FIELD REPORT: NYC Community Discussion on Male Circumcision and HIV Prevention

[I received this report on May 3 from Adrienne Soti, who attended A Community Discussion of Male Circumcision and HIV Prevention with a number of other individuals in New York City on April 26, 2007. Her full report follows after the fold.]

A number of us intactivists attended last Thursday’s presentation by the NY City Health Dept, and we wrote a summary, which I pasted below in case you are interested.

Adrienne Soti

THANK YOU Adrienne for your contribution!


Program and handouts by Laurie Evans

A Community Discussion of Male Circumcision and HIV Prevention

April 26, 2007, 6 – 8 p.m

NYC Department of Health and Mental Hygiene, Bureau of HIV/AIDS Prevention and Control, Bureau of Sexually Transmitted Diseases

Location: Gay Lesbian Bisexual Transgender Center- 208 W. 13 St. NYC, NY

Presenters:

1. Thomas Frieden, MD, MPH, Commissioner, NYC Health Department (Introduction – 5 minutes)

2. Kent Sepkowitz, MD, Professor, Medicine and Infectious Diseases, Weill Medical College of Cornell University (Overview of recent research – 15 minutes)

3. Brian Stone, MD, Assistant Professor, Department of Urology, Columbia University Medical Center (Adult circumcision: clinical options – 10 minutes)

4. Guillermo Chascon, Latino Commission on AIDS (5 minutes) and Anthony Morgan, NY State Black Gay Network (5 minutes) (Cultural issues to consider)

Moderators

1. Monica Sweeney, MD, MPH, Assistant Commissioner, Bureau of HIV/AIDS Prevention and Control, NYC Health Department (Welcome and Q & A Moderator)

2. Christopher Murray, LMSW, Lesbian Gay Bisexual Transgender Center (Q & A Moderator)

After each presentation, there was a 10 minute question and answer period. Then there was 20 minutes at the end for further questions and comments.

Intactivist literature distributed:

1. What is Lost,

2. NOCIRC #11,

3. HIV comic with bullets, and

4. What does this card have to do with your Penis?

Literature distributed from others:

1. CHAMP (The Community HIV/AIDS Mobilization Project) “How did circumcision prevent HIV in clinical trials in Africa.and what does it Mean for the United States?” 8 pages available on the website: http://www.champnetwork.org/media/CHAMP-Circumcision-Brief.doc [Editor’s Note: This is a scandalous little pamphlet, in my opinion. It is strident and demanding. It suggests experimenting in minority communities where circumcision rates are low. It seems to suggest that foreskins are the only reason minority communities suffer disproportionately from HIV/AIDS.]

2. CDC HIV/AIDS Science Facts: “Male Circumcision and Risk for HIV Transmission: Implication for the United States, March 2007”.  6 pages available on the web: http://www.cdc.gov/hiv/resources/factsheets/circumcision.htm

3. Latino Commission on AIDS “The Latino Commission on AIDS recommends health providers consider education and offering male circumcision to heterosexual Latino men that regularly engage in high-risk sexual practices” 3 pages (I didn’t find this on their website.)

24 West 25th St., 9th Floor, NY, NY 10010-2704  (212)-675-3288
dconnolly@latinoaids.org <dconnolly@latinoaids.org>

http://www.latinoaids.org <http://www.latinoaids.org/

4.  Info sheet for Fighting for our Lives: New York’s AIDS Community and the politics of disease by Susan M. Chambre, Rutgers University Press.

There were 5 intactivists in attendance: Jeremy Proctor, Laurie Evans, Liz Malaugh, Adrienne Soti, and Carl Schutt.

Although they did allow many people to ask questions, we were limited to one to two minutes for a question or comment. As in all these meetings, the presenters with their bias, get about 5 to 15 minutes to speak, and the members of the audience have only one to two minutes. In all fairness though, they called on us several times, even after they understood our position.

There were about 50 people in attendance. This included 6 speakers, 5 intactivists, and 1 reporter. There weren’t too many people from the public when you consider that at least 10 and maybe many more were employees of the health department or members of other groups who had someone speaking. A man in the audience identified himself as an Asian activist, and there were several people from Act Up.

Summary of discussion and Q & A by Laurie Evans and Adrienne Soti:

The information presented was very one-sided. They touted the recent African studies, although they said they were unsure whether the results were relevant in the U.S. since there are great cultural differences.  Dr. Frieden said that applying these data to the US is complicated and there are many unknowns and no clear answers.  However, he repeated throughout the evening that the results of the three African studies are unequivocal, unquestionable and firm.  The problem, he believes, is that the studies only examined the spread of AIDS from a positive female partner to a negative male.  Dr. Sepkowitz said the least amount of data is available on whether circumcision could reduce the chances of an infected male spreading the virus to an uninfected male.  This is why at the end of the session, a reporter mentioned in passing that he believes this discussion was presented to the wrong audience, since it least applies to gays.

They downplayed the risks and harm of circumcision. The health commissioner mentioned that the NYC Health Department has implemented a more aggressive education program and widespread condom distribution. They are also implementing a new HIV/AIDS curriculum in the schools. They said that the ABC method (Abstain, Be Faithful, Use Condoms) was not widely practiced and incorrect and improper use of condoms is common.

The speakers said that circumcision was one more tool they were considering and that it would not replace education and condom use. They admitted that men may be less prone to use condoms if circumcised. They also said that circumcised men have gotten HIV. However, they said that in Africa there is a demand for circumcision and hygiene is considered an additional benefit.

They mentioned benefits of circumcision: (what we know as myths)

Lower rate of UTIs, lower rate of penile cancer

Dr. Frieden suggested that companies would invest billions of dollars into a vaccine with a 60% success rate but then later pointed out that circumcision is not a vaccine.

When someone in the audience mentioned that circumcision did not prevent the spread of AIDS in the US, Dr. Sepkowitz replied that while that is true, it is possible that had they not been circumcised, the HIV rate may be even worse in the US.

In a Q & A, Jeremy mentioned that men get breast cancer 3X more often than penile cancer and Laurie mentioned the flawed UTI studies and that they didn’t report whether parents of intact boys had been asked to do prematurely retract.

They mentioned that circumcision may work because the foreskin is rich in Langerhans cells which attract the virus and because the foreskin is susceptible to micro-abrasions during intercourse. Dr. Sepkowitz also said that the protection circumcision offers is only effective when there is a very high background rate of HIV.  Will benefits persist for a lifetime? He posed the question preemptively. Behavioral changes may offset the benefits, he warned.

They said that postoperative problems in infants are uncommon. They said complications in infants occur at a rate of 0.2% and at a rate of 2% in adults. (In comment period, Laurie mentioned that at a health fair last Saturday 7 parents had informed us that their son’s were recommended for corrective surgery.)

They wondered whether wide scale circumcision could be accomplished safely.

A question was asked about the psychological effects on circumcised men, but they couldn’t comment on this. Liz asked, if Langerhans cells make us susceptible to AIDS, and if they are present in the female vulva, wouldn’t it make sense to experiment with cutting some of that away? Dr. Frieden quickly replied that female circumcision is genital mutilation and that it causes problems in urination and adversely affects sexual function.

Dr. Stone said he prefers the ‘sleeve technique’. The surgery takes 30 minutes, it is performed under local anesthesia and is relatively safe. He uses a marking pen before the surgery. He said that bleeding, infection, and wound separation are rare when it is done correctly.

Jeremy mentioned cultural bias. He asked how they can remove 36% of the nerve endings and up to 50% of the outer skin and still say, “There is no damage.”

Dr. Stone, the urologist who also works in oncology, said that he performs about 60 circumcisions a year mostly on diabetic men who have phimosis or other complications. Dr. Stone said that the men who he sees with penile cancer have less than desirable hygiene. He was asked how many more circumcisions he would be able to perform in a year, and he said he didn’t know but there are plenty of urologists available who are capable of performing the procedure. Jeremy asked him what he had learned about anatomy and physiology of the foreskin. He knew very little. He did say that the head of the penis is the most sensitive part. Dr. Stone was asked whether his adult patients reported reduced sexual pleasure from being circumcised, and he said, “No.” as they all had a medical reason to get circumcised and their sexual enjoyment may have been adversely affected by their prior condition.

A question was asked, “How much skin needs to be removed to prevent HIV?”

Answer, “I don’t know.”

Laurie mentioned that some boys did not retract until puberty, and that at the International Symposium a French doctor had presented on non-surgical techniques for true phimosis in adults.

Anthony Morgan from the NYS Black Gay Network, said that Blacks are skeptical as their communities have been exploited. He mentioned sterilization and the Tuskegee experiments. Mr. Morgan suggested that the fear of homophobia be addressed including its impact on HIV education.

Guillermo Chascon, Latino Commission on AIDS, pointed out that Latinos are the fastest growing population in America and less than 20% of them are circumcised.  He thinks their religious views as well as “machismo” will play a role in their resistance to get circumcised but he seemed to welcome the idea.

Dr. Frieden said that NYC is the epicenter of HIV epidemic in the U.S. which is a shame for the U.S. He said there were 4 neighborhoods with high rates: Chelsea, the South Bronx, Bed Stuy, and Harlem. He said poor Blacks and Latinos were more likely to die from HIV than Whites. He mentioned that NY City has the largest population of black immigrants.

At the end someone said, circumcision may be an additional potential tool, and it would be a huge disservice to discard it as a possibility.

Someone asked Dr. Frieden, how would you reply if an intact gay man asked you, “Should I get circumcised or not?” He replied that he finds it difficult to tell someone what he should do but he would certainly share the results of the African studies.

Jeremy brought out the issue of circumcised men recommending circumcision to others.

Liz asked if they explained to men what is lost when the foreskin is removed. She mentioned the nerves, gliding action, and tactile stimulation. To this, they defensively replied that they have not yet suggested to anyone to get circumcised based on these results.

Laurie mentioned how misleading the media headlines of “Circumcision Reduces HIV” are to the unscrutinizing reader, especially when no one reports on what is lost to circumcision.

It was reiterated that individual liberties would be honored and that they might recommend that the issue be discussed further.

Although Dr. Frieden said that no policy is going to be set in New York for now, it was obvious from the information shared that the bias is in favor of completely accepting the results of the recent African studies. Due to this bias, I would guess that some men might opt for circumcision.

Liz had this comment re: the reporter’s article.

I’m really irritated that the reporter mentioned us “accusing city officials of slanting the evidence.”  Questioning and accusing are two very different things.  No one accused anyone of anything during that discussion. The reporter’s remarks are libelous.

Liz M.

Does anyone know the name of the reporter who wrote the article below? Does anyone have his email?

WNYC Newsroom

NEW YORK, NY April 27, 2007 -Health officials held a public forum inGreenwich Village last night to discuss the use of circumcision as a possible strategy for fighting the spread of HIV and AIDS.

REPORTER: Circumcising heterosexual men in Africa greatly reduced the risk of contracting the disease, according to a recent study. The city’s Health Department presented the study’s results, answered questions and opened the floor to discussion. Audience member Gabriel Galindo says he appreciated the dialogue – but wasn’t sure it would lead anywhere.

GALINDO: You can recommend condoms, you can recommend a lot of things and people are going to do what they want. You can recommend circumcision. How well it’s gonna play with anyone, I highly doubt. There’s gonna be a lot of uproar but no ones gonna follow through with it I think.

REPORTER: At times, the discussion got heated, with anti-circumcision activists accusing city officials of slanting the evidence. Health Commissioner Doctor Thomas Frieden said it’s not clear how successful circumcision would be in reducing the spread of HIV among gay men, but that the procedure would be voluntary and would never be a substitute for abstinence, monogamy or condoms.

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