By Edd Lee
This ditty comes from several conversations and (sometimes) heated debates I’ve observed and/or participated in over the last few months.
Most of the discussions were sparked by the data released by the National Institutes of Allergy and Infectious Disease (NIAID) that found medically-performed male circumcision reduced the risk of HIV infection by about half for men who engaged in vaginal sex. (you can see the NIAID press release here.)
The reasons I took the time to chime in about this new development in HIV prevention really have more to do with my commitment to creating more HIV prevention options for people, rather than support of male circumcision
specifically. I hope that you will keep this in mind as you read this blog.Like many of the new HIV prevention strategies currently in clinical research – male circumcision comes with a whole host of questions, concerns and controversies. The debate I have been witness to has been passionate, rich and diverse – all great things! However, there have been a few things that have really concerned me about the discourse about male circumcision so I’ve taken the time to write about them to the best of my ability. I have condensed these concerns into three points:
1. What does the data actually tell us?
2. How good is this data?
3. Is getting your foreskin cut off really what is in question here?
Remember, I am not a scientist or male circumcision expert by any means. You can go get more information for yourself by following this link, where you will find a range of documents and materials about male circumcision for HIV prevention.
1. What does the data actually tell us? Okay – this question is very complex – I would suggest that anyone who wants to really have a meaningful discussion about male circumcision for HIV prevention should follow this link, and check out the range of documents that help explain what the trials found concerning male circumcision.
For those of you who can’t be bothered, this is my basic summary:
--Medically-performed male circumcision was shown to reduce the risk of HIV infection for negative men who engage in vaginal sex by about half in three
independent clinical trials in South Africa, Uganda and Kenya. --We don’t know if male circumcision has any benefit for negative women who have vaginal sex with circumcised positive men.
--We also don’t know if circumcision has any effect in anal sex.
2. How good is this data? Well in terms of HIV prevention research – the data around male circumcision is the strongest data we’ve ever had. Male and female condoms never went through comparative clinical trials (clinical trials where researchers compare HIV infection rates between folks who use condoms versus folks who don’t use condoms). Instead condoms were approved using observational data (that means looking back in time to see if people who used condoms generally had lower rates of HIV infection versus people who didn’t.)
In the case of male circumcision, we have three independent trials, in three different countries that all show about the same rate of protection – about half. This also supports the observational data that found groups of people who practiced male circumcision tended to have lower overall rates of HIV infection. In terms of scientific evidence, this is the most robust we’ve ever had for any HIV prevention intervention.
Folks have raised questions about whether this data is useful in the US – which
is a totally fair question. (For a document that specifically looks at male circumcision in the US click here) However, when people start to pick away at the science behind the male circumcision trials – I have to ask, how well would the science behind currently available HIV prevention options stand up to such scrutiny? And for those who say that these data cannot be applied to the US because they came from countries in Africa – I just need to remind folks that most of the world has implemented HIV prevention, treatment and care strategies based on data that only came from the US. So, why is our data good enough for them but their data is not good enough for us? The reality is that we can’t wait to conduct trials of HIV prevention strategies in every country – there simply isn’t enough money or time. But this doesn’t mean there aren’t still critical questions about male circumcision that need to be answered – like whether it is protective in anal sex or for women partners of circumcised positive men.
And for those who say male circumcision goes against cultural norms and is therefore not a good HIV prevention tool – I bring to your attention this: everything we do in HIV prevention calls for a cultural shift. Talking about sex; talking about sexual activities; reducing partners; and putting condoms on for sex – at one time, all of these activities were considered counter-cultural.
3. Is getting your foreskin cut off really what is in question here? As I observed people talking about the male circumcision data, this question kept creeping up into my mind. For some reason, the debate always seemed to be reduced to “snip or not to snip” – but is that really question?
I feel HIV negative men who engage in vaginal sex need to decide for themselves whether or not a potential 50% reduction in HIV risk is worth the ordeal of getting circumcised. Of course, everyone must be provided with all relevant information about risks and benefits of any intervention – but ultimately I think it is a matter of individual choice. I think we have to get away from the assumption that people are not smart enough to decide if an intervention is good for them – instead we should be focusing our efforts on making sure people get all the right information.
However, I must remind folks that making circumcision accessible to those who cannot afford it is a critical part of giving people choices.
The bottom line is the world needs more HIV prevention options – not less. If we look at birth control, we see an increase in the number of contraceptive options increased the overall use of birth control. I think we should take this lesson to heart for HIV/AIDS. People need to have a range of HIV prevention options to choose from, based on their own individual situation. That means that some interventions will work great for some people and not so well for others. I think it is our job to make as many options available as possible, and to make sure people understand how these options work – so they can pick what is best for them.
Which leads me to ask, just because you as an individual choose not to cut your
foreskin off – does your concern over your foreskin mean you should act in ways that would deny others who want a circumcision to protect themselves from HIV infection the means to do so? Can’t this be another version of opt-out, at least for adults? (To me, infant circumcision is a whole other, larger discussion about autonomy, adulthood and parenting that I don’t think I can properly discuss)Clearly, we cannot make any recommendations about circumcision for men who engage in anal sex because we just don’t have any data. I think the greatest shortcoming of male circumcision research is the lack of planning for further research – particularly anal sex.
