Circumcision (and HIV)

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HIV is the virus that causes AIDS. AIDS is a syndrome which, untreated, leads to death. If treated, it can be a chronic debilitating illness. It is contagious, and is spread through expose to body fluids, essentially. Those body fluids include blood, semen and menstrual fluids.

Male circumcision is the surgical process of removing the foreskin, which covers the end of the penis.

The foreskin, or prepuce, is highly sensitive tissue which protects the glans penis (in a way similar to the protection given to the eye by the eye-lid), and is a key part of the male sexual anatomy. It contains many nerve endings which add to the pleasure of sexual contact.

So much for defining the terms.

In recent years there has been quite a lot of discussion about some research which appears to indicate that male circumcision has a role in the prevention of HIV. This research is mostly based on some studies undertaken in sub-Saharan Africa. While the research is in some ways flawed, it does appear that there may be some weak statistical data supporting the suggestion that male circumcision has a preventative effect. What it appears to do is prevent transmission from a receptive infected partner to an insertive uninfected partner.

Media reports have made circumcision sound like a vaccine against transmission. There has been a lot of coverage of the reports, and a lot of discussion about statistics. There has also been a lot of generalisation of the import of the studies.

The effect is weak. In order to prevent one case of HIV transmission, it would be necessary to circumcise nearly 60 men. In some countries in Africa where circumcision is practiced, circumcised men have higher rates of infection than uncircumcised men.

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What the studies, and the apologists for them (and for circumcision) don’t appear to address are the cultural issues sitting behind the dynamics of disease transmission. Different sexual mores and habits will have an effect on how, and to whom, HIV is transmitted. Who does what to whom and when is an important question. Men who are removed from their families and have sex with sex workers are more likely to be infected. The terrain is far from straightforward:

For several years, researchers have been debating the relationship between male circumcision and HIV. Several studies have indicated that circumcised men are less likely to become infected with HIV than uncircumcised men. However, because circumcision is usually linked to culture or religion, it has been argued that the apparent protective effect of the procedure is likely to be related not to removal of the foreskin but to the behaviours prevalent in the ethnic or religious groups in which male circumcision is practised. In addition, some researchers have assumed that any association between circumcision and HIV must be complicated by the presence of other sexually transmitted infections, which have been found to be more common among uncircumcised men.

Clearly, the correlations are not straightforward. In the higher income countries, the rates of HIV infection among men who have sex with men do not vary greatly even though the circumcision rates do: few men in Europe and Japan but four-fifths of men in the United States are circumcised. In Africa, however, circumcision seems to confer some protection. A study in Nyanza Province, Kenya, among men from the same ethnic group, the Luo, found that one-quarter of uncircumcised men were infected with HIV, compared with just under one-tenth of circumcised men. The protective effect remained even after other factors, such as sexual behaviour and sexually transmitted infections, had been taken into account. A study of over 6800 men in rural Uganda has suggested that the timing of circumcision is important: HIV infection was found in 16% of men who were circumcised after the age of 21 and in only 7% of those circumcised before puberty. A recent review of 27 published studies on the association between HIV and male circumcision in Africa found that, on average, circumcised men were half as likely to be infected with HIV as uncircumcised men. When African men with similar socio-demographic, behavioural and other factors were compared, circumcised men were nearly 60% less likely than uncircumcised men to be infected with HIV.

Even though the weight of evidence increasingly suggests that circumcising men before they become sexually active does provide some protection against HIV, the practical implications for AIDS prevention are not obvious. Circumcision, where it is practised, usually has links to religious or ethnic identities and life-cycle ceremonies, and may customarily be done after puberty. If the same scalpel were used without sterilization on a number of boys, this could actually contribute to the transmission of HIV. Finally, if circumcision were promoted as a way of preventing HIV infection, people might abandon other safe sexual practices, such as condom use. This risk is far from negligible – already, rumours abound in some communities that circumcision acts as a “natural condom”. A sex worker interviewed in the city of Kisumu in Kenya summed up this misconception, saying: “I can sleep with circumcised men without a condom because they don’t carry a lot of dirt on their penis”. While circumcision may reduce the likelihood of HIV infection, it does not eliminate it. In one study in South Africa, for example, two out of five circumcised men were infected with HIV, compared with three out of five uncircumcised men. Relying on circumcision for protection is, in these circumstances, a bit like playing Russian roulette with two bullets in the gun rather than three.

So, what are we to think?

And what are you, if you’re a parent of a boy and are thinking of circumcision for him, to do?

There are some reality checks to be had. If you’re in the west, it is important to know that the studies done on western men don’t support the same generalisations. Remember, the male population of the US is overwhelmingly circumcised, and HIV spread like wild-fire there, among insertive and receptive men alike. Remember, the effect is weak. It isn’t a vaccine, and the effect of behavioural modifications (using condoms, reducing promiscuity etc) is much more effective in the prevention of HIV.

Yes, it is true, circumcision may give some weak benefit, but there are costs, too.

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1 Comment »

  1. One small point, the foreskin doesn’t just cover the end of the penis, but the inner foreskin is in fact itself the most sensitive part of the penis.

    It appears to me that the people promoting circumcision to prevent HIV are either interested in promoting circumcision for its own sake, or are looking for an “anything but condoms” solution to HIV. How else can we explain a nationwide drive to promote circumcision in Rwanda, where men are 66% more likely to be HIV+ if they are circumcised?

    Circumcision can only possibly help men who have unsafe sex with HIV+ partners, so why this bizarre obsession with genital surgery when we know that ABC works better than circumcision ever could? (ABC=Abstinence, Being Faithful, Condoms). The two continents with the highest rates of AIDS are the same two continents with the highest rates of male circumcision. Something is very wrong here.

    It’s not just the media that have compared circumcision a vaccine. The Auvert study described circumcision as “comparable to a vaccine of high efficacy”, in a startling display of researcher bias. Circumcision proponent Brian Morris has also described circumcision as a “surgical vaccine”.

    Latest news is that HIV+ men are more likely to transmit the virus to women if they are circumcised.

    Female circumcision seems to protect against HIV too btw, but we wouldn’t investigate cutting off women’s labia, and then start promoting that.

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