Circumcision: A case of all or nothing?

By Mia Malan

More than half of South African men are now ­circumcised and most of them have been circumcised fully; in other words, the entire foreskin of their penises has been removed, not just part of it. That is according to the third "National HIV Communication Survey", the results of which were released at the International Aids Conference in Washington DC in the United States this week.
Research has shown that men who are fully circumcised are 60% less likely to acquire HIV from their female partners than uncircumcised men. Over time, this preventive benefit increases. A South African study has shown that circumcision reduces men's risk of getting infected with HIV by up to 76% after three years.
About 10000 respondents between the ages of 16 and 55 across all nine provinces were interviewed for the survey between February and May this year. Men were asked whether they had been circumcised and shown ­pictures of full, partial and uncircumcised penises. They then had to identify which picture resembled their penis best.
The study, which was jointly conducted by Johns Hopkins Health and Education South Africa, loveLife and Soul City, revealed that, of the men in the country who had been circumcised, 48.1% had been circumcised medically and 50.1% traditionally. Of those who had been traditionally circumcised, nine out of 10 said they had their entire foreskin removed.
The findings that male circumcision reduces men's risk of getting infected with HIV are based on findings in which study participants' entire foreskin was taken off. A concern with traditional circumcision practice is that none or only part of the foreskin is often removed. The effect of partial foreskin removal on HIV acquisition is unknown.
Communication survey
A study by the Desmond Tutu HIV Centre at the University of Cape Town, which was published in last month's South African Medical Journal, produced notably different results to those of the communication survey. Of about 200 mostly Xhosa men from Nyanga outside Cape Town who were enrolled in the study, 74% reported that they had been traditionally circumcised. Upon medical examination, it emerged that 27%, a percentage almost three times higher than that reported by the communication survey, had some or all of their foreskin remaining. Fourteen per cent (27) of the study participants were HIV infected, of whom most (21) reported that they had been traditionally circumcised.
According to research co-author Professor Linda-Gail Bekker, the difference in results could be attributed to the Cape Town study being focused on a much smaller sample and only on Xhosa men, whereas the communication survey was a national study involving men from several ethnic groups that might have different circumcision practices to those of Xhosa men.
Another difference was that the men in Bekker's study were medically examined – a doctor checked whether every participant's self-reported circumcision was indeed a full circumcision. In the communication survey, no medical assessments were done and the results were based on the men's own perception of the state of their penises.
The national HIV communication survey revealed that there was a huge increase in knowledge about the HIV-reduction benefits of medical male circumcision, with 47% of men and women now knowing that medical male circumcision reduced the risk of HIV infection, compared with 8% in 2009.
According to the survey, about one million men intend to get circumcised within the next year and 80.5% of them would prefer to be medically circumcised. However, although 66% of men in the South African Medical Journal study were aware of the preventive benefit of medical circumcision, most were unwilling to undergo it, stating religion, culture, notions of manhood and social disapproval as reasons.
Simplifying the procedure
According to health department deputy director general Dr Yogan Pillay, 529520 medical circumcisions have been conducted in South Africa.
"Once we have World Health Organisation-approved medical male circumcision devices, which we expect late this year or early next year, we intend to train traditional circumcisers to use them so that we are able to better ensure that men who are circumcised traditionally have their entire foreskin removed," he said.   
Medical circumcision devices make it possible to do bloodless circumcisions and simplify the procedure hugely. Studies have shown that one such device, the PrePex, can be  administered safely by junior nurses without the supervision of doctors.
But such devices first need to be vetted by the WHO, entailing an extensive scientific review and trial process, before large donors will fund their use  
Health Minister Dr Aaron Motsoaledi, who attended the launch of the communication survey results, said his department would do whatever it took to ensure that all South African men in need of medical circumcision were given access to it.
According to mathematical modelling studies, 20% of new HIV infections in South Africa will be averted by 2025 if 4.3-million men between the ages of 15 and 49 are fully circumcised by 2015.
"We need to meet demand, but must also ensure that circumcised men know they should still use condoms because the procedure is not foolproof protection against HIV," Motsoaledi said.  
Mia Malan works for the ­Discovery Health Journalism Centre at ­Rhodes University

Africa's male circumcision crusade: Boon or boondoggle?

By Judy Mandelbaum
View Original

Just imagine that a simple, harmless, one-time medical procedure could provide you, your loved ones, and all your neighbors with lifetime protection from a deadly epidemic. You’d sign up for it right away, wouldn’t you?
This is precisely what the World Health Organization, the Bill & Melinda Gates Foundation, and countless other NGOs and government programs are offering the continent of Africa: A comprehensive adult male circumcision campaign aimed at stemming the devastating HIV/AIDS epidemicAccording to the WHO, “Medical male circumcision reduces the risk of female-to-male sexual transmission of HIV by approximately 60%.” Moreover,
Medical male circumcision offers excellent value for money in such settings. It saves costs by averting new HIV infections and reducing the number of people needing HIV treatment and care. A one-time intervention, medical male circumcision provides men life-long partial protection against HIV as well as other sexually transmitted infections.
Thanks to the WHO’s lobbying and financing efforts, countries across Africa are submitting thousands of their male citizens to the operation. Uganda, which has a 6.5% adult infection rate, launched a giant voluntary circumcision program in 2010. In June, 2012, ten Zimbabwean parliament members announced that they would undergo circumcision to set an example to the population as a whole. More than a million Zimbabweans are living with HIV/AIDS.
This is indeed marvelous news. The way Bill Gates and the WHO describe it, circumcision sounds like the greatest invention since penicillin. And yet the story does raise a question: Is it true? Does circumcision really reduce the transmission of HIV/AIDS, making it serve as a sort of invisible condom?
Stand proud 
In fact, the pro-circumcision consensus the WHO implies in its statements is largely imaginary. Medical experts the world over doubt the wisdom of the campaign, and some studies suggest it is actually counterproductive. In May of 2011, the Panos Eastern Africa NGO determinedthat misconceptions about the procedure – specifically the widespread notion that circumcision alone, without taking additional precautions, significantly protects people from HIV/AIDS – was actually encouraging the disease to spread in Uganda. In December of 2011, an article in the Australian Journal of Law and Medicinecited grave flaws in three studies supposedly proving the benefits of male circumcision in reducing the spread of HIV/AIDS in Africa: “The trials were compromised by inadequate equipoise; selection bias; inadequate blinding; problematic randomisation; trials stopped early with exaggerated treatment effects; and not investigating non-sexual transmission.”
Furthermore, the authors discovered that
In the Ugandan male-to-female trial, there appears to have been a 61% relative increase in HIV infection among female partners of HIV-positive circumcised men. Since male circumcision diverts resources from known preventive measures and increases risk-taking behaviours, any long-term benefit in reducing HIV transmission remains uncertain. 
There is also a concern that the procedure itself can spread the disease among participants and their sex partners if it is not performed under completely sterile conditions and combined with qualified followup care.
So is the Great African Male Circumcision Crusade a boon or a boondoggle? In order to cast some light on what appears to an extremely murky and emotional issue, I contacted Dr. Ronald Goldman of the Circumcision Resource Center in Boston to get some hard answers:
Dr. Goldman, a number of sub-Saharan African nations have begun a crash adult circumcision program aimed at drastically reducing the incidence of HIV/AIDS among their populations. Their leaders, encouraged by foreign governments and NGOs, have apparently convinced themselves that a circumcised penis is practically immune to the virus. What effect do you think the mass circumcision of African men will actually have on suppressing the illness?
Many professionals have questioned the reliability and validity of studies claiming that circumcision reduces HIV transmission. African national population surveys in eight countries found a higher rate of HIV infection among circumcised men compared to men who were not circumcised. There are at least 17 observational studies that have not found any benefit from male circumcision in reducing HIV transmission. Therefore, I do not expect a reduction in HIV transmission. It's even possible that the incidence of HIV transmission will increase because the mistaken belief of protection from circumcision will result in more risk-taking sexual behavior.
In the United States particularly, circumcision has long been regarded as a sort of “magic bullet” against disease and a host of other evils. Why do so many health professionals believe the procedure is so beneficial to society as a whole?
Actually, only a relatively few health professionals believe that circumcision has significant health benefits. Most doctors take a neutral approach to circumcision, following the recommendations of the American Academy of Pediatrics. The AAP is considered to be the highest authority on the subject, but their recommendations also have problems. For example, their current policy is not balanced and uses about ten times more space on the "potential benefits" than on the harm. In addition, there are many questions of harm that have not been studied. Because circumcision is common in the United States, there is a strong psychological motivation to believe it is harmless or beneficial.
 Stand proud.
Since circumcision is a religious duty among Jews and Muslims, do you see any religious ramifications to this policy? For example, could non-Muslims see it as a covert conversion campaign, or could the practitioners believe they are performing “God’s will”?
I don't think so. What is covert about the campaign is that circumcision is being promoted by circumcision advocates that have personal, religious, political, and financial conflicts of interest. They intended to find a benefit for circumcision, and they found it. As I have written elsewhere, there is a strong pro-circumcision bias among those who are circumcised, have circumcised sons, belong to circumcised groups, or have performed circumcisions.
What potential drawbacks or side effects do you anticipate from this wholesale circumcision campaign?
Many of the psychological, sexual, and social effects that I discuss in my book, Circumcision: The Hidden Trauma, could become more common as circumcision becomes more common. We expect that though men may choose circumcision now for themselves (based on misinformation about protection from HIV), the campaign is moving toward forcing circumcision on infants who will then have no choice. This is the source of the trauma. Imagine being forcefully held down and having the most sensitive parts of your genitals cut off. Trauma is remembered by the body and has long-term effects. Feelings, attitudes, and behaviors are affected. For example, some men are angry that they are circumcised. Other men are angry and don't know why. That repressed anger has many effects on their lives and the lives of others.
Condoms have proven to be vastly cheaper and far more effective than circumcision when it comes to reducing the spread of HIV/AIDS, and they also reliably prevent other sexually transmitted diseases as well as unwanted pregnancies. Why aren’t the UN and the Western nations showering Africa with condoms instead of removing men’s foreskins in what looks like an unprecedented social engineering experiment?
There is a lot of psychological motivation behind the advocacy of circumcision. Circumcision is traumatic. Psychologists know that there is a compulsion to repeat trauma on others. Some American circumcised men have placed themselves in administrative and research positions where they can act out this compulsion and influence many others to be circumcised. They are simply using the cultural beliefs and values (e.g, medical studies and authorities that claim that circumcision has benefits, etc.) to accomplish their goal.
 South Africa
From South Africa
As most people probably know by now, so-called female circumcision (a.k.a. female genital mutilation or FGM) is a much more radical procedure than the male version, frequently including the excision of the labia and even the clitoris. Do you see a possibility that government and NGO support for male circumcision could potentially water down campaigns targeting FGM?
I do not think so. I point out that the cutting of male and female genitals are qualitatively the same thing. The harm and violation start with the first cut.
If male circumcision is as harmful as you claim, does this mean that all male Jews and Muslims, not to mention tens of millions of Americans, are essentially “damaged goods” when compared to their non-circumcised contemporaries?
What circumcised cultures do not want to know is that a natural body part, in this case a penis, functions better than a surgically reduced one. We do not need studies to know this. It's just common sense. For example, if we cut off the thumb, the functions of the hand would be adversely affected. It's the same for the penis. Most American circumcised men (and doctors) do not know what they are missing. Based on recent reports, circumcision removes up to one-half of the erogenous tissue on the penile shaft, equivalent to approximately twelve square inches on an adult. Medical studies have shown that the foreskin protects the head of the penis, enhances sexual pleasure, and facilitates intercourse. Cutting off the foreskin removes several kinds of specialized nerves and results in thickening and progressive desensitization of the outer layer of the tip of the penis, particularly in older men.
The current African circumcision drive is being generously financed by the UN and WHO, foreign and national governments, and a variety of NGOs. It is big business for those involved and money, as they say, is the root of all evil. Would it be cynical to speak of a “circumcision-industrial complex” at work in Africa?
Certainly money is an important factor. An African official said, "Profiteering has trumped prevention." A WHO researcher said that billions of dollars have been wasted. The focus on circumcision reduces support for more effective measures.
From Swaziland
Has anyone, aside from yourself and a handful of other circumcision skeptics, openly challenged the policy and called for resistance?
There are very reputable researchers who have been published in foreign medical journals because the peer reviewers for circumcision articles submitted to American medical journals are circumcision advocates. They will not approve of an article that is critical of circumcision. The review process is as deeply flawed as the studies that advocate circumcision.
There are other serious problems that prevent a fair and open debate. Circumcision advocates have access to much money, and American media, reflecting the pro-circumcision bias of the culture, routinely ignore stories critical of circumcision and focus on reports of circumcision "benefits." Journalist regularly violate their professional principles and obligations to report different views on this controversy.
 Botswana circumcision
From Botswana
Finally, circumcision advocates are afraid to debate circumcision critics. This shows up at professional conferences where critics are not provided equal opportunity to participate. The upcoming international AIDS conference will include a one-sided commercial for circumcision. The lack of debate is also apparent in the media. For example, two circumcision advocates refused to debate me on two radio talk shows.
If the circumcision program is indeed misguided, what alternative advice would you give to African governments seeking a viable solution to the HIV/AIDS crisis?
Most HIV infection in Africa are transmitted by contaminated injections and surgical procedures. The advice is simple: sterilize any instrument that will be used on a person's body. Condoms are better than 99% effective, less invasive, and the cost of one circumcision in Africa can pay for 3000 condoms. Unlike circumcision, condoms also have the advantage of also protecting women, and there are no surgical risks and complications. Even the pro-circumcision studies recommend using condoms in addition to circumcisions. With a condom, circumcision adds no significant additional protection value even if the advocates' protective claims for circumcision without condoms are true.
Ronald Goldman, Ph.D. is a psychological researcher, educator, and Executive Director of the Circumcision Resource Center in Boston, a nonprofit educational organization. Dr. Goldman is internationally known for his work on circumcision and is the author ofCircumcision: The Hidden Trauma and Questioning Circumcision: A Jewish Perspective. He gives lectures on the psychosocial aspects of circumcision, counsels parents and circumcised men, and has participated in over two hundred interviews with broadcast and print 

Zimbabwe: Concern over high HIV rates among circumcised males Read the original article on : Zimbabwe: Concern over high HIV rates among circumcised males

By Janet Shoko

Health officials in Zimbabwe are worried that the massive drive to have 1, 2 million men circumcised by 2015 might backfire following indications that HIV prevalence is high among men that have undergone the procedure.

According to research, circumcision reduces the transmission of the HIV virus by 60 percent among heterosexual men.

But the latest Zimbabwe Health Demographic Survey (ZHDS 2010/2011), indicates that the HIV prevalence rate among circumcised men is 14 percent and 12 percent among the uncircumcised.

The findings are for circumcised males between the ages of 15 and 49.

This is blamed on the misconception that circumcision completely shields people from HIV infection.

Circumcision is free at Zimbabwe government health centers to promote the HIV prevention method.

National Aids Council (NAC) public health officer Blessing Mutede said authorities were concerned about the high rate of infection among the circumcised.

Health officials say most men, after circumcision, harbour the false impression that they have been equipped with an invisible condom.

"It is a worrying development that at a time when we are promoting male circumcision as a preventive measure to combat HIV, we are recording a high prevalence rate amongst the group that has been circumcised largely due to uninformed risky compensatory behaviours," Mutede said.

In a survey, a sample of 5 650 men aged between 15 and 49 were tested for the deadly HIV.

 Official figures indicate that the southern Africa country has carried out about 70 000 circumcisions since the programme began in 2009.

To date more than 70 lawmakers have volunteered to go under the knife to show their commitment to fighting the killer disease.

Infection in Zimbabwe runs at about 13 % of the population but rises above 20 % in the teens to early 30s age group.

On Wednesday, it was reported that condom users in Zimbabwe were in danger after it emerged that equipment used to test the quality of condoms was out-dated and no longer had capacity to produce accurate results.

Medicines Control Authority of Zimbabwe director, Gugu Mahlangu said the "equipment was 15 years old"


"We are supposed to test 6-8 sample batches of condoms with the air inflators but at the end we only test three batches because of the backward technology"  she said.

Source: The African Report

When Bad Science Kills, or How to Spread AIDS

A fatal irony: Why the “circumcision solution” to the AIDS epidemic in Africa will increase transmission of HIV

Step 1. How not to design or conduct an experiment

A handful of circumcision advocates have recently begun haranguing the global health community to adopt widespread foreskin-removal as a way to fight AIDS. Their recommendations follow the publication of three [1] randomized controlled clinical trials (RCCTs) conducted in Africa between 2005 and 2007.
These studies have generated a lot of media attention. In part this is because they supposedly show that circumcision reduces HIV transmission by a whopping 60%, a figure that wins the prize for “most misleading possible statistic” as we’ll see in a minute. Yet as one editorial [2] concluded: “The proven efficacy of MC [male circumcision] and its high cost-effectiveness in the face of a persistent heterosexual HIV epidemic argues overwhelmingly for its immediate and rapid adoption.”
Well, hold your horses. The “randomized controlled clinical trials” upon which these recommendations are based (I use scare quotes deliberately) represent bad science at its most dangerous: we are talking about poorly conducted experiments with dubious results presented in an outrageously misleading fashion. These data are then harnessed to support public health recommendations on a massive scale whose implementation would almost certainly have the opposite of the claimed effect, with fatal consequences. As Gregory Boyle and George Hill explain in their exhaustive analysis of the RCCTs:
While the “gold standard” for medical trials is the randomised, double-blind, placebo-controlled trial, the African trials suffered [a number of serious problems] including problematic randomisation and selection bias, inadequate blinding, lack of placebo-control (male circumcision could not be concealed), inadequate equipoise, experimenter bias, attrition (673 drop-outs in female-to-male trials), not investigating male circumcision as a vector for HIV transmission, not investigating non-sexual HIV transmission, as well as lead-time bias, supportive bias (circumcised men received additional counselling sessions), participant expectation bias, and time-out discrepancy (restraint from sexual activity only by circumcised men).
That’s a whole laundry list of issues, so let me highlight a few of the more egregious. First, consider the “lack of placebo control.” What does that mean? Normally, when you’re trying to determine whether some medical intervention has a disease-fighting effect specific to its own (hypothesized) mechanisms—and over and above the placebo baseline—you have to have a control group. That group gets a dummy intervention, and nobody is supposed to know which participants were exposed to the actual treatment until after the results are in.

 After all, if someone knows (or thinks) that they’re getting a great big helping of medicine, they might act in various ways—whether consciously or unconsciously—that have the effect of generating positive health outcomes but which have nothing to do with the intervention itself. In the case of circumcision, however, there’s no way not to know if you’ve received the “medicine”—you have to go through a whole surgery and then you don’t have a foreskin anymore—so this basic condition of a true clinical trial is violated in the first instance.

But that’s just the tip of the iceberg. As Boyle and Hill point out, the men who were circumcised got additional counseling about safe sex practices compared to the control group, and then they had to refrain from having sex altogether for the simple reason that their lacerated penises had to be wrapped in bandages until their wounds healed – leading to what Boyle and Hill refer to as “time-out discrepancy” in the quote above. By contrast, the non-circumcised men got to keep having sex during the full two month period during which the treatment group was in recovery mode. Then, mystery of mysteries, the trials were stopped early. These issues pose serious problems for the scientific credibility of the studies. Taken together with the other flaws, here is why:

Let’s assume for a second that the circumcised men really did end up getting infected with HIV at a lower rate than the control-group men who were left intact—even though, as we will see in a moment, we have very little reason to believe that this is so. Why might that outcome have happened?

If you answered, “Because those men knew they were in the treatment group in the first place, had less sex over the duration of the study (because they had bandaged, wounded penises for much of it), and had safer sex when they had it (because they received free condoms and special counseling from the doctors), thereby reducing their overall exposure to HIV compared to the control group by a wide margin” then you are on the right track.

Step 2. How not to report results Now why should we doubt that the circumcised men actually did have a lower rate of HIV infections in the first place, poor experiment design notwithstanding, as I suggested in the paragraph above? After all, the 60% figure that’s being thrown around in media reports is a pretty big number, and it can’t be off by that much, even if the studies had some flaws, right? Not so fast. Do you know what the “60%” statistic is actually referring to? Boyle and Hill explain:
What does the frequently cited “60% relative reduction” in HIV infections actually mean? Across all three female-to-male trials, of the 5,411 men subjected to male circumcision, 64 (1.18%) became HIV-positive. Among the 5,497 controls, 137 (2.49%) became HIV-positive, so the absolute decrease in HIV infection was only 1.31%. 
That’s right: 60% is the relative reduction in infection rates, comparing two vanishingly small percentages: a clever bit of arithmetic that generates a big-seeming number, yet one which wildly misrepresents the results of the study. The absolute decrease in HIV infection between the treatment and control groups in these experiments was a mere 1.31%, which can hardly be considered clinically significant, especially given the numerous confounds that the studies failed to rule out.

Step 3. How not to make public health recommendations

So far we have been discussing problems with the experiments themselves—what’s called “internal validity” in technical terms. I really want you to read the Boyle and Hill paper here, because they go into painstaking detail about each of a long parade of flaws I can’t hope to cover in one blog post. I mean, there are a lot of flaws. Please read the paper. But let’s switch gears now and talk about the flip-side of things, or what’s called “external validity” – that is, problems with taking what you’ve (supposedly) found in a (relatively) controlled setting like an experiment and applying it to the chaotic mess that is the real world.

Lawrence Green and his colleagues published an important article on just this topic as it relates to “the circumcision solution” in the American Journal of Preventative Medicine. “Effectiveness in real-world settings,” they sensibly point out, “rarely achieves the efficacy levels found in controlled trials, making predictions of subsequent cost-effectiveness and population-health benefits less reliable.” Some major issues with trying to roll-out circumcision in particular include the fact that the RCCT participants—who were not representative of the general population to begin with—had (1) continuous counseling and yearlong medical care, as well as (2) frequent monitoring for infection, and (3) surgeries performed in highly sanitary conditions by trained, Western doctors. All of which would be unlikely to replicate at a larger scale in the parts of the world suffering from the worst of the AIDS epidemic. And of course, circumcisions carried out in un-sanitary conditions (that is, the precise conditions that are likelier to hold in those very places) carry a huge risk of transmitting HIV at the interface of open wounds and dirty surgical instruments. So this is a serious point. What should we conclude? Green et al. get it right: “Before circumcising millions of men in regions with high prevalences of HIV infection, it is important to consider alternatives. A comparison of male circumcision to condom use concluded that supplying free condoms is 95 times more cost effective.” And not only more cost effective, but also more effective—period—in slowing the spread of HIV. Condoms are cheap, easy to distribute, do not require the surgical removal of healthy genital tissue, and—yes—are much, much, much, much more effective at preventing infections. Compare. Condoms: 80% minimum reduction in HIV infection [3]. Circumcision: clinically insignificant absolute reduction, according to the most optimistic presentation of data from three deeply flawed studies. There is no contest.

Step 4. This is serious business

The worst part about all of this is not just that the science behind “the circumcision solution” is so shaky, but that the actual implementation of these recommendations—so vociferously pushed-for by the circumcision advocates doing this research — would very likely lead to more HIV infections, not less. The big idea here is “risk compensation” – the subject of an excellent paper by Robert Van Howe and Michelle Storms. Risk compensation occurs when people believe they have been provided additional protection (wearing safety belts) [such that] they will engage in higher risk behavior (driving faster). As a consequence of the increase in higher risk behavior, the number of targeted events (traffic fatalities) either remains unchanged or [actually] increases. They argue: Risk compensation will accompany the circumcision solution in Africa. Circumcision has been promoted as a natural condom, and African men have reported having undergone circumcision in order not to have to continually use condoms. Such a message has been adopted by public health researchers. A recent South African study assessing determinants of demand for circumcision listed “It means that men don’t have [to] use a condom” as a circumcision advantage in the materials they presented to the men they surveyed. [Yet] if circumcision results in lower condom use, the number of HIV infections will increase. [Citations can be found in the original paper.] In Uganda, as Boyle and Hill uncovered, the Kampala Monitor reported men as saying, “I have heard that if you get circumcised, you cannot catch HIV/AIDS. I don’t have to use a condom.” Commenting on this problem, a Brazilian Health Ministry official stated: “[T]he WHO [World Health Organization] and UN HIV/AIDS program … gives a message of false protection because men might think that being circumcised means that they can have sex without condoms without any risk, which is untrue.” Van Howe and Storms spell this all out: How rational is it to tell men that they must be circumcised to prevent HIV, but after circumcision they still need to use a condom to be protected from sexually transmitted HIV? Condoms provide near complete protection, so why would additional protection be needed? It is not hard to see that circumcision is either inadequate (otherwise there would be no need for the continued use of condoms) or redundant (as condoms provide nearly complete protection). The argument that men don’t want to use condoms needs to be addressed with more attractive condom options and further education: [they need to be told] that sex without a condom and without a foreskin is potentially fatal, while sex with a condom and a foreskin is safe. No nuance is needed. Offering less effective alternatives can only lead to higher rates of infection. Their conclusion? Rather than wasting resources on circumcision, which is less effective, more expensive, and more invasive, focusing on iatrogenic sources and secondary prevention should be the priority, since it provides the most impact for the resources expended. That is my conclusion as well. In this article I have focused on just the science behind—and claimed public health benefits of—“the circumcision solution” and shown how truly weak they are. I’ve completely ignored the attendant ethical issues, though I discuss these here and here. The studies we’ve looked at, claiming to show a benefit of circumcision in reducing transmission of HIV, are paragons of bad design and poor execution; and any real-world roll-out of their procedures would be very difficult to achieve safely and effectively. The likeliest outcome is that HIV infections would actually increase—both through the circumcision surgeries themselves performed in unsanitary conditions, and through the mechanism of risk compensation and other complicating factors of real life. The “circumcision solution” is no solution at all. It is a waste of resources and a potentially fatal threat to public health.

Boyle, G. J. and Hill, G. (2011). Sub-Saharan African randomised clinical trials into male circumcision and HIV transmission: Methodological, ethical and legal concerns. Journal of Law and Medicine. Available as a PDF here.
Green et al. (2010). Male circumcision and HIV prevention: Insufficient evidence and neglected external validity. American Journal of Preventative MedicineAvailable as a PDF here.
Van Howe, R. S. and Storms, M. (2011). How the circumcision solution in Africa will increase HIV infections. Journal of Public Health in AfricaAvailable as a PDF here. 
Darby, R. and Van Howe, R. (2011). Not a surgical vaccine: There is no case for boosting infant male circumcision to combat heterosexual transmission of HIV in Australia.Australian and New Zealand Journal of Public HealthAvailable here.
Green, L., McAllister, R., Peterson, K., and Travis, J. (2008). Male circumcision is not the HIV “vaccine” we have been waiting for. Future MedicineAvailable as a PDF here. A short, readable editorial.
I also recommend Zabus, Chantal (Ed.) (2008). Fearful symmetries: Essays and testimonies around excision and circumcision. Available from here.

[1] Auvert B, Taljaard D, Lagarde E et al, “Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: The ANRS 1265 Trial” (2005) 2(11) PLoS Med e298; Bailey RC, Moses S, Parker CB et al, “Male Circumcision for HIV Prevention in Young Men in Kisumu, Kenya: A Randomised Controlled Trial” (2007) 369(9562) Lancet 643; Gray RH, Kigozi G, Serwadda D et al, “Male Circumcision for HIV Prevention in Men in Rakai, Uganda: A Randomised Trial” (2007) 369(9562) Lancet657.
[2] Halperin DT, Wamai RG, Weiss HA, et al. Male circumcision is an effıcacious, lasting and cost-effective strategy for combating HIV in high-prevalence heterosexual epidemics: the time has come to stop debating the basic science. Future HIV Ther 2008;2(5):399 – 405.
[3] Weller SC and Davis-Beaty K, “Condom Effectiveness in Reducing Heterosexual HIV Transmission” (2002) 1 Cochrane Database of Systematic Reviews Art No CD003255.

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