What a terrific way to begin 2010 that to see medical doctors call on the American Academy of Pediatrics to replace its so-called "neutral" policy on newborn male circumcision with an affirmative statement on the clear benefits of this procedure to the male, his partners, and society as a whole.
That's the focus of an article and editorial in the January 2010 issue of the Archives of Pediatric and Adolescent Medicine. Here are some excerpts from Fran Lowry's story in Medscape Medical News:
“During the past 4 years, substantial new data have been published on the health benefits of circumcision,” write Aaron A. R. Tobian, MD, from Johns Hopkins University School of Medicine, Baltimore, Maryland, and colleagues. “While the historical evidence strongly suggests that male circumcision reduces urinary tract infections and penile inflammatory disorders in infants, we reviewed the more recent evidence with regard to effects on sexually transmitted infections (STIs) in adulthood.”
"To evaluate the effect of circumcision on HIV prevention, the researchers analyzed 3 randomized controlled trials of more than 10,000 men from South Africa, Kenya, and Uganda.
The trials enrolled HIV-negative men to circumcision on enrollment or after 21 to 24 months, and all 3 trials demonstrated that male circumcision significantly decreased male heterosexual HIV acquisition by 53% to 60%, despite differences in age eligibility criteria, urban or rural settings, and surgical procedure.
"Because of this new evidence, the World Health Organization (WHO), together with the Joint United Nations Program on HIV/AIDS (UNAIDS), recommended that male circumcision be provided as an important intervention to reduce heterosexually acquired HIV in men, the study authors report.
"The trials also found that male circumcision decreased herpes simplex virus type 2 (HSV-2) acquisition by 28% to 34% and the prevalence of human papillomavirus (HPV) by 32% to 35% in men.
"Among female partners of circumcised men, bacterial vaginosis was reduced by 40% and Trichomonas vaginalis infection was reduced by 48%, the study authors write.
"The study authors note that the rates of neonatal circumcision complications are between 0.2% and 0.6% of operations performed. The most common complications are bleeding and local infection, which are controlled with pressure and wound care or antibiotics. Other complications, such as phimosis and concealed penis, adhesions, fistula, meatitis, meatal stenosis, and injury to the glans, are extremely rare.
"They add that there was no evidence of change in sexual behavior after circumcision in the African randomized controlled trials. “Thus, there are risks to neonatal circumcision, but serious long-term complications are extremely rare,” the study authors write.
“The rare short-term risks of neonatal circumcision need to be weighed against the potential benefits accrued in infancy and childhood (eg, reduction of urinary tract infections), the longer-term benefits that may accrue in adolescence and adulthood (eg, reduced risks of HIV, HSV-2, and HPV), as well as possible benefits to female sexual partners of circumcised men (eg, reduced bacterial vaginosis and trichomonas),” Dr. Tobian and colleagues write.
"Medicaid does not cover the cost of male circumcision in 16 states, and the lack of coverage particularly affects disadvantaged minorities, who have the highest risk for HIV and sexually transmitted diseases. “These socioeconomically disadvantaged groups could benefit most if Medicaid covered the costs of neonatal circumcision. Thus, the AAP’s policy has important implications for the health of disadvantaged minorities,” they write.
"They conclude that it is time for the AAP policy to fully reflect current data.
"In an accompanying editorial, Michael T. Brady, MD, from Nationwide Children’s Hospital in Columbus, Ohio, writes that the study authors have provided a very objective review of the available data. Although the 3 randomized trials were performed in Africa, “it is clear that circumcision does offer health benefits, even in the United States,” he notes.
"The current evidence on the health benefits of circumcision is adequate enough to include circumcision in medical coverage provided by Medicaid or commercial insurance providers, Dr. Brady points out. “This is particularly relevant since over the past decade many state Medicaid programs have discontinued payment for circumcision.”
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You forgot to add the last paragraph :
ReplyDelete"He concludes that recommendations for routine newborn circumcision will need to wait for well-designed studies that verify its cost-effectiveness for the individual and/or society."
These studies in Africa were conducted on ADULT male volunteers in a country whose aids epidemic does not mirror our own in any way. The primary means of transmission in Africa is through female to male heterosexual sex, which is among the most rare form of transmission in the United States. Recommending circumcision for men who live in a country where 1 in 4 people have HIV could be beneficial. The risk that a man will get HIV from an infected woman in the United States is extremely low, studies show only a .04 % chance, or .0004. Even the most conservative complication rate number for circumcision is well above that number.
"Pooling the data from studies in high-income countries, the researchers calculated that the risk of transmission from an HIV-positive man to his female partner was 0.08% per sexual act: in other words, it was likely to occur once every 1250 sexual acts. When it was the female partner who was HIV-positive, the male partner’s risk of acquiring HIV was 0.04% per sexual act – in other words, once every 2500 sexual acts.
The findings from each of these studies were broadly consistent, with the result that the 95% confidence intervals for the above figures were not too wide (for example, for transmission from men to women, 0.04% to 0.16%). This was not the case for the pooled data from studies in Africa, Thailand and Haiti.
In these countries, the researchers calculated a transmission risk of 0.19% when the male partner was HIV-positive, and 0.87% when the female partner had HIV. However the wider confidence intervals (for example, from men to women, 0.28% to 2.6%), could, the authors suggest, reflect poorer study quality, a wide variation in risk factors between study populations or some under-reporting of high-risk behaviour. They speculate that the overall higher apparent risk could be driven by higher rates of sexually transmitted infections or higher viral load levels.
Nonetheless, they point out that the figures from low-income settings suggest that there is a greater risk of transmission from women to men than the other way round, which is the inverse of the high-income country findings and is generally considered less biologically plausible."
http://www.aidsmap.com/en/news/E1249D29-0DDE-4CFF-9CC7-16B3FADB3E59.asp
America, Australia and Europe is too far from Africa. It seems to me that the researchers don’t have a clue what is the true situation in Africa. According to statistics in the city of Port Elizabeth, one of our townships where only Xhosa speaking people are living, the HIV rate is – according to statistics – 30%. “Aids and HIV are Major issues within Walmer Township. 30% of the township is HIV positive. [http://www.aprilandjon.co.uk/human-dignity-center.html#] These Xhosa men are about 99.9% circumcised, as circumcision is part of the Xhosa culture. How does one explain this? In most Black cultures a person is not considered a man if you are not circumcised and haven’t been to the “Bush”. The answer is given by Mrs. Msutu of the Department of Health: “The major problem in The Walmer township is one of the areas where the prevalence of HIV/Aids and poverty is of concern in the Nelson Mandela Metro”. http://www.ecdoh.gov.za/press_releases/410/Launch_of_the_14th_Walmer_Clinic_services_in_PE/28_July_2008
ReplyDeleteIn Africa People is mostly living crowded in a one-room shack or if they are lucky in a small house, without running water or electricity. Have the researchers from the USA seen women carrying water for a great distance on their heads to their home. This water is for all their household purposes to prepare food and to be used as drinking water. Maybe there will be water to wash their hands, but not their bodies. In most areas there are no toilets available as it is available in the USA, but most of the time the closet toilet is the nearest bush.
The UN is promoting it vigorously in Africa. Male circumcision is suppose to significantly reduce the risk of heterosexual HIV infection and has even been called a "surgical vaccine", but will it really make a difference if people are living in unhygienic conditions? Why are so many young men die in Africa after being circumcised? The answer is: due to infections. There is no proper wound care and medication is too expensive to afford and proper hygiene is out of the question. The world made a joke about our President’s comment about a shower after sex, but they don’t realize that he was actually talking the truth. He was referring to proper hygiene. How many men and women can take a shower after sex especially if they are living in a shack? Where will they find running water?
In Africa circumcision is seen as a permanent condom. Is this not going to worsen the spread of HIV Aids? I think this whole circumcision debate is a waste of time and money. Why can these abortive funs not be utilized to provide for and uplift the poor? Is it not about time that they rather try and fight poverty, which will uplift the people in Africa and will change the HIV rate? In any way many of the Black tribes in South Africa do circumcise. The Xhosa tribes are the second largest tribe in South Africa and they perform circumcision. I feel Circumcision is an unnecessary procedure. How on earth can circumcision prevent HIV if a man uses a condom? Seeing that latex is of no use to men any more, I just hope that doctors are still going to use their latex gloves when they operate on people!
Why do these clever research doctors not tell their patients that after circumcision there is a total loss of sensitivity. After a few years these men that are now circumcised will also find that the sensitivity of the penis head is lost. What I cannot understand is how can circumcision be beneficial if these people who sleep around uses condoms. The condom covers the whole of the penis as well as the penis head, which is normally covered by the foreskin. In other words if one uses a condom the foreskin is also covered with the condom. To me this whole circumcision story does not make sense, however to the medical doctors and those in the foreskin trade it only makes money. I have seen an article stating that the foreskins are used in various facial creams, if that is true I can understand why circumcision is so effective. The more men they circumcise the more money they get!
If these researchers and the CDC are so confident that circumcision would have a positive impact in the US and would show the same risk reduction as in Africa , why not perform a study in the United States to prove their case?
ReplyDeleteThe answer is because they know the studies would fail to show any dramatic difference between circumcised and uncircumcised men and the contraction of HIV, since the risk of female to male transmission is so incredibly low in the United States.
It is very likely that even if researchers got three thousand heterosexual volunteers to sign up for this study and followed them for two years that none or extremely few of them would contract HIV, especially if they were consistently wearing condoms. You would never see the amount of people you saw in Africa getting HIV in a study in the US, unless you were cherry picking drug addicts who have regular unprotected sex with prostitutes.
The numbers would be even lower if certain variables that were poorly controlled for in the African studies were controlled in the United States. Like hiring unbiased researchers and making sure they don't know which men were circumcision and which men weren't when asking questions and giving safe sex advice and making drug tests mandatory to rule out needle transmissions.
I don't dispute Tobian's findings. But he left out one important factor, and it's the factor on which this whole debates hinges, and that is the matter of choice. It's a fact that many men resent the amputation of healthy, normal sexual tissue from their bodies without their consent to the same degree that an adult might resent a forced circumcision. This resentment is the source of the backlash against neonatal circumcision, and blogs with titles like Mandatory Circumcision ironically could only bolster the ranks of the movement to end circumcision.
ReplyDelete"...why not perform a study in the United States to prove their case?"
ReplyDeleteBecause it would never get ethical approval.
"Because it would never get ethical approval."
ReplyDeleteWhy not if it is conducted on competent adult volunteers? genuinely curious.
It probably would get ethical approval, but there are some other reasons why such a study will not be performed.
ReplyDeleteFirst, there's no point. Why conduct an expensive, large-scale study to prove something that's already known? There's no credible reason why the protective effect of circumcision should depend on longitude. If there were substantial biological differences between African foreskins and American foreskins, that might justify such an investigation, but that isn't the case.
Second, when planning such a study you have to ensure that enough participants will likely become HIV positive during the course of the study that you can detect a statistically significant difference, assuming one exists. In African nations with fairly high prevalence of HIV, that's quite likely to happen. But in the US, with a much lower absolute risk of HIV, it means that you either need to run the study for many more years, or you need to include many more participants.
"First, there's no point. Why conduct an expensive, large-scale study to prove something that's already known? There's no credible reason why the protective effect of circumcision should depend on longitude. If there were substantial biological differences between African foreskins and American foreskins, that might justify such an investigation, but that isn't the case."
ReplyDeleteWhat about soap and water that is readily available in the US but not Africa? That in itself could dramatically change the results. Sure, foreskin might could harbor germs and such better than no tissue at all, but there has been no study that showed foreskin to be any less hygienic or have any more germs when cleaned as often as someone who is circumcised.
Also note that why circumcision decreased the risk in Africa by 60 percent in unknown, scientists only speculate. Since there are many variables that are different in Africa ( such as the prevalence of malaria, which lowers your immune system,the prevalence of untreated STDs like genital warts and herpes and genital ulcer disease) it is very possible that when all those confounding factors are controlled for that there would not be such a high number like 60 percent reduction of risk.
"For more than a century medics in the American armed services and M.D.s specializing in the treatment of STDs have recommended post-sex washing to reduce the risk of bacterial STDS like syphilis and gonorrhea, which set the stage for HIV infections by reducing immunity. Dr. Margaret Hamburg, recently appointed head of the U.S. Centers for Disease Control and Prevention, had the Public Health Department in New York City recommend "washing after sex" to prevent the newly epidemic of infection known as MRSA.
"As it is,privately funded health-education web sites in the U.S.A., such as IntelliHealth.com, which carries health information supplied and officially approved by "Faculty of the Harvard Medical School," continue to recommend post-sex washing as a complement to condom use.
Sooner or later, I'm afraid, the drive to promote male circumcision now being undertaken by researchers and reporters who have latched onto to this proxy for penile hygiene will be viewed as a tack initiated and publicized by well-intentioned officials who were and remain naive about the oldest approach to preventing STDs in the world: washing involved body parts after sex."
But, like you said, a study done in the US would not show the cost effectiveness it did in Africa. So one wonders why people still think it is a good idea to subject millions of helpless infants to this procedure, when the vast majority won't ever need the intervention at all.
Jake is right that a study done here likely would show no benefits, simply because so few men would get HIV and other STDs. Thus, using percentage rates determined in African studies to determine policy in the U.S. is deceptive. One has to question whether the cost of circumcising every baby boy, and presumably adult male, can be justified when the benefit is too small to be statistically significant.
ReplyDeleteOf course African foreskins aren't different. The difference is entirely cultural: to have the outrageous incidence of HIV in Africa requires outrageous sexual practices. Changing sexual practices for an entire society may not be easy, but at the same time exporting circumcision to places where HIV is not epidemic, e.g. Europe and the U.S., can't produce much change.
In the U.S. the HIV epidemic is still, after all these years, a disease of the gay community because of their cultural practice of unprotected anal sex with multiple partners. It would be a much wiser use of money to concentrate prevention efforts where they are needed.
Jake is right that a study done here likely would show no benefits, simply because so few men would get HIV and other STDs. Thus, using percentage rates determined in African studies to determine policy in the U.S. is deceptive. One has to question whether the cost of circumcising every baby boy, and presumably adult male, can be justified when the benefit is too small to be statistically significant.
ReplyDeleteI'm afraid you've badly misunderstood, Anon.
I haven't said that a trial would show no benefits. What I have said is that the trial would need to include several times as many participants to have sufficient statistical power to identify a significant difference.
What matters in a cost analysis is incidence, not percentage rates. How many lives will be saved? What will the increase in life expectancy be?
ReplyDeleteGiven the astounding difference in HIV incidence where the African trials were run and the U.S., I'd like to see the proof that you would need only "several" times as many participants to get statistically significant levels. Common sense says you would need proportionally as many people to match the statistical power of the African results. That would be hundreds of times the participants.
Claiming that "there's no point" running these trials in the U.S. is just your opinion, but statistical science is not so easy. Until proven otherwiswe, one must expect confounders, perverse effects, and non-linear relations to prevail. There are no statistical science reasons to believe that one can import wholesale the results of the African trials to the U.S.
Let's see some real data from tests performed in the U.S. before committing to an enormous federal healthcare program of universal circumcision. If circumcision is really going to save so many lives in the U.S., the cost of actually doing the experiment is negligible.
Given the astounding difference in HIV incidence where the African trials were run and the U.S., I'd like to see the proof that you would need only "several" times as many participants to get statistically significant levels. Common sense says you would need proportionally as many people to match the statistical power of the African results. That would be hundreds of times the participants.
ReplyDeleteI'm not sure how you're calculating "hundreds of times". According to the CIA World Factbook, the prevalence of HIV in the US is 0.6%. In Uganda, the figure is 5.4% (or 9x the US rate), in South Africa, 18.1% (or 30.2x), and in Kenya, 6.7% (or 11.2x).
Claiming that "there's no point" running these trials in the U.S. is just your opinion, but statistical science is not so easy. Until proven otherwiswe, one must expect confounders, perverse effects, and non-linear relations to prevail.
I'm sure you'd like to believe that, but I'm afraid that the design of randomised controlled trials is such that any differences are the result of the intervention.
So using the numbers from SA, we would need 30x10,000=300,000 test subjects. I think you'll have to withdraw your claim that 30 is "several."
ReplyDeleteSure, the results of the RCTs are the result of the intervention - on a self-selected group of men, who were paid to do the study, and presumably when sexual advice was given, the circumcision status of the men was known. It's reasonable to expect a different outcome for randomly selected subjects with blind consulting, i.e. the doctors don't know if their patients are in the placebo group. That's standard medicine. I'm sure you'd like to believe otherwise, but medical studies done in the U.S. require much more rigorous control than what was done in Africa.
The researcher bias alone should be enough to discredit these studies. Many of the researchers are well known circumcision advocates, jewish, and male. By their own admission, the trials were stopped early. It is very likely that if the trials had completed their duration the rate of HIV from the circumcised group would have caught up to the uncircumcised group. Circumcision is a risk reduction, not an immunity, after all. If a circumcised man continues to have unprotected risky sex a 60 percent risk reduction is only going to fare well for so long.
ReplyDeleteThe trials they did to try to prove a link with circumcision and reduced risk of HIV in women was stopped early as well, ironically as the number of women getting HIV from their circumcised partners was surpassing the women with intact partners. No worries, they made sure to stop before it became "statistically significant" which would have resulted in the research being null and void, as a risk reduction for one sex and an increased risk for another surely wouldn't fly in the United States. They knew that.
If circumcision were discovered somehow to reduce the risk of contracting Brucellosis by 60%, would you institute mass circumcision? Of course not. It's a disease that strikes a rather well defined set of people with a well known set of risk factors. You would, instead, focus your efforts on those who are at risk, instead of wasting money on a shotgun approach. In a place where 18% of the population has Brucellosis, 60% effective circumcision wouldn't wipe out the disease at all, because it's not targeting the right problem. Better to spend your money on pasteurization equipment, and teaching people to avoid raw milk and unsanitary barnyard conditions.
ReplyDeleteThat's about the situation with HIV. It doesn't just drop out of the sky. Prevention efforts need to be focused, because the disease strikes people whose brand of sexual activity puts them at risk.
So using the numbers from SA, we would need 30x10,000=300,000 test subjects. I think you'll have to withdraw your claim that 30 is "several."
ReplyDeleteWhere are you getting these numbers? There were 3,274 participants in the South African trial, not 10,000.
Sure, the results of the RCTs are the result of the intervention - on a self-selected group of men, who were paid to do the study, and presumably when sexual advice was given, the circumcision status of the men was known. It's reasonable to expect a different outcome for randomly selected subjects with blind consulting, i.e. the doctors don't know if their patients are in the placebo group. That's standard medicine.
I do find it amusing when people make such vehement criticism of studies that they quite evidently haven't even read. To quote from Auvert et al:
"To ensure confidentiality, participants' files were kept in a locked room at the centre and each participant received a number that was used to identify all documents related to that person. To ensure blinding of study personnel, the randomization group information was not available to the personnel in charge of counselling or collecting information in the centre during the participants' visits."
The researcher bias alone should be enough to discredit these studies. Many of the researchers are well known circumcision advocates, jewish, and male.
Circumcision advocates? I suppose it depends on what you mean by that. Certainly some of the authors have researched circumcision and HIV previously, but then one would expect that researchers would not be completely new to the field. Jewish? I've no comment on whether this is true or false, but I do find the insinuation that Jewish people are inherently incapable of being objective about circumcision to be rather unpleasant. No argument from me re that many of the researchers are male. :-)
By their own admission, the trials were stopped early. It is very likely that if the trials had completed their duration the rate of HIV from the circumcised group would have caught up to the uncircumcised group. Circumcision is a risk reduction, not an immunity, after all. If a circumcised man continues to have unprotected risky sex a 60 percent risk reduction is only going to fare well for so long.
Using figures from Auvert, there were 69 infections in 21 months, so yes, if the trial were continued for about 82 years then we might expect all of the participants to be HIV positive. But that's assuming that the men were alive and had similar sexual behaviour for those 82 years. Those aren't realistic assumptions, of course.
The trials they did to try to prove a link with circumcision and reduced risk of HIV in women was stopped early as well, ironically as the number of women getting HIV from their circumcised partners was surpassing the women with intact partners. No worries, they made sure to stop before it became "statistically significant" which would have resulted in the research being null and void, as a risk reduction for one sex and an increased risk for another surely wouldn't fly in the United States. They knew that.
Of course. It was one big conspiracy on the part of the researchers (possibly influenced by the Jews), who weren't really interested in Africa, but instead had a bizarre agenda to use their data in the United States. Let's overlook the fact that the difference wasn't statistically significant. Let's overlook the fact that there is no evidence that it would ever have become statistically significant. And let's overlook the fact that the trial (like the others) was actually stopped by the monitoring board, not the researchers themselves.
Good old paranoia. You have to love it.
Thanks, Jake, for responding in a common sense way to some of the old tired arguments raised by the anti-circ crowd. Is it just me, or is the hint of racism and anti-semitism coming to the surface in these tirades? The notion that African foreskins are somehow more susceptible to HIV than American foreskins strikes me as a chapter from that old Nazi genetics line. And, of course, it's always the Jews fault. Give me a break.
ReplyDeleteSTDs are mainly found among the poor, because malnutrition weakens the immune system. Poor people in the USA are less likely to be circumcised, poor people in the EU are more likely to be circumcised (Hispanic v.s. Muslim immigrants). So STD statistics can be misleading.
DeleteCommon sense tells us that both reduction of STDs and loss of sensation are likely if thin, moist, but highly enervated skin is removed. So both sides tweak science if they deny either.
Dear Friend,
ReplyDeleteA while ago we chatted a lot and exchanged correspondence, but I have lost your name and details. I am the circumcised guy from Hungary who runs his pro-circ site.
Please answer me.
ANDRAS
jovagasufiu@gmail.com
"The notion that African foreskins are somehow more susceptible to HIV than American foreskins strikes me as a chapter from that old Nazi genetics line."
ReplyDeleteI invoke Godwin's Law. Thank you for playing.