Friday, August 24, 2012

Circumcision and HIV

As an intactivist, I have a bias. I already consider that routine infant circumcision is wrong and a violation of human rights. I feel that way because of my own experience, not because of something I read or something I told me. I've felt this way since my doctor lifted a scalpel against my penis.

However, when speaking about science, health benefits and risks, I have to keep things in check. I don't want to advocate based on bad science, and if there is bad science on either side of the equation I want to denounce it and point it. Understanding the issues around circumcision require rationality, but also require a degree of humanity, empathy and compassion.

Intactivists are often accused of being a cult-like organization. However, pro-cutters have never discussed publicly why we exists, why we speak. They say we have something wrong in our psyche, but they can't acknowledge that they messed with our psyche when they cut us. If there's something wrong with us, it started when someone used their rationale to amputate a healthy part of our body without our permission to do so, and no level of rationality is going to change how we feel about it.

However, I want to discuss here how some studies are presented as an absolute truth and used to promote circumcision of infants, while other studies are ignored and dismissed because they show different results. What I want to show here is that the public statements voluntarily omit information in order to sell an idea, that circumcision prevents HIV and so it is a good thing, which most people will accept as a truth after reading it in the newspapers - without delving deeper into the issue and seeing the other side of the coin.

As circumcision programs are embraced in Africa as a preventive measure to curb down the epidemic of HIV based on 3 trials (experiments) ran in 3 different countries, the poorly understood HIV prevention mechanism is promoted by the pro-circumcision institutions as a reason why people should be embracing circumcision of neonates and infants elsewhere. These 3 studies are rumored to be the base for the new AAP statement on infant male circumcision to be released next week.

Johns Hopkins Medical in particular came out with a simulation (which they called a "study") showing how the decreasing rate of circumcision in the U.S. would cause billions in loss due to health care, based of course in the data from the 3 African studies - which they were also participants of. This was basically a self-serving study designed to call the attention of the media by implying billions in losses, to desperately promote circumcision of infants - and to support the AAP's rumored attempt at having Medicare restore coverage for circumcision of infants in those states where it has been dropped.

The first danger here is that people are extrapolating the results of the 3 studies away from the population that generated the data. The characteristics of the epidemic in Africa are different from those in the United States, Europe, Asia, South America or the Caribbean, so what is recommended in one place is not necessary the best approach for all.

According to the WHO ""Countries with high rates of heterosexual HIV infection and low rates of male circumcision now have an additional intervention which can reduce the risk of HIV infection in heterosexual men. Scaling up male circumcision in such countries will result in immediate benefit to individuals. However, it will be a number of years before we can expect to see an impact on the epidemic from such investment."" <-- This means, this recommendation does not apply to the case of the U.S.

To clarify, the U.S. has a high prevalence of circumcision and a high rate of HIV, which seems to run contrary to the hypothesis that circumcision protects from HIV. But this would have to be explained in the fine letter: circumcision appears to have a protective effect to prevent the female to male transmission of the virus through vaginal intercourse. A high percentage of AIDS in the US is attributed to homosexual relations, anal sex and intravenous transmission.

Most of Europe however has a low prevalence of circumcision and a lower rate of HIV. If the African studies could be generalized, Europe should be in a far worse position regarding HIV than it is.

So whether the 3 African studies found a correlation, they didn't find a causality, and furthermore, the correlation cannot be extrapolated, which means that there are several other factors that are not even taken into consideration in the equation. For example: "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"

The second danger is that the institutions that want to push circumcision for the masses are being selective on what data they consider and what studies they dismiss. For example:

There is a new study conducted in Puerto Rico that shows that "While preliminary, the data indicate that in and of itself, circumcision did not confer significant protective benefit against STI/HIV infection. Findings suggest the need to apply caution in the use of circumcision as an HIV prevention strategy, particularly in settings where more effective combinations of interventions have yet to be fully implemented", in reference to the Caribbean region.

The U.S. Navy also conducted a study among its troops, which found  that "Although known HIV risk factors were found to be associated with HIV in this military population, there was no significant association with male circumcision."

See also where circumcision doesn't prevent HIV

Another study, presented along with the African studies, shows that female circumcision had an apparent preventive effect over HIV in Tanzania. However this study was pretty much dismissed: "The surprising and perplexing significant inverse association between reported female circumcision and HIV seropositivity has not been explained by other variables available and examined in these analyses. As no biological mechanism seems plausible, we conclude that it is due to irreducible confounding" - What this means is that they are aware that there are more variables that were not studied - which is what the 3 African trials on male circumcision should have also acknowledged. So why was this study dismissed while the others were so highly touted to push circumcision? Simply because female circumcision has fallen in disgrace in the Western world since  the 80s (even though it's still widely practiced in Africa and the Middle East), so any Western study that appears to promote what the West already recognizes as a cruel and dangerous practice would be a severe contradiction, and furthermore could lead to the question that keeps begging to be asked: Isn't male circumcision of infants also cruel, dangerous and a violation of the human rights of those who are most vulnerable?

More criticism of the African trials:

When bad science kills, or how to spread AIDS

 Circumcision and HIV - The randomized controlled trials

Doctors Opposing Circumcision - HIV statement

Methodological, ethical and legal concerns

 Confusion over circumcision leaves ‘smart men’ in the cold

Boon or boondoggle?

In the recent AIDS conference, while some African countries presented positive results, some other like the president of Uganda decreed circumcision programs as a loss of time and resources, and the results from some countries like Zimbabwe serve as a counterexample of the premises, since the rate of HIV is currently higher on circumcised men than in not circumcised.

Oh, and look, the  US is urging soldiers to circumcise to prevent HIV. Does that sound familiar? Sounds like the when "military doctors published reports proving that Blacks were responsible for the spread of venereal disease and so Blacks were targeted for circumcision." during WWI and WWI.

So where is the ethical value of these organizations? Why do they want us to walk blindfolded into their schemes, why do they perpetuate myths not unlike J.H. Kellogg did 100 years ago when he pushed male and female circumcision to prevent masturbation because it caused epilepsy, tuberculosis, paralysis and more harm that wars and diseases together.

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