A new study from researchers at the University of Puerto Rico offers some much needed data and several clearly worded challenges regarding the current push to circumcise men as a prevention strategy for STIs and HIV.
You might recall that research back in 2005 and again in 2008 with men in Uganda, South Africa, and Kenya found that circumcising adult men reduced their chances of acquiring HIV (and other STIs). Apparently the findings were so dramatic that that they actually stopped one of the major studies to circumcise all the men. The argument was that not circumcising all research participants would be unethical since circumcision provides such strong protective effect against STI and HIV transmission. Despite what was presented as very clear evidence, many questions remain.
Some of those questions are addressed, and even better some confounding data is offered, in an eloquent an clear discussion by Carlos Rodriguez-Diaz and colleagues working in both Puerto Rico and New York. Their paper reports on data from 660 men who were being seen at the largest HIV/STI prevention and treatment center in San Juan.
The men were asked a series of questions about their sexual histories and current STI status, and asked if they were circumcised or not. Then the researchers looked at those men who were circumcised and those who weren't to see if being circumcised provided protection against HIV or other STIs.
What they found was that among their research participants being circumcised in and of itself did not provide any significant protective benefit against HIV or other STIs.
They caution that theirs is preliminary research, the first of its kind in the Caribbean, that they can't explain why they found no benefits when research in Africa found such significant benefits, and in any case that the kind of research can't be directly compared to the studies in Kenya, Uganda, and South Africa.
But they have other cautions, which are equally important and I can only hope that their fellow researchers take note.
They point out that given how unlikely it is that it is a biological factor alone that explains what might protect a group of people from acquiring HIV, it's probably worth looking at sociocultural factors. They continue:
For example, Puerto Rico is a primarily Christian society, with strong prohibitions against sexual contact between men, masturbation, and sexual activities outside of marriage. These types of background cultural factors impact the way in which sexual practices and partnering are organized. While we are unable to specify what factors might explain the discrepancy between our findings and earlier studies of circumcision, it is possible that some combination of sociocultural factors account for the differences in findings. If this is the case, it would suggest that further research on these questions is needed and, indeed, that it may be a necessary precondition to implementation of circumcision in a given time and place.
To be clear, the authors aren't suggesting that it's different or more complicated in Puerto Rico than elsewhere because of sociocultural factors. They are saying that these factors always need to be taken into account and they are unique to every place and in every time. It's a very polite way of suggesting that maybe before we go to an entire continent and start circumcising people, it might behoove us to actually pay attention to things like sexuality and culture in particular places at particular times. Maybe we should try to understand what's going on, what people's lived experience is, before we move in with the knives. Certainly we should think about who "we" are and who "they" are and whose explanations get the most attention and the most funding.
It's encouraging to read this, particularly in a journal that has a tendency to publish work that denies these factors exist, let alone need to be accounted for.
Source: Rodriguez-Diaz, C.E., Clatts, M.C., Jovet-Toledo, G.G., et. al. "More than Foreskin: Circumcision Status, History of HIV/STI, and Sexual Risk in a Clinic-Based Sample of Men in Puerto Rico" Journal of Sexual Medicine. Published online ahead of print August 15, 2012. Accessed August 16, 2012.
This is an interesting but not entirely unsurprising development.
However it’s misleading to suggest that the African RCTs showed significant benefits to circumcision. Rather, the researchers presented their data in a way that suggested that there are significant benefits – big difference. Unfortunately, the world swallowed this trickery in one piece.
This study would be more credible if the circumcision status was determined by the clinicians doing a physical exam rather than by self-reported status. The latter is a source of significant error. That aside, field studies like this, instead of the absurd RCTs clearly designed to be confusing and give the results the funder wants, are a step in the right direction.