Monday, August 23, 2010

Circumcision Highlights Global Differences

A clear North/South divide is emerging in attitudes towards male circumcision. In May the Dutch Royal Medical Association became the first national medical group to declare that the procedure is both medically unnecessary and an abuse of the rights of the child, in the same way as female circumcision, or female genital mutilation.

However, the Dutch have decided to actively discourage circumcision rather than to ban it, as that could drive the procedure underground. About 15,000 boys are circumcised each year.

On the other hand African countries are actively encouraging circumcision because trials in 2007 in Kenya, Uganda and South Africa showed that it dramatically reduced the risk of infection with HIV/AIDS. According to a report in the BMJ, 14 countries in southern Africa are promoting circumcision with radio and television campaigns.

In Swaziland, where HIV prevalence is 45%. circumcision is even regarded as "crucial to the survival of the state". Botswana plans to circumcise all boys by 2012. Even Rwanda, where HIV prevalence is only 3%, is promoting it as a cost-saving public health measure.

However, the Dutch doctors are sceptical of the African data. They believe that while it might delay infection, it will not prevent it. They also say that there are some complications which cannot be ethically justified for a "medically futile" procedure.

In the UK, Australia and the US, the trend is away from circumcision. The Australasian Association of Paediatric Surgeons, for instance, describes circumcision as "inappropriate and unnecessary" but allowable in children over 6 months old when parents "hold a very strong opinion." ~ BMJ, Aug 17


Caroline said...

Thank you for writing about this important, but often ignored topic in American society. I don't know if you've seen this article, but I recommend it. Infant circumcision is now at less than 33% in the US, down from 56% in 2006.

KOTFrank said...

I can't wait until you write about Dr. Diekema bioethicist pediatrician who doesn't talk about the ethics of male circumcision and calls intactivist "emotional". He is obviously pro-circumcision and that's troubling since he also is a member of the AAP's Task Force on Circumcision. I and others think he should step down. Read his NPR interview.
Intactivists have equal concerns about some of the other task force members as they have shown to be pro-circumcision too. Science knows biases can not be overcome. Let's hope the review committees are more even handed.

I also thank you for this writing. I too start talking to people leading with the KNMG. The Royal Dutch Medical Association is says it like it is fearlessly. Though I think circumcision should be driven underground. The botched circumcisions will then limit itself. More children will be saved over time.

Alice C. Linsley said...

You may wish to read this essay on circumcision to understand why there is a global divide on the issue:

Mark Lyndon said...

There are six African countries where men are *more* likely to be HIV+ if they've been circumcised: Cameroon, Ghana, Lesotho, Malawi, Rwanda, and Swaziland. Eg in Malawi, the HIV rate is 13.2% among circumcised men, but only 9.5% among intact men. In Rwanda, the HIV rate is 3.5% among circumcised men, but only 2.1% among intact men. If circumcision really worked against AIDS, this just wouldn't happen. We now have people calling circumcision a "vaccine" or "invisible condom", and viewing circumcision as an alternative to condoms. The South African National Communication Survey on HIV/AIDS, 2009 found that 15% of adults across age groups "believe that circumcised men do not need to use condoms".

The one randomized controlled trial into male-to-female transmission showed a 54% higher rate in the group where the men had been circumcised btw. It apparently would be deemed unethical to repeat such a trial, yet it's somehow ok to plan to divert hundreds of millions of dollars of funding to circumcise 38 million men without knowing whether circumcised HIV+ men are 54% (27%??, 108%??) more likely to infect women.

ABC (Abstinence, Being faithful, and especially Condoms) is the way forward. Promoting genital surgery will cost African lives, not save them.

Hugh7 said...

Since you mention Swaziland, the figures there are also of interest: the HIV rate is 21.8% among circumcised men and 19.5% among non-circumcised men, according to the National Health and Demographic Surveys. That should certainly be explained before undertaking any mass circumcision campaigns, or they may increase the risk.

There are many other flaws with the claim that circumcision will have any effect on HIV transmission. Its as though some people just don't ever want to know anything is wrong about circumcision.