1. Health
Cory Silverberg

Is Mass Circumcision a Good Idea?

By March 30, 2009

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If you read the paper, you've probably heard something in the past four years about circumcision and HIV. In 2005 there was one major study, and then two more in 2008, that took adult men in Uganda, South Africa, and Kenya, circumcised some of them, and then followed them (for as long as two years) to see how their risk of HIV compared to a group of uncircumcised men. All three studies have found large and statistically significant protective effects. The first study found such a large impact that they stopped the study and circumcised all participants, arguing that it was unethical to leave the control group without the protection indicated by the data pointed.

Another study was reported last week, also out of Uganda, this time looking at whether circumcision offers protective effects against HPV and herpes. This study also found large effect sizes and the authors seem to be calling even louder for the scientific and medical communities to recommend population wide circumcision.

It's not the first time the medical profession has recommended mass circumcision for health reasons. Some of their previous guesses about what circumcision protects against included mental illness, tuberculosis, and "excessive masturbation". Which isn't to say the theory is wrong this time, it's just worth remembering that medical knowledge and clinical research are not produced in a social-historical-cultural vacuum.

As a sex educator (who is also Jewish) I get asked a lot about how I feel about circumcision and about whether I would have my son circumcised. Expectant parents, mostly mothers, ask sometimes either for validation of their decisions or because they haven't decided yet. Folks who are anti-circumcision ask because they want to figure out which side I'm on. I think one person who asked me was trying to be flirtatious (it didn't work out).

I've never had a simple answer, but I have to say this research, and the media coverage of it, has me thinking more deeply than I have for years. Here are some of the reasons why:

Conflicting Research, Unanswered Questions
The research makes me question everything I read about research. The truth is that neither scientists nor data agree on circumcision's protective effects against HIV, herpes, or HPV. Some studies show it is, others show it isn't. Why aren't researchers taking the time to think about what accounts for the difference and to explain that to us?

I have to come out and say that there's something a bit creepy about the difference in how research is done in the U.S. and in Africa. The three African studies that have received the most media attention all involved circumcising adult men and then following them and comparing outcomes to a group of non-circumcised adults. You probably won't be surprised to hear that in the U.S. they don't circumcise adult men; they look at men who are already circumcised and compare them to men who are not. I want to know what the methodological differences mean in terms of interpreting the results, and I'd really like to hear some researchers talk about why research that involves circumcising adult men isn't being done in the U.S. (saying "we'd never find subjects" or "we'd never get ethical approval" would just the beginning of the conversation). Plus, in at least one of the African studies, participants received two years of free health care for being in the study in addition to a free circumcision. U.S. studies are rarely as lavish in providing medical monitoring and care.

And much of the research raises more questions than it answers. No one knows what accounts for the protective effect seen in the studies that find one. Researchers have ideas (both anatomical and cellular) but they're no more than educated guesses. We don't know why some studies have shown the effect and others haven't. Nor do we know why such a large the protective effect has been found in studies of men having sex with women, but not in men having sex with men.

Ethical Issues
There are boatloads of ethical issues worth considering before circumcision becomes the norm for health reasons again. Some researchers have written about this, mostly in academic journals, and I'd like to see public comment on these issues. Here are a few things I'm struggling with.

How much protection makes circumcision worthwhile? If you live somewhere where circumcision is already a norm, you might not think of it as a particularly invasive way of protecting people from HIV exposure. But what about places where it is considered invasive? Let's hypothetically say that researchers discovered that people who have a small part of their tongue or ear removed surgically had a lower risk of getting HIV. The amount removed isn't enough to prevent you from eating, speaking, or hearing, but enough that you and others would notice. Would you choose as an adult to have the procedure? Would you have your newborn child's ears or tongue snipped? Would your decision change based on the risk reduction?

And on an even more basic level, does evidence that circumcision protects against penile HPV, urinary tract infections, and penile cancer mean it's the only, or the best, means of protection?. Not only do we need to ask this question , we need to question who and what defines "best" and whether the risk warrants a surgical procedure (for example, in the case of penile cancer the risk is small, the cancer is rare).

...And Race
Falling also in the not-quite-able-to-articulate-it category is my feeling that we aren't talking about race enough in relation to this recent circumcision research and reporting on the research. I went searching for conversations online but came up mostly empty (I did find an excellent, but unrelated, post from Feministe). I'm not claiming there are any sort of conscious racial elements to the research, but race - arbitrary categorization that it is -- is an issue in scientific research just as it is in our daily lives. I believe this research is being done with the best of intentions. But it has to be acknowledged that this research is about imposing a solution from the outside. It's about one group with power and knowledge swooping in to help a group of people considered less knowledgeable and less powerful. And when the group doing the imposition are largely from the west and white (or at least their power/funding is) and the group being imposed on is largely black and African, it feels like not talking about race is like ignoring the elephant in the room. There's something just a little too colonial about the way this research is being done and the way policy changes are being proposed. There are a whole lot of relatively affluent Westerners cutting off small parts of relatively poor Africans penises. These studies aren't addressing any social or cultural implications of the research itself or how the findings could ever be translated effectively into policy.

I don't want to come across as if I am mistrustful of those doing research on HIV prevention, nor am I proposing any sort of conspiracy theories about circumcision or the medical community. I guess the point of this post is to try and make the public discussion a little broader. Working with people one-on-one as a sex educator, I'm aware that the reason most people don't talk about circumcision is that they feel it's "too personal". That's also a reason a lot of us don't talk about sex. In both cases when we don't challenge that construction of the "personal", we're usually the ones who lose out in the end.

Read more - Kaiser Network: Male Circumcision Reduces Men's Risk of Contracting HPV, Herpes, Study Says

Selected Sources:

  1. Hernandez, B.Y., Wilkens, L.R., Zhu, X., et. al. "Circumcision and Human Papillomavirus Infection in Men: A Site-Specific Comparison" The Journal of Infectious Diseases Vol. 197 (2008):787-794.
  2. Laumann, E.O., Masi, C.M., Zuckerman, E.W. "Circumcision in the United States. Prevalence, Prophylactic Effects, and Sexual Practice" JAMA Vol. 277, No. 13 (1997): 1052-1057.
  3. Partridge, J.M., Hughes, J.P., Qinghua Feng, R.L., et. al. "Genital Human Papillomavirus Infection in Men: Incidence and Risk Factors in a Cohort of University Students" The Journal of Infectious Diseases Vol. 196 (2007):1128-36.
  4. Rennie, S., Muula, A.S., Westreich, D. "Male Circumcision and HIV Prevention: Ethical, Medical and Public Health Tradeoffs in Low-Income Countries" Journal of Medical Ethics Vol. 33 (2007): 357-361.
  5. Tobian, A.A.R., Serwadda, D., Quinn, T.C., et. al. "Male Circumcision for the Prevention of HSV-2 and HPV Infections and Syphilis" New England Journal of Medicine Vol. 360 (2009): 1298-1309.
  6. Vermund, S.H. & Qian, H.Z. "Circumcision and HIV Prevention Among Men Who Have Sex With Men No Final Word" JAMA Vol. 300, No. 14 (2008): 1698-1700.
  7. Warner, L. Ghanem, K. G., Newman, D.R., et. al. "Male Circumcision and Risk of HIV Infection among Heterosexual African American Men Attending Baltimore Sexually Transmitted Disease Clinics" The Journal of Infectious Diseases Vol. 199 (2009):59-65.

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Comments
April 1, 2009 at 9:46 am
(1) Rebekka Wallace Roy says:

Thanks for this Cory. My mom and I had a discussion on this very topic a couple of days ago as a result of the article in the Globe and Mail. I share your thoughts on sexual health research and am happy to have a forum that provides us the space to challenge/talk/think about things in a more complex way.

Hope that you’re doing well!
Rebekka

April 1, 2009 at 10:33 am
(2) la fekken says:

Circumcision is a blessing when you have to work in the field of Geriatrics. A penis is so much easier to clean when it is circumcised.
Let’s face it most men are filthy. They need help staying clean and circumcision helps with that.
If you want to keep that extra skin, then you better use a masculine hygiene product(do they make those?).

April 1, 2009 at 4:00 pm
(3) Gary Burlingame says:

You wrote an entire article about circumcision and never once used the word “foreskin”? How absurd. You totally missed what the functions of the foreskin are, and the pleasure it gives its true owner.

April 1, 2009 at 4:24 pm
(4) fungi foto says:

Thanks Cory for opening our eyes. We Africans have been affected by HIV and AIDs in such a way that we take anything without giving a deep thinking.I was happy when the reasrch results were announced.Yeah we need a forum like what Rebekka says. Its high time we question some of these findings. Have these reasearchers gone to areas in SA where circumcision is practised and see how many people are infected. We need real facts for us to accept these results.They need to do a research on how many circumcised men have contracted HIV in Africa.We want a comprehensive research.

April 1, 2009 at 5:15 pm
(5) Desmond Ravenstone says:

Insightful, thanks — especially your critique of the research methodology. I also was not aware that people were looking at the idea of mass circumcisions. Given that its not a sure thing, that does not make sense to me (although educating people, especially new parents, about the risks and benefits so they can make an informed choice, certainly does).

April 1, 2009 at 6:26 pm
(6) Cory says:

@Rebekka: thanks for your comment, one conversation I’m curious about is how this research will/won’t affect individual adults who are having children and their decision to circumcise.

@la fekken: thanks for adding this piece which I think people don’t consider as much; the idea that not all men can physically clean their own penises. I’m assuming your “filthy” comment was sarcasm, if not, I should say that in my experience gender is not the most accurate way of categorizing who does and does not keep their genitals clean!

@Gary, this post was about the research, not the lived experience of people with and without foreskins, sorry it wasn’t of interest.

April 3, 2009 at 1:45 am
(7) Ryan says:

Thanks for this article. I thought it was very interesting and definately gives you some proffessional views. All around the world we seem to have topics like this floating around.

http://qdigitaldesign.ca/news.htm

April 3, 2009 at 6:04 pm
(8) bianca says:

thanks for this roundup. there are several of us sexologists of Color in the US who have discussed this at length and it saddens me that your search came up “empty” of our discussions, i think it speaks to another level of how race intersects with sexuality and technology to demonstrate whose voice really matters and is heard/valued.

Here was my past & present analysis using an intersectional lens that is often forgotten in sexuality and sexuality research.

http://bit.ly/2NBo

April 3, 2009 at 11:57 pm
(9) Cory says:

Hi Bianca,

Thanks for taking time to comment. I wrote that I came up empty quite intentionally to say not “there’s nothing out there” (because I knew there must be) but to say that after I tried to find stuff, and I’m pretty good at trying to find stuff, I couldn’t. You’re right on the money about whose voices get heard loudest online. This is one of the things that makes the notion of the Internet as the “great equalizer” so hard to stomach.

Thanks also for listing your link, I’m on my way there now, and hope others will join me.

April 13, 2009 at 3:33 pm
(10) Mark says:

“If you want to keep that extra skin, then you better use a masculine hygiene product(do they make those?)”

Yes they do. It’s called soap.

Seriously, you think infants should be mutilated because you, as a geriatric crarer, don’t want the hassle of having to thoroughly clean an elderly man’s genitals? That’s preposterous. I’m sure vaginas and anuses are much harder to keep clean than an intact penis. It’s your job. Deal with it.

December 1, 2009 at 8:58 pm
(11) Frank McGinness says:

@Bianca /Cory- Bianca’s link didn’t work for me, strange.
I’m interested in what Bianca has to say her being a sexologist of color. Especially has she read now Black and Hispanic intact men are being singled out for mass circumcision here in the US?

The Israeli group Operation Abraham is keen to teach US doctors their fast mass circ. technique at a CDC sponsored 2009 National HIV Prevention Conference in Atlanta, Georgia, where Operation Abraham took the scientific approach and showed a intact penis of color drew a elephant around it to look like the elephant’s trunk with the words “Yes! A circumcision please.”
http://tinyurl.com/qnmt8b

Also from this article: “Dr. Katrina Kretsinger, of the CDC was asked during one of the sessions if the RCTs would be repeated in the U.S. She replied that they would not because it would be unethical to do so! This raises the question: How were they ethical to start with?”
Best site: CircumcisionAndHIV.com

Obama appointed pro-circ. Thomas Frieden to head the CDC who would have circ’d all the gays, when he head New York, based on the then yet unpublished African studies which later studies showed no affect for msm. Expect more unscientific outpouring from the CDC.

It should also be noted heading up the AAP’s Task Force on Circumcision is Dr. Blank, Frieden’s past N.Y. co worker, is also pro-circ. This echos of a time when the circ. force was headed by Edger Schoen.

Bruce G. Charlton (Editor-in-Chief of Medical Hypotheses) published online 07 September 2009. Writes opening line:”Why is modern science less efficient than it used to be, why has revolutionary science declined, and why has science become so dishonest?”

December 3, 2009 at 3:37 am
(12) Hugh7 says:

Thanks for that – and especially for rising above your own cultural perspective. You’ve touched a lot of the bases.

Circumcision is an extraordinary subject, embracing sex, religion, medicine, identity, conformity/deviance and of course, money. It’s been a “cure” looking for a disease for nearly 150 years – much longer if you include spiritual “diseases”.

It’s pushed on parents with extraordinary passion, and is a most extraordinary thing to have become a cultural norm in any western country – let alone the US, with its proud tradition of individual rights. The rest of the English-speaking world tried it, found it did no good, and has virtually given it up. Most of the rest of the developed world has never had a bar of it.

Nobody has got to the bottom of it, but I have approached it as a memeplex (constellation of units of culture, tranmitted by imitation) at http://www.circumstitions.com/meme.html

I think Gary was making the point that people considering circumcision generally start with the operation, and fail to consider what is removed (what la fekken calls “extra skin”, when it is actually standard equipment). Experts on circumcision have been reduced to sputtering silence at pubic meetings by questions about the functions of the foreskin. The only thing US medical students are taught about the foreskin is how to cut it off.

September 6, 2010 at 7:32 pm
(13) mh says:

I am an MD and supporter of Docs opposing circ and after 30 years of practice including depth psychotherapy, i must admit that there is some underlying madness to this permanently damaging mutilation. it is even a crime to think of it as a medical matter. sheer psychosis of the crowds transmitted intergenerationally by simple brainless mimicry including doctors. the deeper question is why was this ever started and systematically generalized. ? non of the possible answers are ethical nor moral and some foul ulterior purpose might be going on that this savagery continues unabated by even advanced nations. and why is the medical community conned and recruited to propagate this barbaric harm? surely we will not be amputating all pubertal female breasts to prevent any possible future case of breast cancer, are we? plus the stats show no real link to HIV, and even if there were a link, why amputate a mans most sensitive and pleasurable part instead of using simple washing like everyone else?? these are serious questions that transend the medical hulla baloo created by religious fanatics of islamic and jewish “beliefs”. sory for the bluntness but mutilation is a crime and the damage is physical and psychological and very hard to overcome even after many decades.
i also speak of personal experience in addition to hundreds of my patients, so spare me the theoretical rationalizations usually spewed out

December 6, 2010 at 1:36 pm
(14) Daniel says:

I believe one study in the 70′s or 80′s said that the main reason most mothers circumcised their sons was because they didn’t want them to feel weird in the locker room next to all the other circumcised boys. Talk about groupthink!!!!!

September 3, 2011 at 1:57 am
(15) Ann says:

Circumcision is best, much safer for male and future partner

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