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  • David Wilton

    David Wilton is a lawyer by training. He has a long-standing interest in issues of body integrity and HIV/AIDS. He maintains this site and blogs from San Francisco, California. His primary interests outside of nurturing a debate on the controversial measure of removing sexual tissue to reduce the spread of HIV are in the areas of international relations, languages, and journalism.
  • Adrienne Soti
    Adrienne Soti has provided research and monitoring of the media for Male Circumcision and HIV. A native of Hungary who came to the US in 1990, she lives with her husband and two small children in New Jersey. She has a B.A. in Psychology and Philosophy from Rutgers University. She lists biology and medicine among her many interests and is particularly interested in bio-ethical issues. The circumcision controversy came to her attention after the birth of her son in 2005.

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    PO Box 40312
    San Francisco, CA 94140
    wilt31@gmail.com
    [Please put CIRCUMCISIONANDHIV in the subject line.]

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« December 2007 | Main | February 2008 »

12 entries from January 2008

Saturday, January 26, 2008

Reuters repeats for emphasis(?): Circumcision Doesn't Protect Against HIV Among Men Who Have Sex With Men

Reuters is re-reporting the news that three studies have shown no protective effect among men who have sex with men. The story misreports again that black men in the United States are less likely to be circumcised, in a probable attempt to give context to one of the studies that looked exclusively at African-American and Latino men. Ethics of circumcision was not mentioned in the Medscape article summarizing the article published in the Journal of Acquired Immune Deficiency Syndromes.

Circumcision did not reduce the risk of HIV infection in [the] entire study group or in any subgroups, including men who were bisexual, engaged in unprotected insertive anal sex or protected receptive anal sex, or men who reported that their previous HIV test was negative.

The current results do not support circumcision as a means of reducing the risk of HIV infection among MSM in minority groups in the U.S., the researchers conclude.

Link: Circumcision Doesn't Protect Against HIV Among Men Who Have Sex With Men. (Medscape registration required)

Thursday, January 24, 2008

Picking up on SFAF's Statement on Circumcision and HIV

The San Francisco AIDS Foundation, an organization for whom I have raised money, came out with a policy statement on male circumcision and HIV in March of last year. This escaped my attention even though I knew they were formulating a policy. Better addressed late than never ...

Here are the important points made.

  • Being circumcised is not HIV protection. Circumcision may reduce, but does not eliminate risk of HIV infection. Sexually active men, whether or not they are circumcised, should use condoms to protect against acquiring and transmitting HIV and other sexually transmitted infections.
  • There is a potential for men who have been circumcised to believe they are fully protected and to lapse in condom use and other modes of risk reduction, which could have the effect of increasing HIV transmission rather than decreasing it.
  • The studies in sub-Saharan Africa took place in highly controlled medical settings and were conducted by medical experts on previously uncircumcised men who have vaginal sex with women. These men were given counseling about sexual risk and were provided with condoms. Their health was regularly monitored for any adverse outcomes from the circumcision, which were treated upon detection. [Statements that would seem to validate the lack of similar real world outcomes.]
  • There  is no comparable evidence about the effect of male circumcision for gay and other men who have sex with men. [In fact, the evidence is in, and it is that circumcision provides NO protection for gay men.]
  • There is no comparable evidence about the effect of male circumcision for anal intercourse.
  • There is insufficient evidence about whether circumcision in HIV-positive men protects their male or female sexual partners. [In fact, there is some evidence that male and female partners of circumcised men are at greater risk.]
  • There is no evidence about the effect of male circumcision on reducing acquisition of HIV among women. Another study in Rakai, Uganda is currently looking at this, but it is not yet completed. [Preliminary data from this last trial suggested women were at greater risk; see last bullet point above.]
  • The evidence from the trials in sub-Saharan Africa applies to adult men. It cannot tell us specifically about the potential HIV risk reduction benefits of circumcision conducted on newborns or children. [Good as far as it goes. However, any reference to informed consent and voluntariness must recognize that these principles extend to all human life. Decision-making shifting due to age on care not intended to address an immediate health need, like say a polio vaccine shot, leads to lack of consent and involunatary procedures.]
  • Male circumcision has cultural and religious significance in many settings, which may affect its acceptability among different communities.

With the foregoing in mind, the Foundation goes on to state:

  • Circumcision is an invasive medical procedure that must be conducted by trained individuals under sterile conditions with appropriate monitoring and an adequate healing period to eliminate the risk of bacterial infection. Community and health care provider education will be essential for the implementation of male circumcision as an HIV prevention strategy.
  • Payment for the procedure should not be an obstacle to any man who chooses to undergo it; public and private health care programs and insurers should cover male circumcision as part of preventive medicine.
  • Adult male circumcision should always be voluntary, with appropriate informed consent. ["Should" is too weak. It must always be voluntary and with complete informed consent. No overreaching or undue persuasion should be permitted. The loss of sexual function must also be addressed.]
  • The public health community should understand and respect religious and cultural meanings of male circumcision in formulating implementation strategies. [Statements like these require clarification. What about cultural aversion to the procedure? Wouldn't such aversion require the same level or a greater level of respect? The Luo seem to have lost out on this particular principle.]
  • Circumcision is a personal decision that should be made in consultation with providers, pediatricians and others. The Foundation does not make recommendations about individual health choices. [Reference to pediatricians is telling as to where the Foundation lies in its conventionality viz. infant circumcision.]

The SF AIDS Foundation is a non-governmental political body trying to maximize its fundraising potential. It has some obligation to kowtow to have its greatest success. And so in this particular case, it has gone along to a certain extent while trying to make obviously valid points. It fails in the end by pointing to sources, such as the AIDS Vaccine Clearinghouse, which is an egregious choice for information on this issue. Which brings me to a point that needs to be made.

I think it is a stunning success for the proponents of circumcision that they have sold the lie that circumcision prevents HIV with such alacrity. Today whole nations are purportly willing to force their populations under the knife with scant proof that it will do anything in their fight against HIV/AIDS. This is just stunning.

I think anyone with an interest in public health policy would do well to learn from this development. One important message to be drawn (I write here somewhat sarcastically) is that one should start with a plausible proposition that is essentially unverifiable, do your experimenting in and make your weightiest pitches to the most desperate nations far, far away, and publish, publish, publish. It also helps to have an acquiescent media and be employed by prestigious medical and educational institutions who are familiar with and favorable to circumcision as a cultural artifact.

I would recommend everyone who wishes to weigh in on SFAF's policy to write to them. Put the "public" back in health policy.

Contact SFAF:

policy@sfaf.org
415/487-3080

Public Policy Dept.
San Francisco AIDS Foundation
995 Market St, Ste 200
San Francisco CA 94103

Mast_head_articles

Tuesday, January 22, 2008

Rwanda ignores data, buys into circumcision hysteria

The BBC is reporting that Rwanda will begin a mass circumcision campaign to include forced circumcision of minor children. No stranger to drives beginning with "mass", Rwanda's HIV infection rate is higher among the currently circumcised than it is among the intact according to the 2005 Demographic and Health Survey [pdf].  [Original location of pdf.] The HIV/AIDS rate has fallen from 11% of the adult population in 2000 to 3% in 2007 using conventional HIV reduction strategies. A realistic view is that circumcision in Rwanda will likely have no impact on the HIV/AIDS situation or set it back due to disinhibition.

Sunday, January 20, 2008

Results and Result-oriented Studies: Drugs Edition

You can hear their refrain echo in your head now. Not our research. Not this research. Yet, how much attention have the three studies demonstrating no protective effect in gay men from circumcision gotten? A few mentions here and there. Mostly glossed over, minimized, ignored. Yet no distinction is made in the message that is out there now: circumcision is a prevention. How about the research showing no protective effect in real world settings? Or the research that looks at the social constraints that have kept HIV in check in Muslim countries? Has there even been any research on that issue?

"It tells you where they placed their bets before they saw the data."

...

"Not only were positive results more likely to be published, but studies that were not positive, in our opinion, were often published in a way that conveyed a positive outcome."

And so we have a parallel situation in drug research. The following article describes a study that looked at drug studies, published, unpublished, rewritten, and buried. The researchers discuss how drug companies, who have counterparts in universities and international aid agencies, seek to advance their agendas, in this case, drugs. Every time they mention drugs think of circumcision. When they mention a drug company, think of Halperin, Klausner, and Bailey.

Link: Unfavorable drug studies don't get into print: report - Yahoo! News or fair use article after the jump.

Continue reading "Results and Result-oriented Studies: Drugs Edition" »

Tuesday, January 15, 2008

S.F. General researchers follow strain of drug-resistant bacteria

A killer responsible for more deaths than HIV/AIDS. A strain that takes days to kill instead of years. The epicenter localized in San Francisco's gay community. Where have we seen this before?

Oh wait. In San Francisco's gay community.

When AIDS was first identified, people were dead within weeks or months of diagnosis. Today we know the disease incubates for years before causing the opportune infections that result in death. Still, the comparison bears making, however imperfect it may be. Today we have a new formerly harmless infection in the form of a bacteria that is taking shape as a frightening reprise of HIV/AIDS albeit in a very different form.

It's possibly not the best comparison. However, when the HIV/AIDS community is starting to turn to drastic measures such as removal of sexual tissue to deal with HIV infection, we should all be worried about how that might provide an opportunity for another deadly infection to step in.

The unintended consequences of circumcision may come from a direction no one anticipated.

[This article has been reprinted by Reuters.]

Full fair use story below the fold.

Continue reading "S.F. General researchers follow strain of drug-resistant bacteria" »

Friday, January 11, 2008

What will Klausner do if people simply don't want it?

Jeffrey Klausner has published a shrill piece [summary] in Future Medicine decrying the apparent lack of interest in circumcision, which he says is at least as good as any vaccine and the "'only modality for preventing' sexual HIV transmission that has been proven to work by the 'highest standards of scientific evidence.'" [Reference.] Moreover, he claims it prevents a myriad of other sexually transmitted diseases.

He's crazy.

Frankly, I'm not sure whether this is good news or bad news. Such shrillness surely signals the author's sense that people aren't as interested as he would like them to be. On the other hand, he clearly is signaling to the world that he intends to make this his life mission.

There's only one thing to do. Sharpen your pencils and ready yourself for Target Klausner.

Wednesday, January 09, 2008

Notebook: Circumcision as Lucky Charm

A very long time ago in my search for validation of my growing belief that God was a rather implausible and fanciful idea, I remember coming across a piece in some foreign journal that expressed astonishment at the disconnect between the professional lives and religious lives of Los Alamos nuclear scientists. Apparently some Godless European was incredulous at this greater insolvable problem than the mystery of splitting the atom. How could Ph.Ds spend their days dissecting the toughest theoretical and practical problems of the molecular world and their nights believing in mythological tales of creation and some sentient, eternal being in the sky and not suffer some mental break?

Richard Dawkins expressed this paradox by way of explanation. He said in his book, The God Delusion, that religion must have served some purpose for uniting mutually dependent bands of people in allegiance, identity and hope that ensured the survival of the species -- or at least the bands that took up such beliefs. His conclusion in light of the great suffering and destruction done in the name of religion, particularly Abrahamic religions, is that it is time to retire the meme of religious belief. Perhaps he is correct. But surely some other destructive force will fill the void as people in the main still need some tie to bind them to one another -- and means with an element of destruction and sacrifice seem to be the most effective so far.

Ivan_pavlov_nobel To many, male circumcision represents a great hope to humanity. It is a hope that correlates with the great hope that crystallized in the coincidence of some animal or human sacrifice and the lucky salvation of the people who practiced it. (Think Pavlov ...) In those rituals, nothing real was achieved outside of the minds of the practitioners. In reality, a net loss was realized in the loss of the person or the animal. But the sacrifices lasted many multiples of time longer than people have enjoyed the modern era.

The data is pretty clear that circumcision damages the sexual lives of the men who suffer it. This is a truism that has been poorly studied, but amply anecdotally expressed in the internet age. It is done largely without consent, imposed by cultural authority on subordinates, and varies widely in its physical and destructive form. Yet its value remains in the minds of those who have suffered it, and in those who see salvation in it because they are so desperate or so forsaken.

The following article makes the case that HIV/AIDS is a "Darwinian event." A vaccine may never come. The virus works its destruction too slowly to ever "burn itself out" of existence. Except for the rare "elite controllers" and individuals with some mysterious immunity, no biological adaptation is possible for the great majority of individuals. Instead, it will be cultural adaptation that contains HIV.**

In the developed world, people will defeat the disease by learning to avoid and prevent it. Condoms used in more and more intimate settings are an adaptation. Serial monogamy is an existing adaptation in most of the world and one that will be adopted in sub-Saharan Africa where it is rare. Rapid and frequent testing is an adaptation. The article lumps male circumcision in with the others as an adaptation. Of course, male circumcision is not a protection. But it fills the human need for lucky sacrifice to ensure success.

Therefore, as condoms and monogamy take hold, education and testing seeps into the consciousness and routine of individuals, and as some populations are persuaded to embrace male circumcision, the poorer African communities that have been targeted won't really know what's containing the virus. But they will leave nothing to chance and continue to embrace it all.

Meanwhile, people outside Africa will likely use their own adaptations, condoms and testing, to contain the virus. They won't need male circumcision because they already know success without it -- and they aren't dependent on the United States or as dominated by it. The levels of infection have leveled off long ago and begun to decline in most of the world. The great epidemics in China, Southeast Asia, Latin America, and Eastern Europe, predicted in the first decades of the disease will likely remain predictions. But the reality will be something different. America and Africa will be alone in their dogma of destructive sacrifice for success.

**This is probably not true. However, in our fortunate age of advanced medicine and instantaneous communication, the biological processes required over generations to develop an innate immunity will likely never get the chance to occur.

Enjoy the Globe & Mail article below the fold.

Continue reading "Notebook: Circumcision as Lucky Charm" »

Tuesday, January 08, 2008

Running the numbers: relative vs. absolute satisfaction for the intact vs. circumcised

I lifted these numbers from the forums on Mothering.com. Thanks to the posting party, "jwhispers." The interesting point here is the absolute vs. relative values that lead to broad conclusions that may or may not in fact be instructive (or for that matter, misleading). The complexity of informed consent is really hard to fathom with these kinds of numbers.

Some 98.4% (2460) of the circumcised men reported satisfaction, compared to 99.9% (2498) in the control group.

Or rather 1.6% (40) of the circumcised men reported dissatisfaction and 0.1% (2) of the control group.

In terms of ability to penetrate, 98.6% (2465) of the circumcised group reported no problem, compared with 99.4 (2485) of the non-circumcised group.

Or rather in terms of ability to penetrate, 1.4% (35) of the circumcised group reported problems, compared with 0.6% (15) of the control group.

So what they're really saying is 20x more circumcised men reported dissatisfaction and more than 2x as many reported problems with respect to penetration.

To be fair, people who say circumcision does not provide a level of protection against HIV have sometimes stated their position in absolute numbers. But the point here is that people like Gray, Halperin, Klausner, and Bailey gloss over this counterpoint to their relative numbers, but then use absolute numbers in an attempt to persuade the skeptical that it's all ok to submit to a very serious surgery. In fact, their claim is that there is NO difference ("statistically insignificant") when in fact there IS a difference.

Monday, January 07, 2008

Circumcised men experience more pain and have greater difficulty penetrating, study shows; authors, BBC wish it were otherwise

A recent study conducted in Uganda confirms an earlier Korean study that circumcised men experience greater sexual difficulties than their intact brethren. This information is important as the procedure could face a hard sell in Africa with no remedy for buyer's remorse.

Bbc_logo_2 According to the BBC article, quoting from the study published in the British Journal of Urology - International, the same journal that reported last year that four out of the five most erogenous zones of the penis are located on the foreskin:

Some 98.4% of the circumcised men reported satisfaction, compared to 99.9% in the control group.

In terms of ability to penetrate, 98.6% of the circumcised group reported no problem, compared with 99.4 of the non-circumcised group.

One Ronald Gray of Johns Hopkins University, another statistician member of the HIV/AIDS industrial complex, led the study, drawing opposite conclusions than from what the data showed.

Deborah Jack, chief executive of the National Aids Trust (UK), said:

There is a fear that people that have been circumcised will feel they are protected from HIV when they are not.

Condoms remain the best way of preventing HIV through sexual intercourse.

It should be noted that research into HIV and circumcision has been very limited in its scope.

Ms. Jack is not entirely accurate. Three studies have now shown that gay men receive no benefit from circumcision viz protection from HIV infection. One study was conducted by the proponents of circumcision, cutting into their eroding credibility even as they again concluded the opposite of what their data showed.

Clearly, the most difficult part of the study was adjusting for the problems associated with self-reporting. The circumcised men, with no effective way to turn back the clock, may not have felt comfortable admitting that they no longer had the same level of satisfaction and comfort as they had before sexual tissue was removed.

Additionally, unlike a survey of men who use or refrain from using condoms, once circumcised, comparisons are limited to fading memories and wishful thinking. The study did not apparently look at satisfaction longitudinally, which would better measure the well-known problems reported by circumcised men in North America, namely declining sexual sensation and response over time.

Reference

Staff reports. Circumcision 'does not curb sex'. BBC Online. January 7, 2008.

http://news.bbc.co.uk/2/hi/health/7174929.stm

Thursday, January 03, 2008

No. 15 on Discover Magazine's Top Science Stories of 2007

TIME magazine gets a little company in the form of buying into the developing circumcision as "prevention" myth promulgated by Halperin, Bailey, Klausner and others. J. Steven Svoboda, Executive Director of Attorneys for the Rights of the Child (http://www.arclaw.org/) has written a letter, included herein for your review. You can (and should) write your own letter to the address Steven provides therein.

Attorneys for the Rights of the Child
2961 Ashby Avenue
Berkeley, CA 94705
510-595-5550
arc@post.harvard.edu

January 2, 2008

Editor
Discover Magazine
90 Fifth Avenue
11th Floor
New York, NY 10011
editorial@discovermagazine.com

Editor:

We were surprised to see that the list of the “100 Top Science Stories of 2007” in your January issue by Apoorva Mandavilli included as number 15 “Male Circumcision: A New Defense Against HIV” Recent reports indicate that the United Nations and other influential bodies have significantly exaggerated the number of people affected by HIV and AIDS. Moreover, for well over a decade the number of new individuals being infected with HIV has been in decline.

Arc_banner In fact, the real top science story is a bit different and concerns a small group of scientists strangely fixated on removing tissue from penises. These men (for that is almost exclusively who they are) have published three studies suffering from fatal flaws that have been pointed to by numerous physicians and even leading HIV organizations in Australia and France.

The most common medical procedure in the US is the only one never shown to be medically justified to stop HIV or for any other reason. It is untenable, bordering on absurd, to suggest that flawed results regarding adult circumcision in Africa are remotely applicable to circumcision of infants in the US. Modalities of transmission and sociological conditions are vastly different. In Africa, one of the most common ways to become infected is through a visit to a health clinic! Moreover, the circumcision experiment has already been tried and has utterly failed here, as the US has both the highest circumcision rate and the highest HIV rate in the developed world.

With your position as one of this country’s premier science journals comes the responsibility to investigate and publish the truth. We ask that you set the record straight on this issue.

J. Steven Svoboda
Executive Director
Attorneys for the Rights of the Child

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Navigation

Elsewhere on the Web

  • Circumcision and AIDS at MGMbill.org
    A decidedly anti-circumcision site with a calm approach to addressing the human rights issues likely to become problematic in the rush to roll out circumcision as an HIV prophylactic.
  • Circumcision and HIV at circumstitions.com
    One of the most thorough reviews anywhere of circumcision and the history behind the HIV prevention community's study of it. The science behind this prophylactic tool is much more equivocal than the most recent researchers would have you believe. New Zealand based.
  • Circumcision and HIV: Harm Outweighs Benefits from circumcision.org
    From the Circumcision Resource Center, Boston, Massachusetts. This human rights organization has published such books as Questioning Circumcision: A Jewish Perspective and Circumcision: The Hidden Trauma. Sitting on its board are a number of individuals affiliated with Harvard and other Ivy League institutions.
  • Circumcision and HIV infection from CIRP.org
    From the Circumcision Information Resource Pages. Not as up-to-date, but an excellent primer on the issue.
  • Doctors Opposing Circumcision statement on HIV
    Doctor's Opposing Circumcision is a Seattle based physicians group that provides education, information and advice on medical circumcision and its effects.
  • Statement on AIDS and Circumcision from the International Coalition for Genital Integrity
    Another thorough treatment of male circumcision's likely impact on the spread of HIV from an "alliance of organizations dedicated to protecting the normal anatomy of males, females and the intersexed ... [that] was formed to coalesce the many activist organizations, each with a specific focus, into one, common voice."
  • Does circumcision prevent HIV infection? - NORM-UK
    John Dalton puts together a critique of the African studies and their weaknesses. He examines the evidence, appropriateness, and possible outcomes from promoting circumcision and calling it a "prevention."

Sources

  • HIV/AIDS Medscape [free registration required]
    This site is owned by WebMD.com. It is a great source for breaking news. I wouldn't necessarily trust it completely on the issue of circumcision as it is US-based. But the HIV/AIDS coverage is pretty good.
  • UCSF HIV InSite Gateway to HIV Information
    The University of California - San Francisco is a leading medical teaching and research university in the HIV/AIDS field. Generally very reliable, it occasionally oversells or misstates the prevention message, most obviously and unfortunately regarding circumcision.
  • IRIN PlusNews
    I don't like this source because it tends to be a bit sensationalist, in my opinion. But it is pretty good for divining which way the wind is blowing.
  • Aidsmap: Circumcision News
    An otherwise great source, they have recently begun to climb on the bandwagon. The tone of the reports seem reticent as evidenced by their providing some great quotes. Coincidence? Inadvertent? Maybe, but hope not.

Medscape HIV/AIDS Headlines