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HIV and Circumcision: New Factors to Consider
Issues associated with the introduction of circumcision into a non-circumcising society
Male circumcision as prophylaxis
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George Hill, Executive Secretary Doctors Opposing Circumcision, George C. Denniston, MD, MPH
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iconbuster{at}earthlink.net George Hill, et al.
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Dear Editor Kebaabetswe et al0. obviously believe the conventional wisdom that heterosexual sex is the major vector for the transmission/reception of human immunodeficiency virus (HIV), and that male circumcision is an effective deterrent to infection.[1]> Based on that belief, they have constructed an elaborate and impressive study of the acceptability of circumcision as a prophylactic measure in Botswana. Furthermore, they argue for a program of neonatal circumcision in Botswana in hope of reducing the HIV infection rate fifteen years later.[1] Discussion It has been believed since about 1988 that heterosexual coitus accounts for 90 percent of the HIV infection in Africa.[2,3] Many studies do argue that circumcision can reduce the transmission of HIV through heterosexual coitus. The quality of these studies has been criticized for their methodological flaws, including their failure to control for numerous confounding factors.[4] Gray et al. found that transmission by coitus “is unlikely to account for the explosive HIV-1 epidemic in sub-Saharan Africa.[6] It now appears that these studies have not accounted for the largest confounding factor of all—iatrogenic transmission of HIV. Earlier this year the International Journal of STD & AIDS published a trilogy of articles.[3,7,8] These articles, which strongly argue that unsafe health care practices, especially non-sterile injections—not heterosexual intercourse—are the principal vectors by which HIV is transmitted. A program of mass circumcision would be ineffective against iatrogenic transmission of HIV through unsafe health care. Heterosexual transmission of HIV that one sees in Africa also cannot explain the incidence of HIV in children.[3,9] Circumcision has some little known effects that may to promote rather than deter HIV infection The human foreskin has physiological functions designed to protect the human body from infection. The sub-preputial moisture contains lysozyme,[10] an enzyme that attacks HIV.[11] Circumcision destroys this natural protection. Circumcision removes erogenous tissue,[12] desensitizes the penis,[13] changes sexual behavior and makes males more likely to engage in unsafe sex practices.[14] Circumcised males, therefore, are less willing to use additionally desensitizing condoms.[5] Male circumcision produces hardened scar tissue that encircles the shaft of the penis. The scar scrapes the inside of the partner’s vagina during coitus and, therefore, may enhance the transmission/reception of HIV. A program of mass circumcision would expose African males to unsafe genital cutting,[4] would destroy the natural protection of the foreskin,[10] would not be effective against iatrogenic unsafe health care,[4] would divert scarce medical and social resources from measures of proven effectiveness,[5] and, therefore, is likely to increase the transmission of HIV.[5] The proportion of HIV infection attributable to heterosexual intercourse has been placed at 90 percent.[9] Gissellquist & Potterat now estimate the proportion attributable to heterosexual intercourse at only about 30 percent.[8] —only one-third of the previous estimate. Circumcision has not yet been shown to be an effective deterrent against HIV infection.[5] The Council on Scientific Affairs of the American Medical Association says that “circumcision cannot be responsibly viewed as ‘protecting’ against such infections.”[15] The Task Force on Circumcision of the American Academy of Pediatrics identifies behavioural factors, not lack of circumcision, as the major cause of HIV infection.[16] The article by Kebaabetswe et al. seems to show a strong cultural bias on the part of the authors in favour of circumcision. This may be due to their desire to preserve their culture of origin.[17] Bioethics and Human Rights Finally, we would like address on legal and ethical issues. As noted above, male circumcision excises a large amount of functional healthy erogenous tissue from the penis.[12] It is a clear violation of the basic human right to security of the person.[18] Several authorities report that circumcision degrades the erectile function of the penis.<[19,20] Circumcision, therefore, must be regarded as degrading treatment. Degrading treatment is an additional violation of human rights.[21] The leading international statement of medical ethics is the European Convention on Human Rights and Bioethics.[21] Article 20(1) prohibits non-therapeutic tissue removal from those who do not have the capacity to consent. Children have a right to the protection of the security of their person[18,22] and to protection from degrading treatment.[21,23] Circumcision would violate those human rights. Doctors must respect patient human rights.[24] Prophylactic circumcisions ethically may not be carried out on minors. Circumcisions, therefore, would have to be limited to adult males who legally may give informed consent. Political Factors Ntozi warns: It is important that, while circumcision interventions are being planned, several points must be considered carefully. If the experiment fails, Africans are likely to feel abused and exploited by scientists who recommended the circumcision policy. In a region highly sensitive to previous colonial exploitation and suspicious of the biological warfare origin of the virus, failure of circumcision is likely to be a big issue. Those recommending it should know how to handle the political implications.[25] Approval of circumcision by the surveyed Botswana people apparently is based on their belief that circumcision is efficacious in preventing the spread of HIV. If circumcision fails to control HIV, there would be disillusionment and anger. African males would have sacrificed their erogenous tissue for a false hope of preventing HIV infection. There is no evidence that Kebaabetswe et al. have considered the political issues that would arise if a circumcision experiment should fail. Conclusion Kebaabetswe et al. propose the universal circumcision of male children in Botswana. They accept without question that HIV is primarily sexually transmitted in Africa by heterosexual coitus and that circumcision reduces or prevents the transmission of HIV,[1] however, medical authorities do not accept the evidence of this.[4,5,15] Kebaabetswe et al. propose to provide in-hospital circumcision of male children in Botswana.[1] However, there is already a substantial incidence of infection amongst children in South Africa due to iatrogenic infection from non-sterile injections, etc.[2,9] They have not shown that safe, aseptic circumcisions can be delivered in Botswana. A program of mass circumcision, would destroy the natural protections of the foreskin, further expose children to an apparently unsafe health care system, and would be more likely to increase infection than decrease infection. Even if circumcision eventually should be shown to provide some protection against HIV infection, that protection could only work to reduce the 30 percent of infections that now are attributed to sexual activity. It would have no effect on the other 70 percent. Its effect, therefore, would be minimal at best and could not have an effect for the first fifteen years,[1] during which time behavioral changes could be introduced into society through education, and a HIV vaccine could be developed to provide immunity. Circumcision of male children with the intent of reducing an epidemic not of their making is unacceptable from medical, ethical, and legal perspectives. As a public health measure, male neonatal circumcision fails all tests.[26]
George C. Denniston, MD, MPH, George Hill, Doctors Opposing Circumcision References:
(1) Kebaabetswe, Lockman S, Mogwe S, et al. Male circumcision: an acceptable strategy for HIV prevention in Botswana. Sex Transm Inf 2003;79:214-9. (2) Gisselquist D, Rothenberg R, Potterat J, Drucker E. Non-sexual transmission of HIV has been overlooked in developing countries. BMJ 2002;324:235. (3) Gisselquist D, Potterat JJ, Brody S. Let it be sexual: how health care transmission of HIV was ignored.. Int J STD AIDS 2003;14:148-61. URL: http://www.rsm.ac.uk/new/std148main.pdf (4) de Vincenzi I, Mertens T. Male circumcision: a role in HIV prevention? AIDS 1994;8(2): 153-16. (5) Van Howe RS. Circumcision and HIV infection: review of the literature and meta-analysis. Int J STD AIDS 1999;10:8-16. (6) Gray RH, Wawer MJ, Brookmeyer R, et al. Probability of HIV-1 transmission per coital act in monogamous, heterosexual, HIV-1-discordant couples in Rakai, Uganda. Lancet 2001; 357: 1149-53. (7) Brewer DD, Brody S, Drucker E, et al. Mounting anomalies in the epidemiology of HIV in Africa: cry the beloved paradigm. Int J STD AIDS 2003;14:144-7. URL: http://www.rsm.ac.uk/new/std144intro.pdf (8) Gisselquist D, Potterat JJ. Heterosexual transmission of HIV in Africa: an empiric estimate. Int J STD AIDS 2003;14:162-73. URL: http://www.rsm.ac.uk/new/std162stats.pdf (9) Brody S, Gisselquist D, Potterat JJ, Drucker E. Evidence of iatrogenic HIV transmission in children in South Africa. Br J Obstet Gynaecol 2003;110:450-2. URL: http://www.cirp.org/library/disease/HIV/brody1/ (10) Fleiss P, Hodges F, Van Howe RS. Immunological functions of the human prepuce. Sex Trans Inf 1998;74:364-367. (11) Lee-Huang S, Huang PL, Sun Y, et al. Lysozyme and RNases as anti-HIV components in beta-core preparations of human chorionic gonadotropin. Proc Natl Acad Sci USA 1999;96(6):2678-2681. (12) Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996;77:291-29 (13) Falliers CJ. Circumcision (letter). JAMA 1970;214(12):2194. (14) Laumann, EO, Masi CM, Zuckerman EW. Circumcision in the United States. JAMA 1997;277(13):1052-1057. (15) Council on Scientific Affairs. Report 10: Neonatal circumcision. Chicago: American Medical Association, 1999. URL: http://www.ama-assn.org/ama/pub/article/2036-2511.html (16) Task Force on Circumcision, American Academy of Pediatrics . Circumcision Policy Statement. Pediatrics 1999;103(3):686-93. URL: http://www.aap.org/policy/re9850.html (17) Goldman R. The psychological impact of circumcision. BJU Int 1999;83 Suppl. 1:93-103. (18) Article 3, Universal Declaration of Human Rights, G.A. res. 217A (III), U.N. Doc A/810 at 71 (1948). (19) Coursey JW, Morey AF, McAninch JW, et al. Erectile function after anterior urethroplasty. J Urol 2001;166(6):2273-6. (20) Fink KS, Carson CC, DeVellis RF. Adult Circumcision Outcomes Study: Effect on Erectile Function, Penile Sensitivity, Sexual Activity and Satisfaction. J Urol 2002;167(5):2113-2116. (21) Article 5, Universal Declaration of Human Rights, G.A. res. 217A (III), U.N. Doc A/810 at 71 (1948). (22) Council of Europe. Convention for the Protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine. Adopted at Oviedo, 4 April 1997. (23) Article 37, U.N. Convention on the Rights of the Child (1989). UN General Assembly Document A/RES/44/25. (24) Council on Ethical and Judicial Affairs. Principles of Medical Ethics. Chicago: American Medical Association (2001). URL: http://www.ama-assn.org/ama/pub/category/2512.html (25) Ntozi JPM. Using circumcision to prevent HIV infection in sub-Saharan Africa: the view of an African. In: Health Transition Review (Australia) 1997: 7 Supplement: URL: http://www.cirp.org/library/disease/HIV/ntozi1/ (26) Hodges FM, Svoboda JS, Van Howe RS. Prophylactic interventions on children: balancing human rights with public health. J Med Ethics 2002;28(1):10-16. URL: http://jme.bmjjournals.com/cgi/content/abstract/28/1/10 |
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Gregory J. Boyle, Associate Dean (Research) & Professor of Psychology Bond University, Gold Coast, Qld. 4229, Australia
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gregb{at}bond.edu.au Gregory J. Boyle
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Dear Editor A team lead by Kebaabetswe propose the introduction of infant circumcision in Botwana, based on:
1. a survey of its acceptability to Batswana, There are several medical, psychological, sexual, social, ethical, and legal problems with this proposal. Medical effects Male neonatal circumcision is not an innocuous procedure. There are many complications ranging from trivial to life-threatening. Complications generally include bleeding, infection, and surgical accident, including penile necrosis and penile amputations.[2] Bleeding or infection can progress to death.[3,4] It is difficult to control complications with mass circumcisions.[5] Circumcision excises significant amounts of nerve bearing penile skin and mucosa, especially the ridged band structure near the muco-cutaneous boundary.[6] The protective effects of circumcision against HIV remain controversial.[7] UNAIDS has not accepted circumcision as a useful public health measure. In neighbouring South Africa, many children are infected with HIV.[8] This is attributed to unsafe health care. Circumcision creates an open wound through which infection may proceed.[9] It is not clear that safe aseptic circumcisions can be delivered in Botswana. It is possible that mass circumcision may worsen the epidemic. Psychological effects Psychological manifestations of circumcision have been an area of study at Bond University. Neonatal circumcision is an intensely painful, traumatic, and stressful operation.[10] General anaesthesia is unsafe in the newborn. Available methods of anaesthesia are only partially effective.[10] Circumcised infants show hypersensitivity to pain suggestive of posttraumatic stress disorder (PTSD).[11] Our study of the incidence of PTSD in the Philippines found extensive PTSD in circumcised boys.[12] PTSD secondary to neonatal circumcision has been documented in adult males.[13] Victims of trauma tend to reenact their trauma either on themselves or others in a cycle of violence.[14] Circumcised males may rely on psychological defence mechanisms such as rationalisation and denial, and strongly avoid thoughts, feelings, or conversations about circumcision.[15] There are additional concerns. The state of the phallus is closely related to a man’s sense of well-being.[16] Men who were neonatally circumcised may feel unhappy about being circumcised, experience significant anger, sadness, feeling incomplete, cheated, hurt, concerned, frustrated, abnormal, and violated. In addition, circumcised men may suffer from resultant low self-esteem,[16] which frequently can result in a host of disordered behaviours. Circumcision may be difficult to eradicate from a society once it is introduced. In addition, to the reenactment described above,[16] Goldman reports that circumcised men tend to defend the practice.[16] Circumcised doctors tend to develop intellectual arguments to support genital cutting.[17] Fathers who are circumcised may adamantly insist on a son’s circumcision in an emotional defence against their own painful feelings of grief for a lost body part and reduced sexual function.[18] Kebaabetswe et al. (p. 217) reported that, “ Being circumcised was the only significant predictor for a man who would definitely or probably circumcise a male child.” Sexual effects As noted above, circumcision excises large amounts of skin and mucosa from the penis. The removal of the prepuce tightens the remaining skin and makes it relatively immobile. Since stimulation of the sex nerves normally occurs by movement of the mobile skin, this further desensitises the penis,[17] perhaps even more than the removal of the ridged band of erogenous nerves noted by Taylor.[6] Excision of sexual nerve endings necessarily reduces sensory input. A decrease in sensation may therefore decrease the sexual response.[19,20] Male circumcision also may adversely affect female sexual response. A survey of women found that they were markedly less likely to orgasm with a circumcised partner.[21] Social effects There has been little study of social problems that may occur when entire cohorts of males are circumcised and consequently most of the men in a society bear physical and psychological wounds associated with circumcision. We might expect more dependence on alcohol to relieve the symptoms of PTSD. Low self-esteem may generate a feeling of shame. Shame may generate problems with relationship dissatisfaction, poorer health, depression, drug use, and loneliness. Increased sexual incompatibility and marital problems in circumcised societies might be expected due to reduced penile sensory input, increased sexual dysfunction, PTSD, and low self-esteem among circumcised men.[22] Increased anti-social behaviour may also be expected. Thus, we might expect to see higher levels of domestic violence, rape, child sexual abuse, suicide, and theft.[22] Human Rights The fight against HIV-AIDS requires the careful protection of human rights.[23] Amongst these human rights one finds the rights to security of the person and protection from degrading treatment. The unnecessary excision of normal human tissue[6] from unconsenting minor children is an obvious violation of the security of the person. Through amputation of erogenous tissue, circumcision necessarily diminishes sexual sensation and function as described above and may constitute degrading treatment. Ethics Doctors have a duty of care to behave in an ethical fashion. Amongst other requirements, they are expected to respect the human rights of their child-patients.[24] Circumcision has been shown to be a violation of the child’s human rights, and clearly, many ethical doctors are unwilling to carry out destructive circumcisions on normal, healthy boys. The British Medical Association recognises the right to conscientious objection to the performance of circumcision.[24] Law Male circumcision is not unlawful, but valid consent must be obtained. This may be a problem in the case of circumcision performed on unconsenting minors, in the absence of any medical indication. Cases involving the right of parents to consent to the non-therapeutic surgical sterilization of a child have been heard in several nations.[25,26] The cases agree that, in the absence of any medical indication, parents are not empowered to consent to the non-therapeutic, irreversible, surgical alteration of their child’s genitals. In the absence of a valid consent, a circumcision may constitute an assault.[27] Conclusion The value of male circumcision in preventing HIV infection remains unclear. Non-sterile circumcisions may increase the risk. The proposal by Kebaabetswe and colleagues for the introduction of circumcision into Botswana is seriously flawed, and is irresponsible in failing to place the emphasis on safe sex practices. As described herein, there are many medical, sexual, psychological, social, human rights, ethical, and legal aspects that must be considered. Reliance on circumcision to prevent HIV transmission is wishful fantasy, and can only result in a calamitous worsening of the HIV-AIDS epidemic. Once started, circumcision tends to persist even when the need is over. Circumcision was introduced more than 100 years ago in Western nations on the grounds than it would prevent masturbation, which would prevent mental and emotional illness. That, of course, is no longer believed, but the practice of circumcision persists and has proven difficult to eradicate although progress is being made. The incidence of circumcision is declining in Western nations. The Department of Health of the Philippines is trying to discourage circumcision (called “tule”) in that nation where it has persisted.[28] The practice of neonatal circumcision in certain Western countries such as the United States does not constitute a valid reason for introducing neonatal circumcision in Botswana. Extreme care must be taken in a decision to introduce circumcision into a society. References (1) Kebaabetswe P, Lockman S, Mogwe S, et al. Male circumcision: an acceptable strategy for HIV prevention in Botwana. Sex Transm Inf 2003; 79: 214-219.
(27) Boyle GJ, Svoboda JS, Price CP, Turner JN. Circumcision of healthy boys: criminal assault? J Law Med 2000;301-10.
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Dennis C Harrison
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harrisond{at}telus.net Dennis C Harrison
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Dear Editor As a strategy for preventing sexually transmitted infections, surgical reduction of genital tissue has its drawbacks. Taylor et al. found that circumcision removes "an important component of the overall sensory mechanism of the human penis" [1] Winkelmann described the prepuce as a "specific erogenous zone".[2] Fink et al. found a statistically significant decrease in penile sensation following circumcision.[3] In any case, the evidence regarding the medical benefits of circumcision is conflicting. In a national probability sample of 1410 American men, Laumann et al. found that "circumcision provides no discernible prophylactic benefit and may in fact increase the likelihood of STD contraction."[4] Thus the depiction of male circumcision as an innocuous intervention with significant prophylactic benefits is open to question. Even if such benefits exist, controlling sexually transmitted infections by amputating erogenous zones is ethically problematic, especially when the recipients of such treatment are too young to give informed consent. References (1) Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996;77:291-295. (2) Winkelmann RK. The erogenous zones: their nerve supply and its significance. Mayo Clin Proc 1959;34:39-47. (3) Fink KS, Carson CC, DeVellis RF. Adult Circumcision Outcomes Study: Effect on Erectile Function, Penile Sensitivity, Sexual Activity and Satisfaction. J Urol 2002;167(5):2113-2116. |
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