Male Circumcision and HIV

Are gay men's genitals under attack?

Gay men seem to be the primary target of the proponents of circumcision, who are basing their recent push on the three African studies that purported to show a prophylactic effect from circumcision in heterosexual men. While gay men make up some 5% of the population and perhaps less than 50% of new infections, this community has seen the most discussion and frankly misinformation on the issue.

Ironically, the African American community now accounts for 51% of new infections while this group makes up just 13% of the American population. HIV is primarily heterosexually transmitted among African Americans. Yet, the push hasn't yet reached deep into this community. The likely reason is that African Americans are nearly universally circumcised already.

HIV is a highly political disease and so is circumcision. It shouldn't be a surprise that the United States should see such a whirl wind of controversy then. However, it is surprising that gay men, especially intact gay men, aren't more concerned with this sudden attention to their genitals when other methods of HIV prevention have been extremely effective in pushing the overall infection rate down to below 1%.

Article after the jump.

Dr. Stephen J. Fallon misinforms the gay community

It's rather curious that even the experts are confused about the implications of the three African studies being used to build a case for male circumcision. The San Francisco Bay Times recently published an "analysis" piece by Stephen J. Fallon, Ph.d. Let's look at where he goes wrong.

Fallon states that New York City's health department is considering promoting male circumcision and even paying for them. This, of course, is incorrect as this blog has pointed out. As Dr. Thomas Friedan wrote in a letter to the New York Times on April 9, 2007, "The New York City Health Department has not planned, developed or announced a campaign to encourage at-risk men to get circumcised."

Fallon talks about Langerhans cells as if they are the vehicle for infection. He states, "HIV thwarts [the immunological function of Langerhans cells] ... by riding in through [these] cells, and invading the main machinery of the immune system." Yet, he fails to acknowledge, perhaps because he doesn't know of, a study that suggested Langerhans cells could provide a barrier to infection through strengthening their response and production of langerin. See the study. Moreover, the theory he advances is a theory without evidence. To date, there has never been a study determining the mechanism that circumcision allegedly short-circuits to reduce risk.

Fallon criticizes a study that seemed to show circumcised men at higher risk for HIV infection without acknowledging that the African studies suffered from similar weaknesses and limitations in their translation to the American context. He claims different risk trends explain the results when exactly the same issue is presented in the promotion of circumcision in the American context for HIV prevention. HIV infection is almost exclusively centered in intravenous drug users and male-on-male sex populations. Not one of the African studies touched on these transmission methods. And I'm sorry, but Israel is nearly universally circumcised. So if that was the comparison country, then I don't know what he's talking about. And clearly, he doesn't either.

Next, Fallon states that, "A newer, more rational study in the journal Emerging Themes in Epidemiology proves that circumcision directly reduces HIV risk." Epidemiology studies prove nothing. They show apparent outcomes in real world settings. Wikipedia, as good a source as any for definitions, states, "Epidemiology is the study of factors affecting the health and illness of populations, and serves as the foundation and logic of interventions made in the interest of public health and preventive medicine." He probably means the study he speaks of points (correctly or incorrectly as the case may be) to circumcision as a valid public health measure, but fails to mention the highly circumscribed settings for its use.

Fallon makes the jaw dropping oxymoronic statement that, " The three major [incomplete] circumcision studies discussed here only looked at heterosexual males.  Gay men would get the same 48 to 60 percent protection from HIV that circumcision offers, but only when they top." Ok. Did you get that? He says the studies only dealt with heterosexual intercourse, but then says gay men would get the same protection. This is a Ph.d. talking. Fallon has no credibility left by this time in his article for the alert reader. There is no evidence, and the WHO and UNAIDS have also stated as much, that circumcision has any benefit for gay men who have anal intercourse with other gay men. Fallon either knows this and is not telling you or he doesn't know, in which case he is even less to be trusted.

The only bottom line message Fallon manages to get right is that, "HIV doesn’t care if you’re 'mostly top,' or built like a top (whatever that means), or were exclusively the top in your last relationship.  Only your next unprotected sex matters." And a responsible HIV/AIDS educator would add you must use condoms everytime whether you are circumcised or not.

Notebook: AIDS funding, a "no-brainer" becomes complicated

It was once a complete "no-brainer" for human rights supporters to support funding initiatives and fundraising for HIV/AIDS prevention and research. Now, that easy decision has become complicated.

Every year, San Francisco has a long string of Spring fundraising events and drives for AIDS related services and research. One can choose from sporting events to dining out affairs to parties for opportunities to give while engaging in consciousness raising and network building.

Unfortunately, I find myself researching the background and focus of the different groups now to ensure my efforts don't end up promoting circumcision in a population where it is unlikely to have any effect. In other words, I'm worried my efforts, as small as they may be, will be wasted.

The question to ask is whether the fundraising beneficiaries will find themselves embroiled in the business of explaining themselves more than ever, and how this will effect, or detract from, the over all fight for needed funding.

Notebook: Posts and Virginia Tech

I know this is supposed to be a blog about circumcision and HIV. And it is. However, the events of the last week have taken up quite a bit of my attention as I have blogged elsewhere on that terrible event. There will be new posts coming soon.

I want to say how sorry I am for what happened at Virginia Tech. I feel for everyone involved, not least the family of the mentally ill college student who did this. I know it may not be popular to express sympathy and regret for people who hurt others. But I am so sorry for the anguish and suffering that completely knocked Seung Hui Cho off his rocker. I mean no sane person does such things. And while it isn't my place to forgive, I hope the power of forgiveness ameliorates the unbearable pain of the families. And if they can't forgive, that's ok, too. No one should begrudge them one bit for it.

A couple of issues I hope to touch on in coming posts are economic and environmental issues that impact HIV, and how these may impact providing prevention assistance and treatment.

NYT shows it can't tell apples from oranges

It is a sacred tenet of the anti-circumcision movement that each person should be left to define himself and his experience without interference -- whether in sex or identity or any other area of life. In fact, it is the very foundation of why the movement exists. Therefore, it isn't particularly upsetting or disturbing to most people who are against circumcision to hear that some men either like or don't care that they were circumcised as infants. In fact, the whole issue begs the question.

Obviously, it is those who are unhappy with the decision made for them by parents and in some cases doctors who are at issue. However, as if to poke the "anti's" in the eye, the New York Times, as has been its habit of late, has run an opinion piece that purports to speak for most men, implicitly lumping men circumcised as adults in with men circumcised as infants both groups together. No wonder it's reviled by so many.

The piece curtly points out a small British study that purports to show that most men in this particular study, if measured by self-reports on satisfaction post-op, seem to come out satisfied. Now perhaps a 62% rate of satisfaction seems impressive to some people, but to me it is a disaster. If 38% of the men said they were not satisfied or less than satisfied, that's no small number for a self-selected group who voluntarily went under the knife! If it were me, I would want much better odds than that -- measured longitudinally.

Still, it is one thing to look at a self-selected group who have undergone circumcision voluntarily and it is quite another to look at a group that was forced to be circumcised in infancy. They are hardly comparable.

Granted, many of the latter group may have positive or no opinions on their own status, but so what? Sexual satisfaction is a very broad topic, partly penis-focused, partly psychological, partly a whole lot of something else. It doesn't particularly help your case to simplify to the point of meaninglessness. Why not just give the conclusion, forget the argument, and say, "This I believe?" Otherwise, it just shows your poorly disguised bias or your lack of critical thinking skills.

See it for yourself, next page.

Brazil rejects circumcision

This is old news in that it has been reported elsewhere around the web. Nevertheless, I provide the full story and a translation from the Spanish below.

Generally, the reasons given for Brazil's rejection of circumcision as a public health measure, apart from not fitting the profile of a country that UNAIDS and WHO are encouraging to consider the measure, are the following:

• circumcision only provides one way protection, from female to male (partial protection in more ways than one)
• circumcision has the very real danger of providing a false sense of security, thereby causing a drop off in the use of better prevention technologies, aka the condom

I would add another reason. Circumcision damages the penis and has the proven potential to cause sexual dysfunction. Therefore, it should be a last resort in highly impacted populations. Did this idea have some traction at the high level meeting that produced the WHO and UNAIDS recommendations in that only countries with an infection rate of 15% or more are to be encouraged to consider the measure? Or is it more likely a cost ($$)-benefit analysis was the true basis for limiting the recommendation to such countries?

Original article and my translation after the break.

NYT perplexed at lack of groundswell for gay circumcision

Rather than ask the reasonable question, why should men give up their foreskins, the much and rightfully maligned New York Times asks this question instead: "How do you persuade a grown man to get circumcised?" That's it. How do you do it? Not why. But How.

I find it rather interesting that the Times article goes on at some length to admit that the studies in question are not applicable to men who have sex with men, then carries on in a tone befitting the scolding of a small child for not minding his parents. Take this parenthetical:

(Circumcision’s effect on sex is a white-hot issue in the United States for the small but vocal anticircumcision lobby. The lobby’s main focus is on advice to parents of baby boys, but it has offshoot groups, like the “uncuts” who insist that sex with uncircumcised men is superior, and the “foreskin restoration movement” which utilizes tape, small weights and parental resentment.) [Emphasis mine.]

I've read my fair share of discussions viz. parental responsibility for a man's unwanted circumcision. I have never read or seen or heard expressed that the driving motivation to restore was parental resentment. And who are the "uncuts?" Did he just make up some so-called "off-shoot" to make a point? Mr. McNeil exhibiits bigotry -- and the Times prints said bigotry -- for begrudging men who are essentially doing the opposite of what McNeil advocates.

Story after the break.

Notebook: UCSF ignores request for interview

A couple of weeks ago, this site contacted the University of California, San Francisco, HIV InSite, to request an interview with someone in the organization to discuss the UNAIDS and WHO recommendations on male circumcision.

I got no response. However, I know someone in the organization passed the request up the chain of command because shortly thereafter, perhaps a couple hours later, I got a hit from the president's office of UCSF. Coincidence? Maybe. I would be flattered to think the premiere research institution on HIV in the United States had found its way to this site.

During the last few months, I have been struck by the almost total lack of discussion regarding the ethical issues involved. Subsumed therein is how public health policy administrators may handle the cultural sensitivities that have worked as a bulwark against circumcision among certain groups in the United States. Here lies, in my opinion, an ethical minefield due to the temptation to misrepresent or downplay the risks and possible undesirable outcomes -- and the plain ignorance by most American health professionals of negative outcomes.

There are only so many ways to comment on the media's representation and misrepresentation of this story. And so, this site will seek to do some original reporting. Being located in San Francisco makes this uniquely possible. But it is a big undertaking (for someone with a full-time day job -- after all, this is just a blog).

Stay tuned for further developments.

NYC not planning to promote circumcision, says health commissioner

The New York Times published a correction by the health commissioner today stating that the "New York Health Department has not planned, developed or announced a campaign to encourage at-risk men to get circumcised." The health commissioner called such a plan premature.

Ok, fine. But does he think more study will somehow link circumcision to lower HIV infection rates in intravenous drug users? Men who practice both receptive and active anal intercourse? This is how it is passed in the majority of cases in the United States. Circumcision was only studied in the context of heterosexual epidemics.

Despite insistent claims by the authors of these studies, it is impossible to conclude that mass circumcision will have anywhere near the 50% reduction in HIV infections even in Africa since the highest rate of infection is in women from already infected men.

The letter, next page.

THANK YOU to Ron Low for giving me an early morning heads-up on this item.

Letter to the Editor

A very mild caution in a letter to the editor of the New York Times, above the fold.

Circumcision and AIDS

To the Editor:

Re “W.H.O. Urges Circumcision to Reduce Spread of AIDS” (news article, March 29):

Male circumcision may not be brain surgery, but that does not mean that it is simple to provide safely in countries with weak public health services.

I just returned from South Africa, where health clinics are desperately short of skilled personnel, especially in the urban and rural communities with a high prevalence of H.I.V. and AIDS. As countries decide whether to add male circumcision to their prevention mix, they must carefully weigh their capacity to provide it properly.

Another worry is the fact that men should abstain from sex for at least four weeks after the surgery. This seems highly unlikely in the conditions I have observed, in southern Africa and elsewhere.

We must remember that this intervention in itself will do nothing to change the harmful behavior patterns — unprotected sex, coercion and violence — that are putting people, especially women, at risk.

Lyn Messner

New York, March 30, 2007

The writer is program officer, Africa, for the International Women’s Health Coalition.

Reference

Letter to the Editor. Circumcision and AIDS. New York Times. April 5, 2007.

http://www.nytimes.com/2007/04/05/opinion/l05aids.html?pagewanted=print