Male Circumcision and HIV

PROTEANVIEW: Circumcision, Jewish Doctors, and Africans

He makes many good points. Ed of the proteanview YouTube channel:

Weiss, Gray, and all the gang continue to publish according to plan

By now, it is obvious that the organized circumcision lobby has a publishing plan to push mass male circumcision. They are seemingly conscious of the apparent fact that hard data is unnecessary to push an agenda and that funding and acceptance of their thesis are largely based on media reports rather than an examination of the data, assumptions and conclusions of each successive paper they manage to push out to the public.

image / Helen Weiss

Case in point is the publication last October of a dubious paper espousing an eventual protective effect for women from mass male circumcision. No such evidence has been produced from current or past studies. It's pure conjecture, spin, and, well, frankly, lies. Reading through the paper one gets a sense that nothing of substance underlies anything written on the page. 

image / Ronald Gray

Will circumcision provide even more protection from HIV to women and men? New estimates of the population impact of circumcision interventions

[Editor's Note: Notice the strategic use of "even" and "new". A question followed by a reference to seemingly neutural stats is a persuasive writing technique that appeals to the reader's sense of surprise, which will be familiar to consumers of popular and tabloid journalism.]   

Abstract

Background Mathematical modelling has indicated that expansion of male circumcision services in high HIV prevalence settings can substantially reduce population-level HIV transmission. However, these projections need revision to incorporate new data on the effect of male circumcision on the risk of acquiring and transmitting HIV.

Methods Recent data on the effect of male circumcision during wound healing and the risk of HIV transmission to women were synthesised based on four trials of circumcision among adults and new observational data of HIV transmission rates in stable partnerships from men circumcised at younger ages. New estimates were generated for the impact of circumcision interventions in two mathematical models, representing the HIV epidemics in Zimbabwe and Kisumu, Kenya. The models did not capture the interaction between circumcision, HIV and other sexually transmitted infections.

Results An increase in the risk of HIV acquisition and transmission during wound healing is unlikely to have a major impact of circumcision interventions. However, it was estimated that circumcision confers a 46% reduction in the rate of male-to-female HIV transmission. If this reduction begins 2 years after the procedure, the impact of circumcision is substantially enhanced and accelerated compared with previous projections with no such effect—increasing by 40% the infections averted by the intervention overall and doubling the number of infections averted among women.

Conclusions Communities, and especially women, may benefit much more from circumcision interventions than had previously been predicted, and these results provide an even greater imperative to increase scale-up of safe male circumcision services.

[PDF copy of full paper available at the link above.]

JME: Rethinking scientific responsibility

You hear the phrase medical ethics all the time, but how often have you heard the phrase scientific responsibility? Here the authors describe a concept and procedure to bring the concept of responsibility for scientific inquiry into the process. Nowhere is this more needed than in the area of dubious claims of prophylaxis in circumcision without consent, informed or otherwise. Abstract below.

Rethinking Scientific Responsibility

Researchers should be made co-responsible for the wider consequences of their research focus and the application of their findings. This paper describes a meta-reflection procedure that can be used as a tool to enhance scientific responsibility and reflective practice. The point of departure is that scientific practice is situated in power relations, has direction and, consequently, power implications. The contextual preconditions and implications of research should be stated and discussed openly. The reflection method aims at revealing both upstream elements, such as for instance preconceptions, and downstream elements, for example, public consequences of research. The validity of research might improve from such discussions. Validity should preferably be understood as a broader concept than the methodological concerns in science.

Download J Med Ethics-2011-Rethinking Scientific Responsibility

Resurgence of the Constant Gardener

I wouldn't normally embed an entire episode of Democracy Now!, the progressive news program hosted by Amy Goodman and Juan Gonzalez, but this one is just too good. The first segment is on the release on bail of Julian Assange of Wikileaks fame. You can skip over that to get to the relevant segments starting at the 16:50 mark. This episode is inspired by a Wikileaks cable release.

Essentially, the program treats in great and frightening detail the accelerating, unchecked and virtually unregulated overseas outsourcing of medical research. Clearly, the African circumcision trials are implicated. However, the story below is largely focused on drug trials. For a broader, bigger picture view of the rapaciousness of the money-driven research community, this couldn't be better.

You can view this episode on Democracy Now!'s website with a larger viewer here.

(The reference to the Constant Gardener for those who haven't seen the movie relates to the subject matter of that movie. The story is about deadly medical research in Africa by companies and governments who put speed and profits before the safety of the people who are the test subjects.)

VIDEO: Correcting Stephen Lewis

The proponents of male circumcision to reduce the risk of HIV are populated with researchers who hold mixed motives. They are known for intentionally sowing confusion, cherry picking their data, and dismissively waiving off any dissenters. It is pretty well accepted among human rights activists that they are not just behind the promotion of the practice in Africa, but also the attempt to roll back the falling rates of infant circumcision in the United States.

To the unschooled, these people appear objective. They work very hard to come across that way. To many scientists and researchers in the field, they are creepily overly enthusiastic for what appear to be half measures, and one half measure in particular.

It is hard to divine their motives. However, it is likely a combination of sexual and cultural attachment. Like a child molester who becomes a school teacher of children, these men, and a few women, have become proponents of their particular fetish in the fuzzy science of epidemiologists.

Two videos illustrate this point. The first is a critique of Stephen Lewis's passionate praise of forced male circumcision for helpless infants who cannot consent or even understand what's happening to them. You'll have to judge for yourself which makes you cringe more, creepy Mr. McCreepy himself, Stephen Lewis, who is not a scientist, but a politician and former diplomat, or the strong language at the end.

The next video is an unexpected and telling revelation from Stephen Lewis. He describes his "orgy of male bonding" experience over a discussion of his own circumcision with a group of circumcised Zambians. Need we anymore proof that Lewis is less than dispassionate and clearly biased? It starts at approximately the 1:55 mark although I recommend you watch the whole video to fully appreciate Lewis's lack of dispassion and objectivity, appropriate to public health policy. 

BUSINESSWEEK: Two reviews of the circumcision literature offer starkly different views

 Businessweek published a brief review of the current debate on infant circumcision yesterday. Not surprisingly, American researchers largely dismiss any concerns while Australian researchers consider the psychological and complication rate more worthy of consideration. 

A short excerpt:

In general, "there is still a lot of uncertainty surrounding the risks and benefits of circumcision," said Dr. Douglas S. Diekema, a pediatrician at the University of Washington who's familiar with both reviews and serves on a task force working on the academy's recommendations.

"There are some clear benefits to circumcision," he said. "There are some risks to circumcision, although the significant ones appear to be rare."

Not so, write the Australian researchers, who examined eight studies for a review in the latest issue of the Annals of Family Medicine. Two studies involved neonatal circumcision, and six involved older males, roughly 14 to 49 years old.

The review's lead author, researcher Caryn Perera of the Royal Australasian College of Surgeons, said the risk of major complications ranges from 2 percent to 10 percent. "These may be considered unacceptable for an elective procedure," she said.

Parents who think circumcision has medical benefits should be aware that there's "a lack of consensus and robust evidence" on that, she added.

Though African studies have linked circumcision in adult men to lower rates of sexually transmitted diseases, including the virus that causes AIDS, Perera said that only future studies will tell if those findings are applicable to the Western world, where AIDS is much less prevalent.

And there's more to consider, Perera said. She said that circumcision poses problems from a mental point of view, potentially causing "significant anger or feeling incomplete, hurt, frustrated, abnormal or violated."

Link: To Circumcise or Not? Reviews offer differing views on value and risks of procedure

Follow our twitter stream for retweets of more media articles addressing this issue.

Marie Stopes International and the Promotion of Magical Thinking

A number of readers have emailed me with a tip that Marie Stopes International (MSI), a UK-based family planning NGO, has put up a website promoting circumcision in Africa (complete with a circumcisons completed counter dubbed the "MCometer"). From the looks of it, it appears MSI is planning to be a big player in the field of male circumcision. I've been mulling over my reaction to this new front of propaganda in light of the previous post about the 20% of all HIV cases in Africa being caused by medical staff failing to use proper medical protocols.

My sense is that if male circumcision were left to the African health systems in place now, it would be a disaster. The circumcision lobby may be interested in circumcision first and HIV second, but I doubt they would promote a policy that will inevitably provide metrics that circumcision harms more than it helps -- and significantly so. 

MSI's efforts on this issue provide some evidence that this is a battle over funding for direct involvement in an environment where funding has long had a tendency to disappear down some despot's bottomless well of graft. Whatever the intentions of African governments in implementing HIV/AIDS policy with foreign dollars, they have competition, and said competition is the NGO with "expertise" to impart or implement.

While the locals can provide culturally sensitive approaches to behavior change, the foreigners' pursuit of the honey pot only extends to providing the procedure itself, or significant ongoing support. After all, these societies would appear to be already culturally disposed to embrace the magical thinking that surrounds circumcision, and circumcision itself.

The video that MSI has produced embraces this magical thinking by acknowledging that Malawi is a country with high rates of HIV in circumcising districts, but fails to acknowledge that in fact circumcised men have not just high rates, but higher rates of HIV than intact men in that country. Moreover, an unsupported statement that variables other than circumcision make this so, and therefore this difference should be ignored, seeks to gloss over a problem of logic for the circumcision lobby generally.

The video also makes the giant leap that three studies that have produced consistent conclusions makes the science sound. Of course, three flawed studies (not double blind with insufficient follow up, and with vast selection and researcher bias) do no such thing, and certainly do not make the recommendations stemming therefrom unassailable. 

The video seeks to appeal to those concerned with the impact on women by making the absurd claim that circumcised men will create a bulwark against HIV in a society where women do not have the negotiating power to insist on condom use. Somehow, men will have less HIV from the already infected store of women and therefore make condoms, what? Less necessary? No mention is made that one study has hinted at a much greater risk to women from circumcised men (See Wawer et al. [pdf]).

MSI then goes on with the script that circumcision presents a unique teaching moment to impart safer sex messages. It isn't clear what is more uniquely teachable about the context where removal of healthy, erogenous tissue from a man is the final step. Perhaps it's Pavlovian in nature? Extreme pain will be associated with the lesson to always wear a condom?

Of course, the arguments for circumcision are also arguments against circumcision. The young men and boys they use in the video are comfortable with the contradictions and probably prefer to accept the script they have been taught. Hence, they dutifully repeat in direct contradiction to the reasons given for parting with a sizable piece of their penis the mantra that one must still use condoms and respect women. For good measure, the de minimis impact of circumcision on cervical cancer and STD rates is blown up into a supporting reason to go for the cut, equivocal evidence notwithstanding.

And then we come to the part where foreigners or foreign trained personnel become indispensable. The video states circumcision is simple and minor, no big deal really, unless it is left in the wrong hands, "traditional healers, for example." It is also quick, easy, with no or few side effects, and what? It's cheap, too! And so, here we arrive at our final destination: a veiled plea for money.

MSI concludes the video with a woman stating that Malawi is "tired of HIV" over a scene of coffin makers laboring away to make, one is given to think, yet another coffin for yet another dead Malawian, presumably freshly deceased from AIDS. The woman concludes by stating that if we just inform the public how circumcision works (which nobody in the real world seems to be able to explain) and how good it is and how much it prevents HIV, "everybody will want to be circumcised."

Clearly, this video is made for an audience in the developed world, most probably for funders and decision makers in the HIV/AIDS industry. Hence, it is not produced in any of the local Malawi languages (at least yet). It seeks to address almost every issue that we in the intactivist community have argued in opposition. And finally, it uses a storytelling style that is sympathetic and benign, i.e. teenage testimonials, wide shots of vulnerable-looking children riding bicycles down dusty roads, and acoustic guitar.

MSI must understand the controversy surrounding this issue and the rapid reaction force deployable against them because they have disabled the comments on YouTube.com. However, you can comment here. Please do so.

NORM COHEN: Circumcision AIDS Fraud

REUTERS: When it comes to women's bodies and HPV, we can be rational (in Norway)

I just love this quote in a Reuters article viz the Merck HPV vaccine Gardasil:

"Whether a risk is worth taking depends not only on the absolute risk, but on the relationship between the potential risk and the potential benefit," Dr. Charlotte Haug of the Journal of the Norwegian Medical Association wrote in a commentary.

"If the potential benefits are substantial, most individuals would be willing to accept the risks. But the net benefit of the HPV vaccine to a woman is uncertain."

"Even if persistently infected with HPV, a woman most likely will not develop cancer if she is regularly screened. So rationally she should be willing to accept only a small risk of harmful effects from the vaccine."

You would never in a million years hear such a rational, deliberate approach to prophylactic treatment in men ... when the treatment is a procedure that removes 30% - 50% of penile skin and the five most erogenous parts of male anatomy. Never in a million years in the United States of America.

But this comment comes from Norway, a place of universal health care. Are they better than us? No. However, they apparently don't get paid by the procedure.

BREAKING SOON: Further Analysis of African RCTs Indicates Cirumcision Does not Reduce Incidence of Three STDs

A new study soon to be released in the August edition of The Journal of Infectious Diseases reports that circumcision does not reduce the risk of incident Neisseria gonorrhoeae, Chlamydia trachomatis, or Trichomonas Vaginalis. The results come from further data mining of the Kenyan Randomized Controlled Trials. 

At the time of posting, the paper was not available in its entirety. 

It should be noted the infamous Robert Bailey was involved in this study. Expect furious spinning.

As an aside, mentioned in the comments, but not in the main post of yesterday, the equally infamous Ronald Gray was involved in the early termination of the study of sero-conversion among female partners of circumcised, HIV+ men.