Male Circumcision and HIV

Survey of Sloppy Analysis

It has been said that circumcision is the most common surgery in the United States. It is perhaps also one of the most researched medical procedures. For well over a century, study after study has groped for justification and re-enforcement of a procedure which by and large was never widely practiced by Americans until the introduction of modern medicine in America.

The foreskin has been blamed with scant evidence for a stunning number of diseases and conditions, including "nocturnal emissions," masturbation (when it was bad), syphilis, epilepsy, paralysis, bed wetting (and not the cause as in a common circumcision complication, meatal stenosis), curvature of the spine, "paralysis of the bladder," clubfoot, crossed eyes, blindness, deafness, "dumbness," urinary incontinence, "rectal incontinence," tuberculosis, penile cancer, prostate cancer, STIs of every variety, a great number of cancers affecting many different often unrelated parts of the body, urinary track infection (a rather new foreskin related malady), and now from the rooftops, AIDS. The dubious studies have eventually been discredited while the myth often has lingered to take the foreskins of children without consent.

Science as a human endeavor is, of course, subject to bias and mistake. A recent survey published in the PLoS Medicine Journal in August, 2005, and in last month's Journal of the American Medical Association, found most science studies appeared to be tainted by sloppy analysis.  Although for the most part most studies were not intentionally flawed, flaws appeared to be stunningly common. The author of the survey, Dr. John Ioannidis, an epidemiologist, who studies research methods at the University of Ioannina School of Medicine in Greece and Tufts University in Medford, Massachusetts, concluded after an analysis of 432 published works concerning gender and genes, that almost none of the results held up under closer scrutiny.

In an interview with the Wall Street Journal, Dr. Ioannidis said in part, "Overeager researchers often tinker too much with the statistical variables of their analysis to coax any meaningful insight from their data sets. People are messing around with the data to find anything that seems significant, to show they have found something that is new and unusual." Generally most errors were attributed to one or more of three factors: miscalculation, poor study design, and self-serving data analysis.

Journals typically rely on peer review to root out mistakes before publication, but the large volume of submitted works can frustrate those efforts leading to rushed analysis which increases the possibility of missing problems with submissions.  According to the Wall Street Journal, nearly 12,000 papers were submitted annually to the weekly peer-reviewed journal Science alone. One of the most troubling consequences of mistakes getting published is their propensity to linger long after the results are discredited, even being cited in future works.

Nowhere is this more evident than in circumcision research over the last 100 years. That isn't to say that all such research is wrong all of the time. However, considering the past claims and the need of United States' medical researchers to justify and continue infant circumcision, we must be vigilant about prophylactic claims which are frequently so far down in the noise as to often be worthless.

THANKS to Joe Pellegrino for this contribution.

Notebook: NYC Edition

I'm here in New York City, rubbing shoulders with people from every imaginable corner of the world. It's an experience that makes you think about the meaning of acceptability, a concept that has a lot to do with the promotion of circumcision in Africa -- and in developed countries.

A great deal of the news one hears about HIV/AIDS is characterized by its dire tone, desperation, guilt inducing pleas for sympathy, and calls for money. Calls for circumcision over the decades have shared many of these qualities, particularly the direness, the desperation, and the guilt trips. Leave it to Robert Bailey and Daniel Halperin to add the money element.

Money is a funny thing. Price something too cheaply and it appears, seems, and may even look cheap without regard to the reality. Give it away and it often goes begging. Price it too high and desirability rather than quality suddenly becomes the issue. A high price seems to actually induce buying.

Something for free? Take it or leave it. The illusion is of abundance and that one can always come back.

Cheap? You get what you pay for. It won't last. We'll just have to replace it or do it again whatever it is.

Expensive? How can we afford it? How can we rearrange not just our finances, but our very priorities.

What does all of this have to do with the controversy over circumcision as an HIV prevention? Bailey and Halperin have called circumcision an HIV prevention as opposed to a risk-reducing measure, claimed an absurd 75% protective effect, and deflected the controversy by claiming no personal interest in the subject other than helping people. Halperin has said to me personally and elsewhere that most of his writings are about behavior change. But of course, this is subject-changing and deflection to slip his agenda passed lowered defenses. And one he will not be able to honestly make for much longer.

The economics of it are this. Claim an outsized value on something, and get people to pay dearly by buying into what is essentially a genital mutilation. The analogy is not perfect. It breaks down in developed countries when you consider that the value is claimed to be very high while the personal and financial costs are offered as inconsequential. The reality is that the value is close to nil in real world settings while the high cost is disguised.

The analogy is much better suited to Africa. Circumcisions are astronomical in cost both in actual money terms and in the over all resource loss to the medical system while providing no real prevention. It's basically a zero sum gain for prevention and a net loss for the provisioning of not just HIV testing, treatment and prevention services, but for basic medical services in maternity, vaccination, education, and other essential areas of health care. And the personal cost is rightly perceived as very  high because adults are the target and circumcision is not common in the targeted areas. Hence, the promise of a discount for later generations, if only the current targeted group will only pay high now, by the introduction of infant circumcision where it has been unknown before.

So Bailey and Halperin have gone shrill in their calls for money, calling for expensive mobile circumcision services, and their alleged rightful share of the HIV pot to fund them. After all, circumcisions aren't going to perform themselves. And so, the campaigning for cash has begun.

So what can we do? A lot is the short and hopeful answer.

The interest of people of conscience should be two-fold. First, HIV prevention, education, and the integrity of any system that purports to participate in this endeavor. Second, providing these services at the lowest possible cost to the individual and society without dictating how individuals should go about their prevention strategies. And the irony is that working towards the lowest possible cost to the individual is ... you guessed it, expensive.

Therefore, I will be placing all contributions to the Tip Jar and my own personal contributions in trust, pending the formation of an entity that will provide the financial wherewithal and emotional, political, and personal moral support to do this work. We can make a difference, get the attention this cause deserves, and compete (yes, I mean literally compete) with the likes of Halperin and Bailey, who by the way have the full authority and economic support of their institutions behind them.

Finally, I would like to thank Joe Pellegrino for being our second contributor to the Tip Jar. Your contribution is more than financial. It encourages us all. Thanks.

[REVISED third paragraph.]

Notebook: Aidsmap Plays Four Easy Pieces

Homophobia, poverty, poor ARV adherence, and apathy. Four easy pieces.

Reports are coming out of Uganda that PEPFAR funds are being used to promote the homophobic agenda of the government and NGOs in that country. A choice quote from Aidsmap:

James Kigozi of the Ugandan AIDS commission has defended the lack of any reference to gay or bisexual men in the country’s HIV strategy saying, “the practice of homosexuality is illegal.”

PEPFAR has become a slush fund for charlatans (abstinence only promotors, Halperin et al's circumcision) and repressive governments. As usual, money has corrupted so many who have received it in the name of a noble cause.

Most people will readily see the logical linkage between financial worries and health. In the US, it's a matter of ever-pressing concern. Two studies, one in the US and one a meta-analysis of Africa-based studies, have shown that if you are poor, you are likely to fail to adhere to your regimen. HIV may kill, but not without poverty. Secondary lesson: You can give people drugs, but you can't make them take them.

Finally, US researchers have announced the unexpected result that patients are presenting later for HIV treatment than nearly two decades ago. To cut through the clutter, the reasons are boiled down to insurance, universal testing, and the linkage between the two. Again, poverty is the culprit aided by poverty's help-mate, apathy. Poor people and the uninsured, groups that are often interchangeable, present later. And these groups exist in greater number in the US than in the last two decades. The article concludes:

Goicoechea and Smith agree with the study's authors that “these data support the argument for mainstream HIV testing,” but add that, “they also highlight the issue of universal health care coverage.”

“HIV disease is a disease of poverty," they note. "In the United States, HIV infection disproportionately affects uninsured, low-income persons, who constitute a vulnerable population that often has multiple health care needs.”

They conclude by arguing that, "‘universal’ HIV testing also requires ‘universal’ health care for there to be a significant impact on diagnosing HIV infection at the earliest stage possible. As the United States and other resource-wealthy countries move forward to build health care infrastructure and scale-up antiretroviral therapy in resource-limited settings, it is a shameful commentary on our own health care system that the average CD4+ T-cell count before the initiation of antiretroviral therapy in North America is similar to that of some underdeveloped countries in Africa.”

Notebook: Gossip is stronger than truth, "the mother" of all child-rearing wars takes Britain by storm, and studies show circumcision confers no protection viz STDs

Science has finally proven that gossip, despite common sense and evidence to the contrary, is more powerful than truth. It's another way of saying that propaganda and "whispering campaigns" work. So what else is new, you might ask. We've known that forever in the United States as circumcision has maintained its clutch on new mothers for a century despite the evident harms and lack of anything more than the slight benefit it may confer in the rarest of circumstances. You can take it on faith that expectant mommies talk to each other and vie for the informal title of most caring and concerned. It's all done in the name of what's best. What's that old adage about the road to hell and good intentions?

Britain has its own battles to wage in the child-rearing field. It's well known in the legal realm that  an expert is anyone who can cobble together a resume from any old raw material. Schools you've never heard of? No problem. Unverifiable work history? How about a little rehabilitative voir-dire on that. And so in line with gossip as gospel truth, mommy experts are battling online and across Britain for the best child-rearing advice. I wonder however how vitriolic it could be. After all, Britain for the most part doesn't have to  contend with routine infant circumcision.

Finally, circumcision may be worthless in the fight against disease generally, yet a slight lower risk for the contraction of syphilis has triggered old beliefs, engendered by old gossip no doubt, among headline writers in Australia. The rightful headline, "Circumcision confers no benefit against STIs" became "Circumcision may lower syphilis risk" due to a rigorous adherence to old news from the grapevine by The Australian. As long as you know better, you and your child are safe. Headline skimmers, however, may find themselves at a slightly elevated level of danger. Luckily, it would seem most Australians have overcome the rumor mill on routine circumcision.

Notebook: Oh my! Is it Oct 10 already?

I hadn't intended to let this month get away from me like this. But here we are, on Oct 10, and this is this month's first post.

I would like to thank Gillian Longley for being the first contributor to our Tip Jar. Thanks, Gillian.

I have added a blog roll. Please suggest a blog you feel worthy. It doesn't have to be specific to circumcision and HIV, or even HIV, or circumcision. Intelligent writing on any issue or current trend or event that may impact the issue of HIV and promotion of questionable tactics to fight HIV is fair game.

Finally, welcome to NOCIRC of Colorado under our Websites That Have Linked to Us section in the left sidebar. Thank you for the link and the mention on your site.

Please take this moment to participate in an online open mic and leave a comment or two.

- David