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Reproductive Justice and Gender

How Effective Is Male Circumcision at Preventing Sexually Transmitted Infections?

By Kate Bourne, RH Reality Check. Posted July 23, 2008.


What circumcision will and will not offer a man and his partner or partners.
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Adult male circumcision is being pushed as the latest magic bullet for the HIV pandemic. There is good reason for the enthusiasm about a new use for the world's oldest surgical intervention. But let's be clear about what circumcision will and will not offer a man and his partner or partners.

Circumcision programs have captured the attention and funding of governments in East and Southern Africa, global funders, and policymakers. Job postings for "male circumcision specialists" are circulating, and the Bill and Melinda Gates Foundation and the President's Plan for AIDS Relief (PEPFAR), two of the largest funders of global HIV/AIDS programs, have incorporated male circumcision work into their efforts.

First, the good news: Three recent trials have shown that circumcised men are about half as likely to contract HIV from unprotected vaginal intercourse as their uncircumcised counterparts. Circumcision also protects against some other sexually transmitted infections (STIs).

But the reality is that circumcision offers only partial protection. A circumcised man still has a significant risk of contracting HIV and other STIs if he engages in unprotected sex with an infected partner. Circumcision does not offer the man's current female partners any protection from contracting HIV.

On a larger scale, the predictive models that show a significant reduction in the number of new HIV infections assume that between that 80 to 100 percent of men are circumcised. Currently approximately 30 percent of men worldwide are circumcised, although this varies widely between different communities and countries.

Surveys have shown that many men are willing to be circumcised, and the promise of surgical prevention may bring throngs of men into local clinics that do not routinely use health services. It would be shortsighted not to couple circumcision services with education on HIV prevention and safe sex, provider-initiated HIV counseling and testing, and referrals to HIV/AIDS care and treatment.

But given the protection that circumcision provides, men may assume and assert that they are "safe" and insist on having sex without condoms. There are questions about whether newly circumcised men will be willing to abstain from sex for the six weeks necessary for the wound to heal so as to not possibly increase their or their partner(s) risk of contracting HIV or other STIs.

In the communities where the demand for circumcision is high and resources are scarce, unqualified circumcisers may begin offering the surgery to meet men's demands. It would take only a very few unqualified safe surgeons to taint the safety and acceptability of these programs. We cannot allow this to happen.

Clearly, circumcision is an imperfect solution to HIV prevention. Even so, it promises to be one of the most effective strategies we currently have to curb new HIV infections in men.

So, what about those of us who never had a foreskin?

By the most optimistic predictions, male circumcision will not translate into fewer HIV infections in women for decades. The reality of HIV and the epidemic is that women account for the majority of people living with HIV in the most affected region, Sub-Saharan Africa. For biological reasons, a woman is between two to eight times more likely than a man to contract HIV during vaginal intercourse with an HIV-positive partner.

On top of women's biologic predilection to infection, gender inequalities have sustained and feminized the epidemic by limiting women's abilities to negotiate safe sex, refuse unwanted sex, and ask their partners to be monogamous. We must be cautious about how male circumcision may change these realities.


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View:
circumcision is not the answer
Posted by: ml66uk on Jul 23, 2008 9:55 AM   
Current rating: 3    [1 = poor; 5 = excellent]
The studies which allegedly show a reduction in HIV among circumcised men are highly questionable. Not one of them was finished, despite the protective affect appearing to decline well below the oft-reported 65%, and several of the subjects disappearing. The fact that one study described circumcision as "comparable to a vaccine of high efficacy" seems to show clear bias. They appear to have been seeking a certain result. One has to wonder how many of the people promoting circumcision in Africa are themselves circumcised. Daniel Halperin is the grandson of a mohel, and seems to think that "maybe in some small way (he's) destined to help pass along (circumcision)" so his objectivity is questionable.

Other epidemiological studies have shown no correlation between HIV and circumcision, but rather with the numbers of sex workers, or the prevalence of "dry sex".

The two continents with the highest rates of AIDS are the same two continents with the highest rates of male circumcision. Rwanda has almost double the rate of HIV in circed men than intact men, yet they've just started a nationwide circumcision campaign. Other countries where circumcised men are *more* likely to be HIV+ are Cameroon, Ghana, Lesotho, Malawi, and Tanzania. That's six countries where men are more likely to be HIV+ if they've been circumcised.

Cameroon http://www.measuredhs.com/pubs/pdf/FR163/16chapitre16.pdf table 16.9, p17 (4.1% v 1.1%)
Ghana http://www.measuredhs.com/pubs/pdf/FR152/13Chapter13.pdf table 13.9 (1.6% v 1.4%)
Lesotho http://www.measuredhs.com/pubs/pdf/FR171/12Chapter12.pdf table 12.9 (22.8% v 15.2%)
Malawi http://www.measuredhs.com/pubs/pdf/FR175/FR-175-MW04.pdf table 12.6, p257 (13.2% v 9.5%)
Rwanda http://www.measuredhs.com/pubs/pdf/FR183/15Chapter15.pdf , table 15.11 (3.5% v 2.1%)

Something is very wrong here. These people aren't interested in fighting HIV, but in promoting circumcision (or sometimes anything-but-condoms), and their actions will cost lives not save them.

If you read those reports btw, the level of knowledge about HIV is quite frightening. In Malawi for instance, only 57% know that condoms protect against HIV/AIDS, and only 68% know that limiting sexual partners protects against HIV/AIDS. There are people who haven't even heard of condoms. It just seems really misguided to be hailing male circumcision as the way forward. It would help if some of the aid donors didn't refuse to fund condom education, or work that involves talking to prostitutes. There are African prostitutes that sleep with 20-50 men a day, and some of them say that hardly any of the men use a condom. If anyone really cares about men, women, and children dying in Africa, surely they'd be focussing on education about safe sex rather than surgery that offers limited protection at best, and runs a high risk of risk compensatory behaviour.

Circumcised male virgins are more likely to be HIV+ than intact male virgins, as the operation sometimes infects men. The latest news is that circumcised HIV+ men appear more likely to transmit the virus to women than intact HIV+ men (even after the healing period is over). Eight additional women appear to have been infected during that study, solely because their husbands were circumcised. This is not the first time that HIV in women has been linked to partner circumcision.

Female circumcision seems to protect against HIV too btw, but we wouldn't investigate cutting off women's labia, and then start promoting that.

For a good summary of the case against promoting circumcision in Africa, see this link:
http://tinyurl.com/y6jkoe

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Get Cut or Get HIV. And use a Condom as well!!
Posted by: yellow on Jul 23, 2008 10:25 AM   
Current rating: 3    [1 = poor; 5 = excellent]
Many of the circumcized men who get HIV didn't use a condom. Some may have gotten HIV from anal sex or sharing needles in which the Penis is irrelevant. Circumcision does help prevent HIV from vaginal intercourse.

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Why male mutilation and not female?
Posted by: Jacko on Jul 23, 2008 11:56 AM   
Current rating: 3    [1 = poor; 5 = excellent]
Why not push FEMALE circumcison in southern Africa? A study shows it provides a lowering of HIV transmission to women. Both operations (even the lesser FGM that does not remove the clitoruis and is less severe than MGM) remove cells that could provide an HIV gateway (this is really speculative and is not proved). Female circumcision would be a better way to bring down the higher % of females with HIV and would end the problem sooner.

Anyone who says NO to FGM but yes to MGM is being sexist and rediculous. Only men that have these "foreskin" parts, that includes the MOST sensitive part of the p enis, can understand the value of this. People that don't have it understand it like men AND women that don't have a clitoris understand that. To say that a woman's genital integrity is not to be messed with but a man's should be is so outrageous and just plain wrong.

Finnally, if the MGM push succeeds, there will be so many more men with less sensitivity and early onset of sexual dysfunction. If these people don't want to wear a condom now, just think about how they will feel if they think that they have protection AND want to feel their partner.

YIKES what idiots there must be at the WHO.

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» I Have Been Asked If I Am Jewish. Posted by: ranchero42
A few thoughts
Posted by: jorgem on Jul 23, 2008 12:15 PM   
Current rating: 3    [1 = poor; 5 = excellent]
1. Women have a foreskin. Its more commonly known as a clitoral hood. Removal of the clitoral hood, or Type I FGM, is the anatomical equivalent to a typical American circumcision.

2. The United States is the only industrialized country to circumcise a majority (or even a significant quantity) of newborns. Most adult American males are circumcised as the rates peaked at 90% in the late 1970s. It has recently declined to around 56% of newborns still being circumcised.

According to the CIA World Factbook, the United States has the highest per capita rate of HIV infection. It is much higher than all of Western Europe, Australia, Japan, Canada, and every other industrialized country.

In this apples to apples comparison:
United States: High circumcision rate, higher per capita HIV rate
other industrialized countries: low to zero circumcision rate, lower per capita HIV rate

The studies really aren't being confirmed in the real world.

3. As I noted above, U.S. circumcision rates have dropped dramatically in the past 3 decades. I have to wonder if the circumcision studies, highly publicized in the United States, were not simply an attempt to boost a sagging U.S. circumcision rate. After all, if the United States follows the lead of Australia and Canada and stops circumcising, who will be left to carry that torch? If the U.S. stops circumcising, the procedure is going to lose all credibility and eventually just disappear. Spend a little time on some message boards and reading the news and it'll be obvious to you that there are some people who are very, very dedicated to the continuation of genital cutting, especially of minors.

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» RE: A few thoughts Posted by: adjuvant
» RE: A few thoughts Posted by: jorgem
About 30% of males around the world are circumsized. This is an impressive number of people.
Posted by: yellow on Jul 23, 2008 4:57 PM   
Current rating: 3    [1 = poor; 5 = excellent]
The high US circumcision rate will not prevent HIV contracted by men who engage in unprotected anal sex and sharing hypodermic needles. Condoms should be worn at all times but men having unprotected vaginal intercourse are much less likely to contract HIV from an infected partner if they are circumcised than if they are not. They reason is simple. The highly membranous tissue that forms the inner part of the sheath of the foreskin is full of open capillaries that are highly absorbant and exposed to its environment. Female vaginal secretions are rich in the HIV and can be easily absorbed into the foreskin of a mans penis. This is one reason researchers from the UN's World Health Organization and the Center for Disease Control have determined that circumcised men have a 60% or greater chance of avoiding HIV contraction from vaginal intercourse (or anal intercourse where the man is inserting his penis in his partner) with an infected partner than does a man with his foreskin intact.

Circumcision is no guarantee of anything without protection. If done properly at birth, which it usually is, it is highly safe, beneficial and good hygiene. It prevents bacterial and HPV infections that are more common in uncut men. It also reduces the risk of genital warts and herpes for men having vaginal and/or oral sex with an infected partner.

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Surgery not necessary for circumcision "benefits."
Posted by: hankhawk on Jul 23, 2008 8:27 PM   
Current rating: 1    [1 = poor; 5 = excellent]
It's not necessary to have surgery to get
the benefits that circumcision may give.

I was born to European parents and was not
circumcised.

During high school, when we showered after gym class I saw that most of my buddies were circumcised and I felt a bit odd, so I thought of trying something on myself. Each night when I went to bed, I pulled my foreskin back and taped it so it stay pulled back.

At first it was irritating because of the exposure was very sensitive on the exposed area. But after doing that every night for a few weeks, the irritation and sensitivity disappeared and my foreskin stayed in the pulled back position and from then on, I looked just like the surgically
circumcised guys. There was no real
pain, just some sensitivity, so I believe that
same proceedure can be used on adults.

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So, wait a minute...what's the point?
Posted by: blogbooks on Jul 24, 2008 1:38 PM   
Current rating: 4    [1 = poor; 5 = excellent]
You say circumcised men will have lower HIV rates.

THEN you say 100% of women should "negotiate" safe sex 100% of the time.

If you're wearing a condom what does it matter if you're circumcised or not?

Answer, it doesn't.

Circumcision is therefore useless mutilation of the human body. That's in YOUR words.

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» No "gotcha" whatsoever..... Posted by: mjabele
» You're a monster Posted by: blogbooks
Male infant genital mutilation needs to be discontinued, not encouraged
Posted by: blogbooks on Jul 24, 2008 1:44 PM   
Current rating: 3    [1 = poor; 5 = excellent]
You are monsters.

There really are not other words strong enough to describe those who strongly advocate the mutilation of newborn baby boys.

Monsters.

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"50% reduction" sounds impressive, but...
Posted by: hugh7 on Jul 24, 2008 3:28 PM   
Current rating: 3    [1 = poor; 5 = excellent]
...that's a relative reduction, from small to tiny. In fact it was an absolute difference of 1.8% The researchers circumcised a total of 5,400 volunteers and left a similar number intact. After less than two years, 64 circumcised men had HIV, and 137 of the control groups. That is the whole basis of the claim. (It averages 39 circumcisions - a day's work for a fast surgeon - for each transmission "prevented". Surgeons in Africa would be better occupied doing something more efficient.)

What they don't tell you is that 327 circumcised men dropped out, their HIV status unknown to the researchers. But they were encouraged to get tested elsewhere, because it was not considered ethical to tell them they had HIV. So if you had undergone a painful and marking surgery "to prevent HIV" and then found you had it , would you go back to the people who had done that to you? This suggests that a higher proportion of the circumcised dropouts would have HIV than the intact ones, undermining the whole claim. Here is a graphic presentation of that information.

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ETHICS AGAINST AIDS, NOT STATISTICS...
Posted by: Sigismond on Jul 28, 2008 12:51 PM   
Current rating: 3    [1 = poor; 5 = excellent]
... NOR PURITAN PHOBIA
(biased enquiries upon black human guinea-pigs)




“The one who gives up an essential liberty for a fleeting and
uncertain security does not deserve either security or liberty.”
Benjamin Franklin

In order to fight AIDS, the safe and sound methods are personal pleasure (autosexuality), condoms, fidelity and monogamy. Talbott demonstrated (1) that in Africa, the most struck continent, the great carrier of the epidemic is not the foreskin but prostitution. Indeed, African prostitutes are four times more numerous and four times more contaminated than those of the rest of the world. However, “dry sex”, sodomy, multi-partnership, adultery, polygamy and homophilia when it is not zoosexual touring with endemic carriers-of-the-virus monkeys (very probably at the source of the epidemic; indeed, one zoophile homophile was enough to contaminate humanity), must also be rejected steadfastly. Let us insist upon the fact that the use of drugs and the provoked euphoria very dangerously favour risk taking. Violence calls for violence; fighting debauchery by the violence of sexual mutilation is dangerous. At the contrary, for all those who have not yet found a stable relationship with a healthy person, autosexuality is the surest resort. This implies not to have been deprived from its specific natural organs: the clitoris (its ablation can be compared to the castration of the penis) or the foreskin (circumcision is a threat of castration that traumatizes even little girls). In a continent where women are now the first affected by an epidemic initially spread by men, they are the first interested in adopting the ethic of fidelity. And this all the more that it is also an ethic of equality in which the loss of diversity is rewarded by gain in physical and affective security, and deeper relationship.




Human guinea-pigs

Contrary to this obviousness and to the ethical principle forbidding amputation for preventive purpose, the insight of a few researchers makes one's hair stand on end. 3 128 men have been recruited for a research study (2) on the effectiveness of circumcision in preventing AIDS. It succeeded a whole series since twenty years, with similar aim and results. But the press touted again the same dubious conclusion. Circumcised right away were 1 546 human guinea-pigs. The others underwent the mutilation ten months later. For according to the hasty and naive promoters, the venture was so successful that they stopped it to circumcise the rest of the sample.
The authors of the enquiry eased their conscience by providing condoms and advice to their victims. But there was a time when experiments upon humans were sheltered behind the barbed wire of extermination camps. Today they are done in the open; in order to proclaim the so-called positive results of crimes realized with the collaboration of victims fascinated by the title of physician, a few scientists obtain media coverage in the congress of the International AIDS Society. Science, how many crimes are committed in your name!


Men only, blacks only

The enquiry asserts being randomized (statistically representative of the population through drawing lots) but women were excluded from it. But since when is a population composed of one sex only?! Moreover, how could a small town of black people validly represent South African population that includes 11% of whites?! The enquiry, deliberately androcentered and ethnocentered, is all the more statistically biased that it studies the risk of transmission of women to men without having registered the HIV status of women in contact with the subjects of each sample...

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Circumcision is a Religious and Social Loyalty Oath
Posted by: Ohjin on Jul 28, 2008 6:18 PM   
Current rating: 5    [1 = poor; 5 = excellent]
And Clearly Mutilation, and NO THING MORE.

Period.

When you turn over your brand new baby to be ritually butchered, it proves pretty clearly that YOU have bought the social or religious program completely.

Also explains why so many males have a justifiably violent and fear based attitude about the world.

From womb to mutilation...

When the 2 people who you trust the most, turn you over to a stranger so they can improve on God's "mistake" in a horribly painful act of unsedated violence and butchery, it does tend to cloud your future perception and fuck up your view of the world.

The male dominated, fear based, reality of the world today, is proof positive of how any thoughts and practise of infant mutilation cuts us all, ALL WAYS and well beyond childhood.

Let's take a loyalty oath to NEVER mutilate our children and let's permanently circumcise all religious and social attempts at control over our children instead.

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