New research suggests that poor penile hygiene rather than the removal of specialized tissue, such as tissue densely packed with Langerhans cells, is responsible for the prophylactic effect of male circumcision.
[Revised paragraph] The study, published in the latest edition of Sexually Transmitted Diseases, reviewed several hundred men for “penile wetness” in London. In a previous study out of Durban, South Africa, those with a higher degree of wetness were more likely to be infected with HIV. The number of individuals with penile wetness in the London study was much lower than in South Africa. The authors believe that smaller numbers in a developed setting probably indicates that neither circumcision nor encouraging of penile washing would have much impact in a country with a low HIV prevalence, such as Britain. Researchers have previously suggested that wetness is a marker for poor hygiene, which in turn may be responsible for inflammation that allows for greater cellular infectivity.
The researchers suggest that a campaign to encourage hygiene would achieve the same effect as mass circumcision campaigns. Where they miss the mark is in suggesting that circumcision would be easier to enact than encouraging better hygiene through washing. In other words, they believe men either can’t learn the value of washing or be trusted to do it. Africa being the target of circumcision campaigns, the appearance of
racist Western, paternalism is hard to miss.
The value of encouraging better hygiene goes far beyond the reduction in HIV and possibly other sexually transmitted infections. It would encourage the development of water resources and sewage systems. It would help in ameliorating problems associated with contaminated water, poor sewage disposal, and other personal care issues. Moreover, it would likely reduce malaria, cholera, dysentery, and other water borne diseases.
The circumcisionists have suggested that encouraging circumcision would increase the number of clinics and other health services necessary to meet the demand, with many so-called knock-on effects. They speak in years. Ironically, the researchers of this study also speak in years and suggest that circumcision would be faster. However, they ignore previous evidence that encouraging circumcision will not be quick by any means, and even with a demand, meeting it is far from certain.
Development of clean water infrastructure would necessarily precede any development of health facilities. It is likely that with the right efforts, high prevalence countries could develop the infrastructures and not need to reach the point of mass circumcision. A campaign to encourage better hygiene is less invasive, less dangerous, requires fewer or no medical personnel (a major problem in its own right), ameliorates numerous other problems, and probably would meet far less resistance than male circumcision.
The West went through better hygiene campaigns in the 19th and 20th centuries. Africa deserves this before colonial efforts to encourage an invasive, damaging surgery are begun.
Full Aidsmap summary of the research after the break.
UK study looks at relevance of circumcision, genital hygiene for HIV prevention in developed world
Michael Carter, Monday, June 04, 2007
Few patients of a sexual health clinic in London had penile wetness, according to a report in the June edition of Sexually Transmitted Diseases. Penile wetness causes inflammation that can leave cells more vulnerable to HIV infection. The findings of this study may suggest that neither penile washing nor circumcision would have a significant impact on HIV transmission in a low prevalence country, such as the UK.
Poor genital hygiene has been associated with the spread of chancroid, a sexually transmitted infection characterised by a painful sore on the genitals. Although, little is known about penile hygiene and other sexually transmitted infections, a recent study conducted in Durban, South Africa, found that penile wetness was independently associated with an increased risk of HIV infection. The Durban study also found that the protective effect of a dry penis against infection with HIV was similar to that of circumcision. In settings where circumcision is not ethically or logistically possible, encouraging penile hygiene could, it has been suggested, enhance HIV prevention efforts.
Penile wetness prevalence in the UK, where approximately 4% of men are circumcised, has not been examined. Investigators at the Ealing Hospital sexual health clinic in West London therefore conducted a study to determine the prevalence of penile wetness amongst men presenting with a new complaint. The investigators recorded whether or not a man was circumcised, obtained demographic data, and conducted a genital examination to determine if penile wetness was present. They also recorded if the man was diagnosed with a sexually transmitted infection.
The investigators defined penile wetness as a level of moisture over the head of the penis and the under the bulbous groove between the head and shaft of the penis. Men with evidence of inflammation of the foreskin or head of the penis (balanitis) were provided with appropriate treatment.
A total of 480 were included in the analysis. Most of these men were white (244), 109 were Asian, 102 were black, and 25 were of other ethnicities. Almost three-quarters of the men (73%) were uncircumcised, and 48 men were gay.
Penile wetness was observed in 6% of men. This included 8% of uncircumcised men and 1% of circumcised men, a statistically significant difference (p = 0.001).
Balanitis was the condition most associated with penile wetness (41%), but 5% of men diagnosed with non-specific urethritis and 5% of men diagnosed with ‘other’ infections were also assessed as having penile wetness.
Heterosexual and homosexual men were equally likely to have penile wetness (both 6%), and although Asian men were the racial group most likely to present with penile wetness (9%), the difference with white men (7%) and black men (3%) was no statistically significant.
“We found a prevalence of penile wetness of 6.3% in this population of routine STI clinic attendees…this prevalence is much lower than that reported from a population of pretreated black STI clinic attendees in Durban, South Africa, where 49% had penile wetness”, write the investigators.
The investigators believe that penile wetness is a marker for poor genital hygiene. Secretions from the prostate, blisters and urethral discharge are thought to be the reasons for the penile wetness observed in the Ealing study.
“The evidence for the protective effect of male circumcision in protecting against HIV in heterosexuals is now compelling”, write the investigators. “One of the mechanisms by which circumcision might reduce HIV transmission is thought to be through improved hygiene,” therefore, suggest the investigators, “improving male genital hygiene could provide some HIV risk reduction benefit in the way that circumcision might.”
But the investigators suggest that circumcision may be a more viable HIV prevention strategy. Circumcision is a one-off procedure (albeit a procedure that can be extremely painful and take weeks to heal if carried out in adulthood), whereas the investigators suggest that “long-term efforts would probably be required to bring about and sustain genital hygiene.”
The investigators believe that further studies of male penile hygiene are warranted in settings with both a low and high HIV prevalence.
O’Farrell N et al. Low prevalence of penile wetness among male sexually transmitted infection clinic attendees. Sexually Transmitted Diseases 33: 408 – 409, 2007.