Behavioral factors are far more important risk factors than circumcision status.
Studies in Africa claim that adult male circumcision significantly reduces the risk of men acquiring HIV. Many professionals question the reliability and validity of these studies. However, some others take the leap of recommending adult male circumcision as an HIV prevention strategy in Africa for up to 38 million men. Publishing such a report in the United States appears to support the American cultural practice of circumcision. Such judgments are dangerous.
Even if the claim were true, based on the rate of infection in the studies, about 60 men had be circumcised to prevent one HIV infection. The other 59 men did not receive any benefit. However, based on another African report, men circumcised in Africa could be subject to a complication rate of 35% for a traditional circumcision or 18% for a clinical circumcision.
The methods used in the studies were flawed. The effects of other variables that would influence HIV infection were not considered, and critical data were omitted. For example, the HIV status of the female partners of the men in the studies was not determined.
Because it was not known which infections were heterosexually transmitted, the effect of circumcision on the rate of heterosexually transmitted HIV could not actually be determined. The investigators did not seek to determine the source of the HIV infections during their studies. They assumed all infections were heterosexually transmitted when some infections were transmitted heterosexually and some were not. Most HIV infections in Africa are transmitted by contaminated injections and surgical procedures. (See first off site link below.)
The studies were not consistent with other evidence. 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. Among developed countries, the United States has the highest circumcision rate and the highest rate of heterosexually transmitted HIV. Other countries have lower rates of HIV infection than the United States and do not practice circumcision.
Other studies show that condoms are better than 99% effective. That's why the American Medical Association states that "behavioral factors are far more important risk factors for acquisition of HIV and other sexually transmissible diseases than circumcision status, and circumcision cannot be responsibly viewed as 'protecting' against such infections."
Using or promoting unnecessary surgery when much less invasive, much less costly, and much more effective methods are available (e.g., condoms) raises ethical concerns and conflicts with common sense. The cost of one circumcision in Africa can pay for 3000 condoms. Significantly, the studies recommend the use of condoms in addition to circumcision. Because of the superior effectiveness of condoms, circumcision adds little additional protection. Unlike circumcision, condoms also have the advantage of also protecting women, and there are no surgical risks and complications.
If circumcision results in lower condom use, the rate of HIV infections will increase. Unfortunately, with the promotion of circumcision as a "natural condom," some African men have chosen circumcision with the mistaken belief that they will not have to use condoms. In addition, circumcision with instruments that are not sterilized would also increase the transmission of HIV.
The studies did not account for cultural bias on the part of researchers. The lead researchers of the studies are known circumcision advocates. They published previous work that proposed circumcision to reduce HIV infections. Research careers, reputations, and associated funding depended on producing studies with positive results. They found what they were looking for.
The flawed African adult studies cannot be applied to American infants because of the difference between the two groups. Because sexually transmitted diseases obviously cannot be transmitted until an individual engages in sexual activity, a male may make a decision to be circumcised when he is older without losing this claimed "benefit." If you were an adult male and had the option of using a condom and getting virtually assured protection or having part of your penis cut off to get a one in 60 chance of protection, the choice is clear. Furthermore, by the time today's newborn boys become sexually active, HIV vaccine may be available.
American pro-circumcision researchers have found dozens of "benefits," from treating epilepsy and masturbation in the late 1800s to preventing sexually transmitted diseases today. Though such claims generally do not withstand scrutiny by medical policy committees, their continued publication over the years has led to medical myths while raising questions about some researchers' motives. American researchers tend to avoid studying or acknowledging the sexual and psychological harm associated with circumcision. This pro-circumcision bias in American medicine reflects the pro-circumcision bias in American culture. The United States is the only country in the world that circumcises some of its male infants for non-religious reasons. When Europeans learn about this, they think we're crazy.
Knowledge of studies on circumcision harm is important to properly evaluating advisability. There is strong evidence that circumcision is overwhelmingly painful and traumatic. Some infants do not cry because they go into shock. Infants exhibit behavioral changes after circumcision. Changes in pain response have been demonstrated at six months of age, evidence of lasting neurological effects and a symptom of post-traumatic stress disorder. Anesthetics, if used, do not eliminate circumcision pain.
The common American belief is that the foreskin has no value. That's because 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.
In a survey of men who were circumcised after they became sexually active, there was a reported decrease in sexual enjoyment after circumcision. One described it as like seeing in black and white compared to seeing in color. If you have less, you feel less. A study showed that circumcision removes the five most sensitive parts of the penis. (For this reason, many circumcised men are reluctant to use condoms because it contributes to further decreased sensation. Reduced condom usage adversely affects the HIV infection rate.) In a survey of those with comparative sexual experience, women preferred the natural penis over the circumcised penis by 6 to 1.
Surveys of circumcised men and clinical reports show that when men recognize their loss due to circumcision and experience associated decreased sexual sensitivity, they report wide-ranging psychological consequences. Most circumcised men seem satisfied because they may not understand what circumcision is and the benefits of the foreskin, they may not be aware of certain feelings and their connection to circumcision, or they may be afraid of disclosing these feelings.
For American society, circumcision is a solution in search of a problem, a social custom disguised as a medical issue. Beware of culturally-biased studies on circumcision posing as science, and take your whole baby home.
References are available upon request: http://www.circumcision.org/hiv.htm