Male Circumcision and HIV

Peer pressure brings doctors up to speed: study

The answer to outdated practices, such as neonatal circumcision, is peer pressure, which is really a form of shaming. While the reason for the persistence of outdated practices may be inertia, shame plays a part in maintaining and spreading such practices by those with malevolent intent. It's not really a surprise or a difficult concept. It is, however, somewhat surprising that peer pressure goes both ways.

Clearly, the attempt to link foreskins and HIV/AIDS is a play on this concept. And hence, we arrive at the unnerving conclusion that politics play a part for good and for bad.

Full fair use text of Reuters article after the break.

There Is No Virtue In Agonizing Over The Decision To Circumcise

I have to continually remind my Jewish friends and colleagues, of which I have many, that Jews and the Jewish tradition do not own circumcision. Once the practice crawled out of its sacred niche and into the rest of American society, anyone who was touched by it earned an absolute right to comment on it.

In a way, I can see how this fact could be frightening. When you lose the (almost) exclusive claim to a controversial practice, you become vulnerable to influence in how that practice maintains or is carried out.

And yet, I felt the need to preface this post with the foregoing. While we all may own circumcision, it may also be said that we don't all own every argument on the issue. Still, as someone who isn't Jewish, but who is emphatically a non-believer in any faith in the Sam Harris tradition, I felt I had to comment on the comments of Rabbi Asher Lopatin, who sat on a panel following a screening of Eli Ungar-Sargon's film Cut at the Spertus Institute in Chicago recently.

First, I think it would be helpful if readers watched the panel discussion. If you prefer to skip over it, scroll down to my commentary.

The rabbi strains credulity to claim virtue in agonizing over the pain and sacrifice of circumcision where he seems to signal that the decision was foregone.

He states that he circumcised a son even after seeing the movie, a movie that he praises for forcing an examination of the practice where it might otherwise be taken for granted. His implied claim is that the movie has value not for its central points, but for its power to cause the observant Jew to agonize over the decision, provoke Jewish guilt and trigger Jewish ethical tenets. Is he to have us believe that he was unpersuaded by the movie's lessons? Or is he to have us believe that the movie merely forced him to agonize over the circumcision of his second son in a way (or at all) that he didn't with his first son? If the latter, what's the (self-serving) point?

While there may be virtue in making hard decisions, there is no virtue in decisions merely being hard. If there was no possibility of change, better the rabbi own up to it and state clearly, harm or no harm, my son's rights notwithstanding, tradition and connection to the long line of circumcision that ties me to my father, and him to his father are more important than the risk to my son, his rights to a full sexual experience, and any evolved conception of how to treat our children, particularly sons, in their defenseless state.

In a way, the pediatrician/mohel William H. Barrows, even in his folly, was less blameworthy for stating that he circumcises and believes in it, and couldn't care less what anybody thinks about it. He's among the living dead [Ecclesiastis 9:5 *], to put it in Biblical terms. He can be ignored and contained because his message is so blunt and uncritical.

The rabbi on the other hand makes a virtue of considering the harm and doing it anyway. That's a difficult position to accept for a critical thinker, but is very seductive to people who are fence sitters or have their guard down. It is therefore nuanced enough to be dangerous.

* I know there is another Biblical chapter and verse on this, but I'm rather out of practice in my Bible research.

[Slight edit for precision to 6th & 7th paragraphs.]

We've seen the cart, now here comes the horse.

Aidsmap has recently reported on an emerging realization among HIV prevention researchers that asking about anal intercourse is important to rule out this confounding factor in prevention studies based in Africa.

Studies into sexual behaviour in Africa have often neglected to enquire about anal sex, and sex between men. There has either been an assumption that such behaviour was not prevalent, or a sensitivity to cultural taboos and prejudices means that investigators are reluctant to enquire about such behaviour. But studies are now suggesting that anal intercourse is common in Africa in both heterosexual and homosexual contexts and is an important mode of HIV transmission.

Excuse me, but could we get a do-over on those African circumcision trials?? This problem has been suggested before, but I think saying it out loud in the literature ought to get some attention. In studies where the numbers are small, but the difference in infection rate is great (precisely because the numbers are small), the problem of failing to account for all the confounding factors is greatly magnified. The African circumcision trials fall squarely into this trap. Now, will we hear calls to re-examine the studies? Unlikely, and as usual the responsibility to call them out on it will fall to the lay person. That would be most of you who read this blog.

In related news, Aidsmap is also reporting that HIV+ gay men with HPV, or ano-genital warts, have presented in Australia with abnormal cells in the anus that could indicate greater rates of cancer and/or HIV infectiousness. Combine this with the recent survey that demonstrated almost twice the rate of HPV among circumcised men in the USA, and we may be on to something.

Notebook: Puerto Vallarta Edition

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Omar and I were so-looking forward to our little trip down to Puerto Vallarta about three weeks ago. While our collective purpose was to escape the pressures of work, I, incidentally, had my own little private purpose, and that was to leave circumcision and HIV behind for a few days. Believe it or not, this issue taxes me more than my job. Welp, three days into our long sought paradise, whaddya figure pops up? Yep, an article in a local gay rag on circumcision.

The magazine is called Revista Estilo Libre, and the audience is largely gay men. I have seen few better examples of twisted hack journalism than what I read in Estilo Libre. While it's a little hard to get exercised over a mag that has an infinitesimal circulation, it gets easier as you realize the level of error the author achieves -- and who the audience is: mostly intact gay men.

First, the author goes on about the procedure requiring 20 sutures and two weeks to recover from, yet claims circumcision is a minor "intervention." One might think that such a contradictory description would be sufficient to stop the worry. Yet, the reader is quickly disabused of that notion as the author goes on to claim that circumcision prevents cancer of the penis by removing glands that produce smegma, a "carcinogenic." Bad enough, but it gets worse still. The author cites a study that he claims was published in the New England Journal of Medicine wherein 50 Ugandan men were circumcised and exposed to HIV-infected ... wives?? other men?? We aren't told. None were infected, according to the alleged study. Finally and less damaging to gay men specifically, but perhaps slanderous to Jewish people is the claim that ancient rabbis used to circumcise infants with their teeth!! Of course, we are to be calmed by the writer's reassurances that this has been stopped due to the dangers of transmitting tuberculosis!!   

Feel free to send them email and/or visit their website. It's in Spanish. So, it would be helpful if you could write in that language. Otherwise, English will do as I am quite sure they will be eager to get email from a concerned international audience.

http://www.revistaestilolibre.com.mx/

revistaestilolibre@hotmail.com
revistaestilolibre@yahoo.com.mx

A scan of the magazine article after the break.

Will a falling dollar and soaring food prices undo circumcision policy in Africa?

A falling US dollar, a soaring world population, climate change, food shortages ... will this be the undoing of circumcision policy? Change and history rarely turn out as expected. If food becomes an issue worldwide, as it frequently has in Africa, and the donor dollar, which is at historic lows against other world currencies, continues to lose its place in the world trading order, who knows how priorities will change ...

Follow the link for an article detailing this emerging problem and game-changing development.

Link: Focus: Hunger. Strikes. Riots. The food crisis bites | Environment | The Observer.

Notebook: Kenya Braces for Epidemic of Genital Warts

Forgive The Onion-esque headline. Still, I'm just taking two sources and interpreting them together.

Kenya has decided to make circumcision part of government policy in the fight against HIV/AIDS, joining Rwanda, Uganda, and Ghana. I'm not sure what this means in terms of actual on-the-ground changes, apart from payment and training. But this being Africa circumcision, compulsion will likely take some ambiguous form, much as it has in the United States, with ridicule, guilt-trips, misinformation, and other assorted mind games.

To be fair, at least some lip service is being paid to the reality that men will likely skip condoms once circumcised. According to the Kaisernetwork, "Ruth Njeri, an HIV/AIDS advocate, said she fears the new policy might make circumcised men have unprotected sex and think they are safe. 'Men who have been using condoms or those who have been faithful to their spouses will now opt for unprotected sex,' Njeri said."

[Edit: Aidsmap has a much better piece on the Kenya story. Apparently, this is an effort to coerce the non-circumcising communities of Kenya to adopt it, as most of Kenya already circumcises. Of the ethnic minorities that don't, only the Turkana seem to be resistent. The others have already fallen victim to the meme of better sex and greater attractiveness. It's an interesting case of a community acting against its own interests that has its counterparts in politics and psychology.]

Take a study that shows a modest increase in incidence of sexually transmitted disease among the intact, and the MSM (that's mainstream media, rather than men who have sex with men) go ape-shit. Take a story showing a doubling of one type of STD in circumcised men, and you have to go all the way to Sri Lanka to find out about it.* Thank God for the Internet. The Tamil Star is reporting that circumcised men have much greater rates of genital warts than the intact.

Nearly 7% of whites reported having been diagnosed with genital warts

4% of African-Americans reported having been diagnosed

2 1/2% of Mexican-Americans reported having been diagnosed

Circumcision appeared to have an effect on rates of genital warts:

4.5% of circumcised men reported having genital warts

2.4% of uncircumcised men reported having genital warts

Source: April issue of Sexually Transmitted Diseases.

*Ok, I didn't search long and hard for this story elsewhere, opting instead to nick it from the Intactivism Pages. Thanks, Hugh (and others via email).

Editorial note. Coming up this week will be a belated Puerto Vallarta Edition of Notebook.

Hasta entonces!

The Preventioneers: The Biggest Challenge to HIV Prevention

With every new wave of HIV prevention initiatives comes a lament. The new (and not so new) researchers complain that lives are being lost, efforts are being wasted, and governments and policy makers don't "get it."

A recent perspective article published in the New England Journal of Medicine represents the worst of these agony aunt pieces. The authors dwell on the "enormous challenges," the "staggering loss of life," and the "repeated failures of biomedical interventions" except of course that of circumcision, and carry on how we must invest more money, do more research, change the paradigm.

By now, male circumcision has been absorbed into the scientific community's canon of received wisdom. Yet as we shall see in another post, the wisdom is really both a desperate hope and an unwillingness to upset the apple cart of fellow researchers. After all, these people rely on each other for support in their pursuit of new projects and funds to carry them out.

Yet this old song and dance reminds me of that age old (and highly localized) symbol of San Francisco. No, not the Golden Gate Bridge. I'm talking about the haggard man on the corner with his hand out, pleading poverty and helplessness, in a city with 27 places serving free food every day of the week, every day of the year. It's a sympathy play to our most basic instinct for compassion.*

Nevertheless, the authors make some important points. First, they point out that artificial end points and speculative estimates of expected infection rates make drawing conclusions exceedingly difficult. Second, they say that poor trial infrastructure results in participant attrition and lack of follow up, further hampering interpretation of data. Thirdly, they complain about the confusion ethical considerations that require providing safer sex education, condoms and follow up have on determining efficacy.

Now, I'm not an epidemiologist. And I'm not a scientist or statistician. But I am someone who makes a living figuring things out. And to my mind, every single one of these issues applies to the circumcision trials. First, the end points were decided by the researchers and supervisory infrastructure entirely arbitrarily based on "ethical considerations" instead of at a biomedical event, as the authors of this article suggest is desirable. These "ethical considerations," mind you, didn't seem to bother them at the beginning of the trials.  The small number of infections yielded mildly statistically significant differences at 18 months. However, the question whether those numbers would or wouldn't close the gap, or even widen over time, will never be answered.

Second, participant attrition was interpreted as enhancing the efficacy despite the fact that the problem of the control group not receiving the same level of traditional prevention interventions (condoms, education, routine medical care providing further opportunity for reinforcement) was never adequately controlled for. If the control group has less contact with study personnel, wouldn't their attrition rate likely be greater? And if so, how do you factor this in? Follow up was another problem. Has there been any follow up? What do we know about the two groups more than a year after the trials were ended? Very little is the answer because many of the control group were removed therefrom by circumcision. A biomedical event, if you will, that ended any future meaningfulness to follow up.

The third issue is so obvious, so blatant that it hardly needs analysis. Simply put, you cannot adequately separate safer sex messages from the biomedical outcome of circumcision when they are delivered together. This was a problem in a Cambodian microbicide trial that ended in failure, confusion and controversy around the same time.

So what is the answer to HIV/AIDS? It is this. We have prevention technologies that do not involve issues of informed consent, mixed messages (i.e. condoms are still necessary), or complications and botched surgeries where health care infrastructure is lacking or non-existent. They are effective. They are cheap. And they are freely available to enlightened communities. Condoms, encouraging fewer partners and discouraging multiple concurrent partners, frequent testing leading to early detection, and treatment itself. This is not a hard problem on the scientific plane. It is enormously difficult on the political plane, both among governments and scientific organizations because HIV competes with those groups' professional, economic, and organizational agendas.

Reference

N Engl J Med. 2008 Apr 10;358(15):1543-5. Challenges to HIV prevention--seeking effective measures in the absence of a vaccine. Lagakos SW, Gable AR. Harvard School of Public Health, Boston, USA.

Photo credit: Isabella Valentine

*And yes, some homeless are doing the best they can. I understand that. After all, I do indigent criminal defense and am closer to the problem than most. So please no hate mail.

A Curious Thought: Nigerian State Bans Contraceptives, Including Condoms ... Circumcision Next?

The Nigerian state of Anambra has banned contraceptives of all types including condoms because, to paraphrase, contraceptives encourage immorality. I wonder if the state will consider banning circumcision because it too might encourage "immorality." A curious thought.

Link: Global Challenges | Nigerian State Bans Promotion, Distribution of Contraceptives, Including Condoms - Kaisernetwork.org.

The Choir and the Converts: How many of each?

I often get great email. But sometimes I wonder if we reach more than just the choir. I've used Sitemeter for a while now, and now also Google Analytics to gauge how many people lay eyes on my modest attempt to win friends and influence people (Remember ol' Norman Vincent Peale Dale Carnegie? Neither do I.). Here's the last 30 days of stats.

That's a fair number. But how many are people who check in throughout the day as I do on a number of blogs I follow? And how many people are brand new at questioning circumcision and HIV? Hard to know. Google Analytics is a little better than Sitemeter for that info, but they don't have bright and shiny reproducible graphics like the one above. After I've racked up some time on Google's traffic meter, I'll do an update.

[Written 4/1/08, published 4/2/08.]