Male Circumcision and the HIV/AIDS Myth

This year, 1.2 million male babies in the United States will have between 35 and 50% of healthy, functioning penile skin -- containing over 20,000 nerve endings and the five most sensitive areas of the penis -- removed in a procedure that all of the major medical associations in the world, including the American Academy of Pediatrics and the Canadian Paediatric Society, have deemed medically unnecessary.

Overall, routine, non-therapeutic circumcision costs over $2 billion a year; in most states, it is still covered by Medicaid, at a cost of tens of millions of dollars to the taxpayer. Despite near-universal recommendations against performing it routinely, it is the most common surgical procedure performed in the United States.

Having started among ancient Egyptians and ancient Semitic peoples as a religious sacrificial ritual, the practice didn't take hold in Western societies until the late 1800s, when Western society was mired in masturbation-related hysteria. Dr. John Kellogg (yes, the Corn Flakes guy) was seminally (ahem) influential in the fight against what he called the "practice of solitary vice", to prevent which he ardently recommended circumcision, writing:

"The operation should be performed by a surgeon without administering an anesthetic, as the brief pain attending the operation will have a salutary effect upon the mind, especially if it be connected with the idea of punishment, as it may well be in some cases. The soreness which continues for several weeks interrupts the practice, and if it had not previously become too firmly fixed, it may be forgotten and not resumed."

This recommendation was accepted and implemented widely for male children, likely buoyed by the belief that circumcision was, after all, part of Abraham's covenant with God, who doesn't really like dickheads. Because the application of phenol to a girl's clitoris wasn't part of this covenant, this second recommendation from Dr. Kellogg to prevent female masturbation -- an "excellent means of allaying the abnormal excitement" as he wrote in his book Plain Facts for Old and Young -- wasn't embraced as enthusiastically.

I personally debunked Dr. Kellogg's myth as a young, foreskinless pre-adolescent, sometimes several times a day. Science can be fun. But since Dr. Kellogg, many more myths have come and gone.

One had to do with a 1932 study by Abraham Wolbarst claiming that infant circumcision virtually eradicates the risk of penile cancer, an exceedingly rare condition that affects approximately 1 in 100,000 males in the United States. His research was later discredited on several grounds, including the fact that Wolbarst happened to an avid circumcisionist who also believed, like Dr. Kellogg, that circumcision prevented not only masturbation, but also epilepsy and infant death.

We now know that penile cancer is only slightly more prevalent in the uncircumcised, and routine circumcision is not the best way to go about preventing it, just as routine double mastectomy in women who are done with breastfeeding (and thus have no remaining physiological need for their breasts) is not a good approach to preventing breast cancer -- which is much more common than penile cancer. We also know that the human papilloma virus (HPV), which also causes genital warts, is the most important risk factor for cancer of the penis -- and genital warts are more easily contracted by circumcised men. Moreover, penile cancer is much less prevalent in countries like Denmark, where circumcision is uncommon, compared to the United States, where between 50-60% of males are circumcised.

Advocates of circumcision found more ammunition recently when it was reported that uncircumcised heterosexual males were more likely to contract HIV/AIDS than their circumcised counterparts. The finding, based on studies in Africa, specifically Kenya, Uganda, and South Africa, seemed to show that circumcision reduces the chances of heterosexual men contracting HIV/AIDS from women by up to 60%.

The World Health Organization got behind this immediately, and the WHO's HIV/AIDS Department director, Dr. Kevin De Cock (yes, that's his real name) stated unequivocally that circumcision would give a significant "additional benefit" to men trying to avoid HIV infection.

So how do you go about conducting a randomized, controlled intervention trial looking at HIV infection in circumcised adult men? Probably not the way that these researchers did.

First, to be included in the study, men had to be HIV-negative and uncircumcised. The men also had to consent to "avoid sexual contact (except with condom protection) during the 6 weeks following the medicalized circumcision."

The experimental group which underwent the circumcisions was given the following instructions:

"When you are circumcised you will be asked to have no sexual contact in the 6 weeks after surgery. To have sexual contact before your skin of your penis is completely healed, could lead to infection if your partner is infected with a sexually transmitted disease... If you desire to have sexual contact in the 6 weeks after surgery, despite our recommendation, it is absolutely essential that you use a condom."

So the males in the study that underwent circumcision were not only told to abstain from sex for a significant time period after the operation -- reducing their exposure time by six weeks compared to the uncircumcised (control) group -- but told to use condoms, taught how to use them, and educated about their benefits. During this six week period, the men in the uncircumcised group did not have the same restrictions.

There also doesn't seem to be any mention of the researchers calling up the circumcised men after six weeks to say, "Okay, time's up. Ease up on the condom use from here on." The possibility that many of these men might have become accustomed to using condoms, armed with knowledge about their benefits, didn't seem to be much of a concern.

Also, other routes of HIV transmission like blood transfusion, IV needle sharing, or a dentist with dirty instruments (not unimaginable in Africa) don't seem to have been taken into account. Individual variables like hygiene were also poorly controlled for.

Casting further doubt on the theory that circumcision prevents HIV transmission is a simple look at the prevalence of circumcision and the prevalence of HIV/AIDS in different parts of the world.

As a continent, Africa has the highest percentage of circumcised men, over 60%. Africa also has -- as most people know -- the highest prevalence of HIV/AIDS, with South Africa housing the world's largest HIV-infected population. In countries like Nigeria and Kenya, (the latter being one of the countries where the study was conducted) over 80% of males are circumcised, yet they contain the second and fourth largest HIV-infected populations in the world respectively.

Among industrialized nations, the highest prevalence of HIV/AIDS is in the United States, which has the 10th largest HIV-positive population in the world. And yes, the USA also ranks number one among all industrialized nations in its number and percentage of circumcised men: 56% as of 2003, compared to countries in Europe, where circumcision is markedly less common -- as is the prevalence of HIV/AIDS.

Finally, let's address a question that seems to have been largely overlooked: what about the women?

Well, last month, The Lancet -- which refused to publish the male circumcision trials due to certain ethical concerns -- published a study led by Dr. Maria Wawer at the Bloomberg School of Public Health in Baltimore, concluding that circumcising men did not reduce HIV transmission to their female partners.

Actually, it's quite possible that circumcised men are more likely to give their female partners HIV/AIDS than uncircumcised men. Dr. Wawer found that 18% of the women in her study contracted HIV/AIDS from circumcised men, compared to 12% of women who contracted it from uncircumcised men.

The result was not statistically significant, but the Findings section states, "The trial was stopped early because of futility." Futility? The study may not have been "futile" if, with a larger sample size and properly completed, it had showed that circumcised men were more likely to transmit HIV/AIDS to their female partners, would it? An unanticipated result is still a result, specially if there is pre-existing data supporting it, like this Johns Hopkins study suggesting that women are indeed more likely to get HIV/AIDS from a circumcised male partner.

In an interview with VoA, Dr. Wawer appeared to have had a preference regarding her results. "Yes, of course we are disappointed," she said. "But the data are what the data are."

At the end of the day, we're close to busting another myth, and back to where we started with this whole circumcision-HIV thing. Even if the researchers in the Africa trials were right, it would take over 70 circumcisions in Africa to prevent 1 case of HIV. If the data were applied to the United States, it would take over 300 circumcisions to prevent one case of HIV. The bottom line remains the same: the best way to prevent HIV and other sexually transmitted infections -- whether you're circumcised, uncircumcised, gay, straight, male or female -- is through education and condom use. Where these two conflict -- as they did with the Pope's fatwa on condoms this year -- please go with the condom use.

A recent study looking at sensitivity of the penis in the circumcised and uncircumcised male found that the five most sensitive areas on the penis are removed at circumcision, and that the keratinized glans on the circumcised penis is less sensitive than the foreskin-protected, mucosa-lined glans on the uncircumcised penis. The skin removed from the penis at circumcision makes up close to 50% of the total penile skin, amounting to 15 square inches in an adult.

Even the mildest form of female circumcision is illegal, and very rightly termed female genital mutilation. Male circumcision on the other hand, is demonstrably more severe than some of the milder forms of FGM, but still performed widely. It is still covered by many insurance providers, and Medicaid in most states, despite being completely unnecessary.

Suppose for a moment that females who have been circumcised are shown to have a lower risk of acquiring HIV/AIDS. Kind of like it says in this abstract here.

How appropriate would it be for a group of researchers to carry out a massive study like the African male circumcision trials for women?

How long would it take for Dr. Kevin De Cock at the WHO to recommend female genital mutilation -- even in its mildest form -- as a form of HIV/AIDS prevention?

I wouldn't hold my breath.