Male Circumcision and HIV

FOLSOM STREET FAIR: An Intactivism Update

Intactivism outreach activities at Folsom Street Fair this year went well from all accounts. Once again, our presence was sponsored by Attorneys for the Rights of the Child and organized by this blog with a great deal of help from everyone involved. I arrived and set up the booth with Frank McGinniss early Sunday morning. Others arrived later to staff the space and gather signatures for the SFMGMBill.org initiative, partially modeled on efforts by MGMBill.org and with the advisement and assistance of Matthew Hess. This year, I didn't stay the whole time. This is a participant report gleened from the post fair email and facebook discussions online.

From Lloyd Schofield:

We had some excellent examples of how well foreskin restoration works around our booth.  We met Dr. Dean Edell's producer, Heather Hamann, who lives in San Francisco, and offered to get involved.  We also spoke with lots of medical professionals and of course the perennial comment from men about how upset they were with their parents for cutting them as an infant or child.

From Randall:

I have 3 stories.

1. A woman from Texas waiting while her male friend was getting info on tugging told me if she had had more information she wouldn't have circumcised her 3 sons.
2. Another woman waiting for the man she was with answered, "Kids are yucky. I don't want any," when I asked if she wanted to know anything about circumcision in case she had kids some day.
3. An older man with an accent came in and directed all his comments towards Tina. She asked him if he was Jewish and he just said "aside from the religious issue." He was obviously foreign, most likely European. He just kept saying it prevented AIDS and when Tina tried to rebut him he said to her that her comments were "opinion" and his were the "facts." There was no negotiating there. There was considerable emotion in this man. I tried to say something but he didn't even seem to know I existed. So realizing this I said nothing further. He left as quickly as he arrived.

From Frank McGinniss:

The nice man wearing kilt from our neighboring booth came over to check out our restoration devices. He likes wearing a kilt because this is the best way to not have clothing rub his glans raw. He showed me what he had to work with and I showed what level of restoration I was at. This stands out because there was a demonstrable need to restore, to have a foreskin.

The last people I talked with, a young couple, were most memorable. Not only did they feel good when they left and were very appreciative as expressed by the woman (not so much by her man), but also this was the highlight of my day. It was one of the longest talks of the day too. She wanted to know about circumcision and I gave her an earful. He made like he didn't care one way or the other at first and seemed disturbed by the thought initially about talking about circumcision. The more I said, the more she understood circumcision is bad and really was stunned by the complexities of it. I am pleased she really got it. The man mostly was quiet and got more than he wanted by listening in, I could tell he left a changed man and probably will be restoring in the future with her help. Partners can be so instrumental to change through guidance.

I had no difficulties at the Folsom Street Fair.

My favorite person outside the booth was the nude very nice black man, Michael who stood across the way from our booth. He even showed interest in restoration even though he is intact and I think he signed our petition. Another favorite was Rich, a Rocky Horror-esque sweet transvestite, who simply oozed fabulous. And not to forget, the dame with the live goldfish brassiere. (Have pictures!)

From Rick Kurylo:

At the Folsom Street Fair, a man who was nude from the ankles up approached our booth. He appeared to be uncircumcised, but told us that his foreskin was restored. He used the T-Tape method as close to 24 hours per day as possible. Restoration took him one year.

I took a number of short video interviews with a couple of the booth staff. Some didn't want to go on camera, feeling more comfortable interacting with the crowd. Lloyd Schofield discusses his work at the Folsom Street Fair below.

Tina Kimmel was interviewed and discussed her work with the Bay Area Intactivists Group.

As Tina mentions in the video, SFMGMBill.org is a ballot initiative for which we were collecting signatures. At last count, 92-93 signatures were gathered at Folsom.

You can see more video on our Live at Folsom Street Fair show page hosted on UStream.tv or on YouTube.

I'll have an update on the Castro Street Fair and the AAP annual conference soon. Meanwhile, please feel free to add your experiences in the comments if you were there. Or look for links to this post on facebook and comment there.

LIVE: MC_HIV at the Folsom Street Fair 2010

Welcome to the periodic live broadcast from the Folsom Street Fair. We are hosting a booth distributing information on male circumcision and HIV. You can view the streaming content below or go to Live from the Folsom Street Fair to view and engage through chat with other viewers. You can also view the stream on our facebook fan page and leave comments there. Or watch here and leave comments here. Finally, if you'd like to watch the broadcasts again and take your time to reflect on what you'd like to say in the comments, see the archived video on our YouTube channel! Finally, remember this is experimental. If you can't see anything or the video is unwatchable, you can see the content later to YouTube. Thanks and enjoy!

AIDS PATIENT CARE AND STDS Vol 24 Issue 8: Circumcised men who have sex with men may be more susceptible to HIV acquisition

The latest study to suss out the impact of circumcision on rates of HIV acquisition among gay men has provided some important insights. The general conclusion to be drawn is that the failure to show a statistical difference between circumcised and intact men who have sex with men continues to appear in study after study. The study appeared in the journal AIDS Patient Care and STDs, and was entitled "Relations Between Circumcision Status, Sexually Transmitted Infection History, and HIV Serostatus Among a National Sample of Men Who Have Sex with Men in the United States."

The latest study has provided an interesting additional insight. Circumcised men are more likely to use condoms. Yet intact men as a group do not appear to show higher rates of HIV acquisition DESPITE this apparent disadvantage. The converse however may not be true. The higher rates of condom use among circumcised men may mask a greater susceptibility to HIV acquisition among men who have sex with men.

image / flickr / Photos by Mavis / rainbow love bench, yachats, oregon

The authors go on to describe a lower rate of herpes in circumcised men, a finding that can be entirely explained by higher rates of condom use in this cohort.

An additional finding that did not affect the relative levels of HIV in either group is that men who reported always vs. never using condoms was higher among a subset of circumcised men for always wearing condoms.  Yet apparently, never using condoms among a subset of intact men did nothing to change the over all balance between the two groups in HIV acquisition the fact this finding did not change the over all level of HIV acquisition between the two groups is underappreciated and the implications could be disruptive for those proposing circumcision campaigns generally.

The bottom line: circumcision does not result in a protective effect against HIV acquisition. It should be emphasised that circumcised men who have sex with men should be especially careful to continue to use condoms in every encounter with men of unknown HIV status due to the possible greater susceptibility to HIV acquisition.

Reference

Kristen Jozkowski, Joshua G. Rosenberger, Vanessa Schick, Debby Herbenick, David S. Novak, Michael Reece. AIDS Patient Care and STDs. August 2010, 24(8): 465-470. doi:10.1089/apc.2010.0082.

Download Jozkowski et al -Aids Pt Care - 2010

SAN FRANCISCO PRIDE 2010: Images from the parade featuring intactivists sponsored by MGMBill.org

MC_HIV to Document MGMBill.org Contingent at the 2010 San Francisco Pride Parade

MC_HIV will be at the San Francisco Pride Parade tomorrow. Our presence is essentially going to be one of documentarian for the MGMBill.org contigent. Have a look at last year's photos as a primer.

The images above are available free of charge for inclusion in intactivist activities and materials. If you purchase prints or digital copies, you help support this website and it's activities, which include outreach and educational efforts.

JOURNAL OF INFECTIOUS DISEASES: Male circumcision ineffective against HIV in gay men, excess grant money used for cost-effectiveness study

What is one to do when a fourth study (Templeton) shows gay men gain nothing from male circumcision not just in HIV risk reduction, but also in many other sexually transmitted infections? In this case, several boneheaded scientists took the evidence of ineffectiveness and did the math.

In an effort reminiscent of that old saw about the not so savvy businessman, they took the loss and attempted to show they could make it up in volume. To clarify, these researchers based their study on a tiny, apparent advantage in circumcised men whose "expressed preference" (not necessarily matched by actual behavior) was the insertive role in anal intercourse. The sample was so small as to be unreliable. The researchers in the former study seem to admit this, but the latter group has soldiered on to give us an additional unreliable what-if scenario.

For all I know, they may have gotten a brand new grant for this latest study based on mathematical modeling. It is hard to believe more money would be made available to keep beating the dead horse of male circumcision to reduce HIV risk in gay men.

Link: Cost‐Effectiveness of Adult Circumcision in a Resource‐Rich Setting forHIV Prevention among Men Who Have Sex with Men

Ifs and buts aside, circumcision may potentially be protective against possible syphilis infection ... we think

It's almost Christmas and I'm from Texas, so why not use a Texas phrase said to have been popularized by that good ol' boy himself, Don Meredith. Old Don once said, "If ifs and buts were candy and nuts, we'd all have a Merry Christmas."

From the folks that brought you the absurd notion that circumcision is protective against HIV in some gay men who preferred the insertive role, we have this, summarized by our good friends at Aidsmap:

There was no difference in the prevalence of sexually transmitted infections at baseline between circumcised and uncircumcised men.

However, after controlling for potentially confounding factors such as age and number of receptive acts of unprotected intercourse, the circumcised men had a significantly reduced risk of acquiring infection with syphilis (p = 0.019).

The protective effect of circumcision against incident infection with syphilis was strengthened when the men restricted their analysis to men who expressed a preference was the insertive role during anal sex (p = 0. 033). 

A circumcision and an "expressed preference" for the insertive role during anal sex as long as you're not too old (or is that too young?) and the numbers of receptive incidents of unprotected intercourse aren't too great (doubtful too few, right?), and you can breathe easy.

I'd still recommend the use of a condom.

Link: Circumcision may protect HIV-negative gay men from syphilis

Reference

Templeton DJ et al. Circumcision and risk of sexually transmissible infections in a community-based cohort of HIV-negative homosexual men in Sydney, Australia. J Infect Dis (online edition), 2009.

HEADLINE: Circumcision protects gay men with preference for insertive role, almost ENTIRE text concludes otherwise

Gotta love the circumcision lobby's tenacity and hate the AIDS publishing industry's gullibility on this one ...

That's right. Under a headline that concludes circumcision protects "some" gay men, the text provides us with these conclusive quotes:

The study also showed that overall circumcision did not protect gay men from infection with HIV. Earlier data from the study presented to the conference of the International AIDS Society in Sydney in 2007 showed that circumcision had no protective effect.

...

Studies in Africa have shown that circumcision reduces the risk of HIV infection for heterosexual men. However, a recent meta-analysis found no conclusive evidence that circumcision was protective for gay men.

...

Statistical analysis that included the entire study population showed that circumcision did not provide any significant protection against infection with HIV.

Only 10% of the study’s person years of follow-up was contributed by men who reported insertive unprotected sex but not receptive sex without a condom. There were only four HIV infections in these men. Analysis showed that circumcised men who only reported insertive unprotected sex did not have a significantly reduced risk of HIV.

...

So how did these half-wit scientists conclude that circumcision was associated with lower incidence of HIV infection in these gay men?

Next the investigators restricted their analysis to men who stated a preference for the insertive position in all anal intercourse. These 435 men (279 of whom were circumcised) contributed 1710 person years of follow-up.

There were a total of seven HIV infections in these men, five of which were in the uncircumcised men.

Statistical analysis showed that circumcision was associated with a significant reduction in the risk of HIV infection for men with a preference for insertive anal sex (p = 0.049). This association was strengthened when the investigators adjusted for age and potentially serodiscordant unprotected anal intercourse.

They admit in the end that the evidence is weak and designing studies to provide strong evidence would be nearly impossible to design for many reasons, but characteristically omit any mention of ethical barriers. 

Reference

Templeton DJ et al. Circumcision and risk of HIV infection in Australian homosexual men. AIDS 23: 2347-51, 2009.

Link: Circumcision protects gay men who have a 'preference' for insertive sex from HIV

"Studies show that men with foreskins are more likely to contract HIV than men without."

I've always thought circumcision was a blunt instrument. It's an act to be committed against someone, like taking a baseball bat to someone's head in order to get that person's attention. Nobody chooses circumcision for himself. It's chosen by someone, usually bigger and more powerful, to be applied to someone else, usually smaller and less powerful. Even those men who choose it don't really choose it. They usually do it to "fit in" or to appease a romantic partner or because, as they often say, to escape merciless teasing of one form or another. Or, just maybe because they have been terrified into submission.

So when circumcision became the new next big thing to spend HIV/AIDS funds on, it was obvious to me that it wouldn't be applied to only men who have sex with infected women, as the studies suggested it should be. Rather it would be a money magnet, a funds sponge, hoovering up any male with a foreskin in its path, whether heterosexual African or homosexual San Franciscan. And now we have evidence.

In a slick publication developed by Asian Health Services of the Men's Health Project and funded by The California AIDS Clearinghouse, a state office, and the L.A. Gay & Lesbian Center, we have this: "Studies show that men with foreskins are more likely to contract HIV than men without."

Get that? If you're circumcised and fucking men, you can rest easy. You're at lower risk. Three studies say that this, as Penn & Teller would put it, is BULLSHIT.

Peruse these archived MC_HIV stories for all the many references that show a gay man who relies on circumcision for protection will DIE.

[Scroll down for more.]

 

 

We need help to counter this propaganda in the newest battlefield for Genital Integrity: Places where AIDS information is disseminated.

This September we are going to be manning a booth at the Folsom Street Fair* in San Francisco. We have the sponsorship, Attorneys for the Rights of the Child. We have the manpower, Will, Frank, and me. We have much of the materials, generously provided by intactivists of the Bay Area. What we need is money. Space, insurance, appropriate banners, and printing will run us about $750 total, by my estimate.

Help us if you can, damn it!

Subscribe at $10.00!

 

Subscribe at $25.00!

Donate any amount!

*Yes, it's gay. Yes, it's fetish. Yes, it's San Francisco. It's also where we are most likely to find a receptive audience to our message. These many open minds will take off their leather and put on their suits, work clothes, who knows, maybe even their Sunday school attire, and return to the real world with the seeds we plant. It's worthy. Trust me.

Circumcision of No Benefit to Gay and Bisexual Men says CDC

The New York Times is reporting on a new study to be published Wednesday in The Journal of the American Medical Association. The work reviewed the results of 15 separate studies conducted in eight countries which included nearly 54,000 men.

“Over all, we’re not finding a protective effect associated with circumcision for gay and bisexual men,” commented Gregorio A. Millett of the Center for Disease Control and the lead author of the study.

According to a report on this work by the BBC, researcher's noticed that there seemed to be a protective effect in studies conducted prior to 1996 which has since then essentially eroded to non-statistical signifance, possibly due to three developments:

1. The advent of more effective HIV drugs encouraged higher levels of sexual risk taking;
2. The drugs lowered the risk of transmission to the point where circumcision had no further benefit;
3. There may have been a smaller proportion of men in the pre-HAART trials who primarily engaged n receptive anal sex which is known to carry the greatest risk of HIV infection among gay men.

This makes for an interesting list but let's consider each point individually.

Has the advent of more effective HIV drugs encouraged higher levels of risk taking? This would be an especially interesting issue to research since those encouraging circumcision have insisted that such an intervention would have no impact on risk-taking. If access to anti-retrovirals and the knowledge that HIV has moved from a deadly disease to a chronic, but manageable, condition fostered increased risk-taking, how could circumcision realistically be expected not to result in the same outcome? In a WebMd report, behavioral scientist Gregorio A. Millett noted:

"There has been an increase in sexual risk behavior in men who have sex with men since the availability of highly effective treatment for HIV."

"If a man is engaged in unprotected sex or has lots of sex partners, that contributes more to his risk of HIV than being uncircumcised. So in recent years, the benefit of circumcision may have been overridden by the risks of unsafe sex."

In both cases, we have an intervention which is purported to change the variables of HIV. To believe one may encourage risk-taking, but insist the other does not is simply contradictory. As a behavioral scientist, it should be clear to Dr. Millett that as people believe the dangers they face are receding, they are going to adjust their behavior accordingly. It is a predictable reaction that will result in poorly thought out, culturally motivated strategies, such as circumcision, costing vast sums of money and luring large numbers of men, and their unwitting partners, into a false sense of security.

Could the advent of anti-retrovirals decrease the rates of transmission? The evidence is fairly clear that it has. However, the larger challenge has been early detection. The high point of transmission is the first weeks of infection when viral load spikes. Swiss public health officials have even issued guidelines that sero-discordant partners may safely engage in unprotected sex when the positive partner is on a well monitored anti-retroviral regimen.

Whatever the fantasies of straight men who study gay men's HIV risk factors, the proof, time and time again, is that exclusively top or bottom roles among gay men are consistently unpredictable. Identification with one preference or the other does not and never has translated into actual practice. While some researchers, such as Sten Vermund, director of Vanderbilt University's Institute for Global Health, suggest that predominately insertive men make up as much as 40% of gay men in many locations, the indirect evidence seems to show that men switch roles, depending on factors not yet understood. It is probable that age, context, and timing all have more to do with which role is assumed in these encounters. This is precisely why social scientists must be included in HIV prevention studies.

As usual more temperate reaction comes from colleagues in Britain where Michael Carter, of Aidsmap, noted:

"It's my sense that there has been a tempering of the excitement about circumcision, and researchers are now favouring a 'combination prevention' approach.

"Circumcision may have a place in this in some settings, but so too do good sexual health, consistent condom use, and there's real excitement and debate about the role of HIV treatment in prevention."

However, Aidsmap's report also added this important finding.

Finally, the authors found no association between circumcision and reductions in any other STI. Indeed in post-1996 studies and in higher-quality studies, there was a nearly significant increase in HIV infection in circumcised men.

The investigators suggest that studies could be conducted in men who primarily have insertive sex or in resource-poor settings, though there would be considerable ethical issues in the latter case.

It isn't clear how the authors believe the African RCTs avoided similar ethical issues.

Will Nutland, of the Terrence Higgins Trust, a British HIV charity, added:

"This research adds weight to the evidence that circumcision isn't an effective method of HIV prevention for men who have sex with men.

"The majority of HIV infections in men who have sex with men are as a result of receptive anal intercourse and circumcision would make no difference in these cases.

"Rather than encouraging gay men to be circumcised, investment in prevention in the UK should focus on targeted education programmes, condom provision and easy access to testing."

Carter has it partially right. Nutland has it exactly right. Good sexual health and consistent condom use is the foundation of fighting HIV. Anything less is a flawed approach (and incomplete). That is the message that is getting lost. Next to these pillars of HIV prevention, circumcision adds nothing.

Nutland makes a point that is sure to be lost on the CDC. Programs that actually work must be developed.  Conservatively speaking, more than half of the HIV infections in the US, and other first world countries, are among MSM. We know that broadly targeted programs waste resources and are responsible for vastly diluting the efforts among high risk groups.

Advocates for Youth recently pointed out that American youths use condoms less consistently than their European counterparts. The CDC needs to stop waisting time and money and dramatically increase the focus on education and condom use. This is what America needs. This is what at risk groups in America need.

Finally, the negative impact of circumcision cannot be discounted in this calculus. The next challenge is working the study of negative outcomes into the policy statements and over all conversation and debate viz male circumcision and HIV.