180 of 217 people found the following review helpful
- Published on Amazon.com
There clearly are two camps posting comments about this book. Those who endorse Male Circumcision (MC) as an HIV prevention strategy, basing their conclusions on three key African trials, and those who oppose male circumcision for multiple reasons, including: doubting those studies findings, seeing condoms and education as more effective, and seeing MC as an abusive or intrusive practice.
There have several comments accusing others of mis-truths, lies, etc. I know I will have such calls thrown at me, but I'll try to help move the debate forward somewhat as best I can.
Firstly - regarding credentials and conflict of interest - I am a health policy researcher who has worked on HIV prevention in Africa for 15 years, and I hold a PhD on the subject of AIDS in Africa (specifically Uganda). I am a social scientist, not a virologist or epidemiologist, although I have a good understanding of epidemiology from my work. I also know one of the authors of this book as a colleague (I've even once co-authored a short journal communication with him and others). So I am declaring all this upfront.
I am, however, primarily an educator and a researcher, looking to learn and contribute. I hope this comment can help people to do that. There are multiple issues here which seem to come up in these debates which need to be clarified:
1) Whether MC reduces susceptibility to HIV
2) Whether it is ethical or moral to circumcise
3) Whether MC affects sexual performance or pleasure
4) What other complications one might face with MC
5) If other HIV prevention interventions are better or more effective than MC
1) First is whether male circumcision reduces the susceptibility to HIV.
Three large scale experimental trials were done to try to address this in the middle of the last decade (in three different sub-Saharan African countries). They all showed very large (statistically significant) protective effects for men in heterosexual relationships in countries with high background HIV rates. Not perfect protection mind you, but the men who were circumcised were less than half a likely to acquire HIV over a year than those who were not. The men who were offered and received MC were chosen at random and consented to the procedure. The references to those studies can be found here: [...] ; [...] ; [...]
There have been some who question the results. Claims are that over time the effect fades, or that trials are biased - you get better results in a trial than in real life (e.g. if in real life the procedures are done incorrectly more often). These are genuine concerns to consider when trying to ascertain the actual level of protective effect MC may provide. But the concerns do not deny the trial results, just claim they may be more effective than would be achieved in real life. The trials still provide very good evidence of a protective effect in these populations.
Others dismiss these findings because they are convinced by other forms of evidence. A common argument on these Amazon comments is that the US has a high circumcision rate, but more HIV than other high income countries, concluding that male circumcision cannot be effective. There are some problems with this argument, however. To learn the protective effect of MC you would need to compare two identical populations, with the only difference being if men in one group were circumcised. This is what an experimental trial attempts to do (by randomly allocating people from a group to an intervention or not). HIV transmission will be affected by a wide range of things, including the background prevalence in the community (if there is little/no HIV, you will not get transmission whether circumcised or not), and rates of partner change and multiple partners (if everyone is monogamous, you won't get much HIV spread, regardless of circumcision status), and sexual practices such as heterosexual anal sex (which is increasingly common in the US). So you can't compare the US to other countries with different background HIV rates, patterns of partnerships, and sexual practices in order to learn if or how effective MC might be - only an experimental trial can do that.
Overall, a vast majority of epidemiologists who understand the strengths and weaknesses of scientific studies like experimental trials feel the evidence is strong that in heterosexual epidemics with high background rates of HIV, MC does appear to offer significant protection to men (and thereby to populations as a whole).
Finally on point 1, some argue that HIV is spread through other means - e.g. medical practices. There is a very large debate on this and a great deal of evidence to look at. No doubt some unsafe medical practices spread HIV, but there is also a good deal of evidence to show the sexual transmission route is stil quite dominant (e.g. if you look at HIV rates by age group, we see rates rise dramatically dramatically correlated with age of sexual onset, rather than at the age at with which one receives medical procedures). That said, there is always scope in scientific inquiry to look for more evidence and to try to build consensus around that evidence, and even if some HIV infection is due to unsafe medical practice, that does not undermine the potential efficacy of male circumcision.
2) Second - a very different argument is about whether one should circumcise men or if it is wrong to do so. This is a moral and a value argument based on ones view of how important the intact male foreskin is, and on the other benefits or risks of MC. Many of the critics posting here talk about 'pro-cutters' and use terms like 'amputation' of part of the penis. Language carries meaning, we all know this. I don't know why anyone would want to be 'pro-cutter' and circumcise men for no reason. But MC does indeed remove the foreskin. If you believe this is morally wrong to do, you will oppose it. That is your right. But please lets not confuse opposition to the practice of MC on these moral grounds with the evidence discussed in point 1 above. If indeed MC provides protective effect, many of use would argue that MC should be a procedure that people are given the opportunity to choose. You don't force people to do it, you give them the best possible information about it and let them decide if they wish to have the procedure done. Now some critics will argue that in low income countries (like in Africa) governments or international bodies rarely give accurate or fair information. A valid criticism. But, if so, then the onus is to provide full and better information, not to deny people the possible protective effect of the procedure altogether. The value placed on the intact foreskin is a judegment people have to make for themselves. Informed decisions should be made based on the evidence of protective effect, as well as consideration of how someone feels about having MC done.
On a related note, I've seen some arguments linking MC to female circumcison or female genital mutilation (FGM). These arguments need to be looked at carefully. If one is opposed to all body modifications or removal of skin, then yes, there will be similarities. However most critics of FGM are opposed to it because it is usually done without a woman's permission, for the desires of others (e.g. future husbands), and with no known medical or health benefit, but significant known pain for the woman. It appears to further entrench the subjugation of women for a dominant male society. There are many women who have gone through this process who attest to the pain of the procedure, and it can make intercourse severely painful when the vaginal opening is narrowed as part of some procedures. Removal of the clitoris can severely disrupt sexual feeling in a way that removal of the foreskin is nowhere comparable. The moral issues at stake here have to do with individual choice, social imposition of view, and benefits or harms to the individual. In the case of MC, if adult men are choosing the procedure, and it is offered in a way that minimises pain, and is done for potential medical benefit, these are very different situations to FGM. I cannot tell you, the reader, which is the right choice, but it is important to be clear about the different aspects on which we place values in making a decision. We may have strong values on moral grounds which over-ride any protective health effect. But we should not let those values ignore the protective effect that someone else might wish to choose.
3) Third, there is a debate around whether MC affects sexual performance etc, and how much so. It is difficult to measure this, and it is very hard to prove in any case as sexual pleasure is so psychological. Historically, most circumcised men have the procedure done at birth or at a young age before sexual onset - so they can't compare. There are obviously some reports of men who wished to reverse the procedure. There are even some cases of men who had MC as an adult, and wanted it reversed - but these are rare and anecdotal cases. At a conference a few years ago, I asked the authors of one of the African studies if follow-up studies were done with the men who were included in the experimental trials done to see if they showed regret about the procedure. Their response was that there was little to go by one way or another - some said it improved sex, some said it did not, but overall, there was little in it. Now this won't convince everyone, but we have to be realistic about what we know about this. Millions of men historically have led happy sex lives when circumcised, but we don't know if they would have had even happier ones if not. But in the cases where adults have had sex before and after the procedure, there is no strong consensus that it is particularly debilitating.
4) Fourth, some critics of MC note that there are (albeit) rare complications. This is true for any procedure. Anti-malaria tablets have a (low) risk of serious side effects. You don't take them when not in a malarial area, but if you travel, you weigh up the risks. Similarly you don't offer MC in countries with no HIV risk. But in countries with high HIV prevalence rates and patterns of sexual practices similar to that seen in much of southern and eastern Africa, the risk of complications from MC seem much lower than the reduced lifetime risk of acquiring HIV after the procedure is done.
5) Finally, many of those who criticise MC argue that it is irrelevant because there are better and more effective ways to prevent HIV - pointing to education and/or condoms in particular. There are a few issues here that need clarification. First, condoms are highly effective when used consistently. We know this. It is the same idea as those who claim abstinence is 100% effective. Of course if you don't have sex, or if you always use a condom, then MC will be irrelevant. But in practice, in many countries that have been fighting HIV for over 25 years, the promotion of condom use (like the promotion of abstinence) has not led to consistent use. This is because many people, even when they know about the protective effects of condoms, do not use them all the time. Now there will be plenty of people who say 'I use them every time, so you can too'. Yes, some people do and it is physically possible to do so. But evidence from country after country shows that most people do not use them every time, even when years of efforts have been made to convince the to do so. That is why health officials often latch on to medical interventions (like MC) which can be given once and only once and be permanent. Many of the critics argue that it is better to get people to choose to use condoms or to change their behaviour voluntarily than to do a permanent procedure on them like MC. Personally I agree with that, and would encourage someone to use condoms as a first option too. But we have not yet found an effective way to achieve universal condom use across settings. As such, the decision that health professionals must make is whether it is worth providing MC as an option to people (again, as an option they can choose or not). Indeed, when offering MC, men should be told that it is more effective to use condoms 100% of the time, or to abstain from sex altogether. Then they can choose what combination of protective measures they wish to take.
Strong moral values - such as seeing MC as body harm and therefore wrong, or alternatively seeing HIV prevention as the paramount concern for health officials - will influence which pieces of evidence we latch on to, which ones we believe more readily, and which ones we try to pick apart. It is essential we are conscious and explicit about our values and beliefs when looking at evidence to make the most informed and accurate decisions. There will always be differences in values, but it is important not to let our differing values bias how we use evidence. We can have a reasonable discussion of the evidence and its limitations, and another reasonable discussion about the values and morals behind MC (including when provided to adults, provided as a medical intervention, proveded to infants as a religious practice, etc). I imagine both sides of these debates want to see the end of HIV, and want people's rights and choices respected. We should be able to have reasonable discussions to help get there.