The CDC has issued its latest white paper on circumcision and HIV. The inaccuracies and implausible conclusions show heavy lobbying by pro-circumcision forces working in concert to push their agenda on a governmental public health agency.
Let’s take the white paper’s various problems in chronological order.
- Langerhans cells are target cells for HIV. This is untrue and contradicted by this study [pdf]. No scientific evidence exists for this and the state of the evidence today points towards a protective effect from a protein produced by Langerhans cells called Langerin. This protein is overwhelmed by HIV rather than the cells that produce it being a targeted entryway. It has been hypothesized that bolstering the production of Langerin could have applications in new prevention technologies.
- The foreskin is subject to “traumatic epithelial disruptions during intercourse (tears).” This is not only contrary to common sense, but has no basis in any studies conducted to date. It is rank speculation that relies on ignorance of the mechanics of sexual intercourse for its plausibilty. In fact, it is more logical to theorize that tears and skin trauma occur more often in circumcised men where the skin is largely immovable and does not produce the same level of lubrication that an intact foreskin produces. Edit: Hugh mentions in the comments that the keratinized glans and scarring (which varies a great deal between men) could be more disruptive of the vaginal walls than the rolling action of the intact foreskin. I would count this as rather intuitive in that the two sexual organs evolved in tandem. It’s counterintuitive that a foreskin is prone to “tears.” Sounds more like one of those stories passed around to enforce conformity than anything scientific.
- The preputial sac is more conducive to viral survival. Pure speculation without evidence. However, the idea behind this bit of supposing is that HIV can live in closed mucosal environments, giving it more time to cross mucosal barriers or migrate to susceptible cells. But this is all just a guess.
- Higher rates of ulcerative diseases in intact men may increase susceptibility to HIV infection. The latest research contradicts the belief that circumcised men have lower rates of STDs. Read it here. It is likely that the evidence will slowly accumulate that STDs do not increase nor decrease susceptibility, but rather go hand in hand with high risk behavior that is a marker for high risk populations. This has already seen some acceptance outside of the North American context. Moreover, it is obvious that surveys conducted in sexual health clinics where these myths got their start will naturally produce corallations not seen in the general population.
- Of 35 observational studies on circumcision and HIV, 16 had inconsistent results. Of the remaining 19, only two had any statistical significance towards a protective effect from circumcision in the acquisition of HIV. First, these statistics are presented in the paper in a highly misleading manner, making it sound like all the observational studies prove that circumcision is preventative. But in fact, the contradictory and non-reproducible results point in one direction: Insufficient evidence to conclude circumcision is protective. Though the intent is clearly to mislead, at least they
got the stats in theremanaged to characterize the observational studies correctly as inconsistent and contradictory.
- Although links between circumcision, culture, religion, and risk behavior may account for some of the differences in HIV infection prevalence, the countries in Africa and Asia with prevalence of male circumcision of less than 20% have HIV infection prevalences several times higher than those in countries in these regions where more than 80% of men are circumcised. And this alone tells you nothing. It is apples to oranges. The better comparison is between circumcised and intact men within countries, and more precisely of circumcised and intact men of same or similar ethnic backgrounds. This comparison, of course, may be impossible to do due to the inseparable nature of circumcision practices and culture in regions of Africa. Moreover, the way this is presented makes it sound like circumcised Africa has lower prevalence than, say, intact Latin America or intact Asia. The opposite is true. A number of examples of circumcised populations with higher rates of HIV than that of intact men in the same societies include Rwanda, Cameroon, Lesotho, Ghana, Malawi and Tanzania.
- Male-to-female HIV transmission rates in a Ugandan study showed a non-significant trend towards a reduction when adjusted for viral loads. A trend that is non-significant is NO trend at all. In fact, it is simply misleading and manipulation of words and data to call something “non-significant” and a “trend.” These statements, of which there are more, lay bare the agenda of the “consultants” to the authorship of this paper, namely Halperin, Bailey, Kilmarx, and probably Klausner.
- In the randomized African trials, men who had been circumcised had a 60% (South Africa), 53% (Kenya), and 51% (Uganda) lower incidence of HIV infection compared to the uncircumcised control group. But … the studies were never finished. They were stopped midway through for so-called ethical reasons, possibly including ethical reasons not considered when they began. The circumcised groups were counseled on a regular basis regarding safe sex practices, provided routine health care during the trials, and were provided with an unlimited supply of condoms. The control group received none of these. The conclusions drawn are simply not valid under the circumstances in which the trials were conducted. Moreover, they do not comport with real world observations, such as can be seen here [pdf]. Edit: An interesting comparison between the three studies showed a higher incidence of HIV among the circumcised Kenyans than the intact Ugandans. I’m not sure you can mix and match like that in these types of studies, but the contradiction was never addressed by the authors, who btw are the consultants to the CDC. They are the same people who essentially authored this paper.
- Complications in the United States run between 0.02% and 2.0% depending on how you measure, and include bleeding and local infection. … Study of two outbreaks of methicillin-resistent Staphylococcus aureus (MRSA) in otherwise healthy male infants at one hospital identified circumcision as a potential risk factor. True as far as it goes. But here again the authors gloss over this as if it were not important enough to give pause. The worst case for the given stats translate into 24,000 infant victims of complications a year. That’s a whole lotta injured babies. There is no trivializing that number. Moreover, the MRSA is an emerging area the authors of the white paper are clearly reluctant to address, other than the obligatory acknowledgment that it is a problem.
- Most report either improvement or no change to sexual function after adult circumcision. Adults seeking circumcision are not a good group to base conclusions on. They have an overwhelming vested interest in reporting a happy outcome. However, one study [abstract] reports a 20% rate of dissatisfaction. A failure rate of one in five is not a success, from many people’s perspective. Still, the best studies involve those between intact and circumcised men. The most comprehensive and largest study to date has shown that the five most sensitive areas [pdf] on the penis are on the foreskin. Several other studies have sought to measure the number and type of nerve receptors on the foreskin. These number in the tens of thousands. Still sexual function is a highly personal affair prone to misreporting. Therefore, the uncertainty alone should be enough to recommend alternatives, such as condoms, responsible behavior, and frequent testing.
- Circumcision is not associated with a reduced risk of HIV infection in men who have sex with men. The authors get this part correct, but you wouldn’t necessarily realize it after reading the stats they provide. Statements like “a 3.5 fold higher risk for HIV infection … [that still] was not statistically significant” do nothing for the lay reader but befuddle. If it isn’t statistically significant, why mention the insignificant difference at all? In reality, two recent, very large studies have shown that men who have sex with men get NO protection, even for those who report an exclusively insertive role. See them here [pdf] and here [Aidsmap summary].
- The authors acknowledge the ethical concerns “some persons” have raised to elective sexual surgery in infants, but wipe away worries by claiming others see no problem with it. Those “some persons” are frequent visitors to these pages. The “others” who see no problem with it typically are Wiswell, Schoen, Halperin, Bailey, Kilmarx, Waskett, Klausner, Weiss, and Morris, people who subscribe to The Gilgal Society, an organization that has as its main purpose the promotion of circumcision on social or sexual grounds (sometimes referred to as a fetish). And btw, it’s only elective when the patient makes the decision. Parents don’t make elective decisions for their children.
- While the CDC formulates a policy of encouraging circumcision, individual men may wish to proceed with it. And that’s the bottom line. The CDC, infiltrated with pro-circumcision (mostly) men with an agenda, really just want to encourage circumcision despite all the ethical issues and scientific uncertainty.
You can download the full report here [pdf].
See The AAP/CDC Project page for who to contact.