CIRCUMCISION: A surgery looking for a disease

WHAT WE NEED TO KNOW ABOUT HIV/AIDS STUDIES AND CIRCUMCISION

This blog post is a collection of writings, scientific references and explanations of how the world has been duped into pursuing yet another disease for which circumcision might be a cure. One of the best quotes I’ve seen about the unrelenting quest to find a good use for this irreversible, mutilating surgery is this:

“Dr Colm O’Mahony, a sexual health expert from the Countess of Chester Foundation Trust Hospital in Chester (UK), said the U.S. had an “obsession” with circumcision being the answer to controlling sexually transmitted infections.” http://news.bbc.co.uk/2/hi/health/7960798.stm

In order to combat the media attention given to claims of benefits to male genital mutilation, I’ve put together these posts, articles and citations that show the “behind the science” mis-steps that have been taken in trying to find a ‘quick fix’ for the AIDS tragedy in Africa.

The following is taken from discussions with Robert Hettinger:

“The mucosa contains Langerhans cells that produce a protein called Langerin that destroys HIV. Cut off the foreskin and you cut off part of the body’s immune system.

The African studies are fraudulent. They are unethical, have flawed methodology and manipulated data. They are contrived

– by requiring cut men to wear condoms for one third of the study – to create a lower infection rate for cut men. And then, for “ethical” reasons that are really unethical, all men are circumcised early to eliminate the possibility of any long term studies. This is poor science. Those who cite these “studies”, have not looked deeply enough at the flawed methodology.

The USA has the highest HIV infection rate in the developed world and has the highest circumcision rate. In the U.S., we have a circumcision experiment that involves 300 million men over 30 years. The statistics speak for themselves and blow the conclusions of the fraudulent African studies right out of the water.

The hygiene argument is trivial. The health prophylaxis arguments are a completely fraudulent cultural cliché–everything from cancer prevention to STD prevention to UTI prevention to HIV prevention. The arguments are wrong. Better statistics and examples from around the world refute these arguments.

HIV did not get entrenched in the sub-Saharan population primarily through sexual contact, but , more likely, through inoculating up to 50 or more school children for any number of childhood diseases with one of these veterinary guns using a single needle in the 1980s. http://tinyurl.com/y8fht9q The photo below shows a German made pistol grip automatic syringe of the type used.

German made pistol grip auto syringe
Sexual encounters are not sufficient to explain the exponential growth of HIV in this region. Sex is not an efficient way to transmit the virus. Needles are the most efficient method. Those children that were vaccinated in an unsafe way have grown and become sexually active. This is a far more likely hypothesis of the cause of the AIDS problem in modern day Africa.”

* * * * * * * * * * * * ** * * * * * * * *

HEALTHDAY, Monday, March 5, 2007.

Scientists Discover ‘Natural Barrier’ to HIV By E.J. Mundell .

HealthDay Reporter Mon Mar 5, 2:02 PM ET

MONDAY, March 5 (HealthDay News) — Researchers have discovered that cells in the mucosal lining of human genitalia produce a protein that “eats up”

invading HIV — possibly keeping the spread of the AIDS more contained than it might otherwise be. Even more important, enhancing the activity of this protein, called Langerin, could be a potent new way to curtail the transmission of the virus that causes AIDS, the Dutch scientists added.

Langerin is produced by Langerhans cells, which form a web-like network in skin and mucosa. This network is one of the first structures HIV confronts as it attempts to infect its host. However, “we observed that Langerin is able to scavenge viruses from the surrounding environment, thereby preventing infection,” said lead researcher Teunis Geijtenbeek, an immunologist researcher at Vrije University Medical Center in Amsterdam.

And since generally all tissues on the outside of our bodies have Langerhans cells, we think that the human body is equipped with an antiviral defense mechanism, destroying incoming viruses,” Geijtenbeek said. The finding, reported in the March 4 online issue of Nature Medicine, “is very interesting and unexpected,” said Dr. Jeffrey Laurence, director of the Laboratory for AIDS Virus Research at the Weill Cornell Medical College, in New York City. “It may explain part of the relative inefficiency of HIV in being transmitted.” Even though HIV has killed an estimated 22 million people since it was first recognized more than 25 years ago, it is actually not very good at infecting humans, relatively speaking. For example, the human papillomavirus (HPV), which causes cervical cancer, is nearly 100 percent infectious, Laurence noted. That means that every encounter with the sexually transmitted virus will end in infection. “On the other hand, during one episode of penile-vaginal intercourse with an HIV-infected partner, the chance that you are going to get HIV is somewhere between one in 100 and one in 200,” Laurence said.

Experts have long puzzled why HIV is relatively tough to contract, compared to other pathogens. The Dutch study, conducted in the laboratory using Langerhans cells from 13 human donors, may explain why. When HIV comes in contact with genital mucosa, its ultimate target — the cells it seeks to hijack and destroy — are immune system T-cells. But T-cells are relatively far away (in lymph tissues), so HIV uses nearby Langerhans cells as “vehicles” to migrate to T-cells. For decades, the common wisdom was that HIV easily enters and infects Langerhans cells. Geijtenbeek’s team has now cast doubt on that notion. Looking closely at the interaction of HIV and Langerhans cells, they found that the cells “do not become infected by HIV-1, because the cells have the protein Langerin on their cell surface,”
Geijtenbeek said. “Langerin captures HIV-1 very efficiently, and this Langerin-bound HIV-1 is taken up (a bit like eating) by the Langerhans cells and destroyed.” In essence, Geijtenbeek said, “Langerhans cells act more like a virus vacuum cleaner.” Only in certain circumstances — such as when levels of invading HIV are very high, or if Langerin activity is particularly weak — are Langerhans cells overwhelmed by the virus and infected. The finding is exciting for many reasons, not the least of which is its potential for HIV prevention, Geijtenbeek said.

“We are currently investigating whether we can enhance Langerin function by increasing the amount of Langerin on the cell surface of Langerhans cells,”
he said. “This might be a real possibility, but it will take time.

I am also confident that other researchers will now also start exploring this possibility.” The discovery might also help explain differences in vulnerability to HIV infection among people. “It is known that the Langerin gene is different in some individuals,” Geijtenbeek noted. “These differences could affect the function of Langerin. Thus, Langerhans cells with a less functional Langerin might be more susceptible to HIV-1, and these individuals are more prone to infection. We are currently investigating this.” The finding should also impact the race to find topical microbicides that might protect women against HIV infection.

Choosing compounds that allow Langerin to continue to work its magic will enhance any candidate microbicide’s effectiveness, the Dutch researcher said. Laurence did offer one note of caution, however. “In the test tube, this is a very important finding,” he said. “But there are many things in the test tube that don’t occur when you get into an animal or a human.

Having said that, though, this is a very intriguing finding.”

Citation:
1 E.J. Mundell. Scientists Discover ‘Natural Barrier’ to HIV.
HealthDay, Monday, March 5, 2007.
2 de Witte L, Nabatov A, Pion M, Fluitsma D, de Jong M, de Gruijl T, Piguet V, van Kooyk Y, Geijtenbeek T (2007). “Langerin is a natural barrier to HIV-1 transmission by Langerhans cells”. Nat Med 13 (3): 367–71.
http://www.ncbi.nlm.nih.gov/pubmed/17334373

March 29, 2009 Press Release from NOCIRC-SA

A South African human rights group urges government to halt male circumcision adoption, calling the plan dangerous and unethical.

“The promotion of male circumcision is sending the wrong message, creating a sense of false protection, and placing women at greater risk for HIV. Males are already lining up to be circumcised so that they no longer need to wear condoms (v). Women may be the most harmed by the promotion of male circumcision (vi),” says Dean Ferris, director of the National Organisation Information resource Centres – South Africa (NOCIRC-SA).

New studies released since the three randomized control trials (RCTs) on HIV and circumcision show that RCT results cannot be applied to the general population of Sub-Saharan Africa or anywhere else (i).

Two studies published in 2008 concluded that male circumcision is not associated with reduced HIV infection rates in the general sub-Saharan population. The study specifically analysing circumcision rates and HIV in South Africa found that, “Circumcision had no protective effect on HIV transmission (ii).”

Infection rates between both groups leveled off at the end of all the RCTs and circumcision may only delay HIV infection, but does not affect overall rates.

In South Africa, the Zulus do not practice circumcision, while the Xhosas do practice circumcision. The HIV rates of each group are statistically the same.

“Especially troubling is the extraordinarily high rate of complications from male circumcision in Africa. A 2008 WHO bulletin reported an alarming 35% complication rate for traditional circumcisions and an 18% complication rate for clinical circumcisions (iii).

African’s overburdened health care system cannot handle the tens of thousands of circumcision complications that would result from mass circumcision campaigns,” Ferris contends, “A 2008 study found that increased use of condom promotion would be 95 times more cost effective than male circumcision in preventing new HIV infections (iv).”

Ferris goes on to say, ” Studies have shown that the removal of the foreskin results in a less sensitive penis (ix). A less sensitive penis coupled with the reduced sensitivity afforded by condoms, may encourage males not to use them (x). It is unethical for circumcisions to be carried out on adult males unless fully informed consent has been obtained. The number of reports of African males agreeing to circumcision so that they no longer need to use condoms reveals that they are consenting to the surgery and are not being fully informed of its consequences.

Women may be the most harmed by the promotion of male circumcision. In addition to the false sense of security reducing safe sex practices, male circumcision INCREASES the risk of HIV transmission to women before the wound is fully healed [vii]. A 2008 WHO report found that 1 out of 4 circumcised African males still had not fully healed at 60 days post operative [viii].

Of particular ethical concern is the recent increase in advocacy for neonatal circumcision to prevent HIV. Neonatal circumcision places newborns at immediate risk of infection, hemorrhaging, penile damage and in rare cases even death (xi, xii). It is unethical to place newborns in the immediate risk of these complications to potentially reduce their risk, if at all, of acquiring HIV 15-20 years later when other prevention methods may exist.”

Ferris concludes, “the promotion of male circumcision for HIV prevention is fraught with logistical, monetary, ethical and human rights concerns. Proponents of circumcision have yet to suggest a long term monitoring system in order to evaluate failure or success of the exaggerated claims based on the three RCTs which are in contrast with real world population samples. While the world is desperate for a silver bullet to end the HIV epidemic, the use of male circumcision is not the answer that we have been waiting for.”

Wilfred Ascott – NOCIRC-SA: Communications Advisor – wilfred(at)nocirc.sa.co.za
Dean Ferris – NOCIRC-SA: National Coordinator – dean(at)nocirc-sa.co.za

NOCIRC-SA – National Organisation of Circumcision Information Resource Centres – South Africa
www.nocirc-sa.co.za
info@nocirc-sa.co.za

REFERENCES:
[i] Garenne M, Long-term population effects of male circumcision in generalized HIV epidemics in sub-Saharan Africa. African Journal of AIDS Research 7(1), 1–8 (2008).

[ii] Connolly C, et al., Male circumcision and its relationship to HIV infection in South Africa: Results of a national survey in 2002 S Afr Med J 98, 789–794 (2008).

[iii] Bailey RC, Egesah O, Rosenberg S. Male circumcision for HIV prevention: a prospective study of complications in clinical and traditional settings in Bungoma, Kenya. Bull, WHO 86(9), 657–736 (2008).

[iv] McAllister RG, Travis JW, Bollinger D, Rutiser C, Sundar V. The Cost to Circumcise Africa. Int. J, Men’s Health 7(2), 307–316 (2008).

[v] Nyakairu, F. Uganda turns to mass circumcision in AIDS fight. Reuters Africa 13 August (2008). http://www.canada.com/topics/ bodyandhealth/sexualhealth/ story.html?id=2788448d-1b51-44e2-9fef-ab591d723ad7 (March 2, 2009).

[vi] Irin, Swaziland: Circumcision gives men an excuse not to use condoms. UN Office for the Coordination of Humanitarian Affairs 31 July (2008). http://www.irinnews.org/Report.aspx?ReportId=79557 (March 2, 2009).

[vii] Wawer M, Kigozi G, Serwadda D, et al. Trial of male circumcision in HIV+ men, Rakai, Uganda: effects in HIV+ men and in women partners. 15th Conference on Retroviruses and Opportunistic Infections 3–6 February, Boston. Abstract 33LB (2008).

[viii] Bailey RC, Egesah O, Rosenberg S. Male circumcision for HIV prevention: a prospective study of complications in clinical and traditional settings in Bungoma, Kenya. Bull, WHO 86(9), 657–736 (2008).

[ix] Cold CJ, Taylor JR. The prepuce. BJU Int. 83 Suppl.1, 34–44 (1999).

[x] Gusongoirye D. Rwanda: Nothing can fight HIV/AIDS better than discipline. The New Times (Kigali) 12 February (2008).

[xi] Williams N, Kapila L. Complications of circumcision. Brit. J. Surg. 80,1231–1236 (1993).

[xii] Paediatric Death Review Committee: Office of the Chief Coroner of Ontario. Circumcision: a minor procedure? Paediatr. Child Health 12(4), 311–312 (2007).

9 thoughts on “CIRCUMCISION: A surgery looking for a disease

  1. There are some serious factual errors in this blog post.

    For example, it is claimed that the three randomised controlled trials in Africa: ‘requir[ed] cut men to wear condoms for one third of the study – to create a lower infection rate for cut men.’

    That’s incorrect. No participants were required to wear condoms. All men, circumcised or not, were given counselling sessions in which they were given safe sex advice.

    My guess is that you’re thinking of the following. Circumcised men were advised not to have sex during the healing period (but this was only six weeks, not a third of the study duration), and were advised that, if they did have sex, it was especially important to use a condom. The studies tested men for HIV at several points during the course of the studies, so it was possible to determine whether this six-week period was responsible for the differences. As can be seen from the data, it wasn’t – the protective effect continued afterwards.

    Another incorrect claim: ‘And then, for “ethical” reasons that are really unethical, all men are circumcised early to eliminate the possibility of any long term studies”.’

    This is again false. All of the studies were required to offer circumcision to all men at the end of the study, but none of the studies actually circumcised all men. In fact, Ron Gray is conducting a post-trial surveillance study. He reports that: “After four years follow up, HIV incidence in men who were circumcised is 0.67/100 py, and in men who chose not to be circumcised incidence is 2.67/100 py.” (It should be noted, however, that this can no longer be considered truly randomised, so it is less reliable than the original study.)

    Finally, I have to say that it seems highly irresponsible to claim that studies are “fraudulent” or contain “manipulated data”. Surely you’re aware that making such claims without proof is libel?

  2. when I took my two year old son to the ER with an infected penis (his is intact), the first thing the doctor did was tell me that infections of that type are common in uncircumcised children, and that if it happens again I should probably circumcise him. ehh….his penis was better the next day.

    my little guy hasnt had any problems like that before or since, but I’d sure like to know what advice that doctor gives to parents of newborn sons 🙁

    it always shocks me when people still think there is any kind of good medical reason for circumcising newborn boys.

  3. One in 10 boys who are cut will have to be operated on again in the first two years of life for a condition called meatal stenosis (in layman’s language, closing of the pee hole). The boy has to be anaesthetized and the hole re-opened. As far as I know, drs don’t inform parents of that known risk. Of course, it’s a good money maker for the urologists, so they’re not talking.

  4. Ahhh, JAKE, has arrived 🙂

    I’m not worried one bit about my facts or being sued for libel. Do you have a reference for your Ron Gray numbers or is this more b.s. that is on the “public library of science” which makes no bones about the fact that no reputable peer reviewed journal will publish the junk science that they put up on their website?
    Gloria

  5. Hello Gloria,

    My quote is from Gray’s comments at the Center for Global Development’s “Global Health Policy” blog (see comment #5): http://blogs.cgdev.org/globalhealth/2010/01/adult-male-circumcision-as-an-hiv-prevention-tool-should-the-scale-up-of-an-efficacious-intervention-be-evaluated.php

    Though it isn’t from the Public Library of Science, I’m puzzled by your claim. Do you have any evidence whatsoever that “no reputable peer reviewed journal will publish the junk science that they put up on their website”, or are you just lashing out at the journal because you dislike some of the material they’ve published?

  6. When will the madness end? Stop circumcision. Just stop. Stop stop stop.

    Jake I don’t know who you are but do you really need studies to tell you or anyone else that the cutting of the foreskin is wrong?

    I’ve got up too early this morning and when I read this post while nodding my head in agreement and then see comments like Jakes I get a little nuts.

  7. Jake, I’m not going to give you any more time on this blog because it’s never ending circuitous thinking that goes nowhere.  This cartoon illustrates what I’m saying:  http://www.phdcomics.com/comics/archive.php?comicid=1174
    People who like the idea of amputating healthy foreskins can not be reasoned with.

    Going to a poor nation with a bottomless bank account from the Bill Gates Foundation is not the way that legitimate studies are done. There are so many ethical problems with that imbalance of power that a scientific ethics committee would not permit it. The material I have put up in this blog post has journal references . . . I’m not referring to blogs or made-up websites with no governance—a long, pretentious name does not make a website credible. Not interested in arguing this with you unless you can speak from peer reviewed journal evidence. I’ll remove your replies if they don’t comply.

Leave a Reply to Amy Cancel reply

Your email address will not be published. Required fields are marked *