Judy Mandelbaum

Judy Mandelbaum
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JULY 27, 2012 6:51AM

Africa's male circumcision crusade: Boon or boondoggle?

Rate: 12 Flag

 Circumcision

Ugandan government poster

Just imagine that a simple, harmless, one-time medical procedure could provide you, your loved ones, and all your neighbors with lifetime protection from a deadly epidemic. You’d sign up for it right away, wouldn’t you?

This is precisely what the World Health Organization, the Bill & Melinda Gates Foundation, and countless other NGOs and government programs are pushing on the continent of Africa: A comprehensive adult male circumcision campaign aimed at stemming the devastating HIV/AIDS epidemic. According to the WHO, “Medical male circumcision reduces the risk of female-to-male sexual transmission of HIV by approximately 60%.” Moreover,

Medical male circumcision offers excellent value for money in such settings. It saves costs by averting new HIV infections and reducing the number of people needing HIV treatment and care. A one-time intervention, medical male circumcision provides men life-long partial protection against HIV as well as other sexually transmitted infections.

Thanks to the WHO’s lobbying and financing efforts, countries across Africa are submitting thousands of their male citizens to the operation. Uganda, which has a 6.5% adult infection rate, launched a giant voluntary circumcision program in 2010. In June, 2012, ten Zimbabwean parliament members announced that they would undergo circumcision to set an example to the population as a whole. More than a million Zimbabweans are living with HIV/AIDS.

This is indeed marvelous news. The way Bill Gates and the WHO describe it, circumcision sounds like the greatest invention since penicillin. And yet the story does raise a question: Is it true? Does circumcision really reduce the transmission of HIV/AIDS, making it serve as a sort of invisible condom?

Stand proud 

In fact, the pro-circumcision consensus the WHO implies in its statements is largely imaginary. Medical experts the world over doubt the wisdom of the campaign, and some studies suggest it is actually counterproductive. In May of 2011, the Panos Eastern Africa NGO determined that misconceptions about the procedure – specifically the widespread notion that circumcision alone, without taking additional precautions, significantly protects people from HIV/AIDS – was actually encouraging the disease to spread in Uganda. In December of 2011, an article in the Australian Journal of Law and Medicine cited grave flaws in three studies supposedly proving the benefits of male circumcision in reducing the spread of HIV/AIDS in Africa: “The trials were compromised by inadequate equipoise; selection bias; inadequate blinding; problematic randomisation; trials stopped early with exaggerated treatment effects; and not investigating non-sexual transmission.”

Furthermore, the authors discovered that

In the Ugandan male-to-female trial, there appears to have been a 61% relative increase in HIV infection among female partners of HIV-positive circumcised men. Since male circumcision diverts resources from known preventive measures and increases risk-taking behaviours, any long-term benefit in reducing HIV transmission remains uncertain. 

There is also a concern that the procedure itself can spread the disease among participants and their sex partners if it is not performed under completely sterile conditions and combined with qualified followup care.

So is the Great African Male Circumcision Crusade a boon or a boondoggle? In order to cast some light on what appears to an extremely murky and emotional issue, I contacted Dr. Ronald Goldman of the Circumcision Resource Center in Boston to get some hard answers:

Dr. Goldman, a number of sub-Saharan African nations have begun a crash adult circumcision program aimed at drastically reducing the incidence of HIV/AIDS among their populations. Their leaders, encouraged by foreign governments and NGOs, have apparently convinced themselves that a circumcised penis is practically immune to the virus. What effect do you think the mass circumcision of African men will actually have on suppressing the illness?

Many professionals have questioned the reliability and validity of studies claiming that circumcision reduces HIV transmission. African national population surveys in eight countries found a higher rate of HIV infection among circumcised men compared to men who were not circumcised. There are at least 17 observational studies that have not found any benefit from male circumcision in reducing HIV transmission. Therefore, I do not expect a reduction in HIV transmission. It's even possible that the incidence of HIV transmission will increase because the mistaken belief of protection from circumcision will result in more risk-taking sexual behavior.

In the United States particularly, circumcision has long been regarded as a sort of “magic bullet” against disease and a host of other evils. Why do so many health professionals believe the procedure is so beneficial to society as a whole?

Actually, only a relatively few health professionals believe that circumcision has significant health benefits. Most doctors take a neutral approach to circumcision, following the recommendations of the American Academy of Pediatrics. The AAP is considered to be the highest authority on the subject, but their recommendations also have problems. For example, their current policy is not balanced and uses about ten times more space on the "potential benefits" than on the harm. In addition, there are many questions of harm that have not been studied. Because circumcision is common in the United States, there is a strong psychological motivation to believe it is harmless or beneficial.

 Stand proud.

Since circumcision is a religious duty among Jews and Muslims, do you see any religious ramifications to this policy? For example, could non-Muslims see it as a covert conversion campaign, or could the practitioners believe they are performing “God’s will”?

I don't think so. What is covert about the campaign is that circumcision is being promoted by circumcision advocates that have personal, religious, political, and financial conflicts of interest. They intended to find a benefit for circumcision, and they found it. As I have written elsewhere, there is a strong pro-circumcision bias among those who are circumcised, have circumcised sons, belong to circumcised groups, or have performed circumcisions.

What potential drawbacks or side effects do you anticipate from this wholesale circumcision campaign?

Many of the psychological, sexual, and social effects that I discuss in my book, Circumcision: The Hidden Trauma, could become more common as circumcision becomes more common. We expect that though men may choose circumcision now for themselves (based on misinformation about protection from HIV), the campaign is moving toward forcing circumcision on infants who will then have no choice. This is the source of the trauma. Imagine being forcefully held down and having the most sensitive parts of your genitals cut off. Trauma is remembered by the body and has long-term effects. Feelings, attitudes, and behaviors are affected. For example, some men are angry that they are circumcised. Other men are angry and don't know why. That repressed anger has many effects on their lives and the lives of others.

Condoms have proven to be vastly cheaper and far more effective than circumcision when it comes to reducing the spread of HIV/AIDS, and they also reliably prevent other sexually transmitted diseases as well as unwanted pregnancies. Why aren’t the UN and the Western nations showering Africa with condoms instead of removing men’s foreskins in what looks like an unprecedented social engineering experiment?

There is a lot of psychological motivation behind the advocacy of circumcision. Circumcision is traumatic. Psychologists know that there is a compulsion to repeat trauma on others. Some American circumcised men have placed themselves in administrative and research positions where they can act out this compulsion and influence many others to be circumcised. They are simply using the cultural beliefs and values (e.g, medical studies and authorities that claim that circumcision has benefits, etc.) to accomplish their goal.

 South Africa

From South Africa

As most people probably know by now, so-called female circumcision (a.k.a. female genital mutilation or FGM) is a much more radical procedure than the male version, frequently including the excision of the labia and even the clitoris. Do you see a possibility that government and NGO support for male circumcision could potentially water down campaigns targeting FGM?

I do not think so. I point out that the cutting of male and female genitals are qualitatively the same thing. The harm and violation start with the first cut.

If male circumcision is as harmful as you claim, does this mean that all male Jews and Muslims, not to mention tens of millions of Americans, are essentially “damaged goods” when compared to their non-circumcised contemporaries?

What circumcised cultures do not want to know is that a natural body part, in this case a penis, functions better than a surgically reduced one. We do not need studies to know this. It's just common sense. For example, if we cut off the thumb, the functions of the hand would be adversely affected. It's the same for the penis. Most American circumcised men (and doctors) do not know what they are missing. Based on recent reports, circumcision removes up to one-half of the erogenous tissue on the penile shaft, equivalent to approximately twelve square inches on an adult. Medical studies have shown that the foreskin protects the head of the penis, enhances sexual pleasure, and facilitates intercourse. Cutting off the foreskin removes several kinds of specialized nerves and results in thickening and progressive desensitization of the outer layer of the tip of the penis, particularly in older men.

The current African circumcision drive is being generously financed by the UN and WHO, foreign and national governments, and a variety of NGOs. It is big business for those involved and money, as they say, is the root of all evil. Would it be cynical to speak of a “circumcision-industrial complex” at work in Africa?

Certainly money is an important factor. An African official said, "Profiteering has trumped prevention." A WHO researcher said that billions of dollars have been wasted. The focus on circumcision reduces support for more effective measures.

 Swaziland

From Swaziland

Has anyone, aside from yourself and a handful of other circumcision skeptics, openly challenged the policy and called for resistance?

There are very reputable researchers who have been published in foreign medical journals because the peer reviewers for circumcision articles submitted to American medical journals are circumcision advocates. They will not approve of an article that is critical of circumcision. The review process is as deeply flawed as the studies that advocate circumcision.

There are other serious problems that prevent a fair and open debate. Circumcision advocates have access to much money, and American media, reflecting the pro-circumcision bias of the culture, routinely ignore stories critical of circumcision and focus on reports of circumcision "benefits." Journalist regularly violate their professional principles and obligations to report different views on this controversy.

 Botswana circumcision

From Botswana

Finally, circumcision advocates are afraid to debate circumcision critics. This shows up at professional conferences where critics are not provided equal opportunity to participate. The upcoming international AIDS conference will include a one-sided commercial for circumcision. The lack of debate is also apparent in the media. For example, two circumcision advocates refused to debate me on two radio talk shows.

If the circumcision program is indeed misguided, what alternative advice would you give to African governments seeking a viable solution to the HIV/AIDS crisis?

Most HIV infection in Africa are transmitted by contaminated injections and surgical procedures. The advice is simple: sterilize any instrument that will be used on a person's body. Condoms are better than 99% effective, less invasive, and the cost of one circumcision in Africa can pay for 3000 condoms. Unlike circumcision, condoms also have the advantage of also protecting women, and there are no surgical risks and complications. Even the pro-circumcision studies recommend using condoms in addition to circumcisions. With a condom, circumcision adds no significant additional protection value even if the advocates' protective claims for circumcision without condoms are true.

 

Ronald Goldman, Ph.D. is a psychological researcher, educator, and Executive Director of the Circumcision Resource Center in Boston, a nonprofit educational organization. Dr. Goldman is internationally known for his work on circumcision and is the author of Circumcision: The Hidden Trauma and Questioning Circumcision: A Jewish Perspective. He gives lectures on the psychosocial aspects of circumcision, counsels parents and circumcised men, and has participated in over two hundred interviews with broadcast and print media.

 

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I'd been wondering about this. Somehow it really did sound just a little too simple to be true. Can't say I'm surprised by the facts. It makes you seriously wonder what other boondoggles are underway in Africa and elsewhere. (I can think of a few.) Rated.
There should be a much bigger call for disclosure of everything involved in this and just about everything else done by these international organizations.

They claim to defend democracy yet they don't provide the people with the information they need to make decisions or make efforts to get the input from the public.
If Bill Gates were serious about ending in Africa, he would address the real problem - namely income inequality. All this other stuff he does - promoting circumcision, mass vaccinations and (God forbid) genetic engineering and geoengineering (i.e. chem trails) are all a smoke screen (excuse the pun) to distract us from the real problem - horrendous income inequality.
(I tried posting this earlier with supporting links, but it didn't go through, so I'm posting again without the links. Sorry if it appears twice.)

From a USAID report:
"There appears no clear pattern of association between male circumcision and HIV prevalence—in 8 of 18 countries with data, HIV prevalence is lower among circumcised men, while in the remaining 10 countries it is higher."

It seems highly unrealistic to expect that there will be no risk compensation. The South African National Communication Survey on HIV/AIDS, 2009 found that 15% of adults across age groups "believe that circumcised men do not need to use condoms".

It is unclear if circumcised men are more likely to infect women. The only ever randomized controlled trial into male-to-female transmission showed a 54% higher rate in the group where the men had been circumcised.

ABC (Abstinence, Being faithful, and especially Condoms) is the way forward. Promoting genital surgery seems likely to cost African lives rather than save them.
Maybe it is a typo, but does he really believe, "Most HIV infection in Africa are transmitted by contaminated injections and surgical procedures."? If he truly believes that, I might take his other ideas/research with a grain of salt.

I agree, it would be a huge mistake if the circumcised men would stop using condoms.

Those billboards seem misleading, because they almost make it sound like it is safe for the woman if her partner is circumcised.
Based on the studies done so far (which are being called into question here) circumcision seems to be protective for the men only. Maybe it is somewhat true in the sense that if your only partner is at a lower risk of getting HIV, you will be at lower risk too; but the actual risk of a female getting HIV from an HIV+ circumcised male vs. an HIV+ uncircumcised male has not shown to be significantly different in most studies. Females need their male partners use condoms, whether or not a male is circumcised. Males need to use condoms for their own protection, too.

I don't know about the politics, money, ideology, emotional, religious, psychological, etc., aspects of it--that part is very complex and hard to get a handle on--but I do agree if there is a circumcision billboard campaign, it would be less misleading and more informative to say "circumcision + condoms + serial monogamy + early treatment of genital rashes = better protection against HIV " or something to that effect. People need detailed enough information to be able to make good decisions for themselves.

Mechai Viravaidya had a lot of success reducing HIV in Thailand, with a comprehensive program of health care for everyone, first to decrease infant mortality, and subsequently family size, and later to tackle the HIV epidemic; very detailed, accessible, and widespread information about how to prevent the spread of HIV, involving schools, governement, media, etc.; condoms easily accessible to everyone; a campaign to decrease the widespread and very accepted practice of prostitution; decreasing sex tourism (which in Thailand was a significant part of the problem); and as Dr. Bramhall says above, finding ways of developing better economic opportunity for people. Maybe some of his ideas and methods would work in Sub-Saharan Africa, too.

Here is the point of view of the CDC on those studies done. Thanks for posting. It is a huge tragedy, and the more ways there are to tackle this epidemic, the better; but as you point out, it has to be done using methods and ways of communicating that have a real and positive impact on peoples' lives.
Good job bringing such a fine post. I hope that this moves things in the proper direction. Yes, I have read much information on this, which appears to mutate, rearrange the truth, to suit whatever purpose in coverage of Africa coming of age. You shed much light here. The very concerning cultural mess we see in the Sudan and other countries in Africa, is one of possible equivocation: the notorious female 'circumcision', which is in fact, more of a rite of mutilation, apparently a holdover to satisfy the elders in the community. Yikes! Thanks to new levels of awareness, this practice is under fresh scrutiny. We hope. It is a hideous morally bankrupt practice that is mindless in its continued enforcement. And they say that the West is corrupting their values?
Rated>>>>>>
Ron Goldman has thought deeply about brit milah and American routine infant circumcision for now about a quarter century. He is very knowledgeable. That said, I would not term him an "objective" participant in the debate that began with the 1980 publication of Edward Wallerstein's anti-circ monograph. In my view, there are no "objective" participants in that debate, because it is centered on the most sexual part of the male body, the tip of he penis. Circumcision cuts off moving and highly innervated male bits that interact richly with the vaginal wall during intercourse. Even if Freud was only 10% correct, it is probably impossible for humans to be dispassionate about circumcision. In my experience, women are somewhat more objective on average than men.

I agree that the African clinical trials that ground the claim that "circumcision is 60% effective against AIDS in Africa, by reducing female to male transmission," are flawed to the point of being fraudulent. The best academic critique of those trials is:
www.salem-news.com/fms/pdf/2011-12_JLM-Boyle-Hill.pdf

I agree that Africa needs industrial quantities of free condoms, not chopped foreskins. The phenomenon of people growing more careless when something comes along that reduces a risk, is called "risk compensation." It was first noted in a 1975 study that found that the introduction of seat belts in cars during the 1960s, reduced fatalities among car passengers, but increased the incidence of serious nonfatal car crashes, and car-pedestrian collisions. I predict that circumcised African men are about to give us a fine demonstration of risk compensation. Rick compensation would have been revealed if the African clinical trials had been allowed to run for at least 10 years, instead of 12-18 months.

American medical and sexual research has not avoided for 100 years looking for the possible long term adverse consequences of routine and ritual circumcision. This avoidance is blatantly irresponsible, given the ethical duty "first do no harm." All American medical schools teach about the foreskin is how to cut it off of babies. TV, newspapers, and mainstream book publishers have shunned the circumcision controversy for 30 years, presumably because they employ circumcised men, women with circumcised husbands, and do not wish to appear antisemitic. All this strongly colors any discussion of circumcision and AIDS in Africa.
Once again you broach a sensitive subject with total aplomb.

A friend of mine was advised by his doctor he needed circumcision to correct a problem he had. He was in his mid forties and never sought a second opinion.

His sex life was - in his words - wrecked. He told me the change was indescribable. This was more than one year after the procedure. Ample time for things to have settled down.

All forms of mutilation on both female's and male's whether it be on the genitalia or bones through the nose, rings on the neck bits of wood in the lips we all know them. Should be debated in the hope of getting beyond the dogma that enforces them.
Warmest Regards and thanks for the multitude of subjects you so cleverly expose to us all.
Mal
zachery,
I've been close to the foreign aid community for a long time, and this issue is really the tip of the iceberg when it comes to misguided strategies and lack of accountability. Thanks for the link!

Dr Stuart Jeanne,
Yes, this issue makes one wonder where Gates's priorities lie when it comes to the developing world.

Clay,
Thanks for the comparative perspective. I think one of the problems here is the way the hype around the procedure drowns out all the words of caution (e.g. that people should use condoms) that need to accompany it.

Another point that bothers me is that by suggesting that circumcision alone will do the trick, men need give no other thought to their sexual practices and their treatment of women. It seems to be shoring up a highly patriarchal sexual culture.

Roger and Mal,
Thanks, this issue has been on my mind for a long time and I'm glad it is receiving such a response.
I am astounded that this has taken off as a valid idea. When they 61% reduction, what do they compare it to? Foreskins do provide a pocket for bacteria, virus, fungus, and other organisms to thrive, but learning hygiene early in life can protect boys from yeast infection, which is also transmittable between partners. The belief that lack of a foreskin means you won't have infection will become the problem now.
HIV co-infection increases with HSV, HPV and other STDs because of more portals of entry into the skin. The more infections you have, the more likely you are to acquire or transmit HIV. This also includes a period of about 6-8 weeks after a circumcision, when the tissue of the penis is not fully healed, in which there is an actual INCREASED risk of acquiring or transmitting HIV through sexual contact.
The poster with the woman being proud of her circumcized husband helping reduce their risk of HIV is killing me. Not having sex with other people is what reduces your risk of HIV, and then using a condom if you do. I am saddened that millions of women will be again duped into thinking that expensive and dangerous campaigns like this will replace learning about the reality of infection and transmission. We already have a problem (in the US) with young men and women thinking they can't get pregnant (or cause pregnancy) or that anal sex is an appropriately safe way to avoid needing to use a condom to avoid pregnancy, or that they don't have any disease risk if they don't have any signs. In my experience with primary care, men only get treated for STDs when their penis is on fire, covered with spots, and half the time they refuse or delay testing, deny they had sex, and almost always blame their girlfriend. Many infections of HPV were unnoticed, and they can actually see the head of their penis. With women, many of them have no idea they have an infection, and cannot see their genitalia. Only when there is horrible pain do they suspect an STD, most of the time it is blamed on "yeast" and treated with OTC. It is very hard to get people to have their partners treated, because of fear of repercussions and violence. Now, men without a foreskin will get a free pass from scrutiny because they were "so brave" to take a stand.
Rated...The science is way over my head, but the claims do seem inflated at best. Some of your source's remarks about the medical procedure also seem excessive, in light of the long history in North America. This should be an issue at the State Department.