The Circumcision by Barent Fabritius
Should you or your boy-infant get circumcised?
Published: Aug. 11, 2011, 1:45 p.m., Last updated: Aug. 12, 2011, 6:23 p.m.
What are the benefits, risks and ethics of circumcision? These are important questions to answer for South Africa, where the government is implementing a large circumcision programme to reduce new HIV infections.
Unfortunately the discussion on this topic in the media and even at AIDS conferences is often poor, characterised by myths, misconceptions and hysteria. This article is a little different from the usual Quackdown articles in that I will not name the social scientist researchers and journalists talking nonsense. I will not directly expose the silliness of their arguments. Instead, I try to provide the essential information that can help guide men in their decision whether or not to have a circumcision and parents in their decision whether or not to circumcise their infant boys.
Please use the comments for this article to ask questions about circumcision. I will try to answer them.
How should a circumcision be conducted?
Circumcision should always be done under hygienic conditions by a trained expert. It should only be performed on males. In the case of infants, it should never be done without parental or guardian consent and in the case of anyone older than an infant, it must be voluntary. Coercive circumcisions are unacceptable and should be punishable by law.
At present only standard surgical methods should be used for circumcisions, including infant circumcisions. (The exception to this is if you are participating in an approved, ethically conducted trial to test a new device.) The most commonly used method for adults is forceps-guided surgery. Several circumcision devices are currently being tested in trials and some of them are being promoted even though the outcomes of these trials have not been published. The verdict is still out on these devices and they should not be used in adult circumcision programmes at present. Frankly, given the excellent safety record and efficiency of the forceps-guided method, the potential advantages of a device are unclear. Some people argue they will be useful in rural areas where surgical circumcisions in hygienic conditions are difficult to carry out. But I am unconvinced that devices will overcome the particular problems of rural areas. If there is no decent hospital nearby, I would recommend against carrying out a circumcision in such a place, just in case there is a complication.
When all the above conditions are met, circumcisions are incredibly safe. I am on the scientific committee for the ANRS (the French equivalent of the South African Medical Research Council) sponsored circumcision project in Orange Farm, near Johannesburg. Over the last decade, about 25,000 circumcisions have been carried out. Not one permanent injury or life-threatening event has occurred. Ten people were hospitalised, but in all cases their problems were resolved. The adverse event rate has been about 2%. Most adverse events have involved excessive bleeding. These have all resolved. The vast majority of participants have reported satisfaction with their circumcisions. One of the main reasons why young men in Orange Farm report why they are getting circumcised is that their girlfriends encourage it.
Who will benefit from a circumcision?
Circumcision has several health benefits. It removes the risk of phimosis (inability to retract the foreskin, which can be painful). It definitively reduces the risk of contracting human pappiloma virus and herpes simplex virus-2. It probably reduces the risk of contracting penile cancer. There is also some evidence that it reduces the risk of contracting genital ulcers.
But were it not for the HIV epidemic, I would not actively encourage circumcision. However, the evidence that circumcision reduces the risk of a sexually active heterosexual man contracting HIV is beyond reasonable doubt. I am willing to discuss the ethics of circumcision, about which there are complex questions. But people who dispute the current overwhelming scientific evidence of circumcision's efficacy at reducing the risk of contracting HIV are peddling pseudoscience.
In the early 2000s, studies such as this one showed a strong association between circumcision and reduced risk of HIV infection in Sub-Saharan Africa. An association does not imply cause, but it is suggestive. So scientists decided to test whether circumcision indeed reduces the risk of HIV. Three clinical trials were conducted in South Africa, Kenya and Uganda. In all three trials, volunteers were HIV-negative uncircumcised men. Half the participants were randomly selected to be circumcised. The results in all three trials were similar. The relative risk of contracting HIV was less than half in the circumcised men. This really seals the argument that circumcision reduces the risk of heterosexual men contracting HIV. Unfortunately, studies in men who have sex with men have not found a reduction.
We can be confident in the results of these trials because they were all conducted by different teams, but yet showed similar results. Critically, the randomisation in clinical trials removes all confounding factors that the previous studies suffered from, such as religious background and sexual practices. So we can be very confident that their findings are showing a real effect.
There's more good news. The benefit lasts. A follow-up study in Kenya showed that the protective effect was over 60% more than four years after the circumcision.
One of the concerns expressed about circumcision is that after it is done, men would dispense with condoms, undo its effects and put women at greater risk. The fancy term for this is "risk compensation behaviour". But a follow-up study in Orange Farm shows that there is no evidence that this happens. On the contrary, as in Kenya, this study showed that the effect of circumcision on HIV reduction does not diminish; circumcised people were about 75% less likely to contract HIV.
Circumcision works because the foreskin has a high density of immune cells, called Langerhans cells, that HIV can attach to. The foreskin also covers the tip of the penis, protecting it but at the same time leaving it more delicate than a circumcised penis and consequently more prone to microscopic wounds that allow the virus to penetrate the body.
Circumcision is an affordable once off intervention that reduces the risk of HIV infection both in the short and long-term. Currently, there is no other HIV prevention mechanism with these particular advantages. It should be part of a combination of health interventions offered by the state to reduce the number of new HIV infections. As many people have pointed out before, if a vaccine offered this kind of protection there would not be this kind of controversy and anxiety. Admittedly, an operation on the penis is more invasive and painful in the short-term than an injectable vaccine.
Should you get a circumcision?
I would recommend that you get circumcised if you meet all of the following criteria:
- You are HIV-negative.
- You are a sexually active heterosexual or bisexual man living in a high HIV prevalence area, like Southern Africa.
- You either have multiple partners, or you are not in a long-term relationship or you are not sure of your partner's HIV status or your partner has sex or might have sex with other people.
In South Africa, most adult males meet all of these criteria. It takes about four to six weeks for the circumcision wound to heal. You should try not to have sex during that time. Also, you need to continue using condoms, otherwise you really are likely to undo the benefits of the circumcision. The reality of course is that condoms are frequently not used, else we would not have an HIV epidemic.
What about boy infants
Whether or not to circumcise your boy child is an important decision for parents (or guardians). If this is a decision you or someone you know is considering now, I hope this article will help you or your friends make that decision, but the decision is yours and no one else's. If you do decide to get your child circumcised, please make sure it is done by a properly trained competent professional, even if it is a traditional or religious circumcision. Do not risk your child's health and happiness with a quack. I imagine you would only be considering the advice of this article if you are contemplating a circumcision to prevent HIV and not for religious or cultural reasons; in which case only consider a medical circumcision.
No randomised clinical trial has been conducted in boy infants to see if circumcision is effective at reducing their chance of contracting HIV in adult life. Such a trial would be impractical to carry out because it would have to run for at least 16 years. However, the randomised clinical trials in adults are evidence that the association between being circumcised and having a lower risk of HIV infection found by other studies is indeed a causal effect. There is also no known physiological reason why circumcision should be effective only if it is conducted on an adult. The studies in Kenya and Orange Farm show that the effect does not diminish after several years. Therefore, it is reasonable to conclude that circumcising a boy infant will reduce his risk of contracting HIV once he grows up and becomes a sexually active youth or adult.
An ethical argument offered against infant circumcision is that it denies the child the choice to make in later life. Circumcision is, after all, permanent. This is true, but parents have to make many choices for their children that cannot be undone in later life, including their education, their childhood diets and the religious and cultural institutions they get exposed to. These have much more profound effects on children than whether or not they get circumcised. The important consideration is that parents should not do anything that intentionally harms a child. But circumcision on balance almost always benefits children.
Another argument against infant circumcision is that there might be a cure for HIV by the time the infant becomes sexually active. We really have no idea if 15 or 16 years from now there will be a cure. There's certainly nothing close yet.
The big advantages to being circumcised as an infant are that it is easy to do and the child will not remember the pain. It is much more difficult for an adult man to take the decision to get circumcised.
Much of the opposition to infant circumcision seems to be misplaced outrage to me. Hundreds of millions of Muslim boys and many millions of Jewish boys are alive and circumcised today, with no recollection of their circumcision and no substantive reason to feel aggrieved for having had one. I went to a Jewish school. I do not recall any boys in my class ever being the slightest bit upset that we were circumcised.
A correction to this article was made on 12 August 2011. The word "adult" was inserted into this sentence: The verdict is still out on these devices and they should not be used in adult circumcision programmes at present. The reason for this correction is that it was brought to my attention that there are approved devices for infant circumcisions.
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Comments in chronological order (12 comments)
marcus.low wrote on 11 August 2011 at 2:53 p.m.:
Benjamin wrote on 11 August 2011 at 2:58 p.m.:
An interesting article, and I agree with your recommendation regarding circumcision in high risk HIV areas. However the studies say nothing about man to women infection. Reducing the % of men infected helps indirectly, but the most effective protection is still condoms, 85% (via wikipedia) reduction for everyone. Is the government pushing any sex ed programs?
Regarding infants, I think you should be able to show a clear good reason - I think there are some valid ones - but just because the child won't remember is not an argument.
Nathan Geffen wrote on 11 August 2011 at 5:44 p.m.:
Hi Benjamin
Condoms are a critical part of HIV prevention programmes. But the two interventions (circumcision and condoms) do not compete with each other; they are both important.
Government does indeed run programmes to promote condom use. Could they be better? Definitely. Does condom promotion actually increase condom use? The short answer is we don't know; there isn't enough evidence.
On infant circumcision, in my view that people have no memory of the pain associated with the circumcision is an important point. Men have told me how they wished they were circumcised as infants because they are too nervous to get circumcised now.
In any case, it's the parents' choice.
Kevin wrote on 11 August 2011 at 6:02 p.m.:
Thanks for the info Nathan. It isn't clear from the studies what, if any, intervention was involved with the control group - and whether there were any effects contributed purely by the interventionary nature of the circumcision itself?
After all: "have sex-life / remove foreskin, be sore for a while, use condoms for a while / continue sex-life" is quite dramatically different from "have sex-life / continue sex-life". Consider me a little more skeptical and needing a few longer and more serious studies.
But let's be honest as well - the reduction in incidence is not that fantastic - dropping from around 2.5% in the control to 1.2% in the circumcised group. I would have thought the comparative benefits to condom usage would far outweigh this? It 'seems' to me that there is much positive spin being put to this - and efforts could be put to simpler protective measures than enforced circumcision (as some countries apparently appear to be considering).
Also, conversations with other men on the subject suggest far more nonchalance about circumcision amongst Jewish and Moslem men. Generations of cultural enforcement would naturally make it harder to see the downsides. It would have been far more difficult for a non-circumcised boy of Jewish parents at a Jewish school.
'Cut' myself, my initial indifference about having my son circumcised is now replaced by horrified thought. I am very glad we didn't. I am saddened and angry at my parents for having done that to me - not giving me the choice; and I am similarly angered at having been forced to go to church and catechism. These are not things that should be thrust upon a child purely because a parent fancies it.
Vets are now legally prohibited from docking dogs' tails and ears - unless there is a seriously good reason for it. That is considered cruelty.
Benjamin wrote on 11 August 2011 at 8:20 p.m.:
Hi Nathan,
As I wrote, I agree with your advice. I just think condoms are more important, for everyone. Including circumcised men. They are more effective, and have been more convincingly tested. Over promoting circumcision may lead to higher infection, just because men are more careless. Promoting condoms is tricky, but marketing works. It is not a mysterious field, advertising is well established to work, if done well. That, and a comprehensive sex ed program for children, which has also been shown to work in a multitude of different countries to reduce risky sexual behaviour.
Re: Infant circumcision, no you still need to justify causing pain to a child, even if that child won't remember it. If you have a good reason, then the fact that the child won't remember is then a good reason to do it rather earlier than later. Parents have this right, but should they? If there are good reasons sure, otherwise, no. You cannot cause harm to a child just because it is yours, it has no lasting effect, and it won't remember. I mean what would you say to a parent who thought a light beating every morning would toughen the kid up? Justifiable up to a certain age because it wouldn't remember?
Marcus wrote on 11 August 2011 at 11:04 p.m.:
Kevin. I respect that you feel the way you do. I again regret that my parents didn't have me circumcised as an infant. Of course, they are not from a culture where circumcision is traditional and they wouldn't have been aware of the health benefits - so i can't blame them.
As for your concerns about the trials, i'm sured they would be allayed if you read through the actual studies. The combined effect found in these trials are pretty indisputable. These were very well powered trials and as Nathan explained, confounding factors were well controlled for. I agree that relative risk reduction figures can some times be used in a misleading way, but i don't think it is in this case. The protective effect is clearly very big and waiting for even more evidence would be both pointless and harmful. HIV incidence is still shockingly high and we need to use all the tools we have..
Benjamin. I find it strange that you still choose to compare circumcision to condom use. Both should be available. It is not in any way an either or situation. It is however worth pointing out that the two interventions offer different advantages. e.g. while condom-use provides greater protection, it is a continuous intervention that requires both discipline and a supply of condoms. It seems only reasonable to supplement this with the additional protection from circumcision - which is a once-off procedure with lasting benefits.
Also, an interesting aspect of the recently announced Orange Farm findings was that their was no evidence that circumcised men were more "careless" - as you put it. Some people have been making a lot of noise about the possibility of this kind of risk compensation, but the evidence just doesn't bear it out.
Nathan Geffen wrote on 12 August 2011 at 12:16 a.m.:
Hi Kevin
The protocols stipulated that all the men in the three clinical trials were followed up at the same intervals and given the same counselling, irrespective of whether they were randomised to be circumcised or not. The Orange Farm study in PLoS Medicine states, "To ensure blinding of study personnel, the randomization group information was not available to the personnel in charge of counselling or collecting information in the centre during the participants' visits."
Obviously a circumcision study can never be properly blinded, but clearly there was great effort by the trial investigators to treat volunteers in both arms the same.
(I corrected an inaccuracy in this comment on 13 August.)
An analysis of the three circumcision trials shows that the infection rate in the circumcised arms was no less -and quite possibly higher- during the wound healing period. The implication of this is that the argument that the circumcision arms had lower infection rates because people had less sex during the wound healing period is untenable.
Also, I should have included a reference to the Cochrane Review in the main article.
Nathan Geffen wrote on 12 August 2011 at 12:27 a.m.:
This quote from the Orange Farm study describes what all study volunteers received (irrespective of whether randomised to be circumcised):
"The counselling session (15–20 min) was delivered by a certified counsellor and focused on information about STIs in general and HIV in particular and on how to prevent the risk of infection. During this session, participants were encouraged to attend voluntary counselling and testing in a public clinic located 200 m away from the investigation centre or in a voluntary counselling and testing (VCT) centre funded by the project and located in the same building as the investigation centre. Condoms were provided in the waiting room of the investigation centre and were also provided by the counsellor. Participants who had symptoms of STIs, as assessed by the nurse during the genital examination, or who tested positive for syphilis were treated at the local clinic or by doctors working for the project. A specific programme for prevention of opportunistic infections and delivery of antiretroviral treatment, if required, was put in place at the VCT centre to assist participants who attended VCT and who tested positive for HIV."
Benjamin wrote on 13 August 2011 at 8:49 a.m.:
Re:Marcus
I agree both should be available, and with Nathan's post. My point was your point, it is not an either or. If you are having (risky) sex you should be using a condom, circumcised or not. I agree with you that circumcision helps, just trying to point out that it isn't a solution.
Nathan Geffen wrote on 13 August 2011 at 9:14 a.m.:
Hi Kevin
I'll try to address some of your points.
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On infant circumcision, I think we simply have a difference of values here. While scientific findings might strengthen our positions one way or another, science is unlikely to resolve the disagreement. I assume though that you accept that properly informed adult males have the right to make a choice about whether or not to have a circumcision?
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The lifetime risk of a male in South Africa contracting HIV is about 40%. If the circumcision effect is durable -- the available evidence indicates it is-- then the risk reduction benefit is very substantial and not just the small drop in risk given by the incidence figures you've quoted, which are over a much shorter period than a lifetime.
Kevin wrote on 16 August 2011 at 10:25 a.m.:
Thanks Nathan,
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Difference of values - yes. Agreed, science is not likely to resolve that. Agreed, informed adult males absolutely have the right to make their own choice. Perhaps you need to be clearer about separating the science from your own moral judgements though. Is it "misplaced outrage" when it comes to objecting to docking tails and ears of dogs? This is a completely different debate, but it is hard to separate the science from the moral values when it is about something so close to my hand ;-) You chose to enter that debate though in a way that to me does not display the same depth of thought. To me there is an unclear distinction between the acceptability of circumcision for religious or 'normative' purposes (so he looks like his father and cousins) and the acceptability of FGM? I hear similar arguments from the proponents of each. Please note: I am not trying to equate the two - FGM is far more barbaric, the loss of a foreskin is nowhere near as objectionable.
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"If ... is durable". That I guess is my point, the length of these studies is nowhere near the lifetime of a man - projecting that far out may be more problematic. Don't get me wrong - I'm not knocking the science or the obviously measurable positive effect; I just think there has been far too much spin on this which is not yet backed up by the science. Based on these studies some are wanting to implement enforced circumcision. But let me ask you this: if you had a limited pot of money for HIV/Aids prevention, based on this research, what percentage of that money would you direct to a volunary cicumcision program, and what percentage to ABC?
Nathan Geffen wrote on 16 August 2011 at 11:30 a.m.:
Hi Kevin
I'm just going to stick to the science/health policy questions.
You ask:
If you had a limited pot of money for HIV/Aids prevention, based on this research, what percentage of that money would you direct to a volunary cicumcision program, and what percentage to ABC?
I can't give detailed specifics because this is a highly technical question dependent on costing exercises, but I will try to give an answer about what to do in principle.
There is in fact a limited pot of money for HIV/AIDS. It is however not so limited that we are faced with a choice between either public information programmes, like Abstain, Be Faithful, Condomise (ABC) or circumcision, or severely limiting the one or the other.
Nevertheless the evidence supporting the effectiveness of ABC in South Africa and elsewhere is very limited and disputed. We have spent billions of rands on behavioural change public information programmes with very little to show for it.
Incidentally, it's important to separate the ABC programme from the condom distribution programme. Condoms work if they are used consistently. We don't know what if any benefit has been derived from the ABC public information programme.
There should be some kind of scientific evaluation of the efficacy of ABC and if it is found ineffective or only a little bit effective, we should re-evaluate how much we spend on it and what a good public information programme requires.
On the other hand, distributing condoms across the counry is something that should continue and even be stepped up.
So should the circumcision rollout (and you agree with me with regard to adults).
I'm pretty confident we can meet the need for both circumcision and condoms. Neither are budget-breaking. PEPFAR is prepared to cover the cost of circumcision incidentally, but if we can pay for it out from SARS revenue we should.
There's enough money for a public information programme too, but only if it's really useful.
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Thanks for a very clear and very sound article Nathan.
I think it is worth pointing out that voluntary medical male circumcision programmes for men are likely to offer very substantial indirect benefits to women as well. If HIV infection is reduced by 60% in men, infection rates in women will also be reduced since most HIV transmission is heterosexual.