The Use of Male Circumcision to Prevent HIV Infection - A statement by Doctors Opposing Circumcision
Both the public and the medical community must guard against being overwhelmed by the hyperbolic promotion of male circumcision and must receive these new studies with extreme caution. There is contradictory evidence that male circumcision is not as effective as proponents claim. One study found that male circumcision had no protective effect for women51 and another study found that male circumcision increased risk for women.52 Grosskurth found more HIV infection in circumcised men.53 Barongo et al. found no evidence that lack of circumcision is a risk factor for HIV infection.54 A study from India found little difference between circumcised and non-circumcised men in the conjugal relationship.55 A study carried out in South Africa found that male circumcision offered only a slight protective effect.56 A study carried out among American naval personnel found no difference in the incidence of HIV infection between non-circumcised and circumcised men.57
The RCTs on which the current claims are based have been carried out by men who have a previous history of promoting circumcision. DOC has little confidence in such studies, especially since contradictory evidence exists.
Male circumcision may increase male-to-female transmission of HIV and mitigate any reduction in female-to-male transmission. A preliminary report confirms the increased risk to women.65
Instituting a program of male circumcision is of dubious value. It will divert resources from proven methods of epidemic control and it may generate a false sense of security in males who have been circumcised. The desensitization of the penis that frequently results from male circumcision is likely to make men less willing to use condoms. A program of male circumcision very likely may worsen the epidemic.
The epidemic in Africa may have little to do with lack of circumcision and everything to do with the percentage of the female population engaged in female sex work. Talbot (2007) has established a correlation between the number of female sex workers in the population and the level of HIV infection.66
Calls are being heard for the circumcision of children although (assuming that male circumcision is effective at controlling female-to-male infection) this could not be helpful until the child becomes sexually active. As previously stated, the non-therapeutic excision of healthy body parts from non-consenting children is a violation of human rights44 and medically unethical.45 Therefore, the true motivation of the circumcision proponents must be questioned.46 It may be perpetuation of neonatal circumcision, not control of HIV.
DOC believes that more emphasis on education, behavior change—such as abstinence before marriage and fidelity after marriage, provision of condoms, treatment of other sexually transmitted diseases, treatment of genital ulcer disease, control of malaria, and provision of safe healthcare would be more likely to produce beneficial results. The ultimate answer is likely to be one or more of the vaccines now in development.
We continue with an piece about the foreskin:
The Case Against Circumcision - Paul M. Fleiss, MD
The foreskin has numerous protective, sensory, and sexual functions.
Protection: Just as the eyelids protect the eyes, the foreskin protects the glans and keeps its surface soft, moist, and sensitive. It also maintains optimal warmth, pH balance, and cleanliness. The glans itself contains no sebaceous glands-glands that produce the sebum, or oil, that moisturizes our skin.11 The foreskin produces the sebum that maintains proper health of the surface of the glans.
Immunological Defense: The mucous membranes that line all body orifices are the body's first line of immunological defense. Glands in the foreskin produce antibacterial and antiviral proteins such as lysozyme.12 Lysozyme is also found in tears and mother's milk. Specialized epithelial Langerhans cells, an immune system component, abound in the foreskin's outer surface.13 Plasma cells in the foreskin's mucosal lining secrete immunoglobulins, antibodies that defend against infection.14
Erogenous Sensitivity: The foreskin is as sensitive as the fingertips or the lips of the mouth. It contains a richer variety and greater concentration of specialized nerve receptors than any other part of the penis.15 These specialized nerve endings can discern motion, subtle changes in temperature, and fine gradations of texture.16, 17, 18, 19, 20, 21, 22, 23
Coverage During Erection: As it becomes erect, the penile shaft becomes thicker and longer. The double-layered foreskin provides the skin necessary to accommodate the expanded organ and to allow the penile skin to glide freely, smoothly, and pleasurably over the shaft and glans.
Self-Stimulating Sexual Functions: The foreskin's double-layered sheath enables the penile shaft skin to glide back and forth over the penile shaft. The foreskin can normally be slipped all the way, or almost all the way, back to the base of the penis, and also slipped forward beyond the glans. This wide range of motion is the mechanism by which the penis and the orgasmic triggers in the foreskin, frenulum, and glans are stimulated.
Sexual Functions in Intercourse: One of the foreskin's functions is to facilitate smooth, gentle movement between the mucosal surfaces of the two partners during intercourse. The foreskin enables the penis to slip in and out of the vagina nonabrasively inside its own slick sheath of self-lubricating, movable skin. The female is thus stimulated by moving pressure rather than by friction only, as when the male's foreskin is missing.
Circumcision is almost unheard of in Europe, South America, and non-Muslim Asia. In fact, only 10 to 15 percent of men throughout the world are circumcised, the vast majority of whom are Muslim.29 The neonatal circumcision rate in the western US has now fallen to 34.2 percent.30 This relatively diminished rate may surprise American men born during the era when nearly 90 percent of baby boys were circumcised automatically, with or without their parents' consent.
Mensactivism.org had a piece up with several interesting tidbits:
The Finnish Medical Association takes the stand that child circumcisions are in conflict with medical ethics. (source)
Circumcision of young boys for religious and non-medical reasons ought to be banned in Sweden, urged the Swedish Paediatric Society (Svenska barnläkarföreningen, BLF). In a statement submitted to the National Board of Health and Welfare (Socialstyrelsen), the society called the procedure an assault. "We consider it to be an assault on these boys," Staffan Janson, chairman of BLF's committee for ethical issues and childrens' rights, said to newspaper Göteborgs-Posten (GP). (Source)
The Royal Dutch Medical Association (the KNMG) has published a ground breaking position paper on non therapeutic male child circumcision which calls for a "powerful policy of deterrence", if not an outright ban. The paper states that non therapeutic circumcision is an infringement of a child's rights to bodily integrity and personal autonomy, that its risks are underplayed, and that to reject all forms of forced female genital cutting while allowing forced male genital cutting is ethically inconsistent. [...] The position of the KNMG is jointly endorsed by: The Netherlands Society of General Practitioners, The Netherlands Society of Youth Healthcare Physicians, The Netherlands Association of Paediatric Surgeons, The Netherlands Association of Plastic Surgeons,The Netherlands Association for Paediatric Medicine, The Netherlands Urology Association, and The Netherlands Surgeons’ Association. (Source)
The above had a link to a position paper of the KNMG which summarizes more official positions on circumcision, which makes a nice list:
In 2003, the British Medical Association stated: ‘The medical benefits previously claimed have not been convincingly proven. (…) The British Medical Association considers that the evidence concerning health benefits from non-therapeutic circumcision is insufficient for this alone to be a justification for doing it.’25
The American Academy of Pediatrics stated in 1999: ‘Existing scientific evidence … [is] not sufficient to recommend routine neonatal circumcision.’26 The American Medical Association endorsed this position in December 1999 and now rejects circumcision for medical/preventative reasons. The AMA further states: ‘parental preference alone is not sufficient justification for performing a surgical procedure on a child’.27
Other doctors’ organisations in Australia and Canada have taken similar positions.28 For example, the Royal Australasian College of Physicians asserts: ‘Review of the literature in relation to risks and benefits shows there is no evidence of benefit outweighing harm for circumcision as a routine procedure in the neonate.’29 In its viewpoint, the Australasian Association of Paediatric Surgeons states: ‘the AAPS does not support the routine circumcision of male neonates, infants or children in Australia. It is considered to be inappropriate and unnecessary as a routine to remove the prepuce, based on the current evidence available’.
The Canadian Paediatric Society states: ‘The overall evidence of the benefits and dangers of circumcision is so evenly balanced that it does not support recommending circumcision as a routine procedure for newborns’.30
The American Academy of Family Physicians believes that the medical benefits of circumcision are ‘conflicting or inconclusive’. The decision should therefore be left to parents: ‘The American Academy of Family Physicians recommends physicians discuss the potential harms and benefits of circumcision with all parents or legal guardians considering this procedure for their newborn son’.31
The position paper of the KNMG sums circumcision up pretty well:
Position of the KNMG with regard to non-therapeutic circumcision of male minors - 2010
- There is no convincing evidence that circumcision is useful or necessary in terms of prevention or hygiene. Partly in the light of the complications which can arise during or after circumcision, circumcision is not justifiable except on medical/therapeutic grounds. Insofar as there are medical benefits, such as a possibly reduced risk of HIV infection, it is reasonable to put off circumcision until the age at which such a risk is relevant and the boy himself can decide about the intervention, or can opt for any available alternatives.
- Contrary to what is often thought, circumcision entails the risk of medical and psychological complications. The most common complications are bleeding, infections, meatus stenosis (narrowing of the urethra) and panic attacks. Partial or complete penis amputations as a result of complications following circumcisions have also been reported, as have psychological problems as a result of the circumcision.
- Non-therapeutic circumcision of male minors is contrary to the rule that minors may only be exposed to medical treatments if illness or abnormalities are present, or if it can be convincingly demonstrated that the medical intervention is in the interest of the child, as in the case of vaccinations.
- Non-therapeutic circumcision of male minors conflicts with the child’s right to autonomy and physical integrity.
And finally, another large overview resource paper, this time by ICGI. This is just way too much to summarize, so I will just dot out the summary:
Position Paper on Neonatal Circumcision and Genital Integrity - 2007
The foreskin is a multifunctional structure that has physiological value and is worthy of retention. Considerable cultural controversy surrounds neonatal circumcision, including medical, legal,
and ethical considerations. Non-therapeutic circumcision of male children has been shown to be ineffective at improving health, and as such, it falls outside acceptable standards of care. This
places physicians in a precarious position when they are expected to perform the surgery. Medicalization of circumcision, beginning over one-hundred forty years ago, has resulted in a circumcision cycle where “American parents have been conditioned to request it, that physicians perform it, and that insurance companies pay for it, helps to reinforce the aura of legitimacy surrounding circumcision.”411
The International Coalition for Genital Integrity recommends against circumcising infants. Appropriate physician action includes not initiating circumcision discussions, because infant circumcision is not indicated and non-therapeutic. However, since many parents—and other physicians such as pediatricians and obstetricians—are not yet aware of these facts, physicians should provide information during prenatal care appointments explaining that the benefits do not outweigh the risks, according to our current understanding, and that the procedure is not recommended for infants. Physicians should provide specific information on the potential harm and disadvantages of circumcision, including requesting that the parents witness a circumcision, either live or on
Finally, physicians should provide all parents with verbal and written information on the care of the intact penis.