Male Circumcision and HIV

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

2010-08-29T12:05:46-07:00

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

DEFUNDING CIRCUMCISION: Where Medicaid doesn't pay, parents ask why do it, leading to better informed consent (and a decline in the procedure)

2010-08-14T09:52:20-07:00

Why has the circumcision rate fallen to <33%? Amber Craig explains that parents often feel coerced by hospitals and doctors eager to collect Medicaid funds for the procedure. I would add they are bribed by Medicaid funding. Who can refuse a free service purporting to "help" one's child? Morevoer, where Medicaid doesn't pay, parents ask why more often. When a genuine conversation on the procedure ensues, parents more often than not opt to keep their baby boys intact.

A CALL TO ACTION: Lobby the CDC to release the numbers on neonatal circumcision

2010-08-12T07:52:35-07:00

As the United States starts to fall in line with the rest of the world viz neonatal circumcision, many would like to see the trend reversed. The stats delivered at the AIDS 2010 conference in Vienna, purportedly from the CDC, would seem to be a sharp reversal for the likes of Halperin, Kilmarx, Bailey, Epstein, Bailis, Gray, Fenton and the others who harbor a fixation on genital cutting.

How should the challenge to our momentum be confronted? First, we need to lobby the CDC to release the numbers. With Halperin's self-described "cabal, mafia of nerds" in charge at the CDC, we shouldn't expect them to release these numbers voluntarily unless it serves their purpose of promoting infant male genital cutting. El Bcheraoui's slide may have been an oversight with an unintended consequence of rallying the intactivist troops. So let's capitalize on that, and get CDC to open their books and release the numbers.

Centers for Disease Control and Prevention
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800-CDC-INFO (800-232-4636)
TTY: (888) 232-6348
24 Hours/Every Day - cdcinfo@cdc.gov
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Poor reporting, cooked books or the truth? Slide appears, seemingly to verify sharp drop in American neonatal circumcision

2010-08-11T13:39:52-07:00

This slide (below) has been making the facebook rounds. Looks legit, and it apparently was presented during Charbel El Bcheraoui's AIDS 2010 - Vienna presentation on circumcision complications. It does not provide a source for these numbers, which is a little concerning.

Photo Source: Intact America?

If true, this is a stunning success for the intactivism movement. I wonder if it is a prelude to a backlash led by the insurgency at the CDC and AAP, or represents a backlash to the insurgency itself. It's more than a little confusing for those who have labored for years against the practice.

American circumcision rates at 33%? Don't believe it! And btw, they aren't safe, either

2010-08-10T19:04:36-07:00

With the recent assertion that neonatal circumcision rates have suddenly and dramatically fallen in the US at a time that it is being feverishly pushed in Africa to "prevent" HIV, it is worth looking deeper to see what is behind this claim.

The paper, entitled "Rates of selected neonatal male circumcision-associated severe adverse events in the United States, 2007-2009," first presented at the AIDS 2010 conference in Vienna (abstract here), and detailed online on mdconsult.com, seems to be concerned first with the rates of complication. The mdconsult.com article (full article available here in pdf) reports the authors' claim that the complication rate is small within the first 90 days post surgery. They go on to claim that the complication rate is considerably higher for older children, but is still very low. (Hint, hint: cut 'em early!)

image (left) / flickr / nats / Circumcision Services

The first concern here is that 90 days is not long enough to follow a cohort after circumcision. Complications of this surgery are varied and myriad, often unacknowledged and denied, and frequently result in familial embarrassment and a reluctance to come forward unless there is an immediate need for correction. Moreover, the psychological fallout, also very much a complication, may be suppressed for years or decades. Complications often do not always get treated right away due to parental ignorance and because many American parents may not have the means to get follow up medical care.

A better way to measure complications is to survey not birth statistics or hospital admissions alone, but rather to look at the data comprehensively from all sources, such as from the private practices of pediatric urologists. One such pediatric urologist, M. David Gibbons, commented not too long ago following a poorly researched Mens Health article (2/2009) sternly and tursely entitled, Should all males be circumcised?

His comment:

Neonatal circumcision is totally unnecessary, and there is no current role for preventative or prophylactic neonatal circumcision. Unfortunately, 70-80% of neonatal circumcisions are performed by obstetricians, who can neither manage their complications (2-5% incidence) nor obtain proper informed consent (defined as outlining risks and benefits of a procedure, as well as alternatives-including nothing) for neonatal circumcision. Currently, the American College of OB-GYN (ACOG) have no parameters for training (learning and performing neonatal circumcision, managing complications) of residents, who then go out and continue this practice.

In my practice, as a pediatric urologist, I manage the complications of neonatal circumcision. For example, in a two year period, I was referred >275 newborns and toddlers with complications of neonatal circumcision. None of these were 'revisions' because of appearance, which I do not do. 45% required corrective surgery (minor as well as major, especially for amputative injury), whereupon some could be treated locally without surgery. Complications of this unnecessary procedure are often not reported, but of 300 pediatric urologists in this country who have practices similar to mine...well, one can do the math, to understand the scope of this problem...let alone, to understand the adverse cost-benefit aspect of complications (>$750,000) in this unfortunate group of infants and young children.

Fortunately, neonatal circumcision is on the decline as parents become educated...but the complications still continue. Until the time that the USA falls in step with the rest of the planet who does not submit newborns to neonatal circumcision, ACOG should assure that the training of obstetricians to perform this procedure is adequate, particularly in avoiding and managing complications of a procedure that is unnecessary, and that obstetricians learn to obtain proper informed consent from parents who have no idea of the problems that can ensue.

M.David Gibbons, MD
Associate Professor, Pediatric Urology, Georgetown University School of
Medicine and George Washington School of Medicine.
Attending Pediatric Urologist, Childrens National Medical Center,
Washington, DC.
Director, Pediatric Urology, Georgetown University Hospital,
Washington, DC.
Head, Pediatric Urology, Inova Fairfax Hospital For Children, Falls Church,
Virginia.

It doesn't take a math major to see that 275 complications in two years multiplied by 300 pediatric urologists, as the good doctor suggests we do, comes to 82,500 incidents. While that is a relatively small percentage of all infants circumcised in the US (>1.6 million per year - see below), for an unnecessary and painful operation that robs the patient of erogenous tissue under circumstances where he cannot voice his preference for or against ... and holy effing cow, that's a lot! Now, multiply the incident cost (>$750,000) by 300 as the good doctor suggests, and we have a financial burden approaching $62 billion over two years.

Now frankly, that sounds rather high until you realize that the costs vary greatly by region and likely include by extrapolation thousands who never get treated for lack of insurance or an understanding that a painful penis or weird appearance is not normal and needs corrective medical attention. Therefore, the cost is probably lower because complications are likely undertreated.

Now what about that sudden and dramatic drop in American circumcision rates? Well, it is probably mere hyperbole. According to the mdconsult.com article, there were some 6,571,500 US neonatal circumcisions during the years beginning in 2006 and ending in 2009. That works out to 1,642,875 US neonatal circumcisions per year if you accept the number of yearly male births at 2,170,000, calculated by taking <14 live births per 1000 people divided by 2 with an estimated current population of 310 million (CIA Factbook). Hence, we get a neonatal circumcision rate of about 76% on their numbers.

Where's the drop? I call bullshit.

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

2010-08-07T21:18:55-07:00

Intactivists at San Francisco's 2010 Pride Celebration - Images by David Wilton

BERKELEY: An assessment of the 11th International Symposium on Circumcision, Genital Integrity and Human Rights

2010-08-03T09:49:14-07:00

The just concluded 11th International Symposium on Genital Integrity, Circumcision and Human Rights achieved its dual aim of bringing together a diverse group of people to share information and connect on a personal level.

Many of the presentations were highlighted in various press releases describing the content and importance of each one. See the summaries and links to the pdf versions below.

The event took on an unexpected urgency this year due to a series of related events, beginning with the AAP's apparent softening of its position against female genital cutting. The organizers commented on these in several press releases.

"In May, the American Academy of Pediatrics flirted with approving a kind of female genital cutting, even though that is illegal in the US. Scores of boys have died of tribal circumcision in South Africa in the last few weeks. And a Cornell doctor has been testing a new method of cutting back the genitals of intersex children - without knowing what sex they might want to be when they grow up,” co-organizer Marilyn Milos says. “We see events like these as related, all breaches of the simple right of people to control the destiny of their own bodies.”

“On the plus side, the Dutch Medical Association has came out unequivocally against male genital cutting and several more countries have passed laws against female cutting,” co-organizer Frederick Hodges adds.

Download GI-symposium-media-release

Ironically, the proffered justification for the AAP's change in outlook implies that boys are in a substantially similar position as girls viz genital cutting.

“The AAP’s recent, short-lived policy on female genital cutting described a proposed ‘ritual nick’ as ‘much less extensive than male genital cutting’ but it now rejects even that nick. Sessions at the Symposium will deal with the harms and risks of both male and female cutting, and non-therapeutic operations on the genitals of intersex babies,” co-organizer Frederick Hodges says.

Download GI-symposium-media-release-2

Now for the critique. After three of these conferences, I have come to believe in their importance. However, I have also begun to see unmet needs that could be easily addressed with a little planning and cooperation.

The Symposia serve as a place to look inward. Everyone comes together to talk about the intervening two years. We discuss progress, set backs, and plans. But mostly we network and renew our sense of hope.

The good and bad news is that we need something that is both more and different. Strategy and planning is something we come away from the Symposia without when that is exactly what we need right now in spades. We also need the kind of training that is fostered through an interactive experience to expand our ability and confidence to reach beyond ourselves, beyond our walled garden.

In the years ahead, I hope that we can reach out beyond the walls and interact not just with the people who agree with us, but also with those who disagree with us. Perhaps it is too soon to talk about what that may mean in actual practice. However, the time is coming when we can and must do so.

Marilyn Milos of NOCIRC, Amy Callan of Intact America, the interns,
Georgeann Chapin of Intact America, David Smith of NORM-UK

Symposium Press Releases

Circumcising makes the penis smaller: doctor

Circumcising babies in America always causes disfigurement in men, a family physician told an international conference this afternoon.

“By any cosmetic or surgical-outcomes criteria, their penises are harmed - twisted, bent or scarred” Christopher Fletcher MD of Santa Fe said, “and though it is counter-intuitive, they are smaller and skinnier than those of non-circumcised men.”

...

Download GI-symposium-media-fletcher

African health care “an HIV risk”

Circumcision experiments “like Tuskegee”

Health care in Africa is a risk for HIV transmission, a conference at Berkeley was told today.

The World Health Organisation and UNAIDS warn UN employees of this, but it has been kept from ordinary Africans for 25 years, Dr David Gisselquist said.

He told an International Symposium on Genital Integrity at Berkeley, California, the current push for circumcision is an example of the distracting emphasis on sex alone as the cause of Africa’s AIDS disasters.

“The key to stopping AIDS in Africa is to trace and investigate suspicious infections in children and adults to find their source,” he said. “When Africa’s medically-caused HIV outbreaks have been investigated and uncovered, it will be possible to have a rational discussion about circumcision in Africa.”

...

Download GI-symposium-media-gisselquist

Circumcision device ‘like BP in Gulf’, conference told

Many devices have been invented for circumcising boys and men, but none overcomes all its problems, a researcher from New Zealand told an international conference on genital cutting today.

“No device takes full account of the actual structure it is designed to remove,” Hugh Young said. “Only one even acknowledges that the cut is not exactly circular.”

He was particularly scathing of the Accu-circ, a new single-action disposable chopper that resembles a cork-puller, works like a stapler and conceals the penis when it cuts.

“In poor countries, if it can be dismantled, it will be re-used, raising the risk of cross-infection - including HIV,” he said.

“If it won’t dismantle, and if it fails to cut completely, or sticks part-way, the operator is left like BP in the Gulf of Mexico, but perhaps with blood leaking out instead of oil.”

...

Download GI-symposium-media-young

Circumcision “more harmful than imagined”

Circumcising babies is much more harmful than most people imagine, an international conference was told this morning.

Cutting off the foreskin of baby boys without medical need causes not only physical damage, but psychological and cultural consequences, Dr George Denniston told the 11^th International Symposium on Genital Integrity at the University of California at Berkeley.

Dr Denniston is Clinical Assistant Professor at the Department of Family Medicine of the University of Washington in Seattle. He is founder of the international medical organisation, Doctors Opposing Circumcision.

Dr Denniston says that there are many areas - abortion, divorce, lowered self esteem, and even war - where it is obvious that harm has occurred, but the harm has not been quantified. The implications of that harm are so vast that, when taken together, they can diminish an entire culture.

Speakers have come to the symposium from Australia, Brazil, Canada, Egypt, England, Ireland, Italy, and New Zealand.

###

Download GI-symposium-media-denniston

Don’t foreclose kids’ options with operations, conference told

Children are entitled to an “open future,” with no options foreclosed that could not wait for the child’s expressed preference, a conference on genital cutting was told this morning.

Seattle attorney John Geisheker successfully argued the case of a 14-year-old Oregon boy who did not want to be circumcised after his father’s religious conversion.

Geisheker, Executive Director of Doctors Opposing Circumcision, said courts pay undue deference to parental discretion - cultural and religious – at the expense of the child’s human rights. He suggests the best guiding principle is the “open future” articulated by philosopher Joel Fienberg.

The Feinberg Principle, Mr. Geisheker argues, should apply even more strongly where the child is subject to irreversible and non-therapeutic bodily alterations of any kind, which include many other interventions than male circumcision, though that is easily the commonest. They include operations to flatten the ears, Europeanize Asian eyelids, assign gender to intersexed children and “normalize” boys’ and girls’ genitals.

The 11^th International Symposium on Genital Integrity is being held at the University of California at Berkeley.

Speakers have come to the symposium from Australia, Brazil, Canada, Egypt, England, Ireland, Italy, and New Zealand.

###

Download GI-symposium-media-geisheker

Hospitals risk legal action over circumcision

Hospitals and medical providers face special legal risks when they allow healthy newborn babies to be circumcised, a conference on genital cutting was told today.

Zenas Baer, a Hawley, Minnesota lawyer with extensive experience in circumcision cases involving informed consent, says our society is morally and legally committed to the principle of self-determination, which implies the right of every person of sound mind to determine what shall be done with his or her own body.

...

Download GI-symposium-media-baer

Intersex surgery “not for parents or doctors to decide”

Whether to operate on an intersexed child is not a simple clinical decision, an international conference on genital cutting was told this morning.

An official Australian children’s advocate said the decision was not one to be taken by doctors, nor by frightened parents following clinical advice, nor the dictates of culture or religion

Paul Mason told the 11^th International Symposium on Genital Integrity that children are children first and girls and boys second.

“If genital surgery on an intersex child is not necessary to preserve the child’s life, or to treat or prevent a likely and serious illness, the decision whether and how to operate can be put off until the child is old enough to express an informed view about the options, and in a forum that addresses any conflicts of interest,” he said. “That age depends on the intervention and the risks.”

...

Download GI-symposium-media-mason

BERKELEY: 11th International Symposium on Genital Integrity (Day 3)

2010-07-31T23:59:00-07:00

Two statistics of the Day:

100% of circumcised men exhibited some form of complication from skin tags, skin bridges, twisting, or curvature to one side vs. 9% of intact men exhibiting curvature to one side in a small sampling of one physician's practice in New Mexico.
Over 15,000 foreskin restoration devices sold from only one manufacturer.

Interesting factoids of the day: Men with circumcision complications didn't seem to care or even understand that their complication was not part of their normal anatomy. Intact men in the above sampling expressed no desire to be circumcised.

More to come ...

image / flickr / mrwillowby / a crotch in sevens