Circumcision and sexual injuries

A study called Circumcision and Reduced Risk of Self-Reported Penile Coital Injuries published in the Journal of Urology recently looks at whether circumcision reduces the incidence of injuries to the penis during sex, which may increase the risk of HIV infection. It found that the incidence of injury was less in circumcised than uncircumcised men.


Between 2002 and 2005, 2,784 men aged between 18 and 24 in Kisumu, Kenya were randomized into two groups, immediate circumcision and delayed circumcision after two years.

Injuries were classified as 1) penis feels sore during sex 2) penis gets cuts, scratches or abrasions during sex and 3) penis bleeds after sex. At the start of the two-year period, 64.4% of the men reported injuries and 10.5% reported all three. Having two or more sex partners in the last 30 days, applying substances to the penis before sex and having ulcers increased the risk of injury. Increased age was associated with increased risk, possibly because of 'a broader range of sexual practises'.

Any conclusion that circumcision in itself reduces injury risk is not substantiated by the research, however.

Both groups had intensive STI and HIV risk reduction counseling and were provided with unlimited free condoms. The prevalance of STIs decreased, condom use increased and reporting multiple sex partners decreased. After two years, it was found that circumcision, condom use, being married or living with a partner and cleaning the penis within one hour of sex reduced injury.

At the beginning, the 64.4% reporting injuries split into 65.1% of circumcised and 60% of uncircumcised men. After two years, 31% of circumcised men and 42.8% of uncircumcised still reported injuries.

A few points:

The incidence of injury was almost the same in circumcised and uncircumcised men at the start of the trial which would suggest that it was something else that happened during the trial that caused the reduction.


The groups were not divided into men having sex with men and with women. The assumption is that all of the men's partners were female.


Injuries and sexual practices were self-reported. The types of sexual practice were not recorded. There was no enquiry into why injuries were so high to begin with or how conselling may have influenced sexual practices - or the self-reporting of them - although the conclusion admits the need to verify the injuries and questions whether familiarity with study questions may have had an influence. Why the injuries were not verified during a trial based on counting them and why familiarity was not factored in at the start are not clear if they were going to undermine the findings. It is also not possible to separate out the effects of counselling and condoms.

50% of circumcised men reporting injuries at the start were still reporting injuries at the end of the trial which suggests that other factors are involved in injury reduction.


There's a bit of an anomaly in the table showing condom use. At the start of the trial, 1010 men hadn't used condoms at their last sexual encounter; by the end of the trial, this had fallen to 259. However, 765 had used a condom the last time they had sex but two years later, this number had fallen to 275 so overall, the number of men using condoms had fallen.

Another point the research raises is that 'the high frequency of coital injuries in uncircumcised men could place sex partners of HIV positive uncircumcised men at greater risk for HIV acquisition'. However, even if circumcision does protect men, there is no good evidence yet that it helps prevent transmission from HIV positive men to women. A trial in Uganda reported in The Lancet found that rates of transmission to women increased with circumcised men. The trial had to be abandoned for ethical reasons.

The research concludes that 'circumcision, condom use and penile hygiene provided protection against reported penile coital injuries. (...) The mechanisms by which circumcision confers protection against penile coital injuries remains unknown'.

It also states that 'recent circumcision did not increase penile coital injury risk' and this is about all that it can be said to have found. Condoms, reducing the number of partners, counselling and washing are all said to reduce injury but circumcision in itself has not been demonstrated to do so independently of these other factors. Too many variables.

Evidence against circumcision for HIV prevention and the risks involved here, here and here.

UPDATE: An interesting comment on this article from Lay Science:
The big drop in injuries for both groups after six months in the study is a sign of the Hawthorne Effect - just going in a study makes a difference. The difference between the two groups after that has been excluded is relatively small.

They don't seem to mention the commonest penile injury to intact men, torn frenulum ("banjo string"). This usually happens once in a lifetime, if at all. It is hardly surprising if having a sensitive moving part on one's penis might make it (slightly) more prone to injury. Circumcision as a way to reduce penile injuries is not indicated.

This is only the latest in a steady stream of papers originating from the same few researchers (Daniel Halperin, Robert Bailey, Ronald Gray, Stefan Bailis, Stephen Moses, Malcolm Potts, Thomas Quinn, Maria Wawer, Helen Weiss, Brian Morris, Jeffrey Klausner, Edgar Schoen and Thomas Wiswell - in this case, Bailey) claiming to show that circumcision is good for everything and harms nothing. I wouldn’t call it a “conspiracy”, but many of them have authored papers jointly, and their common interest seems to be in promoting circumcision, rather than any particular benefit.

Circumcision and HIV/AIDS: UPDATES

Rather than lots of short posts with updates and additional information, this post will collect them all together.

July 5 2009

The debate continues with two pieces in the Observer today, both by the same journalist, Alex Renton. They are both strongly pro-circumcision and, although detailed, don't look at the case against. Renton is a food journalist.

July 16 2009

A piece on the BBC website about how research from John Hopkins School of Public Health found that circumcision does not prevent HIV positive men transmitting  the virus to women:

"Circumcision of HIV-infected men did not reduce HIV transmission to female partners over 24 months; longer-term effects could not be assessed."

The trial was stopped because of the rates of infection. However, they continue to recommend circumcision, in conjunction with condom use. They suggest both circumcising earlier (ie circumcising boys)  and continuing to circumcise HIV positive men in order not to stigmatize them.

"Women are disproportionately affected by HIV in sub-Saharan Africa, and - as this study shows - will still be at risk whether their partners are circumcised or not (...) The best way to guard against HIV is by always using a condom".

July 20

The link to the source article for the BBC story above, in The Lancet .

Circumcision and HIV/AIDS: 2

Ritual circumcision is a different area but its practice in South Africa, for example, has important ramifications for the promotion of circumcision as an HIV/AIDS prophylactic.

 This story was in the news this week:

 Eight boys have died and three are in hospital after botched circumcisions in the South African province of Mpumalanga, officials say. The teenagers were at an initiation school in the town of Kwamhlanga. One of the initiates died in hospital and the seven others were found by health officials dead at the school.

These circumcisions were done as part of a widespread traditional rite of passage for boys before they can be considered men and play a full adult role in their community.

 There are two separate issues here, the ethical/moral and the medical.

Commenting on another culture’s traditions has become taboo in some circles thanks to Post Modernism and cultural relativity where one culture may not be judgmental of another, especially if it’s a Western culture commenting on a Third World one. This is seen as a kind of cultural imperialist invasion or at best patronizing and ignorant. Just because something is considered wrong in one culture doesn’t mean it’s wrong for another. Everyone’s traditions and beliefs should be respected because there are no absolutes.

 The question of whether it is a cultural crime to raise ethical and Human Rights objections to children being mutilated without their consent, putting their health and sometimes their lives at risk is not the subject of this current post. But the serious implications for HIV/AIDS prevention is germane.

 The South African Government recognizes the health risk of ritual cutting; in 2001 it passed an act (The Application of Health Standards in Traditional Circumcision Act) requiring a license from a medical officer for each (male) circumcision. But the act seems to be having little effect. In July last year, 15 boys died and 90 were taken to hospital after botched circumcisions. The main causes of death and hospitalisation are blood loss and dehydration.

 Despite the Government’s attempts, community leaders are resisting medical supervision and licensing because, as they said, this ‘infringed community rights’.  Protecting children’s lives is apparently less important than protecting beliefs.

Researchers found that ‘in general, communities considered morbidity and mortality as par for the course. Interviewers were told that "deaths and injury were seen as a way of separating out those boys who were not fit to play the role of men in society." Compounding this 'natural selection' technique, another popular belief is that if an initiate suffers medical complications, he has brought it upon himself through some form of wrong doing, and is therefore being punished.

 There may be cultural resistance to condom use – albeit a different kind of resistance, based on male preference rather than ancient tradition – but overcoming entrenched beliefs about who has the right to cut boys and in what context (ritual rather than clinical) makes it difficult to see how an initiative to encourage it as a preventive will work in areas where it is seen as belonging to cultural practice, a ritual based on a belief that may not be invaded by science – even in the minimal form of sterile conditions and instruments.

 Moreover, some research has found that ritual cutting can increase infection rates:

Traditionally an assegaai is used. Implements may be blunt or reused. This practice has been implicated in the spread of blood-borne infections, such as Tetanus, Hepatitis B and STDs, including HIV/AIDS (source as above).

 In addition, one researcher has revealed a further problem:

 Of late, the practice has degenerated into a money-making operation. People pay as much as R400 per boy for the attendance of (circumcision) schools. The schools are launched annually at some localities (as opposed to the old tradition of every five years) (as above).

 Illegal procedures will prove even harder to monitor and medicalise.

 Even if it were possible to tap into an existing culture of circumcision to use it as a preventive, research done in South Africa and published in the South African Medical Journal states that:

 It is, however, questionable how circumcision, and particularly neonatal circumcision, could achieve such a goal. A rational and critical analysis of the scientific evidence ought to conclude that non-therapeutic infant circumcision is merely the medicalisation of an old ritual that should not, in the 21st century, be advocated as prevention strategy for HIV/AIDS. (my underlining)

 This whole article is worth reading.

 The evidence against circumcision is stacking up. The statistics do not show that it is an effective protection. Ritual circumcision is likely to prove an obstacle to (the alleged benefits of) medical prophylaxis and may also worsen the problem.

Finally, some further information from this article to add to last week’s post about the situation in America, the country behind PEPFAR, a major partnership initiative to promote preventive circumcision in America.

 Teens 15 years and older in the USA have the highest rate of STDs in any industrialised country and half will contract a sexually transmitted disease by age 25, despite two-thirds of young males having been circumcised. Such reports suggest that the social experiment of circumcision to prevent STDs, including HIV, has already failed in the USA, which has the highest rate of non-therapeutic infant circumcision in industrialised countries and the highest rate of HIV in the developed world.

 The call for neonatal non-therapeutic circumcision for prevention of HIV by some members of the Catholic Church suggests misunderstanding of the local context, and supporting genital surgery on newborn boys but discouraging the more effective preventive measure of condom use lacks logic.

 Of course, it is not just the Catholic Church and Catholic organisations that are anti-condom (and often pro-abstinence), there are other religiously-inspired organizations promoting circumcision as the list of PEPFAR partners discussed in the previous post shows.

 

 

Circumcision and HIV/AIDS

An article in the Independent on May 19 2009 reports that:

'Three landmark randomised controlled trials conducted in South Africa, Kenya and Uganda between 2005 and 2007 demonstrated that adult male circumcision reduced the risk of contracting HIV by 50 to 60 per cent'.

 It opens with the assertion that:

'New evidence suggests removal of the foreskin can protect not just against HIV, but other diseases that kill millions. Now some doctors are reconsidering their views on an ancient and controversial procedure'.

 What exactly are (or should be) doctors considering? Is circumcision the best option worldwide for HIV/AIDS prevention and why is it being promoted above condom use? Currently, around 30 per cent of males worldwide are circumcised, but this is done mostly for religious and cultural reasons rather than medical ones.

 I discussed this with Dr. Antony Lempert of the Secular Medical Forum who pointed out that interpretation of this latest research has to be tempered by the fact that the Cochrane collaboration who reported on these trials stated that the risk of bias is very high.

 Moreover, the mechanism by which circumcision may work is not even known yet. The New England Journal of Medicine (NEMJ) report, from which the Independent article is drawn, reports: ‘How circumcision prevents HIV transmission is not completely understood, but scientists believe that the foreskin acts as a reservoir for HIV-containing secretions, increasing the contact time between the virus and target cells lining the foreskin's inner mucosa’.

Even if the research can be shown to be good and that circumcision does reduce the transmission of HIV/AIDS, it still only brings the risk down to around 50:50 and it does not tackle the whole problem of sexually transmitted infections (STIs). According to the article, there is some emerging evidence that circumcision also reduces infection with Human Papilloma Virus (HPV) by 35% and Herpes Simplex (HSV) by 25% but again, these are not persuasive percentages when compared with condom use.

In fact, it may worsen the problem as men who have been circumcised see the operation as a licence to ride bareback, thus spreading other STIs and, of course, causing unwanted pregnancies. In fact, they may ask what is the point of being circumcised if you still have to wear a condom. Many men are not keen to use condoms as they reduce sensitivity so it is hard to see why they would opt for an operation that reduces it permanently.

 Although HIV/AIDS is the most serious of STIs, chlamidia and gonorrhoea are not without long-term risks if undiagnosed or untreated, which could be the case in remote, rural or some highly religious communities in the developing world (the jury is still out on the effectiveness of circumcision against syphilis).

 Who will benefit even from the 50:50? The NEMJ report also says: ‘Reaching women through other prevention methods is important because there is no direct evidence to date that circumcision reduces the risk of transmission from men to women.’

 In addition, the new research looks only at adult men having sex with women, not at the long-term effect on boys or men having sex with men.

In fact, the Independent article quotes Professor Terence Stephenson (President of the Royal College of Paediatrics and Child Health), who says that there is ‘no evidence that circumcision is protective in men who have sex with men’.

The risks of adult circumcision are small but not negligible, especially if they are not carried out in sterile circumstances. One recent report indicated that severe complications developed in 18% of men, and 6% had permanent adverse sequelae including mutilation of the glans, excessive scarring, and erectile dysfunction. (NEMJ).

So adult male circumcision doesn’t appear to protect women or men having sex with men. With such scanty evidence in favour, who is promoting adult male circumcision, particularly in Africa?

One of the largest bodies is PEPFAR, the US President's Emergency Plan for AIDS Relief who are ‘working with local governments and public health partners to create an acceptable and sustainable model for implementing circumcision programs’ in Africa and other countries (including Haiti and Vietnam). 

Who are these partners? They include the Catholic Relief Services, Family Health International and the Elisabeth Glaser Paediatric AIDS Foundation. The PEPFAR website lists them and their areas of concern. For many of them, ‘Abstinence and Be Faithful’ are on that list. Taking a random sample of countries, in Rwanda 11 out of the 23 partners promote abstinence and in South Africa, 28 out of 93 partners – for a few of them,  this is their only agenda.

Given the Catholic Church’s opposition to condoms to the point of lying about their effectiveness, and that of many American Evangelical organisations, could it be possible that circumcision is being promoted over condom use for less-than scientific reasons? Abstinence has been shown to be an ineffective programme in the US and under the Bush regime, many lies were spread about condom use, so are they promoting circumcision rather than condoms? Pro-abstinence campaigners, especially religious ones, are often anti-condom.

In America, circumcision has been declining in some states but the overall prevalence is still 65% (compared with 16% in the UK). As Dr Lempert points out:  ‘the majority of the American male population has been circumcised whilst they have a rather high rate of HIV infection’.

There is also the issue of consent. Adult men may be able to weigh the facts and make their own decision, but boys and new borns cannot.

To go back to the Independent article, it implies that all parents should seriously weigh up circumcising their male children. But the issue is far more complex than is being presented. There is undeniably resistance to condom use in many cultures for a variety of reasons that need to be overcome and logistical questions of distribution, but the promotion of both circumcision and condom use is tainted with many unknowns and mixed motives; should anyone – doctors, funding bodies, sexually active men or parents - be contemplating or recommending an irreversible surgical procedure just yet?

 

 

 

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