|South Africa: Circumcision not a silver bullet|
The following article by two public health authorities at the University of Capetown, South Africa, throws doubt on recent extavagant claims that universal circumcision is the best and only answer to the southern African AIDS epidemic. Coming from a society which (unlike the developed world) really does have a serious HIV problem in the general population, the paper is of particular significance.
Male circumcision: The new hope?
A. Myers, J. MyersSouth Africa Medical Journal, May 2007
Before we rush to administer the ‘silver bullet’ of circumcision in the fight against HIV/AIDS, it is important to take a long cool look at the practice, and at the historical and contemporary rationales for its use.
Circumcision practicesIn his book, Circumcision: A History of the World’s Most Controversial Surgery,  medical historian David Gollaher makes the intriguing suggestion that ‘as the history of female circumcision suggests, if male circumcision were confined to developing nations, it would by now have emerged as an international cause célèbre, stirring passionate opposition from feminists, physicians, politicians, and the global human rights community’.
There are clearly ethical issues involved in practising genital surgery on non-consenting infants and children in a modern human rights context; however, because male circumcision has long been familiar in the West, it continues to be justified and escape scrutiny.
Rationalisations for circumcisionOver the centuries there have been various justifications for male circumcision. The practice has served in part to identify those outside the religious/cultural group. The unsubstantiated rationale is that the circumcised penis is ‘cleaner’ than the uncircumcised one. This argument is often encountered among Jews, Muslims and Americans, all of whom circumcise the majority of males in infancy or childhood, but the notion is absent for example in Scandinavian countries where circumcision is rare.
More serious and superficially more convincing justifications for this surgery, such as ‘health benefits’ or ‘medical’ reasons have abounded since the mid-19th century. The first medical justification was that circumcision prevents masturbation,  which Victorians believed led to a range of maladies including insanity, idiocy, epilepsy, tuberculosis and paralysis.  This claim proved false. At the turn of the 20th century it was claimed that circumcision prevents sexually transmitted diseases (STDs), with studies  finding differences in the rates of syphilis and other STDs among Jews and non-Jews. These early studies did not adjust for confounding factors, and later well-conducted studies failed to find a protective effect.  In the 1930s circumcision was said to prevent penile cancer.  However, because penile cancer is so rare (every year there is 1 case per 100 000 men in the USA and 0.3/100 000 in Japan ), the American Cancer Society estimates that the number of fatalities from circumcision would exceed the number of fatalities from penile cancer.  In the 1950s an association was observed between circumcision and low rates of cervical cancer in women; however, this finding was not substantiated in further studies.  In the 1980s the new scare was urinary tract infection in the first year of life.  It was argued that the likelihood of this would be decreased if the infant was circumcised. However, even accepting this to be true, the absolute risk reduction is very small (under 1%).  Interestingly, girls are far more susceptible to urinary tract infections than both circumcised and intact boys. In girls (and in the small number of excess cases in intact males), antibiotic treatment is effective. It is also worth noting that none of the abovementioned conditions are eliminated by circumcision. The most that can possibly be said is that it offers some degree (often slight) of risk reduction in the circumcised.
Medical circumcision policy and practice and practice in Anglophone countriesAs medical justifications for routine infant circumcision have been steadily overturned, medical organisations in Anglophone countries (the only countries with a history of medicalised non-therapeutic or preventive circumcision) formulated policies that withheld endorsement of routine circumcision of infants, and accordingly the rates dropped considerably in all but the USA. The UK stopped coverage of circumcision via the National Health Service in 1949 because of lack of evidence of benefit,  and the American Academy of Paediatrics (AAP) stopped endorsement of routine circumcision in 1971, citing no valid indications.  An AAP statement in 1989 elaborated on risks and benefits,  and in its most recent policy statement in 1999 the AAP reaffirmed that routine circumcision was not recommended. 
Until recently infant male circumcision has been on the decline, as parents in developed countries began increasingly to perceive that genital surgery on non-consenting subjects was not only unnecessary, but also inhumane and out of step with an evolved human rights culture. Circumcision appeared to be going the way of other outdated practices such as corporal and capital punishment and less humane slaughtering and animal sacrifice practices. In the USA, UK and Israel, small but increasing numbers of Jews oppose the practice as antiquated, and refuse to have it done to their infants, despite its religious and cultural significance. [16-19]
The evidence for HIV preventionBefore the implementation of properly designed randomised control trials (RCTs), the authoritative Cochrane Review of recent studies on the subject found ‘insufficient evidence to support an interventional effect of male circumcision on HIV acquisition in heterosexual men’.  Results of observational studies were conflicting and no strong association was observed. However, results of recent RCTs [21-23] examining the effect of adult male circumcision on the risk of HIV infection have once again led to renewed medical justifications and calls for circumcision. [24-27] There have been calls for mass circumcision campaigns, even though these might be impractical in many circumstances. Although some commentators have been careful to emphasise that circumcision has only been shown to reduce the risk, many lay people are beginning to believe that circumcision can prevent (in the sense of eliminate) the risk. Recent RCTs have shown that over a maximum period of 24 months of observation post circumcision, a man’s risk of contracting HIV is reduced by between 60% (see South African study ) and 53% and 51% (see Kenyan  and Ugandan  studies) respectively. Garenne  has pointed out that a 60% reduction in the risk of infection is similar to the effectiveness of the rhythm method of contraception, which reduces fecundity by around 50% without protecting women against pregnancy.
A circumcised man cannot hope for full immunity to HIV; the best he can hope for is perhaps a longer period of time and/ or a greater number of sexual encounters before he becomes infected as a consequence of his reduced risk. The problem is that if people are led to believe that circumcision is actually ‘protective’ in the sense of conferring full immunity, this could be seriously counterproductive, resulting in behavioural disinhibition in circumcised men and their abandonment of other preventive methods.
At the population level there is no notable correlation between circumcision and HIV status. In Europe, where few men are circumcised, HIV prevalence is the lowest in the world. In the USA, where most men are circumcised, HIV prevalence is highest in the developed world. In Ethiopia, despite the universal practice of circumcision, the number of HIV cases increased from 0% in 1984 to 7.4% in 1997.  In the Eastern Cape, where most men are circumcised, the prevalence rate is not meaningfully lower than in KwaZulu-Natal (KZN), where most men are not circumcised. The pandemic in the former province appears merely to be lagging behind that in KZN.  While these findings are not incompatible with evidence from trials showing that circumcision reduces the risk of HIV transmission, they demonstrate that there are far more important factors affecting HIV spread than the absence of circumcision. Actuarial modelling showing the impact that mass circumcision might have in South Africa provides an estimate of a modest 9% reduction in the incidence of HIV cases over the next 10 years  (an average risk reduction of less than 1% a year).
Unbalanced circumcision advocacyThe current zeal and naïve enthusiasm for promoting circumcision as an AIDS prevention tool show lack of regard for the limited degree of benefit likely. Potential harms include disinhibition and surgical complications like infection and worse at the individual level, and increased costs and strain on thinly stretched health services and the opportunity cost of deemphasising other crucial health services at the societal level.
Recent research has shown that HIV infection is about three times more likely as a result of the circumcision procedure itself in three African settings (Kenya, Lesotho and Tanzania).  One should also not lose sight of the ethical issues of circumcising non-consenting infants.
Cultural double standardsIt is also useful to ask ourselves how consistent attitudes are in relation to preventive surgery. Hypothetically, imagine that female circumcision had also been shown to have a similar ‘protective’ effect. Would we be any more likely to promote it? Would women be lining up for it, and would young parents, eager to do the best for their children, request it for their daughters? If female circumcision was medicalised in a similar way to male circumcision, it could be made safer and less damaging. Nevertheless, that sort of argument does not convince.
Although it is not deemed ethically possible to study female circumcision by means of a RCT, a large Tanzanian study, which controlled for confounding variables, found that this practice reduced HIV transmission.  Biologically the explanation for this is probably the same as for male circumcision.
The downplaying of these facts in the media is a powerful reflection of Western cultural attitudes. We have already decided that female circumcision is an appalling human rights violation and so do not even flirt with the idea of using it as an HIV prevention tool. Similar arguments apply to mastectomy in teenage girls, even though this would be effective to prevent breast cancer in later life. The difference with male circumcision is that it is still tolerated in Western and other parts of the world, rendering it politically acceptable. This has tended to lower ethical barriers to recommending male circumcision as an HIV/AIDS preventive measure.
Caution and more research are neededMore research is needed into integrated HIV/AIDS management that examines the long-term preventive effects of circumcision. Research should focus on the duration of sexual activity in men (as with the rhythm method of contraception over the reproductive years of women), the impact on female risk of acquiring HIV, and on the issue of disinhibition in circumcised men. The impact on women is a key issue, and recent research in Uganda shows that female partners of circumcised men appear twice as likely to contract HIV;  while South African research shows that of the principal group at risk for HIV infection – 15 - 24-year-olds – a massive 90% of those newly infected were women.  In summary, the evidence for preventive benefit of male circumcision is rather modest and does not warrant heroic policies or practices.
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A. Myers is a humanities student at the University of Cape Town, South Africa, and has researched the history and practice of circumcision.
J. Myers is Professor of Public Health at UCT, and is interested in the reduction of the provincial burden of disease.
South Africa Medical Journal, Vol. 97, No. 5, May 2007