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.
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).
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
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