I’ve been involved in many heated discussions on Twitter. The funniest thing, though, is the MOST heated discussions have always been with fellow atheists, on a single topic- Male circumcision.
“No, Mel! Don’t! Don’t go there, please!!!”
I understand this is a controversial topic. I understand it is an emotional topic. But I’ve seen far too many otherwise rational people attack me for my stance on circumcision, without knowing 1) What my stance actually is, and 2) WHY that is my opinion. Never in my life have so many people put so many ridiculous words in my mouth… such as “Oh, so you think it’s ok to mutilate a boy’s penis without his consent?” or “Oh, I guess we should all cut our tits off to avoid breast cancer!” (which some people do, when at high risk, by the way… *cough* Angelina Jolie *cough*)
So, here I am, to clear it up, hopefully once and for all.
Before I begin, let me be very, very clear: I have not, ever, said that I support infant male circumcision. I refuse to discuss infant circumcision because it is far too emotional. Everything I discuss with respect to circumcision is done with respect to adult men who have consented to having the procedure done. So don’t ask me about infant circumcision. I won’t discuss it.
Male circumcision and HIV
Whenever I bring up this topic, I am immediately met with anger and mockery, and any actual facts I bring to the table are shot down without a second thought. Why? I think I’m beginning to understand. So many people have so many varied issues with INFANT circumcision that any potential benefit of any circumcision must be treated with suspicion. Well, I’m here to tell you that I think that opinion is very unfair. To dismiss an important finding like this based on your opinion of circumcision, without even being willing to hear the data, is a bit ridiculous. So, what’s the evidence, you ask? Let me share it with you.
Several studies have found a link between male circumcision and a reduced risk of becoming infected with HIV-1. Initially, these studies were observational, and a meta analysis (combined statistics done on several similar studies) showed a protective effect of male circumcision. Of course, observational studies do not provide a CAUSAL link; in other words, though there was an association between male circumcision and HIV infection, it was not possible from these studies to say that one is necessarily causing the other. This led to 3 randomized circumcision trials- one in Kisumu, Kenya (http://www.ncbi.nlm.nih.gov/pubmed/17321310), one in Rakai, Uganda (http://www.ncbi.nlm.nih.gov/pubmed/17321311) and another in South Africa (http://www.ncbi.nlm.nih.gov/pubmed/16231970). Each of these studies showed between 50-60% reduction in HIV infection in the circumcised males.
For a more in depth discussion, I typically cite the study done in Kisumu, Kenya, as it was conducted by colleagues of my research group, and I’ve had the pleasure of discussing the results of this trial at length with one of the authors of the study. I suggest you read the articles yourself if you’re interested- but I can assure you, they were all very well conducted studies, in a large enough sample population to have enough power to be statistically valid. Counselling, testing, and condoms were provided to both the men who were circumcised, and those who were not. Here are some important issues that have come up….
1) Oh, they probably just used condoms/riskier behaviours/some other thing unrelated to circumcision status!
In these studies, as with ANY study on HIV, behavioural characteristics were very closely evaluated. Condom use, having sex with men, number of partners, condom use with last partner, concurrent sexually transmitted infections (Chlamydia/gonorrhoea etc) were all accounted for. These factors can be assessed and put into something called “multivariate analysis”, to eliminate the possibility that “something else” is having the effect we think circumcision is. Also, as this was a randomized study, many of those variables would be evenly distributed between the circumcision/non circumcision arms. At any rate, the point is that these factors were ALL considered in the analysis, and circumcision was still found to be the reason for the lowered risk of HIV.
2) That’s dumb. Just use condoms!
Yes, thank you. Condoms are an EXTREMELY effective way to prevent HIV- 99% when used properly. Of course… if people used condoms, HIV wouldn’t be an issue, would it? As with any HIV study, the participants are ALWAYS educated on condom use and why its important. These people are living in countries where 6-30% of the adult population are infected with HIV. They know about HIV. The vast majority know someone who has been infected or died. HIV has become such a normal part of their world that most of the time (in my opinion) they are too desensitized to it to be interested in using condoms. Is this ridiculous? Of course. But men don’t like condoms. Many people in these countries view condom use as something only done if you’re having an affair- why use them in a stable partnership? Even if one or both partners have other sexual partners on the side, using condoms would be a signal that they are unfaithful. This is not acceptable to them. You may say “if they won’t use condoms, how on earth do you get them to be CIRCUMCISED?” That’s a fair question that I don’t have an answer to. But when men were told they’d lower their risk of HIV by being circumcised, they lined up around the block to be involved.
3) If circumcision reduces HIV, why is there still HIV in places like the USA where circumcision rates are so high?
This line of reasoning ignores a VERY important point with respect to circumcision. Circumcision is effective in preventing female to male transmission of HIV. There are no studies which show a protective effect in men who have sex with men (MSM) or, obviously, injection drug users (IDU). MSM and IDU are the MAIN modes of transmission in the majority of the developed world, which is why circumcision doesn’t seem to have an effect.
4) No studies have been done in the US/Canada/Europe! THIS CAN’T BE REAL!
There are several very good reasons this has not been replicated outside of sub-Saharan Africa. The rates of HIV are simply too low in other parts of the world for trials like this to be feasible. In order to actually see any impact, the number of men who would need to be enrolled would be outrageous to power the study to be statistically significant. The rates are just too low. Furthermore, as I pointed out already, transmission is not typically through heterosexual sex in these populations- which is the mode in which circumcision is protective.
5) These studies ended early! People dropped out! They CAN’T be right!
Yes, all 3 studies were ended early- because at an interim review of results, the effect on reduction of HIV was found to be too strong to ethically continue. In other words- the intervention worked, very well, and it was then thought to be ethically unsound to continue the trial (ie, to not allow the “uncircumcised” men to be circumcised would be unethical, knowing it was so protective). This is very typical in trials of this type- to be ended early either because they are not effective, or because they are VERY effective. Also very typical of large trials is something called “loss to follow up”. In any trial, many participants will drop out. They move, die, don’t want to continue, refuse to be tested or take their medications… any number of things. That is extremely common and does not, in any way, reduce the validity of these studies.
6) Well female circumcision also shows a protective effect!
NO. It absolutely does not. There was one study conducted in the early 90′s that showed, through univariate analysis, that women who were circumcised were at a lower risk of contracting HIV-2. HOWEVER (this is very important, please listen!), upon MULTIVARIATE analysis, this effect was lost. This means (and the study authors confirm it in their conclusions), that the reduction in HIV-2 acquisition was due to some other confounding factor, and NOT due to clitoral excision.
So, there you are. I hope this has cleared up a few things. First, what the link between HIV and circumcision is, and second, that admitting this link is real doesn’t immediately mean one supports infant circumcision. There’s just no reason to argue so hard against good, sound science because you don’t like circumcision. This is a great victory in HIV research that should be supported, not ignored. Believe whatever you want about circumcision- but this link is real. There’s nothing wrong with accepting it.