April 15, 2007
Tough Sell
Preventing H.I.V., but at What Price?
By DONALD G. McNEIL Jr.
READ the next sentence aloud, and watch all the men around you involuntarily cross their legs:
How do you persuade a grown man to get circumcised?
Answer: it's not easy, even in America, where most men are circumcised at birth.
Now that three clinical trials in Africa have shown that circumcision helps protect men against AIDS and the World Health Organization has endorsed it, public health doctors elsewhere — including in New York City — are contemplating whether to recommend it. Then comes the difficult part — how to sell the idea.
Unfortunately, the data from Africa does not translate well. Those trials were of heterosexual men in countries where the virus is everywhere, education about safe sex is practically nonexistent, and condoms get in the way of the need to father children.
In the United States, the AIDS epidemic is very different. The highest risk groups are men having sex with men (whether openly or covertly or even forcibly — in prison rapes, for example), people who share needles and women who, often unknowingly, have sex with high-risk men. Although it has been killing people here for 25 years, AIDS has not turned into a generalized epidemic like it has in Africa. Sex education, condoms, abstinence, antiretroviral drugs and the fear of death have concentrated it mostly in small pockets of the population.
And for most of those people, circumcision probably won't do much good. It might help protect gay men who are exclusively "tops" — that is, they have only penetrative anal sex, never receptive. It presumably would protect men having sex with infected women. It might protect women who choose circumcised men — but even that wasn't proved in the African studies, which had to be stopped early because the benefit for men was so glaring.
Because of these unknowables, no domestic medical authority, from the New York City Health Department to the American Urological Association, has a policy on adult circumcision yet.
And, besides, there hasn't been a groundswell of demand.
"We haven't gotten a lot of calls," said Noel Alicea, a spokesman for Gay Men's Health Crisis, which runs a hotline.
"Not a one," said Tokes Osubu, executive director of Gay Men of African Descent.
"A few," said Mark McLaurin, executive director of the New York State Black Gay Network. "The first ones wanted to make sure that it wasn't going to be mandatory. And then there were others who said 'Tell me more — how much does this reduce my risk?' "
Mr. McLaurin said he would advise most gay men to "hold off until we have more data."
But, he added, "for someone who was predominantly or exclusively a top, and said he was really having a hard time reducing his risk by practicing safe sex — I'd have a hard time recommending against it."
But, he quickly added, he was certain that few men in his network would want it.
"We've had a hard time recruiting black and Latino men even for vaccine trials," he said.
"Because of everything from Tuskegee on up," he explained — referring to the notorious medical experiment in which black men with syphilis were left untreated for decades — many black Americans mistrust the medical establishment.
In Africa, it is relatively easy to talk men into getting circumcised, said Daniel Halperin, an AIDS researcher at the Harvard School of Public Health who has interviewed hundreds of African men about sex, AIDS and local customs.
Some tribes circumcise teenagers to welcome them to full manhood. Many men who can't get enough water to bathe regularly think foreskins are unhygenic. And some, he said, "say circumcised men get all the women" because of a widespread belief that, with slightly lessened sensation, they can make love longer.
(Circumcision's effect on sex is a white-hot issue in the United States for the small but vocal anticircumcision lobby. The lobby's main focus is on advice to parents of baby boys, but it has offshoot groups, like the "uncuts" who insist that sex with uncircumcised men is superior, and the "foreskin restoration movement" which utilizes tape, small weights and parental resentment.)
For adult men, circumcision takes about 30 minutes, said Dr. Craig Niederberger, chief of male reproductive surgery at the University of Illinois at Chicago. It is an outpatient procedure and, like dental work, can be done with local injections of Novocain.
"But with many men," he added, "if you use the words 'scalpel' and 'penis' in the same sentence, they say 'put me to sleep!' So then we do it under general anesthesia."
There is no official national estimate of how many adults have the operation each year.
Most of his patients have phimosis or balanitis — a painfully tight foreskin or swollen glans, which can become a crisis if urination is blocked.
But, because he practices in a black Chicago neighborhood, some of his young, healthy patients are volunteers — perhaps the only demographic group of African-American men currently lining up for the operation.
They are converts to Islam, which requires circumcision.
"They come in very committed," he said. "It's a personal choice that's very strong."
A spokeswoman for the Nation of Islam, the Black Muslim group also based in south Chicago, said she presumed most adherents were circumcised at birth, "but I'm the wrong person to ask," she added. A male official she suggested for comment did not return a phone call.
In any case, that appears to be the answer: Until more trials are done, it's going to take a medical emergency. Or divine intervention.
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