and Treatment. Rio de Janeiro, July 25-27, 2005.

2. Essén B, Sjöberg N-O, Gudmundsson S, Östergren P-O, Lindqvist PG. No association between female circumcision and prolonged labour: a case control study of immigrant women giving birth in Sweden. Eur J Obstet Gynecol Reprod Biol 2005; 121: 182-5.

3. Catania L, Abdulcadir O, Puppo V, Verde JB, Abdulcadir J, Abdulcadir D. Pleasure and orgasm in women with Female Genital Mutilation/Cutting (FGM/C). J Sex Med 2007; 4: 1666-78.

4. Applebaum J, Cohen H, Matar M, Rabia JA, Kaplan Z. Symptoms of posttraumatic stress disorder after ritual female genital surgery among Bedouin in Israel: myth or reality? Prim Care Companion J Clin Psychiatry 2008; 10: 453-6.
Cavalier and selective attitude to the medical literature

Tobian and Gray’s commentary on infant male circumcision refers to “anecdotal reports that male circumcision can cause sexual dysfunction.” This statement indicates that the commentators are either unfamiliar with or are purposely mischaracterizing the medical literature. Several small studies that documented a lack or improvement or decline in sexual function following circumcision in adult males circumcised for medical indications. [1] There are several studies, with the exception of two performed in Turkey, that have shown a higher rate of premature ejaculation in adult male who are circumcised compared to the non-circumcised. In one study of 207 men, premature ejaculation was nearly five times greater in circumcised adults (adjusted OR 4.88, 95%CI=2.35-10.15).[2] These are not anecdotal reports.

In a study of 139 women who had sexual experience with both circumcised and non-circumcised men these women reported that sex with a non-circumcised partner had significantly less vaginal discomfort, a higher likelihood of vaginal and multiple orgasms, longer duration of coitus, and more positive post-coital feeling. On a rating scale between –10 and +10 these women rated coitus with circumcised men at an average of 1.81 and with non-circumcised men at an average of 8.03.[3] This study may have been influenced by a selection bias; however, a national health survey of 5552 adults in Denmark confirmed these findings. In this survey circumcised men reported a greater number of sexual partners and a greater rate of reporting frequent difficulties with orgasm (adjusted OR=3.26, 95%CI=1.42-7.47). Women with a circumcised male sexual partner reported greater rates of incomplete sexual fulfillment (AdOR=2.09, 95%CI=1.05-4.16), difficulties with orgasm (AdOR=2.66,95%CI=1.07-6.66), and dyspareunia (AdOR=8.45, 3.01-23.74).[4] A national survey is not an anecdotal report.

The studies from Africa mentioned by the commentators need to be taken with a grain of salt. The participants in these trials were extremely well compensated by African standards, so both the Hawthorne effect and willingness to please the participant’s benefactors may have been in play. These studies focused on changes in overall sexual satisfaction, leaving readers uninformed about the actual levels of sexual satisfaction reported. The men in the study also reported implausibly high levels of sexual satisfaction. This suggests that the measure of sexual satisfaction used may not have been able to measure a difference if it existed. In the future it would be better if JAMA published commentaries written by individuals who are familiar with the medical literature and unwilling to mischaracterize it.

References

1. Coursey JW, Morey AF, McAninch JW, Summerton DJ, Secrest C, White P, Miller K, Pieczonka C, Hochberg D, Armenakas N. Erectile function after anterior urethroplasty. J Urol 2001; 166: 2273-6.

2. Tang WS, Khoo EM. Prevalence and correlates of premature ejaculation in a primary care setting: a preliminary cross-sectional study. J Sex Med 2011; epub ahead of print.

3. O’Hara K, O’Hara J. The effect of male circumcision on the sexual enjoyment of the female partner. BJU Int 1999; 83 (suppl 1): 79-84.

4. Frisch M, Lindholm M, Grønbæk. Male circumcision and sexual function in men and women: a survey-based, cross-sectional study in Denmark. Int J Epidemiol 40.5 (October 2011): 1367-1381. See news item at Science Nordic.
Violates research and publications ethics

One of the first ethical questions a new editor of a medical journal faces is, how does a journal deal with well-financed zealots who want to promote their own unethical, poorly designed research? It appears that for the new editor of JAMA that the answer is to give them open slather and silence any critical voices.

In the last year Tobian and Gray have authored numerous opinion pieces to promote male infant circumcision in the United States. [1] Hot on the heels of their multi-million dollar NIH- and Gates Foundation-funded studies in adults, these researchers, turned lobbyists, are telling us that infants in the USA are really adults in Africa and need to be circumcised. Unfortunately, their enthusiasm is hollow and desperate, and their studies were unethical. Before their studies began, it was known that more effective, less expensive, less invasive methods for preventing HIV infection were available. To include humans in an experiment knowing that the intervention is inferior and more invasive than currently available options was clearly unethical. To follow HIV-infected men, without informing them or their partners of their infection status, to see how long it took before their female sexual partners became infected may be the most unethical study in several generations. It remains unclear how these clearly unethical studies were approved by the Investigational Review Board of Johns Hopkins or published by a well-respected journal such as The Lancet.
The methodological shortcomings of the studies out of Johns Hopkins have been discussed in detail elsewhere and may explain why these studies lack external validity. [2,3]

Finally, from reading Tobian and Gray, you would never know that there is a study on circumcision that does not list one of them among the authors. Such academic narcissism should not be encouraged, although it provides insight to the commentators’ motives. In 2005 certain sceptics suggested that circumcision advocates were studying circumcision and HIV in Africa as method of shoring up waning support for infant male circumcision in the USA [4] It looks like this prediction has come true. Readers of JAMA do not want to read unsubstantiated propaganda. Fresh on the job, and the new editor has already earned a failing grade.

References

1. Tobian AAR, Gray RH, Quinn TC. Male circumcision for the prevention of acquisition and transmission of sexually transmitted infections: the case for neonatal circumcision. Arch Pediatr Adolesc Med 2010; 164: 78-84.

2. Garenne M. Long-term population effect of male circumcision in generalised HIV epidemics in sub-Saharan Africa. Afr J AIDS Res 2008; 7: 1-8.

3. Green LW, Travis JW, McAllister RG, Peterson KW, Vardanyan AN, Craig A. Male circumcision and HIV prevention insufficient evidence and neglected external validity. Am J Prev Health 2010; 39: 479-82.

4. Van Howe RS, Svoboda JS, Hodges FM. HIV infection and circumcision: cutting through the hyperbole. J R Soc Health 2005; 125: 259-65.
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Anti-Circumcision activists are all Antisemites:
'Monster Mohel'

By JAMES TARANTO
"The primary backer of an effort to get a ban on circumcision on the ballot in Santa Monica [Calif.] is abandoning her push, saying the proposed legislation had been misrepresented as an effort to impinge on religious freedom," the New York Times reports. But "a similar measure in San Francisco is scheduled for a fall vote."

Jena Troutman, the woman the Times has chosen as the face of this weird political movement, is a young mother of two, who seems like an innocuous hippy-dippy sort. In an earlier story, the paper noted that she "has worked as a lactation educator and a doula"--a sort of assistant midwife--that "she is fond of rattling off sayings like 'Your baby is perfect, no snipping required,' " and that she has "often approached women on the beach to warn them about the dangers of circumcising." But for trying to impose her views on others through law, she's a harmless eccentric.


Foreskinman.com

'Monster Mohel'
.The same can't be said of Matthew Hess, author of the initiatives and of a comic book called "Foreskin Man," one issue of which features a villain called "Monster Mohel," a rabbi who attempts to circumcise a boy (against the mother's wishes but in cooperation with the father), only to be thwarted by the eponymous blond superhero.

The Anti-Defamation League is, not surprisingly, outraged: "Some of the imagery calls to mind age-old anti-Semitic canards such as the blood libel, the accusation that Jews ritually murder Christian children. Another comic in the series also calls up more subtle anti-Jewish themes, such as when a character complains that the 'pro-circumcision lobby' has 'all of the well-connected doctors and lawyers.' "

The blood-libel comparison seems a bit of a stretch. The infant in the comic book is Jewish, not Christian, and the mohel does not attempt to kill him. Besides, a literal depiction of circumcision involves the drawing of blood from a child.

But "Foreskin Man" employs some common anti-Semitic visual tropes. In the image shown nearby, "Monster Mohel" is depicted with devouring jaws (he appears to have at least 40 teeth) and a visage dehumanized by blank eyes. Pajamas Media shows another image of the character with a huge hook nose, placed separated-with-birth style between a pair of posters for the 1940 Nazi film "Der Ewige Jude" ("The Eternal Jew").

(For background on these visual tropes, see Yaakov Kirschen's paper "Memetics and the Viral Spread of Antisemitism Through 'Coded Images' in Political Cartoons," published last year by the Yale Initiative for the Interdisciplinary Study of Antisemitism. Incidentally, the New York Post reports that Yale plans to kill the institute after it came under criticism for its refusal "to ignore the most virulent, genocidal and common form of Jew-hatred today: Muslim anti-Semitism.")

The Times quotes Marc Stern of the American Jewish Committee: "People are shocked that it has reached this level because there has never been this kind of a direct assault on a Jewish practice here." It's an encouraging sign that Jena Troutman has been shamed into abandoning her effort. We'd be surprised if the initiative passes even in San Francisco; and if it did, the courts would likely strike it down as a violation of religious freedom.

Still, there's a warning in all this: Hippy-dippy types are harmless enough in themselves, but their poorly developed critical thinking skills may leave them at increased risk of infection by the virus of hatred.

http://online.wsj.com/article/SB10001424052702304259304576375540364440776.html

Circumcision: A guide for parents
by Professor Brian Morris

Circumcision is a simple surgical procedure that removes the foreskin ­ a sleeve of skin covering the tip of the penis. Parents have the legal right to authorize circumcision. In order to make an informed decision, they must carefully consider the benefits and risks.

Since the foreskin traps bacteria and other infectious agents, as well as accumulating malodorous smegma, its removal improves genital hygiene and reduces risk of diseases and other conditions over the lifetime for the boy and his future sexual partners.

History

Circumcision has been performed for thousands of years as part of the culture of indigenous people who live in hot environments such as in Australia, the Pacific Islands, equatorial countries, the Middle East, Africa and the Americas. In Australia all newborn boys were once circumcised routinely. Circumcision then decreased in the mid-1970s, but is now rising again, in line with research. Over 60% of Australian men are circumcised.




Benefits of circumcision

Eliminates the risk of phimosis, which affects 1 in 10 older boys and men. This condition refers to a tight foreskin that cannot be pulled back fully, so making cleaning under it, and passing urine, difficult. Phimosis also greatly increases the risk of penile cancer, and is the cause of foreskin and catheter problems in nursing homes.

Reduces by 3-fold the risk of inflammation and infection of the skin of the penis. One in 10 uncircumcised men get inflammation of the head of the penis, which is covered by the foreskin. This rises to 1 in 3 if the uncircumcised man is diabetic. (Diabetic men also have other severe problems.) In contrast only 2% of circumcised men get this condition.

Over 10-fold decrease in risk of urinary tract infection. Whereas risk of this is only 1 in 500 for a circumcised boy; 1 in 50 uncircumcised male infants will get a urinary tract infection. This very painful condition is particularly dangerous in infancy, and in 40% of cases can lead to kidney inflammation and disease; sepsis and meningitis can also result.

Over 20-fold decrease in risk of invasive penile cancer, which has a high fatality rate. One in 600 uncircumcised men get penile cancer, which often requires penile amputation.

Uncircumcised men have 1.5 ­ 2 times the risk of prostate cancer, which affects 1 in 6 men.

Reduces by approximately 3-fold the risk of getting HIV (AIDS), during sex with an infected woman. HIV enters via the vulnerable inner lining of the foreskin of a healthy penis, but can also infect via sores anywhere on the penis (caused for example by genital herpes). In countries such as Australia that have a low prevalence of HIV the risk of a heterosexual man being infected with HIV sexually is generally low. His risk, especially if uncircumcised, will be much greater if he engages in unsafe sex with people of countries in which HIV abounds.

Circumcision also affords substantial protection against sexually transmitted infections such as papilloma (wart) virus, syphilis and chancroid.

Circumcision reduces by up to 5 times the risk of the man's female partner being infected by chlamydia or getting cervical cancer (which is caused by human papilloma virus). The load of infectious bacteria and viruses that accumulate under the foreskin is delivered into the female genital tract during sex. Chlamydia has more than doubled over the past 5 years in Australia and can cause infertility (in both sexes), pelvic inflammatory disease, and ectopic pregnancy.

If not circumcised soon after birth, up to 10% will later require one anyway for medical reasons.

Credible research shows that most women prefer the appearance of the circumcised penis. They also prefer it for sexual activity. Hygiene is one reason.

There is no significant difference in sensitivity of a circumcised and uncircumcised penis.

In general, sexual function is the same or better.
Risks of circumcision

For 1 in 500 circumcisions there may be either a little bleeding ­ easily stopped by pressure or, less commonly, requiring stitches (1 in 1000), the need for repeat surgery (1 in 1000), or a generalized infection that will require antibiotics (1 in 4000). Although there can be a local infection, often what seems like a local infection is actually part of the normal healing process.
Serious complications (requiring hospitalization) are rare ­ approximately 1 in 5000.

Mutilation or loss of the penis, and death, is virtually unheard of with circumcisions performed by a competent medical practitioner. Ensure your doctor is experienced.

If a bleeding disorder such as haemophilia runs in the family, then the doctor needs to be advised as circumcision may require special preoperative treatment.

Anaesthetic is imperative, preferably a local, since a general anaesthetic carries risks, and is unnecessary. For age 0-4 months a local, not general, and for older children or teenagers a mild sedative might be considered in addition to the local. Young children who wriggle can be gently restrained. For pain after the anaesthetic wears off, an oral analgaesic medication is often prescribed.

Delay means stitches being used for circumcision of older children, teenagers and men.

So if circumcision is delayed past 4 months, total cost will become increasingly greater.

In conclusion
Circumcision confers a lifetime of medical benefits. 1 in 3 uncircumcised boys will develop a condition requiring medical attention. This means various degrees of suffering and, in rare cases, death. In contrast, risk of an easily-treatable condition is 1 in 500, and of a true complication is 1 in 5000. A successful circumcision is very unlikely to have any long-term adverse consequences.

Thus, benefits exceed moderate risks by over a hundred to one!
http://www.circinfo.com/parents_guide/gfp.html

Circumcision - Benefits Outweigh the Risks
Dr Tom Wiswell, a respected authority in the USA was a strong opponent, but then switched camps as a result of his own research findings and the findings of others. This is what he has to say: "As a pediatrician and neonatologist, I am a child advocate and try to do what is best for children. For many years I was an outspoken opponent of circumcision ... I have gradually changed my opinion" [Wiswell, 1988; Wiswell, 1992]. This ability to keep an open mind on the issue and to make a sound judgement on the balance of all available information is to his credit ... he did change his mind!

Wiswell looked at the complication rates of having or not having circumcision performed in a study of 136,000 boys born in US army hospitals between 1980 and 1985. 100,000 were circumcised and 193 (0.19%) had complications, mostly minor, with no deaths, but of the 36,000 who were not circumcised the problems were more than ten-times higher and there were 2 deaths [Wiswell & Hachey, 1993].

A study by others found that of the 11,000 circumcisions performed at New York's Sloane Hospital in 1989, only 6 led to complications, none of which were fatal [Russell, 1993]. An early survey saw only one death amongst 566,483 baby boys circumcised in New York between 1939 and 1951 [National, 2003].

There are no deaths today from medical circumcisions in developed countries.

Very similar to the study by Wiswell above, it was found that of 354,297 infants born in Washington State from 1987-96, only 0.20% had a complication arising from their circumcision, i.e., 1 in every 476 circumcisions [Christakis et al., 2000]. Most of these ‘complications’ were minor and readily treated. It was concluded that 6 urinary tract infections could be prevented for every circumcision complication, and 2 complications can be expected for every penile cancer prevented [Christakis et al., 2000].

Problems involving the penis are encountered relatively frequently in pediatric practice [Langer & Coplen, 1998]. A retrospective study of boys aged 4 months to 12 years found uncircumcised boys exhibited significantly greater frequency of penile problems (14% vs 6%; P < 0.001) and medical visits for penile problems (10% vs 5%; P < 0.05) compared with those who were circumcised.

http://www.circinfo.net/benefits_outweigh_the_risks.html

Circumcision - Why the Foreskin
Increases Infection Risk
As a prelude to this, one needs to first understand the anatomy. The foreskin is composed of an outer layer that is keratinized (as is skin generally), and an inner lining that is a mucosal surface. The inner lining thus resembles other mucosal epithelia such as constitute the cervix, nasal passages and rectum. It had been suggested that the foreskin protected the glans from drying out and becoming keratinized. However, histological examination has shown the same amount of keratin in the skin of the head of the penis irrespective of circumcision status [Szabo & Short, 2000]. Interestingly, whereas most consider the inner foreskin to be thinner, one study has reported there is no difference between the keratinization of the inner and outer foreskin [[Dinh et al., 2010]. This study was, however, flawed because (1) the foreskins studied were from men circumcised for a medical indication, where balanitis, infections and phimosis could have made the keratin layer of the inner foreskin thicker, and (2) the authors do not indicate what part of the foreskin they studied, where inner foreskin is thinner close to the base at the coronal sulcus than at the distal end [R.H. Gray and R.C. Bailey, personal communication].

The inner layer of the foreskin lines a ‘preputial sac’, which becomes a repository for shed cells, secretions, and urinary residue that accumulates [Parkash et al., 1973; Cold & Taylor, 1999]. It is also a hospitable environment for the growth of bacteria and other microorganisms.

During an erection the head and shaft of the penis extend so that the inner layer becomes exteriorized along the distal half of the shaft. This exposes it to infectious agents during sexual intercourse.

It has been speculated that the foreskin is a source of secretions, pheromones, etc, but given the dubious authorship of these reports and the absence of any research support, such suggestions should be regarded as fanciful. In fact, for references that cite evidence to the contrary see [Waskett & Morris, 2008].

It has been suggested [Caldwell & Caldwell, 1996] that the increased risk of infection in the uncircumcised may be a consequence of the following:

• The foreskin presents the penis with a larger surface area.

• It has been suggested that the moist inner lining of the foreskin represents a thinner epidermal barrier than the more cornified outer surface of the foreskin and the rest of the penis, including the glans. It should be noted that the glans of a circumcised and an uncircumcised penis have the same amount of keratin (i.e., similar skin thickness and protection from invasion of microorganisms) [Szabo & Short, 2000]. Although the keratin thickness of the inner and outer foreskin was suggested to be similar [[Dinh et al., 2010], the samples used were from men with pathology that could have increased keratin thickness, and could have been from the thicker distal end of the foreskin. The thin, moist inner lining may be a potential entry point into the body for viruses and bacteria, but more information is needed on how this occurs. (A photograph of a histological section that illustrates the much thinner inner than outer foreskin can be found later, in the section on the AIDS virus.)

• The presence of a prepuce is likely to result in greater microtrauma during sexual intercourse, thereby permitting an entry point into the bloodstream for infectious agents.

• The warm, moist mucosal environment under the foreskin favours growth of micro-organisms (discussed in detail later). The preputial sac has even been referred to by Dr Gerald Weiss, an American surgeon, as a 'cesspool for infection' [Weiss, 1997], as its unfortunate anatomy wrapped around the end of the penis results in the accumulation of secretions, excretions (urine), dead cells and growths of bacteria as referred to above. Parents are told not to retract the foreskin of male infants, which makes cleaning difficult. Even if optimal cleansing is performed there is no evidence that it confers protection [Wiswell, 1997a; Wiswell, 1997b]. Rather, the foreskin tends to trap and transmit micro-organisms, both to the man himself, and his sexual partners.

http://www.circinfo.net/why_the_foreskin_increases_infection_risk.html

Biological basis for the protective effect conferred by male circumcision against HIV infection
B J Morris, DSc PhD*⇓ and R G Wamai, PhD†
+ Author Affiliations

*Basic & Clinical Genomics Laboratory, School of Medical Sciences and Bosch Institute, University of Sydney, Sydney, NSW, Australia
†Department of African-American Studies, Northeastern University, Boston, MA, USA
Correspondence to:
Professor B J Morris, School of Medical Sciences and Bosch Institute, Bldg F13, The University of Sydney, NSW 2006, Australia Email: brian.morris@sydney.edu.au
Abstract
Here we provide an up-to-date review of research that explains why uncircumcised men are at higher risk of HIV infection. The inner foreskin is a mucosal epithelium deficient in protective keratin, yet rich in HIV target cells. Soon after sexual exposure to infected mucosal secretions of a HIV-positive partner, infected T-cells from the latter form viral synapses with keratinocytes and transfer HIV to Langerhans cells via dendrites that extend to just under the surface of the inner foreskin. The Langerhans cells with internalized HIV migrate to the basal epidermis and then pass HIV on to T-cells, thus leading to the systemic infection that ensues. Infection is exacerbated in inflammatory states associated with balanoposthitis, the presence of smegma and ulceration – including that caused by infection with herpes simplex virus type 2 and some other sexually transmitted infections (STIs). A high foreskin surface area and tearing of the foreskin or associated frenulum during sexual intercourse also facilitate HIV entry. Thus, by various means, the foreskin is the primary biological weak point that permits HIV infection during heterosexual intercourse. The biological findings could explain why male circumcision protects against HIV infection.

http://ijsa.rsmjournals.com/content/23/3/153.short

Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial
Original Text
Prof Robert C Bailey PhD a , Prof Stephen Moses MD c, Corette B Parker DrPh e, Kawango Agot PhD d, Ian Maclean PhD b, Prof John N Krieger MD f, Carolyn FM Williams PhD g, Prof Richard T Campbell PhD a, Prof Jeckoniah O Ndinya-Achola MBchB h
Summary
Background
Male circumcision could provide substantial protection against acquisition of HIV-1 infection. Our aim was to determine whether male circumcision had a protective effect against HIV infection, and to assess safety and changes in sexual behaviour related to this intervention.
Methods
We did a randomised controlled trial of 2784 men aged 18—24 years in Kisumu, Kenya. Men were randomly assigned to an intervention group (circumcision; n=1391) or a control group (delayed circumcision, 1393), and assessed by HIV testing, medical examinations, and behavioural interviews during follow-ups at 1, 3, 6, 12, 18, and 24 months. HIV seroincidence was estimated in an intention-to-treat analysis. This trial is registered with ClinicalTrials.gov, with the number NCT00059371.
Findings
The trial was stopped early on December 12, 2006, after a third interim analysis reviewed by the data and safety monitoring board. The median length of follow-up was 24 months. Follow-up for HIV status was incomplete for 240 (8·6%) participants. 22 men in the intervention group and 47 in the control group had tested positive for HIV when the study was stopped. The 2-year HIV incidence was 2·1% (95% CI 1·2—3·0) in the circumcision group and 4·2% (3·0—5·4) in the control group (p=0·0065); the relative risk of HIV infection in circumcised men was 0·47 (0·28—0·78), which corresponds to a reduction in the risk of acquiring an HIV infection of 53% (22—72). Adjusting for non-adherence to treatment and excluding four men found to be seropositive at enrolment, the protective effect of circumcision was 60% (32—77). Adverse events related to the intervention (21 events in 1·5% of those circumcised) resolved quickly. No behavioural risk compensation after circumcision was observed.
Interpretation
Male circumcision significantly reduces the risk of HIV acquisition in young men in Africa. Where appropriate, voluntary, safe, and affordable circumcision services should be integrated with other HIV preventive interventions and provided as expeditiously as possible.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)60312-2/fulltext

Abstract
Background
Male circumcision is being promoted to reduce human immunodeficiency virus type 1 (HIV) infection rates. This review evaluates the scientific evidence suggesting that male circumcision reduces HIV infection risk in high-risk heterosexual populations.
Methods
We followed the updated International Consultation on Urological Diseases evidence-based medicine recommendations to critically review the scientific evidence on male circumcision and HIV infection risk.
Results
Level 1 evidence supports the concept that male circumcision substantially reduces the risk of HIV infection. Three major lines of evidence support this conclusion: biological data suggesting that this concept is plausible, data from observational studies supported by high-quality meta-analyses, and three randomized clinical trials supported by high-quality meta-analyses.
Conclusions
The evidence from these biological studies, observational studies, randomized controlled clinical trials, meta-analyses, and cost-effectiveness studies is conclusive. The challenges to implementation of male circumcision as a public health measure in high-risk populations must now be faced.
http://www.springerlink.com/content/g5x2m107374r3734/
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http://www.jewsagainstcircumcision.org/



Traditions

Judaism is a fluid religion that has been subject to change as it meets challenges and reaches new and better understandings. This is shown with the advent of non-traditional ceremonies, like Bat Mitzvah, and other significant changes to advance the roles of females including the ordination of women rabbis, chazzans and shamases.

Jews say that circumcision is tradition. The following are also "traditions" and they are among the actions punishable by death according to the Torah:

Cheating on your husband, (Lev. 20:10).
Fornicating - if you’re female (Deut 22:21).
Homosexuality (Lev. 20:13).
Blasphemy (Lev. 24:16)
Insulting one’s parents (Exod. 21:17)
Disobeying one’s parents (Deut 21:18-21

Obviously, we no longer apply capitol punishment for committing the above mentioned acts because we are no longer a primitive society and we have come to believe in human rights. Other practices sanctioned by the Torah that we no longer do because we are educated and enlightened are:

Slavery (Exod 21:1-11) (Deut. 15:12-18)
Animal and Human Sacrifices (Lev. 4:3, 4:23, 4:32, 5:7, 5:15; Judges 11:20, 11:33)
Divorce for men only (Deut 24:1)
Female subservience to men including obedience to every order and no right to refuse sex, (Genesis 3:16).












Moses Maimonides

Moses Maimonides, the famed medieval Jewish rabbi, physician and philosopher, recoginized the real reason circumcision is performed and wrote about it in his book, THE GUIDE TO THE PERPLEXED, translated by Shlomo Pines. (University of Chicago, 1963)
Part III, Chapter 49, Page 609:

Similarly with regard to circumcision, one of the reasons for it is, in my opinion, the wish to bring about a decrease in sexual intercourse and a weakening of the organ in question, so that this activity be diminished and the organ be in as quiet a state as possible. It has been thought that circumcision perfects what is defective congenitally. This gave the possibility to everyone to raise an objection and to say: How can natural things be defective so that they need to be perfected from outside, all the more because we know how useful the foreskin is for that member? In fact this commandment has not been prescribed with a view to perfecting what is defective congenitally, but to perfecting what is defective morally.

The bodily pain caused to that member is the real purpose of circumcision. None of the activities necessary for the preservation of the individual is harmed thereby, nor is procreation rendered impossible, but violent concupiscence and lust that goes beyond what is needed are diminished. The fact that circumcision weakens the faculty of sexual excitement and sometimes perhaps diminishes the pleasure is indubitable. For if at birth this member has been made to bleed and has had its covering taken away from it, it must indubitably be weakened. The Sages, may their memory be blessed, have explicitly stated: It is hard for a woman with whom an uncircumcised man has had sexual intercourse to separate from him. In my opinion this is the strongest of the reasons for circumcision.
Page 611:

This class of commandments also includes the prohibition against mutilating the sexual organs of all the males of animals, which is based on the principle of righteous statutes and judgments, I mean the principle of keeping the mean in all matters; sexual intercourse should neither be excessively indulged, as we have mentioned, nor wholly abolished. Did He not command and say: Be fruitful and multiply? Accordingly this organ is weakened by means of circumcision, but not extirpated through excision. What is natural is left according to nature, but measures are taken against excess. He that is wounded in the stones or hath his privy member cut off is forbidden to marry a woman of Israel, for such cohabitation would be perverted and aimless. Such a marriage would likewise be a stumbling block for the woman and for him who seeks her out. This is very clear.


Other Facts

Any medical procedure that involves even the possibility of risk to life is halachically forbidden. Judaism affirms the sanctity of human life, embracing the idea that every life is of infinite value. Halakah also tells us that since danger to life takes precedence over all else, medically hazardous procedures are strictly forbidden. The halacha (jewish law) recognizes the potential for harm that circumcision can bring, and so it stipulates that if a mother has 'lost' a child to circumcision , she is not obligated to circumcise future sons... this can be extrapolated to our shared humanity..enough mothers and children have suffered from this procedure..enough sons have been lost..let love and healing take precedence over fear and cutting

It is a violation of Torah commandments to physically assault or harm another person (Exodus 21:18-27). Yet that is exactly what circumcision is! Thus, it is against the most fundamental concept of Jewish law.

Additionally, some Jews object to pain relief by a physician. As if two to four needles in his penis - even if they are filled with pain killing drugs - isn't considered torturous enough to accomplish this amputation for his parents' psychological benefit. Are we now to assume that only topical anesthesia is acceptable? Do mohels have such deep-seated psychological issues over their own circumcisions that the only way it can be done to satisfy them is if the baby writhes in pain? Isn't it bad enough that he's having the most sensitive part of his genitals cut off against his will and at his parents' whim? Must he be made to suffer the maximum agony to accomplish this domineering goal?

We must embrace the notion of Bris Shalom, in which the genital mutilation part of the ceremony is omitted.

Some Jews are afraid to look at circumcision for what it is because they think that if you’re against circumcision, you’re anti-semitic. That is a ridiculous notion. Jews are not defined by our practices. In fact, the only requirement for Judaism is that you are born of a Jewish mother. Jews are taught to pursue education and question everything. We have questioned many practices in the Torah. Due to our enlightment and education, we no longer practice some of them.

For people who use the anti-semitism argument, the analogy I like to use is, if 90% of all black people smoke and you’re against smoking, you’re not anti-black, you’re anti-smoking. It’s the practice, not the people.”

Jews are smart. We are 1/3 of 1% of the population, yet we hold 33% of the Nobel prizes. This means that we are smart enough to understand that sexually mutilating our boys’ genitals is NOT acceptable.
Recommended Reading:

CIRCUMCISION: THEN AND NOW
By: James E. Peron, Ed.D.

Questioning Circumcision, A Jewish Perspective
By: Ronald Goldman, Ph.D.

Covenant of Blood
By: Lawrence A Hoffman




Medical Aspects

MGM (Male Genital Mutilation) is a cruel, painful, mutilating, torturous, violative act without valid medical benefit that not only contravenes the UN Charter but also violates every principle of human kindness and medical ethics in every civilized country in the world. The very foundation of modern medicine is "First, do no harm." Yet, circumcision does just that.

The American Medical Association, the American Academy of Pediatrics and equivalent organizations in Canada all state that routine circumcision is not medically justified.

Growing up, we heard the same myths that all of you have heard - it’s just a snip, it doesn’t hurt. Lies! They have attached EKGs and EEGs to babies during circumcision. Their blood pressure rises, their brain waves go off the chart, they writhe in pain, and they go into shock. It hurts, trust me.

Circumcision removes healthy, erogenous tissue. It has been estimated by Canadian researchers that up to 80% of a male's erogenous tissue is amputated during a circumcision.

We've also heard people say, “It’s cleaner.” If boys can learn to blow their nose, brush their teeth, and wipe their butts after using the toilet, they can learn to pull back their foreskin and wash. (Incidentally, the foreskin is normally attached to the Glans and may not separate until puberty. When this is the case, it should be left alone, not forcibly retracted).
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