[tt] NS: Circumcision: To cut or not to cut?

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Circumcision: To cut or not to cut?
http://www.newscientist.com/article.ns?id=mg19926651.900&print=true
16 July 2008
Vivien Marx
Graham Lawton

IMAGINE a quick and simple surgical procedure that trials have shown
could give your newborn child lifelong protection against HIV and
may ward off sexually transmitted diseases and cancer too. It
involves a little pain and bleeding, and occasionally goes wrong,
but the risk of serious adverse effects is tiny. Would you have it
done? Chances are you would. But what if you found out that other
trials have called the procedure's benefits into question, and that
it involves cutting off part of your child's penis. Now how do you
feel about it?

This, in a nutshell, is the dilemma facing the parents of newborn
baby boys. According to the increasingly vocal advocates of male
circumcision, slicing off the foreskin is one of the most effective
public-health measures ever invented and should be done routinely,
like vaccination. Not so fast, say opponents. They insist that
circumcision has no medical benefits and damages a man's sex life.
The debate has rumbled on for decades, but recent findings about the
role circumcision can play in preventing transmission of HIV have
placed the foreskin - or its absence - firmly back on the
public-health agenda.

Globally, approximately 30 per cent of men have been circumcised,
making it probably the world's most common surgical procedure, says
epidemiologist Helen Weiss of the London School of Hygiene &
Tropical Medicine. Most circumcisions are carried out for cultural
or religious reasons, but there have long been those who advocate
the procedure on medical grounds, to improve hygiene and prevent
infections.

The latest disease claimed by the circumcision lobby is HIV. Back in
the mid-1980s, an American urologist called Aaron Fink noted that a
large proportion of the men in Africa who had AIDS were
uncircumcised (The New England Journal of Medicine, vol 315, p
1167). Over the next few years, stacks of observational evidence
came in suggesting that circumcised men were less likely to be
HIV-positive, and by 2000 the idea was widely accepted (AIDS, vol
14, p 2361).

What was still needed, however, was proof from a large, randomised
clinical trial that circumcision could protect men against the
virus. The first study of this kind to report results began in July
2002 at Orange Farm, a large township near Johannesburg in South
Africa. It was supposed to run for three years but was halted early
when a halfway analysis showed that circumcision was lowering HIV
infection rates by 60 per cent - a result that had trial leader
Bertran Auvert of the French National Institute of Health and
Medical Research (INSERM) in Saint-Maurice comparing circumcision to
"a vaccine of high efficacy" (PLoS Medicine, vol 2, p e298).

Two more big trials, one in Kisumu, Kenya, and the other in Rakai,
Uganda, were also stopped early on the strength of overwhelmingly
positive results. When these two studies were published in The
Lancet (vol 369, p 643, and p 657) an accompanying editorial
declared "a new era for HIV prevention" (The Lancet, vol 369, p
615). Auvert calculated that circumcision could avert up to 3.8
million infections and half a million deaths in sub-Saharan Africa
between 2006 and 2016, and up to 5.8 million deaths by 2026 (PLoS
Medicine, vol 3, p e262).

Circumcision primarily protects men during heterosexual intercourse,
but it also appeared to benefit women. Anthony Fauci of the US
National Institute of Allergy and Infectious Diseases - which helped
to fund the Kisumu and Rakai trials - greeted the results with the
comment: "While the initial benefit will be fewer HIV infections in
men, ultimately circumcision could lead to fewer infections in women
in those areas of the world where HIV is spread primarily through
heterosexual intercourse."

So how does circumcision protect against HIV? As Brian Morris, a
molecular biologist at the University of Sydney in Australia and a
leading supporter of circumcision, explains, it is the inner lining
of the foreskin that is the weak point. While the virus does not
easily pass through the keratinised skin of the foreskin's outer
surface and the penis shaft, the inner surface of the foreskin lacks
keratin and is packed with immune cells such as Langerhans cells
that HIV uses as an entry point. This makes it "very, very
vulnerable", says Morris. "HIV goes straight in."

The African trials have encouraged the World Health Organization and
Joint United Nations Programme on HIV/AIDS (UNAIDS) to set up
programmes to help African countries establish or scale up
circumcision services for adult men - though they emphasise that
circumcision does not make men immune, and that couples should still
practise safe sex. "This is a huge opportunity for prevention,
particularly in areas of Africa with high HIV prevalence," says
Daniel Halperin, an epidemiologist at Harvard School of Public
Health and former global HIV adviser at USAID, the US Agency for
International Development. "To me, this is the greatest medical
advance in 20 years," adds Jeffrey Klausner, who directs sexually
transmitted disease prevention and control services for San
Francisco's Department of Health.

Yet as with most things circumcision-related, all is not necessarily
as it first seems - starting with the trials themselves. Numerous
criticisms levelled at their design and execution have cast doubt on
whether circumcision will be anywhere near as effective in the real
world as the results suggest (Future HIV Therapy, vol 2, p 193). It
is widely recognised, for example, that clinical trials which are
stopped early because the results are good generally exaggerate the
beneficial effect (The Lancet, vol 368, p 1236). Many researchers
argue that if the trials had continued for the full three years and
beyond, many more circumcised men would have caught the virus.

According to Michel Garenne of the Pasteur Institute in Paris,
France, factors like this make the vaccine analogy highly
misleading. A 60 per cent reduction in infection rate over 18 months
is not the same as the near-complete protection offered by a
vaccine, and may not do very much to protect men over a lifetime of
sexual activity (PLoS Medicine, vol 3, p e78). He also warns against
generalising from the studies which found that circumcised men tend
to have lower rates of HIV, pointing out that in some countries -
notably Cameroon, Lesotho and Malawi - the opposite is true (African
Journal of AIDS Research, vol 7, p 1).

Then there is the issue of whether circumcision protects women. At a
major AIDS conference earlier this year, a team from Johns Hopkins
University in Baltimore, Maryland, reported that men who are
circumcised when they are already HIV-positive are more likely to
infect their partners. The reason, according to team leader Maria
Wawer, is that some couples resume sex too early, before the
circumcision wound heals, thus exposing the woman to virus-infected
blood.

Of course, circumcision cannot protect men who are already
HIV-positive, but the fear is that if circumcision becomes the norm
such men will have the procedure done - either because they don't
know they are infected or because uncircumcised penises come to be
seen as a marker of being HIV-positive.

Another fear is that circumcision could encourage risky sexual
behaviour by lulling men into a false sense of security, or even
making them believe they are immune and so can stop using condoms.
Auvert's team has estimated that this effect would reduce the
effectiveness of circumcision from 60 per cent to 50 per cent (PLoS
Medicine, vol 3, p e517). Another model found that if 40 per cent of
circumcised men significantly increased their risky behaviour, the
benefits of circumcision would be completely eliminated
(International Journal of Epidemiology, DOI: 10.1093/ije/dyn038).
However, a real-world Kenyan study found no increase in risky sex
acts such as failure to use a condom among recently circumcised men
(Journal of Acquired Immune Deficiency Syndromes, vol 44, p 66).

As the controversy over circumcision in Africa continues, it has
spilled over into a secondary debate in the western world. If
circumcision is an effective weapon against AIDS in Africa, does
that mean it should be promoted elsewhere?

Convincing evidence one way or the other is thin on the ground. Huge
regional differences in the nature of the epidemic mean that
applying the African findings to other parts of the world is not
straightforward, Halperin says.

In sub-Saharan Africa, for example, the main mode of HIV
transmission is heterosexual sex, whereas in the developed world it
is sex between men, prostitution and injected drugs. That calls into
question the public-health benefits of a procedure established only
as a way of protecting men during sex with women. What's more, HIV
is much less prevalent in the west than in Africa, and the
predominant subtype is HIV B, rather than A, C and D - factors which
have unknown consequences for the effectiveness of circumcision. And
while a handful of observational studies have looked at HIV and
circumcision in the west, the results have been inconclusive (PLoS
Medicine, vol 4, p e223).

Last year, the US Centers for Disease Control and Prevention (CDC)
assessed evidence relating to HIV and concluded that there was no
compelling reason to advocate widespread circumcision in the US,
though there may be a case for certain high-risk men choosing to
undergo the procedure. New York City's health authorities have also
considered whether to start promoting circumcision (New Scientist,
15 April 2007, p 6).

But HIV is not the only reason advocates still claim that boys
should be routinely circumcised. They point to a large and growing
body of evidence - though much of it is disputed and none of it is
yet from randomised controlled trials - that circumcision can
prevent numerous other health problems, from mild urinary tract
infections to cancer.

Some studies have shown, for example, that circumcised baby boys
have a lower rate of urinary tract and kidney infections. Others
find that uncircumcised men have a higher risk of catching sexually
transmitted diseases, including chlamydia, genital warts, herpes,
gonorrhea, syphilis and chancroid. Circumcision also prevents a
problem called phimosis, where the foreskin is overly tight making
erections and urination painful; phimosis is a strong predisposing
factor for penile cancer. Circumcision also offers protection
against human papilloma virus (HPV), another cause of penile cancer.
One recent review concluded that uncircumcised men are more than 20
times as likely to get penile cancer (Journal of the American
Academy of Dermatology, vol 54, p 369). Some studies even show that
uncircumcised men have a higher incidence of sexual dysfunction.

All in all, says Morris, 1 in 3 uncircumcised men will eventually
require medical attention for a condition that could have been
prevented by circumcision. "There are benefits at all ages," he
says. "There is a huge public-health problem if you're not
circumcising" (BioEssays, vol 29, p 1147). There are also claimed
health benefits for women. The female sexual partners of
uncircumcised men have a moderately increased risk of cervical
cancer, probably due to HPV, along with an elevated incidence of
herpes and chlamydia.

Despite this, medical authorities are loath to promote circumcision.
The American Academy of Pediatrics is looking into the issue in the
light of the HIV data but its current position is that the potential
medical benefits are not sufficient to recommend routine
circumcision. The British Medical Association, meanwhile, describes
the medical evidence as "equivocal". These positions are echoed by
authorities across the developed world.

One reason for this caution is the risk of complications arising
from the procedure. These are largely minor, such as bleeding, pain
and the side effects of anaesthesia. But very occasionally they can
be more serious: a few cases of severe infection or injury and even
death have been recorded. Figures for the incidence of complications
are inconsistent, however, not least because the conditions under
which circumcision is performed vary so widely. The CDC says that
somewhere between 0.2 and 2 per cent of circumcisions in the US
result in complications, almost all of them minor.

This uncertainty makes the relative costs and benefits of
circumcision hard to calculate. For example, Morris reckons that
circumcising just 1000 boys will prevent one case of penile cancer,
but other analyses argue that the number is closer to 300,000.

As the pro-circumcision message has gained momentum,
anti-circumcision groups have proliferated, arguing that the
supposed benefits are overblown and are outweighed by the risks.
Some argue that circumcising a child without consent is a violation
of his human rights. "Circumcision is the harmful removal of a very
important part of a man's body," says George Denniston of Doctors
Opposing Circumcision in Seattle, Washington.

Circumcision proponents say the objections are based on anecdotes
rather than science. "I don't think there is any evidence other than
emotion that drives people to say we cause harm," says Irwin
Goldstein, director of sexual medicine at the University of
California, San Diego.

The debate is at its most raucous and scientifically murky when it
comes to sex. According to supporters, circumcision has no effect on
a man's sex life and can improve that of his partner's. Opponents
say the exact opposite, claiming that the foreskin is a highly
sensitive part of the penis that is necessary for normal sexual
function and enjoyment. Here too, the science is equivocal. Some
studies have shown that circumcised men have reduced sensation to
fine touch (BJU International, vol 99, p 864). Many more, however,
including one by William Masters and Virginia Johnson in their
classic 1966 book Human Sexual Response, find no difference in
penile sensitivity. A recent example is reported in The Journal of
Sexual Medicine, vol 4, p 667.

Outside the laboratory the results are equally contradictory. Most
of the information comes from non-scientific surveys that tend to
confirm the prejudices of the people carrying them out. In 1988, for
example, circumcision advocate James Badger found that men who had
experienced sex both uncircumcised and then after being circumcised
said it was better circumcised, while women found circumcised
penises more attractive. However, a similar survey by circumcision
critic Kristen O'Hara found that women overwhelmingly preferred
"natural" intercourse (BJU International, vol 83, p s79).

The most recent contribution to the sex debate comes from the
circumcision trial in Uganda. A team led by Ronald Gray of Johns
Hopkins University compared two groups of more than 2000 men: the
members of one group underwent circumcision at the start of the
two-year study, while those in the other group remained
uncircumcised throughout. When they asked the men about their sexual
desire, functioning and satisfaction, the researchers found no
significant difference (BJU International, vol 101, p 65).

"I think we need quite a bit more data on the direct effects of
circumcision on penile sensation," says Erik Janssen, a sex
researcher at the Kinsey Institute in Bloomington, Indiana. "Is it
leading to additional types of stimulation that are more
pleasurable? I don't know of really good research on this topic; if
there was funding for it, I would study it."

For now, the debate over circumcision continues to arouse passion,
prejudice and confusion on both sides. What is urgently needed is
rock-solid data from randomised, controlled trials. "Scientists keep
an open mind," Morris advises. "Ten years down the track, if there
is evidence circumcision is not necessary, I will just back off."

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Weblinks

CDC factsheet on circumcision
http://www.origin.cdc.gov/hiv/resources/factsheets/PDF/circumcision.pdf
Round up of anti-circumcision arguments from the International
Coalition for Genital Integrity
http://www.icgi.org/Downloads/ICGIPositionPaper.pdf
Evidence-based pro-circumcision site
http://www.circinfo.net/