Science moves on bodies of evidence

I’ve long made the point that science moves on bodies of evidence, not individual studies. If you don’t have repeatable data, then you don’t have much of anything. This is why the media is frequently so bad when it comes to reporting on recent studies; they report (or at least imply) individual study results as conclusions that are being made by the scientific community at-large. The truth is usually more like, one group of researchers found some interesting results.

And with that in mind, I turn to one of my favorite topics in science, circumcision. My numerous posts are easily searchable, so I won’t bother to link them, but for those who are unfamiliar with my stance, let me be clear: I am hugely in favor of circumcision because the science is in – circumcision saves lives. Furthermore, there is a very clear body of evidence that circumcision does not decrease sensitivity or sensation. In fact, a recent study found just the opposite:

Of 454 circumcised men, 362 (80%) returned for a follow-up visit 6 to 24 months after VMMC (voluntary medical male circumcision). Almost all (98%) were satisfied with the outcome of their VMMC; most (95%) reported that their female partners were satisfied with their circumcision. Two thirds (67%) reported enjoying sex more after VMMC and most were very satisfied or somewhat satisfied (94%) with sexual intercourse after VMMC. Sexual function improved and reported sex-induced coital injuries decreased significantly in most men after VMMC.

For someone like me who is greatly in favor of circumcision, this is great news. While it is only a survey study rather than a research study, it still provides evidence that circumcision is even better than the scientific community thought. However, that’s just not how science moves. Find me another several dozen studies like this using a variety of methods, and if they show a trend that confirms the results here, then I’ll start believing it. But as things stand now? I can’t make the leap. There is a standing body of evidence that says circumcision doesn’t affect sensitivity or sensation one way or the other; for every study that reports positive results, there’s one that reports negative results (and more often, studies report mixed or push results).

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Why circumcision is a very good thing

I’ve written numerous posts about circumcision and its benefits, but I want to write one more big one. My goal here is to gather together all the relevant information to the debate in one place. Certain myths need to be dispelled in some places while the details of arguments need to be laid out with ridiculous clarity; the anti-circumcision crowd is as stubborn as young Earth creationists. As such, this post isn’t so much directed towards the entrenched anti-circumcision folk as it is towards the people on the fence. Perhaps there are a few people out there who have simply bought into easy arguments, and so their commitment to their position can be swayed. I would equate these people with the occasional church patron that grows up learning the Universe is 6,000 years old, only to later shed that false belief when engaged on the matter. I hope I’m able to adequately mount a defense of circumcision and change the minds of any such people who end up reading this post.

There are several topics that should be addressed when discussing circumcision. Safety, efficacy, and ethics are the broad categories, and each one contains its share of details. Let’s start with safety.

Safety:

As with any surgery, complications are possible. The most common complication due to circumcision is minor bleeding, which can be fixed with a little bit of gauze. Infections occasionally happen, but they’re rare. Circumcision should always be done under sterile conditions to maintain this rarity. (That means the Rabbis and other non-medical professionals out there who do these things need to be stopped.)

Pain and Trauma:

A favorite of the anti-circumcision crowd is to find awful looking restraining devices doctors use to keep infants steady. Aside from the fact that those devices aren’t the iron maidens people make them out to be, circumcision needn’t be painful in the least. Any search will find a mix of estimates for how frequently anesthesia is used during circumcisions, but it is certainly used a majority of the time, and its use is always increasing. Any parent worried about the pain their baby may feel can simply request anesthesia be used. This 100% addresses any pain argument the anti-circumcision crowd wants to raise. Indeed, it also addresses any trauma argument they wish to raise, but it isn’t necessary for that purpose. Trauma is something which has lasting physical or psychological damage. Since no infant can possibly remember being circumcised, there’s no way any amount of pain could be traumatic here. Moreover, the pain of being squeezed through a vaginal canal just days earlier is clearly much more significant than any minor medical procedure.

Nerve Ending Hypothesis:

There is a popular hypothesis that because the foreskin has 10,000 to 20,000 nerve endings, any removal of it must affect sensitivity. It makes sense and it’s worth investigating. Unfortunately, it’s that investigation aspect that many in the anti-circumcision crowd don’t like; for many, the hypothesis is conclusive. Occasionally, though, they may point to a study or two they incidentally find – so long as it supports their beliefs, of course. These studies (which are usually actually just subjective surveys) sometimes indicate decreased sensitivity in circumcised men. Other times, they show just the opposite. (The anti-circumcision crowd ignores those.) Mostly, though, they show statistically insignificant differences. Moreover, the better studies and meta-analyses out there show the same wash. Since science operates on bodies of evidence rather than individual studies – if you can’t repeat your data, it’s bullshit – the correct conclusion here is that not only is there no body of evidence that circumcision decreases sensitivity, but there is actually an active body of evidence which shows it has no effect.

Efficacy:

This is where the majority of this debate centers. It isn’t enough to look at all the evidence and conclude that circumcision is low-risk, painless, non-traumatic, and inconsequential in sexual sensitivity and performance. That’s all great, but none of that adds up to a reason to circumcise someone, much less to implement it as a public health policy. What we need is data which show circumcision offers some sort of benefit. You’ll never guess what we’ve had for the better part of a decade.

Three randomized control studies were undertaken and completed between 2005 and 2007. These studies looked at the effect of circumcision on HIV transmission rates from women to men during heterosexual intercourse. (Prior to these studies there was a body of observational studies which indicated a likely link between circumcision and HIV, but it wasn’t nearly concrete enough to enact any type of policy.) These studies concluded that circumcision significantly reduces HIV transmission in the aforementioned context; one study went so far as to compare the reduction to what would be achieved by “a vaccine of high efficacy”. Between the studies, the relative risk reduction was 60%.

Relative versus Absolute

For some time I had an anti-circumcision troll around here. He enjoyed raising the issue of relative risk versus absolute risk. I’m not sure he understood the difference, though. Whereas the relative risk reduction for circumcised males was found to be 60%, the absolute risk reduction is between 1.3% and 1.8%. Choosing the latter of these numbers is a good way to muddle the discussion. Here’s what these numbers mean.

Relative risk reduction is how much a given treatment, behavior, or characteristic reduces a given risk in one group versus another. This is the number that matters most of the time in lay terms. Absolute risk reduction, on the other hand, looks at an entire population and takes into account its susceptibility to some given condition. For instance, most people aren’t going to get the flu. It doesn’t matter whether a person has the vaccine or not. Odds are low that he or she will catch anything. That’s why anti-vaccine quacks love to use absolute numbers. The flu vaccine is generally somewhere near 60% effective, but absolute numbers are closer to 1.5%. That isn’t an argument against getting vaccinated, though.

Problems with the Studies

The three aforementioned studies were robust and have been largely accepted by the scientific community. The WHO, UNAIDS, the CDC, the Bill and Melinda Gates Foundation, and a dozen and a half African health ministries have all embraced their results. Of course, that isn’t going to stop the anti-circumcision crowd from coming up with something to question. Most commonly, the issues raised are non-issues. For instance, I’ve frequently seen the point raised that condoms are more effective. This is like when a creationist tries to argue against evolution by talking about the Big Bang. It just isn’t on topic. Other issues include the region where the studies took place, the early termination of the studies, and control and intervention groups being treated differently. Let’s start with where these studies took place.

It should first be noted that, as I mentioned earlier, there is a large body of observational studies on the effectiveness of circumcision in HIV transmission reduction. This body is global; what it indicated panned out in these trials. Second, Africa is massive. Uganda and Kenya are neighbors, but South Africa isn’t even close. These places have commonalities, but they are also significantly different in a host of aspects, including culturally. Repeated results across a wide swath of area cannot be simply dismissed out of hand: the limited region of each individual study could be a confounding factor, but when taken as a whole, the studies necessarily reduce any potential confounding factor due to regional affect.

Each study was halted early on ethical grounds. The results were so overwhelming, the monitoring boards for each study had no choice but to put an end to the trials and recommend that all the uncircumcised men be circumcised. Regardless, the studies still all lasted between about a year and a half and two years. Potential bias as a result of these abrupt endings were taken into account. From the Kenya study:

Because the Data and Safety Monitoring Board recommended to stop the trial after the intermediate analysis, it was not possible to follow all the participants as initially planned, and, as a consequence, only those participants recruited at the beginning had a full follow-up. This potential bias was taken into account by adjusting the analysis for the recruitment period; such an adjustment cannot fully account for the confounding effect associated with partial follow-up. When restricting the analysis to those participants who had a full follow-up, the intervention had an effect that was similar in size and significance, suggesting that this potential bias had a negligible impact.

Another common complaint is that a large number of participant follow-ups were lost due to the early terminations. The effect was likely negligible since the numbers actually weren’t that significant for these type of studies, plus many of the follow-ups were actually lost for reasons unrelated to HIV infection (such as moving from the area). Knowing this is one of the benefits of having actually read the studies rather than agenda-driven websites.

Finally, I frequently come across Internet comments that declare the control and intervention group were treated differently. The claim is that the intervention (circumcised) group was given education, condoms, and counseling over and above what the control group was given. This is simply a lie. I’m not sure of its origin, but I’ve seen it enough that I feel it deserves to be killed. The groups were given and/or offered consistent treatment. The only reason to say otherwise is for the same reason Lyndon Johnson told one of his aides to spread the story that one of his opponents fornicated with pigs. He knew it wasn’t true, but if he could make the other guy deny it, he would be giving it credence by simply addressing it. As usual, I’m willing to forgo the public perception in favor of assuming a literate readership.

How It Works

The evidence is in when it comes to circumcision, but how it works is still up for question. One hypothesis says that the foreskin offers a relatively damp environment that is friendly to various pathogens. Another hypothesis says that Langerhans cells are a target of HIV, causing them to act as a vector. Since the relatively thin foreskin has these cells, that means there is an increased surface area and number of these cells where HIV can attach.

Other Benefits

Circumcision has been found to have a host of other health benefits (.pdf). UTI’s are decreased among newborns, penile cancers are reduced, general infections are reduced, and HPV is 30% less prevalent. One study from 1954 to 1997 that looked at cases of invasive penile cancer found that 87 out of 89 (98%) of the men were uncircumcised. Other studies have found a 30% decrease in contracting herpes.

Developed World Efficacy

The CDC has recently come out as endorsing circumcision has a healthy decision for parents to make. It’s a one time cost for a procedure with a low incidence rate of what are only minor complications anyway. The child feels no pain, there is no trauma, sensation isn’t affected at sexual maturation, and a host of diseases are reduced. If the CDC didn’t stop short of recommending circumcision as a health policy for political reasons, then they only did it because STD’s are not an epidemic in the United States. But, then, neither is the flu.

Condoms and Hygiene

The anti-circumcision crusader may get to this point and say, “Fine, even if everything to this point is true, it’s still undeniable that condoms, education, and basic hygiene can best take care of the major health issues raised here where Africa is concerned.” And that’s fair enough. Condoms are 97-99% effective at preventing sexual transmitted diseases. Retracting the foreskin and washing with soap and water will prevent most (maybe even all) infection. But this is a poor understanding of reality.

Let’s start with condom use. Even with wide spread education campaigns, millions of Americans have unprotected sex with untested partners every single day. STD’s are still transmitted here and teen pregnancy (and other unintended pregnancies) still exist. It strikes me as near-racist to assume that we can throw education and condoms at people in Africa and get great results. They aren’t monkeys we first worlders get to train. People in Africa will largely behave how people around the globe behave. Some will use condoms. Some won’t. Some will be willing but unable. Sometimes people run out of condoms and want to have sex. Sometimes they will have sex where they don’t happen to keep their condoms. Sometimes they want to take a risk because it feels better. The “they” here is global.

It’s obviously true that condoms and education are key components in the fight against HIV. However, we should never limit ourselves to one option simply because it may be the most effective option. This fight isn’t a zero sum game; we can – and should – use every tool available. Doing so will literally save lives.

As for hygiene, even with rigorous cleaning practices, infections can still happen. I have a friend who got circumcised in his early 20’s for this exact reason. He showered every day and was specific about his cleaning regimen, but he still had issues. That won’t be the case for everyone, but it will certainly be the case for many. It’s far easier to entirely prevent this issue after birth than to force men to see doctors later in life for something that needn’t be an issue.

Ethics

The anti-circumcision crowd has lost on the scientific front. Circumcision protects against HIV and other STD’s. It reduces penile cancers and other infections. It doesn’t hurt and it doesn’t alter sensitivity. Aside from the minor risks of surgery (which exist largely by virtue of what surgery is in the first place), it literally has zero physiological drawbacks. That leaves the anti-circumcision folks with limited recourse in the debate. Enter the ethical argument.

There is effectively only one ethical argument against circumcision. It isn’t a good one, but it does have a basis in established ethical theory. However, before I address that argument, I want to address a common philosophical argument I hear. It isn’t technically about ethics, but we’re in the same ballpark. It’s the argument that says removing the foreskin in order to protect against disease is like removing a foot to prevent foot cancer or gout. Eventually, the argument usually ends with the suggestion of death in order to prevent all disease. Even without the especially absurd end, this is nothing more than an argumentum ad absurdum. Removing a piece of skin which has no discernible function and the loss of which has no negative consequence is not the same as removing a significant body part or altering the body in a way which affects quality of life negatively.

The primary ethical argument against circumcision – the argument from bodily autonomy – is slightly better. This argument says that it is wrong to permanently alter a person’s body without their consent for non-medically necessary reasons. That means a haircut is fine, or even a piercing (though there may be other objections to the latter). Indeed, any life-saving procedure is allowed under this argument. Like with most ethical arguments, there will be examples that raise gray areas (and those will generally come down to personal judgement calls more than anything), but there are certain things that are black and white. Tattooing one’s infant wouldn’t be allowed, for example. The child necessarily cannot consent and the procedure is absolutely not medically necessary, so there is not justification for it.

With circumcision, it is true that the procedure is not medically necessary. All the benefits laid out above are still very much true, but that doesn’t make the procedure necessary. A person who doesn’t get circumcised can live a perfectly happy life, free from all sexually transmitted diseases and infections. Indeed, billions have done and are currently doing it. Furthermore, it cannot be reversed. Once that foreskin is gone, it’s gone. Some people will say it can be returned, but it will simply be extra skin, at best.

Now let’s make a comparison.

Vaccines are some of the greatest achievements of science. Everyone should get at least the basic vaccines we expect people in the 21st century to have. And for those who live in certain areas or travel to certain areas, a number of other vaccines are recommended. For instance, I have a vaccine for yellow fever because I visited Tanzania about 5 years ago. If I visit any similarly at-risk location 5 years from now, I’ll get a booster shot first. All that said: vaccines are not medically necessary. Again, they’re fantastic and everyone should get them. Public policy should dictate all students must get them. These are things which save lives. But, again, they are not medically necessary. Even when polio was a significant public health concern, very few people actually died from the disease. Only a small minority of the population ever contracted it, and of that small minority, only a minority became sick at all. It was great when a vaccine became widely available. Lives were saved. But being unvaccinated did not put someone at active risk of sickness or death; being unvaccinated was a passive risk. This exactly mirrors the issue with circumcision. Furthermore, vaccines cause permanent change to the body via the addition of anti-bodies. This again mirrors the permanent change of circumcision.

The first counter to this comparison is generally to note that anti-bodies aren’t a visible change whereas removal of the foreskin is. The argument from bodily autonomy makes no such exception. The argument doesn’t say it’s wrong to permanently alter a person’s body without their consent unless you totally can’t see it. That would entirely gut the argument, making it into nothing more than a cosmetic argument. Something so superficial doesn’t pass any sort of ethical muster in my book. Besides, I’m not so sure the anti-circumcision crowd should be making a cosmetic argument anyway.

The second counter to the circumcision-vaccine comparison is to note that whereas vaccines add something to the body, circumcision actually removes something. I suppose that’s true, but I don’t see where such a distinction would matter within the argument from bodily autonomy. We can no more rid ourselves of anti-bodies than we can rejuvenate foreskin.

Before I reach the end of this post, I want to quickly recap the argument from bodily autonomy. The argument says it’s wrong to permanently alter a child’s body without his consent unless it’s for a medically necessary procedure. Neither circumcision nor vaccines are medically necessary. Both are highly effective and both save lives. Without either, we would have fewer people in the world, that’s for sure. However, neither one is required to live a long, happy, and healthy life. This, of course, is not an argument against either one. This is an argument against this incantation of the argument from bodily autonomy. That isn’t to say bodily autonomy isn’t important. It is. But it isn’t an argument that works under the auspices of libertarian ethics as applied to global health issues. That is, bodily autonomy is important because it is the best way to protect the individual and populations at-large; it isn’t important in and of itself/because it maintains liberty. (Dead people don’t have liberty.) Or to put it another way, bodily autonomy only works under a utilitarian framework.

Conclusion

This one is simple. Circumcision is a safe procedure that needn’t cause pain, doesn’t cause trauma (indeed, it can’t cause psychological trauma by definition), and it doesn’t affect sexual sensitivity, satisfaction, or performance. Furthermore, it reduces female-to-male HIV transmission, invasive penile cancers, UTI’s, STD’s, and general infections. Along with education and condom use, circumcision is a phenomenal tool in the fight against HIV; circumcision literally saves lives. The World Health Organization, UNAIDS, the Bill and Melinda Gates Foundation, a dozen and a half African health ministries, the CDC, and the AAP all support it as good health practice. The science and the ethics are in: Excepting for the minor (and rare) risks inherent with surgery by virtue of what it is, there are literally zero drawbacks to circumcision; when performed under sterile conditions and by medical professionals, circumcision increases the odds a boy will have a disease and infection free life.

Circumcision: The evidence still isn’t vanishing

Increasingly, circumcision is becoming a health policy in places where it is needed most. WHO, UNAIDS, and especially The Bill and Melinda Gates Foundation are some of the groups are the forefront of this fight against deadly diseases and infections. More recently we’ve seen American groups such as the American Academy of Pediatrics come out in favor of circumcision. This is in large part due to three extremely strong studies that came out in 2006, but those were really just the final straw. Evidence has been building for the effectiveness of circumcision in fighting disease and infection since the late 70’s, and more specifically it has been building against fighting HIV since the late 80’s. The evidence is in: Circumcision helps protect against infections, penile cancer, and STD’s, including HIV. It’s an extremely important tool that should be promoted around the world. And so, as the debate quickly pivots from whether or not circumcision is effective to figuring out why it is so damn effective, more organizations are coming out in favor of it in ever stronger terms:

U.S. health officials on Tuesday released a draft of long-awaited federal guidelines on circumcision, saying medical evidence supports the procedure and health insurers should pay for it.

The Centers for Disease Control and Prevention guidelines stop short of telling parents to have their newborn sons circumcised. That is a personal decision that may involve religious or cultural preferences, said the CDC’s Dr. Jonathan Mermin.

But “the scientific evidence is clear that the benefits outweigh the risks,” added Mermin, who oversees the agency’s programs on HIV and other sexually transmitted diseases.

I went into the circumcision debate many years ago without a dog in the fight. I was neither passionately against the practice nor fervently in favor of it; my general indifference parted greatly with what any Google search will show. However, as I began to hear more and more about the topic, and as I began to study global health issues more and more (especially during the time I was studying and volunteering my time in Haiti), I found my position slowly shifting. But it was indeed a very slow shift. With degrees in both biology and philosophy it was easy to be torn. The evidence had clearly tilted – at the least – in favor of circumcision, but what about the ethical arguments against it? I would need to resolve those concerns before I would support circumcision as a health policy. And that I did. The sole argument the anti-circumcision crowd has against circumcision is that it violates bodily autonomy. But so do other things which many in that crowd clearly support. Namely, vaccines can and do permanently change a person’s body for life without their consent. Looking at circumcision and vaccines, then, under the isolation of the argument from bodily autonomy, what’s the difference? They both change the body forever and neither is done with consent when done to infants/toddlers. The only responses I ever get to this is that vaccines are more effective or that the changes aren’t visible. Pshaw. They aren’t always more effective, and even where they are, so what? The argument from bodily autonomy doesn’t get to be put on the shelf when it’s convenient to ignore. The effectiveness of a procedure is irrelevant; all that matters is the necessity of the procedure. Vaccines and circumcision are both necessary to a healthier world, but neither is an absolute necessity to survival. Yes, more people will die without either, but that’s immaterial. And as for the changes being internal, I guess I wasn’t aware how aesthetics-focused the anti-circumcision crowd was.

I went on a bit of a rant there, but I hope it was effective. The ethical argument – singular, not plural – is weak. Yet the biological argument is strong. And as I learned more, it became quite clear that it was stronger than I initially thought. I freely admit that by the time I became involved in this debate (likely 2009, and as early as 2010 on NBS) I should have done all the proper research; I could have easily found myself where I am right now rather than going through a slow shift.

One of the things which always kept me tilted towards being pro-circumcision was the dogmatic attitude of the anti-circumcision crowd. It didn’t matter what evidence was presented to them, their ethical stance trumped everything. That would be fine, of course, since it would be a valid basis for opposition (even if I or anyone else disagrees with it). Unfortunately, this crowd has a habit of attacking perfectly valid science. PZ Myers did this back in 2011 when he said the following:

The health benefits. Total bullshit. As one of the speakers in the movie explains, there have been progressive excuses: from it prevents masturbation to it prevents cancer to it prevents AIDS. The benefits all vanish with further studies and are all promoted by pro-circumcision organizations. It doesn’t even make sense: let’s not pretend people have been hacking at penises for millennia because there was a clinical study. Hey, let’s chop off our pinkie toes and then go looking for medical correlations!

Emphasis mine. Clearly, whereas the organizations promoting circumcision as a health policy or recommendation have had a history of different positions on the matter, it’s ridiculous to say they’re inherently pro-circumcision. Moreover, the irony meter here is off the charts. The anti-circumcision crowd is incredibly vocal, despite being a scientific minority. Indeed, whereas the pro-circumcision groups came to their conclusions only after being presented with evidence, the anti-circumcision groups are composed entirely of people who oppose the practice on ethics first; they cherry-pick the science after the fact.

But that isn’t the important point here. As the title of this post says, the evidence of the benefits is not vanishing. It’s not vanishing with further studies. It’s not vanishing with time. It’s not vanishing at all. All we’ve been seeing is 1) more and more groups coming out in favor of the practice and 2) research focused on why it’s so effective. (Of course, all this criticism is coming from a guy who once had a debate with Jerry Coyne where he said that no evidence could ever convince him of the existence of God. While I share his lack of theistic belief, I don’t share his position here. I can’t imagine a more anti-scientific thing to say than that there is no possible evidence that could convince me of something. I could be convinced unicorns exist. I greatly doubt that will happen, but it’s possible; denying these possibilities when speaking in abstract terms is doltish.)

Anyway.

[The new guidelines] are likely to draw intense opposition from anti-circumcision advocacy groups, said Dr. Douglas Diekema, a Seattle physician who worked on a circumcision policy statement issued by the American Academy of Pediatrics in 2012.

“This is a passionate issue for them and they feel strongly that circumcision is wrong,” said Diekema, a professor of pediatrics at the University of Washington.

Indeed, the head of one group did argue against the CDC’s conclusions on Tuesday, saying they minimize potential complications from the procedure.

The guidelines “are part of a long historical American cultural and medical bias to attempt to defend this traumatic genital surgery,” said, Ronald Goldman, executive director of the Circumcision Resource Center.

Notice the name of the anti-circumcision group in that quote: Circumcision Resource Center. Hmm, what other group of people try desperately to sound legitimate despite everything they hold dear? Perhaps it’s the people who run sites and groups like Evolution News and the Discovery Institute and the Geoscience Research Institute – creationist groups. Honestly, I’m not sure who should be insulted more by this association.

Circumcision as a public health policy

At this point it has been established that circumcision reduces female-to-male HIV transmission rates by around 60%. Like it or not, the science is in. Now the question has shifted to being about why it reduces transmission, as well as how we can best introduce circumcision has a public health policy. On the first point, the general answer is that the foreskin is a relatively large surface area subject to tearing and softer (non-keratinized) skin. On the second point, though, I wasn’t aware of any actual policies in place to save the lives of men and women in regions particularly vulnerable to the spread of HIV. As it turns out, multiple sub-Saharan countries have undertaken measures to dramatically increase circumcision rates – though much work is still required:

Zambia is still 75 per cent short of its target of two million circumcisions by 2015. So is Uganda, having completed 1.5 million towards its 4.1 million target. Kenya has achieved its target in numbers – but not among the “right” men.

The donors who are pouring cash into male circumcision following the landmark 2006 study which showed that it reduced the risk of HIV infection by 60 per cent, have neglected a crucial factor – the attitude of women.

A man who gets circumcised is often viewed as a man who is looking to sleep around as much as possible. And, indeed, this has become something of a problem, as HIV rates in some areas have remained steady. This may also be due to men not waiting the necessary 6 week healing period – 40% of newly circumcised men had sex while still healing, actually resulting in an increase in their likelihood of contracting HIV. Furthermore, we may be seeing the problem of moral hazards at play. This is where risk is reduced for one thing or another, so people are less cautious in return. Some examples are playground materials and car safety. In playgrounds, children are often getting hurt as much if not more than in previous years because they’re playing on soft wood chips or rubber, leading them to believe they can fall harder and get hurt less. With cars, safety has greatly increased and deaths have fallen, but accidents remain steady or on the rise. People with seat belts are willing to speed more than those without them.

But the real problem in these sub-Saharan nations is a lack of education and peer support:

Carol Musimami, one of 30 “technical advisers” who counsel the men, said: “You will see the older ones come after dark. They don’t want to be with the youth. We are targeting the 25 to 35-year-olds –they are the ones with the money, they buy the women, they are exposing themselves [to infection]. But they are hard to get. They don’t want others to know,” she says.

Leadership is key. In Kenya, the circumcision programme in Nyanza province in the west – one of the three centres in the landmark 2006 trial that proved its effectiveness – was faltering when Raila Odinga, the Prime Minister and a member of the non-circumcising Luo tribe, responded to protests from tribal elders fearing the loss of their identity by declaring: “We don’t lead with our foreskins, we lead with other faculties. This is a medical issue.”

The speech, in 2008, proved a pivotal moment and more than 500,000 Luos have since been circumcised.

This is a major issue in global health. Science can find all sorts of answers to major problems, but that doesn’t mean it’s all just a matter of policy implementation after that. For instance, Jimmy Carter and WHO launched a campaign to eradicate Guinea worm disease in 20 African nations in the 1980’s. The primary approach to this was to make sure people had clean drinking water. With funding, wells were built and larvacide was added. However, one of the biggest pushes was to get people to drink clean water was to give them simple cloth filters. Unfortunately, this came with two problems. One was simply logistical: the filters clogged. The other was that the cloth material was too aesthetically pleasing, so people would often use them as decorative items. When the Carter Center, Precision Fabrics, and DuPont worked together to distribute plain nylon cloth filters (and education), the problem quickly shrank. There were 3.5 million cases of Guinea worm disease in 1986. As of 2005, the number had dropped to 11,000. This underlines the need for cultural understanding in addition to the simple cold science of the matter. Greater peer interaction and promotion of circumcision may be the key in getting places like Zambia to that 2 million goal.

At any rate, I’m very pleased to hear about these ongoing efforts to spread circumcision in developing nations in order to curb the spread of HIV. This is a triumph of common sense, global health initiatives, science, and basic humanity.

Cell type, HIV transmission, and circumcision

This is taken from a paper I did in a capstone course for my undergrad studies. I happened to come across it recently and I thought it would be interesting to post here.

Cell type matters in HIV infection. Transmission is higher amongst homosexual men who engage in rectal intercourse where the cells there are different as compared to cells on the genitals. Thin columnar epithelium that lines the rectum is assumed to facilitate the transmission of HIV; thick stratified squamous epithelium lines the vaginal and oral mucosa and appears to transfer protective properties against HIV acquisition. Video image analysis has shown that the latter is nine to twelve times thicker than the former [2]. In addition, intercourse causes more severe trauma to the former, thus allowing viruses better access not only beyond the mucosa, but, for the rectum, a richer bed of blood vessels.

Keratinized cells are a known protector against HIV. Like the body surface of a scorpion, they prevent attachment and entry of foreign agents. In both circumcised and uncircumcised men a keratinized, stratified squamous epithelium covers the penile shaft and outer surface of the foreskin. This acts as a protective barrier against HIV. However, the inner mucosal surface of the foreskin is not keratinized [1]. Furthermore, this surface is rich with Langerhans’ cells, cells which have been associated with higher rates of HIV infection due to their expression of CD4 glycoprotein which bind directly to gpl20 on the surface of HIV [2]. Since the foreskin is pulled back during intercourse, the surface area containing Langerhans’ cells is increased, thus giving HIV more opportunities to infect a host.

Observational studies back up the hypothesis that circumcised men are less susceptible to HIV infection. A 1989 study found uncircumcised men to be over 8 times more likely to be infected versus circumcised men [3]. A 1996 Ugandan study compared HIV infection between religious groups. Once abstinence, alcohol consumption, and number of sexual partners were accounted for, it was found that the likely reason Muslim men had lower rates of HIV infection versus other religious groups was due to higher rates of circumcision [4]. A 1999 study found that circumcision amongst rural Ugandans provided significant protection against HIV infection, but only if it occurred prior to the age of 20 [5].

Another 1999 study looked interviewed close to 200 uncircumcised men and close to 200 circumcised men. Amongst non-Muslims, circumcised men were found to have a greater risk profile than uncircumcised men. That is, those who were circumcised engaged in riskier behavior and had more partners on average. However, particular sex practices and hygienic behaviors were not notably different, and so they did not account for the higher risk of HIV infection amongst uncircumcised men [6].

~~~

The paper continues with a discussion germane to the requirements for the particular assignment, so I won’t reproduce any more here. However, it should be noted that the science on the matter does continue into more recent years, resulting in most major health organizations (WHO, UNAIDS, etc) supporting male circumcision in developing nations as one valuable method in the fight against HIV/AIDS.

Citations:

1. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1127372/?tool=pubmed

2. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1383923/pdf/immunology00069-0131.pdf

3. http://www.sciencedirect.com/science/article/pii/S0140673689905898
4. Kiwanuka, Noah; Gray R., Sewankambo N.K., Serwadda D., Wawer M., Li C. (7–12 July 1996). “International Conference AIDS.”. Religion, behaviours, and circumcision as determinants of HIV dynamics in rural Uganda. Vancouver, British Columbia. Retrieved 2008-09-25

5. Kelly R, Kiwanuka N, Wawer MJ, et al (February 1999). “Age of male circumcision and risk of prevalent HIV infection in rural Uganda”. AIDS 13 (3): 399–405.

6. Bailey RC, Neema S, Othieno R (November 1999). “Sexual behaviors and other HIV risk factors in circumcised and uncircumcised men in Uganda”. J Acquir Immune Defic Syndr. 22 (3): 294–301.

Breakthrough study of 2011 and the tools for curbing HIV

The journal Science has named the HPTN 052 clinical trial, a study looking at the ability of antiretroviral medication to prevent HIV transmission, as the 2011 Breakthrough of the Year:

Led by study chair Myron Cohen, M.D., director of the Institute for Global Health and Infectious Diseases at the University of North Carolina at Chapel Hill, HPTN 052 began in 2005 and enrolled 1,763 heterosexual couples in Botswana, Brazil, India, Kenya, Malawi, South Africa, Thailand, the United States and Zimbabwe. Each couple included one partner with HIV infection. The investigators randomly assigned each couple to either one of two study groups. In the first group, the HIV-infected partner immediately began taking a combination of three antiretroviral drugs. The participants infected with HIV were extensively counseled on the need to consistently take the medications as directed. Outstanding compliance resulted in the nearly complete suppression of HIV in the blood (viral load) of the treated study participants in group one.

In the second group (the deferred group), the HIV-infected partners began antiretroviral therapy when their CD4+ T-cell levels—a key measure of immune system health—fell below 250 cells per cubic millimeter or an AIDS-related event occurred. The HIV-infected participants also were counseled on the need to strictly adhere to the treatment regimen.

It was found that those taking the medication while their immune system was still highly healthy were 96% less likely to transmit HIV to their partners. This result was so stupendous that, even though the trial is still ongoing, an early public release of the findings was ordered. It is important that people know how to best combat transmission. That spread of information is what is needed to prevent the spread of infection:

“On its own, treatment as prevention is not going to solve the global HIV/AIDS problem,” said Dr. Fauci. “Yet when used in combination with other HIV prevention methods—such as knowing one’s HIV status through routine testing, proper and consistent condom use, behavioral modification, needle and syringe exchange programs for injection drug users, voluntary, medically supervised adult male circumcision, preventing mother-to-child transmission, and, under some circumstances, antiretroviral use among HIV-negative individuals—we now have a remarkable collection of public health tools that can make a significant impact on the HIV/AIDS pandemic.”

“Scale-up of these proven prevention methods combined with continued research toward a preventive HIV vaccine and female-controlled HIV prevention tools places us on a path to achieving something previously unimaginable: an AIDS-free generation,” Dr. Fauci added.

I added the emphasis to the above excerpt because I am reminded of the utter irresponsibility displayed by PZ Myers on this issue in the past. While I still very much like what the guy has to say on many subjects, he was dead wrong to dismiss any one of the listed tools. In this case, he specifically dismissed the notion that there is any evidence whatsoever that circumcision has any impact on HIV infection rates. As I’ve documented elsewhere, he is absolutely wrong on the facts. That evidence does exist and it is important that it is known. That is why Dr. Fauci noted it amongst all the other ways we must use to combat this disease. HIV/AIDS is one of the most serious epidemics facing the developing world today; no one should be proud to exacerbate the problem, especially when the motivation is ideological in nature – we’re talking about god damned human lives here.

Nope, wrong

PZ has a post about circumcision where he goes through the arguments in favor of the procedure based upon a video. (I haven’t watched the video nor will I because from what I gather it’s just a hack piece which does not focus on circumcision as performed by medical professionals in a medical setting.) Two of the arguments he quotes are apparently from a single guy and should just be boiled down to one: ’cause religion says to do it. Another one appeals to tradition, which is also a bogus argument, but then PZ has this last one:

The health benefits. Total bullshit. As one of the speakers in the movie explains, there have been progressive excuses: from it prevents masturbation to it prevents cancer to it prevents AIDS. The benefits all vanish with further studies and are all promoted by pro-circumcision organizations. It doesn’t even make sense: let’s not pretend people have been hacking at penises for millennia because there was a clinical study. Hey, let’s chop off our pinkie toes and then go looking for medical correlations!

PZ is wrong. The evidence has not suddenly vanished that circumcision prevents the transmission of HIV in high risk groups. Furthermore, it is blatantly invalid to dismiss this evidence because it may be used by pro-circumcision organizations, whatever those are.

If PZ wants to argue that circumcision holds little to no health benefits in places like the United States and other low risk nations for certain diseases, he can do that and be perfectly accurate. But if he wants to argue that circumcision has zero benefits in all circumstances, then he is in denial of the preliminary evidence.