Thursday, November 5, 2009

New Study: Circumcision Reduces Herpes & HPV in Males

How long must we wait for the Centers for Disease Control and the American Academy of Pediatrics to take account of the growing body of medical evidence that points in only one direction -- every boy should be circumcised to protect himself, his partners, and society as a whole.

This week, still another study in the New England Journal of Medicine confirms that male circumcision reduces a male's chance of getting genital herpes and HPV.

After years of such evidence, it's amazing that the CDC and AAP feel so threatened by a small group of anti-circumcision fanatics that they appear to be back-pedaling on doing what is medically right. I will never understand why the foreskin fetishists go to such extremes, but eventually even the docs at the CDC and AAP will yield to medical science and declare what most of us know is true: circumcision is good for every boy!

For more evidence of that, read the full Reuters story, as reported in the Vancouver Times Colonist:

Circumcision protects men from genital herpes and a virus that causes genital warts and cancer but it does not appear to guard against syphilis, U.S. and Ugandan researchers said on Wednesday.

The report in the New England Journal of Medicine adds to the debate over whether men — and newborn boys — should be circumcised to protect their health and perhaps the health of their future sexual partners.

The findings from two trials in Uganda build on related research showing that circumcision cuts a man's risk of HIV infection through heterosexual intercourse by more than 50 per cent, said Anthony Fauci of the National Institutes of Health in the United States, which funded the study.

They also come at a time when circumcision rates are declining in places like the United States even as evidence mounts that the practice can provide important health benefits.

"Medically supervised adult male circumcision is a scientifically proven method for reducing a man's risk of acquiring HIV infection through heterosexual intercourse," he said.

"This new research provides compelling evidence that circumcision can provide some protection against genital herpes and human papillomavirus infections as well."

The human papillomavirus, or HPV, is the most common sexually transmitted infection in the world. It causes cervical cancer, which kills 300,000 women globally every year.

The team, which also included researchers from Johns Hopkins University in the United States and Makerere University in Uganda, conducted two parallel clinical trials to analyse the impact of male circumcision as a public health tool.

The combined results of the studies looking at more than 3,000 men showed circumcision reduced the risk of herpes by 25 per cent and of HPV by one third. HPV also causes anal and penile cancers.

Circumcision also appeared to reduce the odds of genital warts but had no effect on the incidence of syphilis, the researchers added.

The study highlights the potential of using circumcision to protect people most at risk of the infections in the developing world, especially Africa, where HIV and HPV are widespread.

"Efforts to scale-up male circumcision could have tremendous benefit," said David Serwadda of Makerere University in Uganda, who worked on the study.

Since 2007, circumcision has been promoted by the World Health Organization and the United Nations Program on HIV/AIDS as a way to reduce the risk of AIDS in areas where heterosexual transmission is high.

When done in children, the operation reduces the chance of urinary tract infections and phimosis, a problem with the foreskin.

19 comments:

  1. The College of Physicians and Surgeons of British Columbia has just issued new guidelines. They recommends against non-therapeutic circumcision.

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  2. It's great news that circumcision is found to reduce HPV and herpes by so much. Hopefully, people will stop listening to the anti-circumcision nuts at some point.

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  3. Hopefully, people will stop listening to the anti-circumcision nuts at some point.

    I'm not altogether sure that most people listen to them now. I think they had some influence in the 1990s and early 2000s, but that has diminished considerably. In the academic sphere, I think their credibility fell as a result of their irrational but sadly predictable reaction to the HIV RCTs in '05 and '06, making it clear that their denial of benefits would continue regardless of the quality of evidence.

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  4. Thanks, R, for your comment. Reducing herpes by 25% and HPV by 33% through a simple circumcision is absolutely another positive health benefit. Of course, the foreskin fetishists will deny this, as they do every medical study that supports universal male circumcision.

    And, once again, Jake, you hit in on the head. The anti-circs have lost credibility because of their refusal to follow the science. Unfortunately, they have only become louder as a consequence. My concern is that the CDC and AAP are listening to the screams rather than the science.

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  5. I think Jake is right: the minority with anti-circumcision sentiments are not drivng the reduction in circumcision rates in the U.S., and if there were no anti-circumcision advocates, rates would still be dropping.

    With respect to medical issues like HIV and HPV, the safe sex campaigns of the last 20 years have had an impact: many people are informed enough to understand that having unsafe sex is the overwhelming risk factor for getting sexually transmitted diesases. I wouldn't chop off part of my penis for this "25%" reduction, because I know how to make my risk essentially 0%. Getting an STD is not like getting hit by a meteor.

    In the U.S., the biggest risk factor for getting HIV is still being homosexual. And to be fair to the medical community, many have labored to discover how to prevent homosexuallity - and its attendant harm to the homosexual and his future sex partners - with the idea that it's the net benefit to society that counts.

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  6. I keep reading that men in the African trials who were circumcised got safe-sex counseling, but those who were not circumcised did not get this advice. Is that true?

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  7. Abstinence cuts the herpes & HPV risk to 0.

    That circumcision lowers those risks is irrelevent to the debate. If you believe in a society based on personal choice, the information should be out there, and we should be frank about it.

    But leave circumcision up to the individual. If a woman doesn't want to 'risk' being with an uncut man, she has that choice. If a man wants to better protect his partner, he has that choice. Just like people can choose to use condoms, can choose to use diaphragms, can choose to remain abstinent.

    Don't you think the government enforcing people top use condoms every time they have sex in a breach of civil liberties? I think it is. And I think the same about circumcision.

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  8. I keep reading that men in the African trials who were circumcised got safe-sex counseling, but those who were not circumcised did not get this advice. Is that true?

    No.

    I keep reading this, too, and I find it amazing that people make these claims without (apparently) bothering to check the studies. It's easy enough to do so, and it is quite apparent that all participants received safe-sex counselling. The South African study, for example, reported:

    "At each of the four visits, each participant was invited to answer a face-to-face questionnaire, to provide a blood sample, and to have a genital examination and an individual counselling session. ... The counselling session (15–20 min) was delivered by a certified counsellor and focused on information about STIs in general and HIV in particular and on how to prevent the risk of infection."

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  9. Pro circ "nuts" say anti circ "nuts" "ignore the science".
    Anti-circ "nuts" say "the science" is irrelevant when something is unethical.
    (It is unethical because it is perfomed without consent. It is unethical because even if these trials were applicable to Western countries, it still wouldn't be right to do it because it is done without consent, AND there are better ways to prevent HIV. What is more these better ways allow the individual autonomy.)
    Who is right? The anti-circ "nuts" of course.

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  10. Who is right? The anti-circ "nuts" of course.

    No, both are.

    The pro-circ "nuts" are right because anti-circ "nuts" frequently do ignore the science.

    The anti-circ "nuts" are right because, according to their system of ethics, circumcision without consent is indeed unethical. (The mistake they usually make is to assume that theirs is the only valid system of ethics.)

    Anyway, since whether it is ethical or not depends on the observer, it's logical to concentrate on more objective issues - namely the science.

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  11. Thanks to all for the ongoing debate on this blog.

    Forgive me. But I simply do not understand this so-called "ethics" issue that foreskin fetishists have concocted over male circumcision. Since when is it unethical for a parent to act in the BEST HEALTH INTERESTS of their children?

    From time immemorial, parents were expected to do what is necessary to protect their children, and the removal of the disease-susceptible foreskin at birth is clearly within those rights we give all parents. There is no "ethics" issue here, except maybe the lack of ethics -- or at least, lack of common sense -- by parents who fail to protect their children by leaving them uncircumcised.

    Jake is right. Medical science trumps whatever ethics claim the foreskin lovers make. In my view, because they have lost the medical debate, the anti-circumcision "nuts" are playing the last card in their deck. Unfortunately, most people see it as a Joker!

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  12. You're truly out of your mind if you believe everyone against circumcision are "foreskin fetishists". To be honest I tend to think this entire blog is a troll.

    If it came out tomorrow that female circumcision somehow made aids untransmittable to females, I would still be against it. Taking a knife to somebodies genitals is not comparable to something like a vaccine.

    Additionally, STD's are not comparable to congenital diseases. If removing the foreskin somehow eliminated a threatening problem the child is born with, I could be for it. You're taking a knife to someone's genitals to help them avoid a disease they don't even have, and something they are extremely unlikely to catch until the teen years. Let the individual decide how they want to avoid STD's.

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  13. "I keep reading that men in the African trials who were circumcised got safe-sex counseling, but those who were not circumcised did not get this advice. Is that true?"

    Almost: they got more safe-sex counselling - reinforced in a particularly vivid way.

    Men in the first trial (by Auvert et al. at Orange Farm, South Africa) were told this:

    When you are circumcised you will be asked to have no sexual contact in the 6 weeks after surgery. To have sexual contact before your skin of your penis is completely healed, could lead to infection if your partner is infected with a sexually transmitted disease. It could also be painful and lead to bleeding. If you desire to have sexual contact in the 6 weeks after surgery, despite our recommendation, it is absolutely essential that your (sic) use a condom.

    Having a dramatic and painful operation on one's penis would strongly reinforce this message.

    PD asked: "Since when is it unethical for a parent to act in the BEST HEALTH INTERESTS of their children?"
    When they are cutting a healthy, integral, functional, non-renewable part of his body off, and those "health benefits"
    * affect ailments that are rare,
    * minor, or
    * may be prevented or treated otherwise;
    * don't accrue until he is a sexually active adult who is old enough to make up his own mind how much of his own penis he wants to keep;
    * are less than the health detriments of elective surgery to a neonate, or
    * are actually bogus.

    Be that as it may, the Royal Australasian College of Physicians says:

    "...ethical concerns have focused on recognition of the functional role of the foreskin, the non-therapeutic nature of the operation, and the psychological distress felt by some adult males circumcised as infants. The possibility that routine circumcision contravenes human rights has been raised because circumcision is performed on a minor for non-clinical reasons, and is potentially without net clinical benefit for the child."

    And the College of Physicians and Surgeons of British Columbia says:

    "Human Rights Considerations 
    ...  
    Under the Canadian Charter of Rights and 
    Freedoms and the United Nations Universal 
    Declaration of Human Rights, an infant has 
    rights that include security of person, 
    life, freedom and bodily integrity.  Routine
    infant male circumcision is an unnecessary 
    and irreversible procedure.  Therefore, 
    many consider it to be “unwarranted 
    mutilating surgery”.
     
    Many adult men are increasingly concerned 
    about whether their parents had the right 
    to give consent for infant male circumcision.
    They claim that an infant’s rights should 
    take priority over any parental rights to 
    make such a decision.  This procedure 
    should be delayed to a later date when the 
    child can make his own informed decision.  
    Parental preference alone does not justify 
    a non‐therapeutic procedure.

    Ethical Considerations 
    Ethical considerations regarding infant 
    male circumcision centre on the welfare 
    (or “best interests”) of the infant and the 
    potential benefit and harm associated with 
    the procedure.  Ethics points us to 
    corrective vision, i.e. to question 
    practices that have become routine, or 
    which we take for granted."


    Or are the RACP and CPSBC all "foreskin fetishists"?

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  14. I keep reading that men in the African trials who were circumcised got safe-sex counseling, but those who were not circumcised did not get this advice. Is that true?"

    Almost: they got more safe-sex counselling - reinforced in a particularly vivid way.


    As can be seen, the evidence Hugh7 cites is, unsurprisingly, somewhat at odds with his claim. The "more safe-sex counselling" actually consists of a single sentence advising men to use a condom if they have sex during the six weeks after surgery.

    PD asked: "Since when is it unethical for a parent to act in the BEST HEALTH INTERESTS of their children?"
    When they are cutting a healthy, integral, functional, non-renewable part of his body off,


    This seems a little strong...

    and those "health benefits"

    I'm going to address the following one by one to show that they barely even apply in the case of circumcision. For clarity, my response is not intended to be taken as acceptance of Hugh7's criteria for unethical procedures.

    * affect ailments that are rare,

    The lifetime prevalence of UTI in men is about 14%. I wouldn't call that "rare".

    * minor, or

    Clearly inapplicable: consider HIV or penile cancer, for example.

    * may be prevented or treated otherwise;

    This may apply, but it seems a peculiar requirement. Indeed, it has some rather absurd consequences. Consider a hypothetical situation in which two methods of prevention or treatment exist. When considering either method of prevention or treatment, it is true that it "may be prevented or treated otherwise"; so the apparent conclusion is that neither is ethical!

    * don't accrue until he is a sexually active adult who is old enough to make up his own mind how much of his own penis he wants to keep;

    Partially applies, though of course many benefits of circumcision accumulate through infancy and childhood (eg., protection against UTI and balanitis), and others (eg., protection against penile cancer) can only be achieved through neonatal circumcision. And of course there are greater costs (in the broad sense of the word) associated with later circumcision.

    * are less than the health detriments of elective surgery to a neonate, or

    Not applicable.

    * are actually bogus.

    Not applicable.

    Be that as it may, the Royal Australasian College of Physicians says:

    "...ethical concerns have focused on recognition of the functional role of the foreskin, the non-therapeutic nature of the operation, and the psychological distress felt by some adult males circumcised as infants. The possibility that routine circumcision contravenes human rights has been raised because circumcision is performed on a minor for non-clinical reasons, and is potentially without net clinical benefit for the child."


    You seem to have missed the fact that the RACP are not expressing these concerns themselves, but instead they are remarking that others have raised them. It's analogous to my comment that "the anti-circumcision lobby believes that circumcision without consent is unethical": presumably you understand that I am not expressing this view myself, but am instead commenting that it is a view held by others.

    The situation with CPSBC is similar.

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  15. "The pro-circ "nuts" are right because anti-circ "nuts" frequently do ignore the science."

    Actually, the science isn't really on the side of the pro-circ nuts, as there is no overwhelmingly conclusive evidence that proves cutting newborns is beneficial. And all too often, the pro-circ nuts come across as people who take some sort of sick pleasure in knowing that a baby boy's genitals have been mutilated. It's illegal to cut the genitals of female babies in America. Boys deserve the same protection. It's an issue of human rights AND the fact that the science is not on the side of the pro-circ crowd.

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  16. To respond to "Cyn":

    Actually, the science isn't really on the side of the pro-circ nuts,

    That seems rather like black-and-white thinking, as though there were only two possibilities - that the science was on one side or the other. In reality, there are a lot of shades of grey in between; some scientific evidence favours the arguments of one side, while other evidence favours those of the other.

    as there is no overwhelmingly conclusive evidence that proves cutting newborns is beneficial.

    That's somewhat ambiguous: do you mean that there is no such evidence that there are benefits to neonatal circumcision, or do you mean that there is no such evidence that there is a net benefit?

    There is plenty of high-quality of the former, and this is frequently ignored (or simply denied) by the anti-circ "nuts".

    And all too often, the pro-circ nuts come across as people who take some sort of sick pleasure in knowing that a baby boy's genitals have been mutilated.

    Even if this were true, I fail to see how it is relevant to the issue of which arguments are right. Isn't it just a textbook ad hominem?

    It's illegal to cut the genitals of female babies in America. Boys deserve the same protection.

    Again, I can't see the relevance of this to the matter which we were discussing. Still, I'll address it anyway:

    Firstly, your description of the law is inaccurate. US federal law does not discuss "cutting genitals". Instead, it is much more precise, specifying certain types of cutting and applying to certain, specific body parts: "...whoever knowingly circumcises, excises, or infibulates the whole or any part of the labia majora or labia minora or clitoris of another person who has not attained the age of 18 years...". This is less general than your description.

    Secondly, it should be noted that boys do not have these body parts, hence it is meaningless to talk about them having "the same protection" (and for that matter, if a boy was born with some or all of these body parts, the wording of the law would apparently protect him).

    So to be more accurate, what you are saying is that girls are protected from a certain group of procedures, and boys should be protected from another, different group of procedures. And the obvious question is, why? It seems to me that the onus is upon you to show that the net harm that justifies the illegality of one also applies in the case of the latter?

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  17. Jake alludes to intersexual issues above. If, for example, a girl is born with a large clitoris, it is perfectly legal in the U.S. to cut it off, even if only to alleviate the suffering of the parents. Similarly, a boy born with a small penis can be castrated. For his own good, mind you. The majority of intersexual operations are not lifesaving at all, though some are, and the vast majority are done on babies and children. Few people are even aware of intersexual issues - witness the dunderheads on Olympic committess who insist that each person is unequivocally male or female, even though there are intersexual conditions that defy sexual identification.

    Against this setting, there is no doubt that amputating foreskin from boys at parental request is legal, and always will be. It's just intersexual surgery lite. The medical hysteria to circumcise - or chop parts off poeple whose genitals don't measure up - is not driven by medicine, but by stone-age social customs. And doctors will keep on inventing studies that by design show they are right, that amputating sexual tissue is a good thing. That's the world we live in.

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  18. Don't be so sure that circumcision "always will be" legal, Anonymous. Lots of things were legal (and widely accepted) until recent times and now they're not. (If I give examples, people will say "How dare you compare ...!?" so I won't.)

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  19. I notice you claim here that "CDC and AAP will yield to medical science and declare what most of us know is true: circumcision is good for every boy!" When the reality is that circumcision doesn't help boys. Infant boys are not vulnerable to HIV or HPV or Penile Cancer, or most of the other things circumcision allegedly protects against.

    Since children are not vulnerable, doesn't it make more sense to let them choose whether or not to be circumcised for themselves, once they're adults with something for circumcision to "protect" against?

    Also, what makes you think that the "CDC and AAP will yield to medical science and declare what most of us know is true: circumcision is good for every boy!" When fewer and fewer Americans are choosing to violate their childes right to choose?

    30 Years ago 90% of American boys were being circumcised each year. Today, less than 50% of American boys are circumcised yearly. World wide, less than 30% of males are circumcised, most who are being in the middle east, America, and Africa where admittedly circumcision may be an unfortunate necessity, since getting them to use condoms or stick with one partner for life without cheating is unfortunately difficult.

    Circumcision has some few benefits, but it's a human rights violation to force these benefits on people who can't make an informed decision for their own body. Especially since it does them no good at all until way later, when they would have been able to decide for themselves.

    I think that circumcision, like tattooing and drinking, should always remain legal.

    However, I think that forcing it on infants, just like tattooing and drinking, will soon be considered a crime.

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