Category: Circumcision

Anything to make parents feel better is logical, I guess.

Even though the studies (and circumcisions) were performed on grown men, the study results are relevant to baby circumcisions since the biology is the same — presence of penis foreskin increases the risk of contracting HIV, whether the circumcision was performed at birth or in adulthood.

In addition to focusing on males circumcised as adults, these studies only analyzed female-to-male HIV transmission. Any assumption beyond that is nothing more than an assumption, with potentially dreadful consequences for the male circumcised as an infant to prevent an unlikely HIV infection. We’re not discussing insignificant decisions. We’re discussing medically unnecessary surgery. There should be more than “this is probably true”.

That’s all nice, but the specific facts of the writer’s theory are fascinatingly wrong. The biology is fundamentally not the same. The infant foreskin is attached to the infant glans by synechia. This bond will not separate for several years, at the earliest, unless forcibly torn apart as is required in infant circumcision. Any sort of tearing may lead to bleeding and scarring. The surgeon will also have no effective method for determining how much skin is too much. He or she must guess how the infant’s penis will develop. Of course, he or she will not have input from the patient as to how much of his foreskin he might like to keep. (The answer might be 100%.)

With adult circumcision, the foreskin is no longer attached to the glans. The bond is broken. There will be no need to forcibly separate the two parts of the adult penis. The adult penis is fully developed. The surgeon may judge how much foreskin he or she has to work with. But his or her judgment isn’t necessary. The male to be circumcised is fully aware of the decision. It’s his penis being operated on and he is presumably intelligent enough to request how much foreskin he’d like to keep. The decision changes from an uneducated guess to informed consent.

The study results are not relevant because the biology is not the same.

This article addressing whether or not circumcision is required for conversion to Judaism contains two fascinating quotes. (Three actually, but I don’t want to rant on the third.)

Marlon Franklin, 37, recently underwent a brit milah. Born into a Catholic family in Venezuela, he directs commercials and promotions for Spanish-language television. This past year, he converted after participating in the University of Judaism’s introductory course given by Weinberg.

“The [brit milah] wasn’t bad at all,” Franklin said. “Dr. Sam Kunin explained everything, both before and during the procedure. I had local anesthesia, so I could see what was going on. It was excellent, no complications, no problems.”

Franklin said he was very conscious of the ancient, spiritual nature of the ritual, which made it “an awesome experience.”

I’ve argued this point in the past. We must consider that men who choose circumcision for themselves will find greater significance in the procedure, or ritual, if allowed to choose for themselves. When imposed, that possibility is lost. Any “awesome experience” for the circumcised is intellectual only. That makes no sense to me as an expression of faith. That, among many reasons, is why non-medically-indicated circumcision should never be forced on anyone.

The second quote is a bit less reassuring since it implies that something I’ve tackled before is more widespread than it should be.

“I don’t understand the fuss people make,” [Dr. Kunin] said. “In Africa now they’re circumcising thousands of adult men for AIDS prevention. If it were such a big deal, don’t you think word would get around and the men would stop doing it?”

It’s clear that Dr. Kunin doesn’t understand the fuss, for the fuss over circumcision isn’t about whether or not adult men should choose it. They have the right to decide whatever they want for their body. Instead of looking at the controversy as a whole, and how it applies to children, he used the pressure of past acceptance to dismiss valid opposition. That’s convenient but not intellectually fair given that boys will lose a healthy part of their anatomy to such poor logic.

I’ve come to expect everything but fairness in this debate.

As I posted earlier this month, I’m not foolish enough to take news that clearly helps me and run with it on first appearance. Everything should be aired, but qualifiers are useful. Skepticism is the lifeblood of future wisdom since evidence can be fleeting after more than a glance. Being in the minority on an issue also means I have to be more careful. Some of what I believe in is too important to have my stance tossed aside because I touted incorrect data. But it should embarrass society that the intelligent stance must play conservative while mass opinion gets to push any sort of nonsense that wouldn’t pass a third-grader’s scrutiny if all facts were treated equally.

With that, I offer this study recently published in the British Journal of Urology.

OBJECTIVE
To map the fine-touch pressure thresholds of the adult penis in circumcised and uncircumcised men, and to compare the two populations.

SUBJECTS AND METHODS
Adult male volunteers with no history of penile pathology or diabetes were evaluated with a Semmes-Weinstein monofilament touch-test to map the fine-touch pressure thresholds of the penis. Circumcised and uncircumcised men were compared using mixed models for repeated data, controlling for age, type of underwear worn, time since last ejaculation, ethnicity, country of birth, and level of education.
…

CONCLUSIONS
The glans of the circumcised penis is less sensitive to fine touch than the glans of the uncircumcised penis. The transitional region from the external to the internal prepuce is the most sensitive region of the uncircumcised penis and more sensitive than the most sensitive region of the circumcised penis. Circumcision ablates the most sensitive parts of the penis.

By default this should be assumed true because circumcision is not medically indicated at birth. It is up to circumcision advocates to disprove this idea and the common sense behind it. It is no longer acceptable for people like me to have to protest that removing skin full of nerve endings causes a harm or that the owner of the skin is the only person qualified to voice an opinion on its removal.

I know wishful thinking won’t turn this truth into reality. Every new data point helps, no matter how obvious I know it to be.

Spot the obvious obfuscation in this New York Times article:

While circumcision may help protect a man from catching the AIDS virus, men who are already infected and are then circumcised should refrain from sex until they have fully healed, researchers said last week.

That’s not the full story, is it? Is the Times suggesting that circumcised men, once healed, can then engage in risky, unprotected sex after the healing process finishes? I doubt it. I fully expect the Times to mention condoms at some point.

Further down in the article, it does, so the relevant question pops up. How effective are condoms at preventing HIV infection as compared to circumcision? Reasonable estimates place the success of condoms at 80-90% and above, when used correctly. Why not include this in the opening paragraph? Does it skew opinion too far to the rational understanding that there are better methods of HIV prevention than circumcision? (We haven’t even addressed the serious ethical questions involved.)

It’s useful to consider what the Times says on condoms:

In any case, Dr. Wawer said, men should practice abstinence or fidelity, and use condoms. All the men in the study, including 5,000 who were not infected when they were recruited, were given that advice and free condoms. But many clearly did not follow the recommendations.

Three studies in Africa in the last year have shown that circumcision cuts a man’s chances of catching the virus by 50 percent or more. If an AIDS vaccine that worked that well had just been invented, “the world would be jumping for joy,” Dr. Wawer said.

We already have a tool that reduces a man’s chances of catching the virus by significantly more than 50 percent. Yet, no one is jumping up and down. Instead, we get the condescending reminder of what civilized people are supposed to know about Africans. “Clearly” men are not following that advice. (That’s not what the Times wrote last April.) So start chopping. That’s amateurish and insulting.

Now note the emphasis placed in these two paragraphs:

Women who had sex with recently circumcised men who had not waited about four weeks to heal seemed to have a slightly higher risk of catching the virus from them, according to scientists conducting a circumcision trial in Rakai, Uganda. …

The researchers emphasized that their data were “very preliminary” and based on only 124 couples followed for only six months out of a study meant to last two years. They released the findings, they said, only because the World Health Organization was writing guidelines for circumcision in African countries with skyrocketing AIDS rates, and they felt obligated to raise the alarm about the risks of sex before healing.

I’m okay with skepticism, even when it makes it harder for me. I want to succeed in convincing people that circumcision is unnecessary and unacceptable, but lying or tweaking the truth won’t help. I’m even frustrated now when reports on this story leave out the fact that the newly circumcised men were already HIV-positive, which is where the risk to women ultimately comes from. There’s no reason to hide anything, helpful or harmful.

Excess skepticism, though, seems unjustified. The results, however preliminary, are common sense. A wound isn’t healed? Blood will be involved. HIV-tainted blood. I don’t understand the over-the-top caution on these findings. Again, is anyone going to suggest that the couples in this study shouldn’t use condoms?

The larger lesson from those paragraphs reveals a lot. How is this fact pattern any different than what media outlets have claimed since December (and before)? None of that skepticism existed when the studies showed a lower risk after a short time frame in studies designed to last two years, yet these crucial bits appear now in force. The overall results surrounding circumcision and HIV are not concrete to the point that we should just say circumcision is “good” and set aside the significant ethical concerns. This shows a bias that doesn’t address the scope of the topic. Clearly.

This is the most sensible article I’ve read concerning circumcision as an HIV prevention tool. It’s brilliant from start to finish. An excerpt:

All of a sudden a quick and cheap solution to reducing the ravages of AIDS seemed at hand; line up all males, nip off their foreskins, and voila, you have reduced the possibilities of future HIV infections by half!

Among the few voices that expressed caution was that of Uganda’s President Yoweri Museveni, who said he didn’t think it was that simple. Museveni should know. Uganda, after all, has Africa’s — and one of the developing world’s — best record in reducing HIV infections. In the 1990s, Uganda had among the highest infection rates in Africa of well over 30 percent. In the last eight or so years, it has sliced that down to just under 6 per cent. The awards Museveni has received for this achievement can fill the State House garage.

I don’t know anything about the science of this study to fault or laud it. But its politics are very troubling.

Read the whole thing. It’s worth your time.

Here’s one more inconvenient blip on the ethical radar:

The world could have a new vaccine designed to kill the AIDS virus in as little as three to four years according to an Atlanta-based group working on the vaccine.
…

The vaccine works using a one-two pharmaceutical punch to prime the body then kill the virus.

“It raises both antibodies that can block the virus and it raises white blood cells called t cells that can kill the virus infected cells,” said Dr. Robinson. “So it really has two methods of controlling an HIV/AIDS infection once it enters the body.”

Will this work out? No one can know for sure, but if it does work within 15 years or so, many people will owe a significant apology to millions of boys around the world. The apology wouldn’t be worth much, but they’d still owe it.

Via Fark.

This is the last one for the day, I promise.

Earlier today I asked whether or not new findings on HIV prevention might generate an “Oops?” from circumcision advocates. I’ll ask again:

Men with HIV who get circumcised hoping they will be less likely to transmit the AIDS virus may have a greater-than-normal risk of infecting their partners if they resume sexual activity too soon after the operation.

That observation — drawn from preliminary analysis of a study in Uganda — threatens to complicate efforts to tout circumcision as a new weapon against HIV in Africa.

The men in question already had HIV when circumcised. There should be no surprise that they can infect their female partners. Perhaps it’s surprising that the risk is greater than normal, but the bottom line is that the eventuality of infection is a given. Circumcision will only delay the inevitable. This coincides with the truth that responsible, safe sex practices are the only prevention, whether the individuals involved are intact or circumcised, HIV-positive or HIV-negative.

Instead, we’re left with this sentiment¹:

Specifically, it suggests that public health campaigns promoting circumcision must also include messages, directed principally at women, warning of the extreme hazard of intercourse with HIV-positive men who have just had the procedure.

There were obvious reasons not to rush head-first, unthinking into promoting circumcision before these findings. Researchers, politicians, and parents didn’t want to hear this before. Will they now, even though these efforts should’ve been seen as complicated from the beginning, with adequate restraint applied?

¹ Full Disclosure: I exchanged e-mails with the reporter for this story, David Brown, after he wrote a story on circumcision and HIV prevention in August. We had a brief exchange, but my questions were inadequately addressed. Our disagreement partially focused on this statement about the educational approach needed. From that article:

It would also require drawing a clear distinction between that procedure and the misleadingly named “female circumcision,” a form of ritual mutilation with no medical benefit.

The FGM issue is more complex than the simple view that women are mutilated to damage their sexuality while men are mutilated to provide them with medical benefits. That begs addressing the specific issue of male circumcision with a skeptical eye. Instead, he seemed to approach the complex ethical and scientific aspects of male circumcision with the same faulty assumptions accepted by society in general, even when the facts we discussed contradicted his statements. This is not surprising, but it’s also not advisable for a reporter, in my opinion.

Unlike the scientists, politicians, and parents who couldn’t wait to proclaim victory when a few studies showed a correlation between the male foreskin and HIV infection, I will not make bold pronouncements about these findings.

Researchers have discovered that cells in the mucosal lining of human genitalia produce a protein that “eats up” invading HIV — possibly keeping the spread of the AIDS more contained than it might otherwise be.

Even more important, enhancing the activity of this protein, called Langerin, could be a potent new way to curtail the transmission of the virus that causes AIDS, the Dutch scientists added.

Langerin is produced by Langerhans cells, which form a web-like network in skin and mucosa. This network is one of the first structures HIV confronts as it attempts to infect its host.

However, “we observed that Langerin is able to scavenge viruses from the surrounding environment, thereby preventing infection,” said lead researcher Teunis Geijtenbeek, an immunologist researcher at Vrije University Medical Center in Amsterdam.

You’ll recall, of course, that the primary “benefit” of male circumcision as a defense against HIV is that it removes many Langerhans cells. Read through most of the articles in the last year or so on this topic and you’ll see “scientists believe”. Not “scientists know,” but “scientists believe”. Oops?

The question mark on the end of my last sentence is intentional. I have no idea how substantial this research is, or whether it can be replicated. I’m willing to read this last qualification in the story and understand that life is often more complicated than controlled findings.

[Dr. Jeffrey Laurence, director of the Laboratory for AIDS Virus Research at the Weill Cornell Medical College] did offer one note of caution, however.

“In the test tube, this is a very important finding,” he said. “But there are many things in the test tube that don’t occur when you get into an animal or a human. Having said that, though, this is a very intriguing finding.”

Instead of the glee that my viewpoint is now supported, I’ll approach this with caution, the same way circumcision supporters should approach the recent findings on HIV. I suspect the difference is that I know I don’t need science to validate my stance. I’m correct before we get to the science. Circumcision advocates rush to every justification. Why?

But looking at the science, we’re finding information in the short-term. It’s reassuring to project that information long-term, but we must remain open to the possibility that we’re wrong. That is true of any new discovery, but it should be required when the decision is to alter a human body. We should add another, higher standard because that body does not belong to us.

If researchers verify these new findings through real-world tests, will anyone apologize for rushing to circumcise as many males as possible? The answer is an obvious “no”. Those now advocating circumcision will still fall back on the tried-and-true defenses. We’ll okay some version of “alright, it’s not important, but still…“. I can accept that if someone makes decisions about his own body and life. I can’t accept that when someone makes it about someone else’s body and life. But still… isn’t enough.