Surgically removing foreskins, in the erroneous hope that it will reduce HIV rates is both misguided and unethical. In South Africa we already have large population samples that have been circumcised, such as the Xhosa tribe, yet their HIV rates are no different from tribes that have not been circumcised, such as the Zulu tribe. Using the studies, performed in sterile situations, that do not represent real world settings, to justify circumcision while selectively ignoring real world data that contradicts their findings, is disastrous.
Already circumcision programs have begun throughout Africa, with none having instituted proper follow-up research to monitor the men that they are cutting and their sex partners. This is not an example of evidence-based medicine, and will cause much harm.
INTERNATIONAL COALITION for GENITAL INTEGRITY
1970 North River Road www.icgi.org West Lafayette, Indiana, 47906, USA
We recognize the inherent right of all human beings to an intact body.
Without sexual, racial, or religious prejudice, we affirm this basic human right.
Male Circumcision – A Dangerous Mistake in the HIV Battle
Mass male circumcision has been identified and promoted as a method of curbing the AIDS pandemic in sub-Saharan Africa. Stopping the spread of HIV requires strategically using available resources. However, circumcision’s costs and harms are significant, and there is recent evidence indicating that its use in the HIV battle would result in more harm than good.
Mass circumcision campaigns will divert resources from other proven prevention programs, result in a high number of complications, increase risk-compensation behaviors, and put women at higher risk for HIV.
Circumcision is a relatively expensive and risky procedure that is claimed to reduce risk by 5060% for heterosexual males only. Condom promotion and safe-sex education have already been shown to reduce infection rates more effectively for both males and females, at a lower cost.
Adult males are vulnerable to the belief that circumcision offers them immunity,1 raising ethical concerns about promoting adult male circumcision, and questioning the effectiveness of the intervention.
Some have proposed circumcising infants, but this, too, has ethical ramifications.2 Removing healthy tissue from children deprives them of their birthright to a fully functional body. Surgery of any kind places them at immediate risk from complications; the benefit, if any, is 15–20 years away.
Circumcision does not protect women,3 in fact, it increases their risk following the procedure.4
Circumcision does not protect men having sex with men.5 6
Results from three random clinical trials (RCTs) in Africa, showing a reduction in female-tomale transmission of HIV after circumcision, have focused attention on promoting male
circumcision to reduce HIV transmission. This has been followed with funding to rollout mass
surgical interventions in sub-Saharan Africa, as well as influencing male infant circumcision
policy in the United States.
Questionable RCT Results
A number of confounding factors present in the studies warrant caution in extrapolating results to larger populations. All three studies were terminated early, and more than 700 participants were lost to follow-up, their HIV status unknown. In other words, 4.5 times more participants were lost to follow-up than were reported to have been protected from HIV by circumcision. Unlike in any real-world setting, study participants were provided free condoms and extensive education and counseling,7 8 9 a number of reported HIV infections were contracted from nonsexual means,10 and the participants were paid.
The Cochrane Collaboration Report of 2003 cautioned about researcher bias, stating: “Circumcision practices are largely culturally determined, so there are strong beliefs and opinions surrounding them. It is important to acknowledge that researchers’ personal biases and dominant circumcision practices of their respective countries may influence interpretation of findings.”11 The Cochrane Collaboration has since issued an updated report, which now states: “No further trials are required.”12 The updated version no longer warns against researcher bias.
The RCTs practices are questionable. All three studies were halted earlier than designed. In one study, the circumcised men’s infection rates were increasing toward the intact men’s rate. All participants not initially circumcised were then offered circumcision, eliminating the possibility of accurate follow-up data. We will never know if the short-term effect was permanent.
A physician-scientist, who participated in one of the African studies, reportedly called it, “Completely dishonest. About one-third of the way through the study, when the results were not favorable to the lead researchers, the study was halted.” According to him, coming from his friend calling into an Austin, Texas television show, the purpose of the study wasn’t to investigate their hypothesis, but to provide proof to support male circumcision.13
The only conclusion that can be drawn from the RCTs is that circumcision might delay HIV infection for half of the circumcised males, and no delay in the other half, while having no affect on infection rates for women, and an unknown effect on male infants.
Two recent studies examining African circumcision rates and HIV prevalence found that circumcision was not significant. One study examined data from 13 sub-Saharan countries to determine circumcision was not associated with lower HIV rates,14 and another found circumcision made no difference in HIV rates in South Africa.15
Recent evidence demonstrates that Langerhans cells in the foreskin have a protective effect against pathogens—including HIV—by secreting langerin.16 The original theory (which lead to promoting circumcision to stop HIV) was that Langerhans cells are an entrance-point for viruses. It now seems that the theory was partially true, but that the true mechanism at work is that Langerhans cells set a trap for viruses in order to destroy them with langerin.
A 2007 study concluded that, once commercial sex-worker patterns are factored in, male circumcision is not significantly associated with lower HIV.17
Male Circumcision Increases Risk of HIV
The long-term consequences of promoting circumcision might worsen the HIV epidemic by implying that circumcision protects males—a false sense of security, undermining safe-sex practices and condom usage.18 19 African males are already lining up to be circumcised, thinking they no longer need to use condoms.20 21 22 Even if the 50-60% protective effect the RCTs claim is true, and if all African males were circumcised over the next 15 years, it would only reduce the number of infection cases by 8%, and related deaths by 1%.23
HIV infections are greater following the circumcision of virgins, both male and female, indicating that circumcision itself spreads the infection, probably from unclean conditions.24 25
Male Circumcision Endangers Women
Male circumcision offers no protection to women.26 It endangers women if sex is resumed before the wound has completely healed.27 In a recent WHO study, one-fourth of circumcised males still had not healed sixty days after the surgery.28 Further, it places women at greater risk of unsafe sex practices forced on them by circumcised males who wrongly believe they are immune from HIV, or insist that they are.
Circumcision Will Result in Burdensome Complications
A recent issue of the WHO Bulletin says that African ritual circumcisions have a 35% complication rate. African clinical circumcisions have an 18% complication rate, much higher than in developed countries.29 A neonatal circumcision complication rate of 20.2% was found in Nigeria.30
Unethical Medical Practice
Circumcision permanently removes healthy, functional, and beneficial tissue.31 It is unprecedented for a prophylactic surgery to be offered as a “health benefit” to adults who have safer and more effective ways of avoiding infection, and to parents of newborns to reduce risks of an adult-acquired disease.32 Circumcised men will still have to wear condoms for full protection (as well as to protect their sexual partners) and there is no evidence that being circumcised and wearing condoms is any better than wearing condoms alone. Considering that circumcision can result in acquiring the infection, and its complications, promoting it must be seriously questioned.
Informed Consent Issues
For fully informed consent to occur, all adult males must be educated about the risks and sensory losses from circumcision, as well as made aware that it does not offer full protection, and that they will still need to wear condoms during sex. The number of reports of African males agreeing to circumcision so they no longer need to use condoms, reveals that fully informed consent is not always occurring.33 34 35
An Effective Social Program Already Exists
Education, safe-sex practices, and consistent condom use are proven, effective measures of curbing HIV transmission. Uganda demonstrated a 47% reduction in HIV prevalence from increased safe-sex education and condom promotion—this social-prevention program is available now, is highly effective, and does not involve the numerous risks and losses from surgery.36 A study revealed that condoms are 98% effective at hindering HIV transmission, and 95 times more cost-effective than circumcision.37 Consistent condom use reduces lifetime risk by 20% 38 as compared to circumcision’s 8%.39 A recent report from South Africa shows condom use significantly increased from 2002 to 2008, and the HIV rates finally began to level off.40 There is no evidence that diverting resources to circumcision would aid this progress.
Promoting an intervention that at best reduces the risk of infection for only half the population half of the time while creating a false sense of security is irresponsible. Circumcision offers no protection for men who have sex with men, and it increases the risk to women. Male circumcision will result in unacceptable complications, the treatment of which will further burden the healthcare infrastructure. Promoting male circumcision drains resources that should be devoted to proven measures such as condom promotion, and increased safe-sex education.
21 June 2010: An open letter to the KwaZulu-Natal Health Department
Circumcise now – no questions later:
Dear KZN Health Department,
We are greatly concerned to learn of the circumcision campaign initiated in Eshowe and request an urgent review of your policy.
As an organisation devoted to protecting children’s rights to bodily integrity, we are even more disturbed by a report in the Soweton newspaper suggesting that the KwaZulu-Natal Health Department is also encouraging the circumcision of newborns, stating:
“Although the circumcision programme targets mainly men between 14 and 25 years of age, it also encourages women to circumcise their newborn children immediately after birth.”
It is important for you to realize that there is currently no epidemiological evidence to suggest that circumcising newborns will have any impact on their HIV status when they reach adulthood. Furthermore, the KZN Health Department is legally obliged to protect the bodily integrity of children since the circumcision of children (anyone below the age of 16) is illegal according to the new Children’s Act. The Children’s Act only allows circumcision of children for“medical reasons, i.e., with pre-existing and diagnosed pathology.” The claim that the removal of undiseased infant foreskins ‘may’ reduce the chances of infants contracting an infectious disease when they become sexually active some 12-14 years later is tenuous at best and does not come close to constituting a valid medical reason for removing healthy erogenous tissue from a baby. Furthermore, circumcision at this age is highly traumatic and has lifelong negative psychological and physical effects on sexual relationships. It also denies the child freedom of choice in a matter of great personal consequence for future happiness.
Last week we requested that your department provide complete details as to how you plan to track the HIV status of men (and their partners) AFTER circumcision, a requirement in order to accurately document the effectiveness or lack thereof of your intervention and thereby prove if circumcision is truly effective to such an extent that its implementation may be relevant to the choices men in the general population may wish to make. Much already documented epidemiological evidence suggests that the currently proposed circumcision drive is unlikely to yield reliable data supporting the claims now touted as compelling beyond all doubt (see references below). For example, there are currently no differences between the HIV rates of non-circumcising (Zulu) and circumcising (Xhosa) cultures. In fact, the rate of HIV infection in the Xhosa culture is very high, despite very high circumcision rates. If circumcision has failed to curb the rates of HIV in that culture, what hope is there that it will do so in currently non-circumcising cultures? There is much evidence to suggest that the opposite is true.
European countries have very low circumcision rates but also have the lowest HIV rates of all developed countries. This directly contradicts the pro-circumcision research, with a real-world population size that dwarfs anything that the studies used. Also, the USA has the highest rate of circumcision in the developed world, yet that country also has one of the highest HIV rates. These anomalies have not been explained, yet policy to circumcise has surged ahead in an effort to show that something is being done to stop HIV.
It is of vital importance to consider that these population sizes are vastly greater than the tiny samples used in the studies, and devoid of confounding factors inherent in the non-real world conditions of a study. Thus, these three non-blinded trials do not have parallel, real-world examples consistently showing them to be accurate. Circumcision on a vast scale, therefore, cannot legitimately be justified as a routine policy on the basis of the African studies.
The Mishra study shows no important correlation between circumcision and HIV and concludes, ‘We find a protective effect of circumcision in only one of the eight countries for which there are nationally-representative HIV seroprevalence data. The results are important in considering the development of circumcision-focused interventions within AIDS prevention programs.’ (Mishra, V, et al, Is male circumcision protective of HIV infection?http://www.iasociety.org/abstract/show.asp?abstract_id=2197431)
Thailand, Uganda, and Brazil are all non-circumcising nations. Yet these nations have successfully turned around their HIV infection rates through the proper and consistent application of ABC techniques alone, without resorting to circumcision.
A government agency such as the KwaZulu-Natal Health Department has a responsibility to carefully monitor every intervention it makes, and we encourage you to review your policy. Should you decide to go ahead in spite of the urgent concerns expressed in this letter, accurate research and recording is required to document the successes and failures of such an intervention. Trends show that HIV rates have already peaked and are doing so anyway. Will circumcision get the credit if this is the case?
We are sure that the circumcision strategy is likely to backfire as reports throughout Africa begin filtering through of men believing they are now immune to HIV as a result of circumcision, putting them and their partners at increased risk of infection. Anything that weakens the ‘wear a condom’ message should be heavily discouraged, especially since circumcised men do not like wearing condoms, an inevitable consequence of the reduced sensitivity that follows circumcision. What concerns us most is that history shows that circumcised men usually perpetuate this practice by circumcising their own children. This means that even if you cease explicitly recommending neonatal circumcision, the fact that you are circumcising adult men indirectly undermines your responsibility to protect the rights of children.
Please could you acknowledge receipt of this letter and urgently email us:
1) The consent forms that you intend for men who are undergoing circumcision to sign.
2) Details of how you plan following up these men (and their partners), including post circumcision questionnaires to see how their sexuality had been affected, etc.
3) Written confirmation that you are encouraging minors under the age of 18 to undergo prophylactic circumcision?
- Experts weigh success of circumcision against HIV: Circumcised men in South Africa are currently as likely to be HIV-positive as their uncircumcised counterparts, according to a study in the latest edition of the South African Medical Journal.
The South African Medical Journal included the following articles questioning the drive for circumcision, and in particular neonatal circumcision, to ‘prevent’ HIV.
- Editorial comment: Male?circumcision?and?HIV?infection
- JP van Niekerk
- Neonatal Circumcision does not reduce HIV Infection Rates
- Daniel Sidler, Heinz Rode, J Smith
- Rolling out male circumcision as a mass HIV/AIDS intervention seems neither justified not practicable
- A Myers, Jonathan E Myers
- Male circumcision and its relationship to HIV infection in South Africa: Results from a national survey in 2002
- Catherine A Connolly, Leickness C Simbayi, Rebecca Shanmugam, Ayanda Nqeketo
- NOCIRC-SA statement 2006: Circumcision of children for HIV prevention problematic and unethical
- South African Medical Journal article on circumcision and HIV (May 2007): Male circumcision: the new hope?(Myers)
- Unprecedented WHO/UNAIDS recommendations for mass circumcision are Playing Russian Roulette with African lives (May 2007)