Male circumcision: A contentious cut
23 November 2006
Andy Coghlan
"THERE are already queues of men demanding circumcision," says Mark Stirling, regional director of UNAIDS for Eastern and Southern Africa. His team has been investigating how to help African governments meet this sudden and unexpected surge in demand for male circumcisions.
Last week, Swaziland became the first African country to make voluntary circumcision more widely available, eventually hoping to offer it to any man who is sexually active. Another four - Lesotho, Zambia, Tanzania and Kenya - have already consulted the public on the issue and are deciding whether to follow suit.
So why are African men swarming to volunteer for a painful procedure that faces growing opposition in countries such as the US - where it has been practised routinely for decades - principally because of claims that it blunts sexual pleasure (see "To snip or not to snip").
The reason is a welter of new evidence suggesting that circumcision protects men against HIV and other sexually transmitted diseases. A study published this month showed that in a group of 510 men from Christchurch, New Zealand, who were followed from birth to age 25, cases of sexually transmitted diseases (STDs), including syphilis, could have been cut by half had they been circumcised at birth (Pediatrics, vol 118, p 1971).
The most robust evidence that circumcision cuts transmission of HIV came from a study of more than 3000 men living in Orange Farm township near Johannesburg, published last year. Volunteers who were newly circumcised at the outset of the study were 60 per cent less likely than uncircumcised men to be infected with HIV (New Scientist, 29 October 2005, p 5).
"It means that if you have 10 infections in a group of men, you'd get only four infections if they had been circumcised," says lead author Bertran Auvert of the University of Versailles in France. The results were so stunning that the trial was halted early to let uncircumcised volunteers receive surgery too.
“The results were so stunning that the trial was halted early to let uncircumcised volunteers receive the treatment too”
By mid-December, interim results should be in from two similar studies in Kenya and Uganda to see if the benefits can be replicated elsewhere in Africa. Panels at the US National Institutes of Health will check the results - unknown even to the researchers themselves so far - to judge if they are so unequivocally positive that these trials too should be halted early to offer circumcision to everyone.
Other African countries considering routine circumcision are holding fire till these results from Kenya and Uganda are in. But ever since the publication of the Orange Farm study, UNAIDS (the Joint UN Programme on HIV/AIDS) has been anticipating huge increases in demand for the procedure and working feverishly to draft background information, guidance and advice to governments who want to offer it more widely. Currently, around two-thirds of African men get circumcised for cultural reasons, either at birth or puberty, but the remaining third are often in the belts of southern Africa worst affected by HIV.
However, the concept remains controversial for several reasons. Few countries in Africa presently have the facilities or staff to meet a huge surge in demand for male circumcisions, which until now have largely been carried out by tribal leaders. The procedure can sometimes result in fatal bleeding, cross-infection or even accidental amputation of part of the penis - especially if not performed by trained medical practitioners.
For this reason, UNAIDS is making safety top priority for countries considering such programmes, and has drafted guidance on the logistics and surgical options, as well as legal and ethical advice. "We're concerned we don't give opportunities for quacks and charlatans to injure and mutilate young men," says Stirling.
“We're concerned we don't give opportunities for quacks and charlatans to injure and mutilate young men”
This week it presented its latest advice to interested governments at a meeting in Nairobi, Kenya. The gathering was intended to help them decide whether circumcision is likely to prove acceptable, whether they can afford it, or whether alternatives such as more free condoms would work better. Other countries considering such programmes include South Africa, Mozambique and Botswana.
"We're not trying to stampede any countries into a particular policy, but to look at what suits them," says Catherine Hankins, chief scientific adviser to UNAIDS. Practical options might include mobile clinics, for example, or equipping hospitals to carry out the procedure, while allowing traditional practitioners to manage ceremonial aspects.
Aside from the surgical risks, there are other hazards to consider. The most serious is "disinhibition", the possibility that circumcised men may overestimate the protection it provides from HIV, forsaking other methods of defence such as condoms and having fewer sexual partners. Using fewer condoms would pose an even greater risk for women, who already account for the majority of Africans infected with HIV (see Chart). UNAIDS says it is vital that this doesn't happen, and believes men need to be educated about the risks. "Circumcision doesn't mean any less emphasis on condom use or partner reduction," says Stirling.
If countries do decide to introduce circumcision programmes, it will have to be done with great political and social care and sensitivity, adds Hankins. "Countries will need to know what proportion of their population is already circumcised, what the current complication rates are, who's doing the procedure and what people's attitudes to it might be."
In Kenya, for example, 80 per cent of men are circumcised, but not members of the large Luo tribe. Their attitudes must be taken into account if voluntary circumcision programmes are to meet their goal of cutting HIV infections. "We're trying to assist countries to be ready for decision making for what they want to do," says Hankins. "But there's no single solution."
Meanwhile, researchers are debating whether the findings in Africa strengthen the case for circumcision to help halt HIV and other sexually transmitted diseases in western countries. Last week the UK's Health Protection Agency warned of a dramatic increase in cases of syphilis, while HIV and other STDs are also on the rise. Auvert doubts that there is a strong case. "All these factors imply it's very important for Africa, but it's not so clear for the rest of the world," he says. "You need high HIV prevalence to make circumcision programmes worthwhile."
The American Academy of Pediatrics says it is not yet ready to shift from the conclusion it published in 1999 that any evidence of medical benefit is too weak to merit routine circumcision of babies. However, Jack Swanson of the McFarland Clinic in Ames, Iowa, who co-authored the policy, says the academy would be revisiting it in the next two years to take account of the latest evidence from New Zealand, Africa and elsewhere. "Maybe it will lead to a change," he says.
From issue 2579 of New Scientist magazine, 23 November 2006, page 8-9
To snip or not to snip
Whatever the scope for circumcision to prevent the spread of HIV in Africa, it is doing little to silence groups in the US and elsewhere who oppose the practice. "It will doubtless become the latest excuse to justify circumcision," says John Warren, a retired consultant physician who chairs Norm-UK, a group that opposes routine circumcision of babies. Like similar groups, Norm is principally concerned about two things. One is the (contested) claim that circumcision robs men of sensitive tissue important for sexual pleasure. The other is the ethical objection to circumcising healthy babies who cannot consent and also suffer pain from the procedure.
"In America, we've mutilated most penises by taking off the best part," says Marilyn Milos, founder of the National Organization of Circumcision Information Resource Centers in San Anselmo, California. "We don't have a right to cut off normal body parts."
Opponents and backers of circumcision do at least agree on one thing - there has been very little research into the effect of circumcision on sexual pleasure.
Sensitive issues
Warren cites a postmortem study published in 1996 in the British Journal of Urology (vol 77, p 291) that found particularly high numbers of sensitive cells called Meissner's corpuscles in the folds and ridges formed when a foreskin is retracted behind the glans. But the extent to which these findings mean that circumcised men experience less pleasure is not known.
Backers of circumcision say that given the history of the practice any widespread problems with sexual pleasure would have come to light long ago. A study in Turkey in 2004 found no negative impact on sexual function; circumcised men did take longer to reach orgasm, but this was considered beneficial.
Meanwhile, a separate study in the US found that circumcised men were less anxious about sex, especially elderly men, and suffered only half the amount of penile dysfunction as they aged (The Journal of the American Medical Association, vol 277, p 1052). And a study of 15 men in 2002 in The Journal of Urology (vol 168, p 2134) reported no difference in reported sexual drive, ability to achieve erection, ejaculation or overall satisfaction.
Gateway for disease
Better understood is how circumcision prevents the transmission of HIV and other sexually transmitted diseases.
A recent study by Betty Donoval and her colleagues at the University of Illinois in Chicago describes how HIV targets and infects specific white blood cells found on the inner mucosal surface of the foreskin. These are not present on the surface of a circumcised penis (American Journal of Clinical Pathology, vol 125, p 386).
"It's easier for the virus to enter these cells in foreskin," says Helen Weiss of the London School of Hygiene and Tropical Medicine, lead author of a pivotal review in 2000 demonstrating the benefits of circumcision. "No one is saying that circumcision completely protects, but the evidence suggests it at least halves infection," she says.
The area under the foreskin is also a warm, moist environment favourable to pathogenic organisms. This helps explain this month's findings from New Zealand that circumcision offers protection against other sexually transmitted diseases, including syphilis and chlamydia (see main story). "My study strengthens the case for general susceptibility to a range of infections in uncircumcised men," says David Fergusson of Christchurch School of Medicine and Health Sciences, who carried out the research.
It also stokes the debate about whether all men - not just those in countries where HIV is rife - could benefit from having the snip. One claim used to justify routine circumcision of newborn babies is that it reduces their risk of infections of the urinary tract in the first year of life. But these are rare - for every 1000 babies, up to 14 uncircumcised infants would get infections compared with two circumcised babies. Circumcision also reduces the risk of penile cancer, but again this is very rare, affecting just 1 in every 100,000 men in the US.
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