Does Circumcision Prevent HIV Infection?

John Dalton Bsc,Msc

Last updated on 18th January 2001

This page comprises NORM-UK's response to the BBC Horizon documentary "The Valley Of Life Or Death" screened on BBC2 on Thursday November 16 2000 at 2100 GMT. It is our view that the programme was biased, ill-informed and irresponsible. The prevention of sexually transmitted HIV is by safe sex, not surgery on misinformed or unconsenting individuals.

The page comprises

• General Comments on the Programme
• Evidence to contradict the claims made
• Other reasons why it is inappropriate to recommend circumcision of unconsenting children to prevent HIV.
• Conclusions
• References
• Letter of complaint sent to the BBC

Where links to other sites are provided, these will open in a new window.

General Comments on the Programme

The opening scenes of the circumciser drawing a liquid from a bottle for injection were misleading as to the conditions of male circumcision in Africa. As was the use of a clean scalpel and binding of the wounded penis with clean gauze. Most circumcisions in Africa are done in unhygienic conditions and may be a factor for the transmission of HIV[1]. It was noteworthy that we did not see any injection being made.

The programme showed US-based research on a freshly removed foreskin. No mention was made however that most Male Americans are circumcised neonatally[2]. This has not prevented the USA from becoming the industrialised country most burdened with HIV.[3] Furthermore, no mention was made of the likelihood that the foreskin was being removed because of disease and may not be representative of a healthy foreskin. The programme did not query the fact that the freshly cut foreskin, with a further cut in the lab, thus had cuts which were a portal of entry that did not exist in the intact penis. This work has not been published or subjected to the scrutiny of Peer Review.

Although it was claimed that the behaviour patterns of 2 tribes, did not differ other than in circumcision practices, the appeared to be little detailed examination to support this.

Researchers supporting the hypothesis were properly interviewed and were identified by name together with their qualifications and affiliations. The only people to speak in opposition were not so identified although these included a lawyer, a psychologist and a nurse.

Large amounts of airtime were given to Frank Plummer who has been instrumental in developing and promoting the hypothesis that male circumcision prevents HIV. No comparable time was given to others whose research would contradict the hypothesis.

The narration included emotionally loaded statements such as "Few scientists could see a biological reason why the foreskin could be responsible for so many deaths..." or that Langerhans cells "are a Trojan Horse" introducing HIV to the body.

In fact Langerhans cells, along with other classes of dendritic cells, are universally found in all skin,. There is minimal variation between parts of the body in their content of Langerhans cells. They are found in all genital tissue including the glans, foreskin, shaft, scrotum, clitoris, clitoral hood, labia, and the vagina. It therefore seems odd to claim that uptake of HIV by Langerhans cells in the foreskin should justify removal of the foreskin in protection.

Only 1 minute 45 seconds of the programme covered opposition to the ethical aspects of male circumcision, and part of this was interrupted by an interview with Plummer.

The programme generously described NOCIRC as "A powerful international anti-circumcision lobby based in the US" and stated "for a group such as NOCIRC, even if the science were absolutely convincing" would see circumcision as mutilation". However the question of whether or not male circumcision is mutilation stands independently of the question as to whether or not scientific research supports the hypothesis that male circumcision prevents HIV. The programme contained no discussion of the function of the foreskin or losses due to circumcision and sought to make the NOCIRC meeting look foolish.

Plummer's statement that circumcision is an emotional issue; not treated dispassionately; nor on rational basis may be true, but its applicability is not only to the views of NOCIRC; a viewpoint implied by insertion of this remark in the middle of the section covering opposition to circumcision.

The interview with Hayes suggested that his research had eliminated confounding factors from the analysis. But there was nothing to show that this had dealt with any variable other than religion.

The Programme commented on the years that would be needed to develop a vaccine there was no comment to the effect that a similar time would be needed for circumcisions of unconsenting infants to have any impact on the sexual transmission of HIV. If indeed it has any impact at all.

Although it was claimed that there was a high level of acceptability about circumcision; it was lamentable that the programme saw it as a human rights issue that that facilities were not available and that individuals are not able to make an informed choice. An informed choice requires information about the downside of circumcision, including the very high risk of complications.

Although it was stated that it was still important to use a condom, the safe sex message is undermined by the inference of the programme that circumcision prevented HIV.

The programme promoted male circumcision with an evangelical tone but made no mention that prevention of Sexually transmitted HIV does not justify surgery to healthy unconsenting children.

The programme drew heavily on the work of Short and Szabo which has not been published except as an opinion article in the BMJ. The validity of this work is open to question if it has not appeared in any peer reviewed journal.

Evidence to contradict the claims made

The design of retrospective epidemiological studies on this subject, which did not examine any patients has been criticised.[5]

Many of the African studies did not directly verify the circumcision status of the study subjects. The circumcision status was guessed based on tribal or religious affiliation. Without actually examining the patients to determine their circumcision status, it is obviously impossible to conclude that circumcision does or does not have a protective effect.

Most of those studies that claimed a positive correlation between circumcision and reduced HIV incidence had a small sample size. If there had been only a small number of misclassifications of circumcision status, the results of those studies are no longer statistically significant. This is especially problematic in those studies that did not directly verify circumcision status (as above).

Most African studies fail to control for the practice of "Dry sex" which is a pervasive practice, purported to increase sexual pleasure, in sub-Saharan Africa. The practice is clearly associated with increased risk of HIV, but all epidemiological studies in Africa neglect consideration. Genital ulcer disease is another potentially confounding factor. More information on matters such as dry sex is available at www.cirp.org.

Female circumcision has been identified as a contributing factor to the spread of HIV.[6] The confounding effect of female circumcision, common in parts of Africa, has not been studied. Nor do published studies control for other potential cultural factors, although male circumcision is clearly a marker of cultural identity.

Many of the African studies used unrepresentative high-risk sample populations, such as clients of prostitutes, or visitors to a sexually-transmitted-disease clinic. These groups are hardly a representative sample of the population in terms of sexual behavior, general health and other factors.

An American study has shown that circumcised men have a greater tendency to engage in riskier sexual practices and unsafe sex [7]. This may contribute to the high rate of HIV infection in the United States, where circumcision rates are still of epidemic proportions.

A meta-analysis by, Van Howe[8] found that circumcised men were at statistically greater risk of acquiring HIV than a man with a non-circumcised penis. It has been shown that intact epithelium (skin and mucosa) is resistant to penetration by HIV.[9]

Angus Nicoll of the British Communicable Disease Surveillance Centre recommended that circumcision should not be used to control HIV infection on the basis that the risks and costs are unlikely to outweigh the benefits and that it is unlikely that safe circumcision could be provided in developing countries.[10]

The Fetus and Newborn Committee of the Canadian Paediatric Society examined the data on HIV, and concluded that more study would be necessary before a recommendation for circumcision could be made.

The Circumcision Policy Statement of the American Academy of Pediatrics concluded "behavioral factors appear to be far more important risk factors in the acquisition of HIV infection than circumcision status."

The Council on Scientific Affairs of the American Medical Association has concluded, in a report titled Report 10: Neonatal Circumcision, that "...behavioral factors are far more important risk factors for acquisition of HIV and other sexually transmissible diseases than circumcision

The conditions in Africa are very different from those in the developed world. It would be wrong to apply findings from Africa to the developed nations.

Seropositive couples were similar to seronegative couples in the circumcision status of the husband.[11]

Circumcised HIV infected males to be equally infectious to their female partners as those who are not circumcised.[12]

A study of roadside communities in the Mwanza Region, Tanzania found no evidence that lack of circumcision was a risk factor.[13]

A Rwandan study found partner circumcision to be a risk factor for HIV-1 infection for pregnant women.[14]

A Tanzanian study found an increased prevalence of HIV in circumcised men and that there was no protective effect for circumcision,.[15]

The UK Sexual attitudes and lifestyles survey,[16] considered circumcision status in relation to HIV but found no relationship between in bivarate analysis between circumcision and rates of attendance at an STD clinic.

More information on these matters is available at www.cirp.org.

Other reasons why it is inappropriate to recommend circumcision of unconsenting children to prevent HIV.

Circumcision is associated with many complications. The risk of wound infection found in British Day Case Surgery is 21%.[16] Overall, between 2% and 10% of circumcisions result in significant complications.[17]

HIV does not justify surgery to healthy unconsenting children: when at risk of sexually transmitted disease individuals have sufficient age or maturity to give or consent to surgery in their own right.

The programme made no serious discussion of the moral, legal or ethical implications of removing normal tissue from normal unconsenting children. In particular it did not state that it is UK Government policy that States "Surgical interventions should only be performed when clinically necessary, especially in children".[4]

The foreskin is very highly innervated and has a ridged band which is the highly sensitive and may have a role in the normal control of ejaculation.[18] During sexual intercourse, this ridged band area of the prepuce is stretched when it passes over the glans penis and, by this stretching action, the pleasure sensors in Taylor's ridged bands are stimulated. Cold and Taylor published a more detailed examination of the structure and innervation of the prepuce in 1999.[19]

A survey of 138 women who had experience with both circumcised male partners and intact complete male partners showed that 20 out of the 138 preferred circumcised male partners while 118 (85.5%) preferred intact male partners with anatomically complete penises over circumcised males. The respondents reported that circumcised partners tended to ejaculate prematurely more frequently than intact male partners. Some respondents commented that unaltered male partners appeared to enjoy coitus more than their circumcised counterparts.[20]

Study of the prepuce of male and female human beings, and those of other primate species, shows that the prepuce is highly evolved and has a specialized function in each species.[21]

Somerville discussed the legal distinction between therapeutic and non-therapeutic procedures and between operations on competent and incompetent people in a 1980 paper.[22-23]

Brigman has argued that circumcision is child abuse, and discussed possible legal remedies.[24] A number of legal writings have specifically called into question the lawfulness of non-therapeutic circumcision of normal unconsenting children.[25-40]

Conclusions

The BBC Horizon documentary "The Valley Of Life Or Death" gave weight to claims that male circumcision is effective in the prevention of HIV without questioning the quality of the research evidence or acknowledging the body of evidence to the contrary.

The programme mislead the viewer by implying that male circumcision is appropriate for the prevention of HIV but did not acknowledge the harmful aspects of the procedure or the unnacceptability of infant circumcision.

As such, the BBC should offer a retraction of the programme.

References

1. Hardy DB. Cultural practices contributing to the transmission of human immunodeficiency virus in Africa.Rev Infect Dis 1987;9:1109-119.
2. Wallerstein E. Circumcision: the uniquely American medical enigma. Urologic Clinics of North America 1985;12(1):123-132.
3. World Health Organisation. Working estimates of HIV seroprevalence as of end 1994. Wkly Epidemiol Rec 1995;70:356-7.
4. Cm 3793, 1997, Government response to the reports of the health committee on health services for children and young people.
5. de Vincenzi I, Mertens T. Male circumcision: A role in HIV prevention? AIDS 1994; 8: 153-160.
6. Brady M. Female genital mutilation: complications and risk of HIV transmission. Aids Patient Care STDS 1999;13(12):709-16.
7. Laumann EO, Masi CM, Zuckerman EW. Circumcision in the United States: prevalence, prophylactic effects, and sexual practice. JAMA 1997;277:1052-7.
8. Van Howe RS. Circumcision and HIV-infection: meta-analysis and review of the medical literature. Int J STD AIDS 1999; 10: 8-16.
9. Dezzutti CS et al. Mechanisms of HIV Transmission through Epithelial Cell Barriers. 12th World AIDS Conference. Geneva, June/July 1998 [abstract 278/32124].
10. Nicoll A. Routine male neonatal circumcision and risk of infection with HIV-1 and other sexually transmitted diseases. Arch Dis Child 1997;77:194-5.
11. Carael M, Van de Perre PH, Lepage PH, et al. Human immunodeficiency virus transmission among heterosexual couples in Central Africa. AIDS 1988 2:201-205.
12. Guimaraes M, Castilho E, Ramos-Filho C, et al. Heterosexual transmission of HIV-1: a multicenter study in Rio de Janeiro, Brazil. VII International Conference on AIDS. Florence, June 1991.
13. Barongo LR, Borgdorff MW, Mosha, FF, Nicoll A., Grosskurth H, et al. The epidemiology of HIV-1 infection in urban areas, roadside settlements and rural villages in Mwanza Region, Tanzania. AIDS 1992;6:1521-1528.
14. Chao A, Bulterys M, Musanganire F, et al. Risk factors associated with prevalent HIV-1 infection among pregnant women in Rwanda. National University of Rwanda-Johns Hopkins University AIDS Research Team. Int J Epidemiol 1994; 23:371-380.
15. Grosskurth H., Mosha F, Todd J, et al. A community trial of the impact of improved sexually transmitted disease treatment on the HIV epidemic in rural Tanzania: 2. Baseline survey results. AIDS 1995;9(8):927-934.
16. Johnson AM, Wadsworth J, Wellings K, Field J, Bradshaw S. Sexual attitudes and lifestyles. Oxford: Blackwell Scientific, 1994.
17. de la Hunt MN. Paediatric Day Care surgery: a hidden burden for primary care? Ann Royal Coll Surg Engl. 1999;81:179-82.
18. Williams N and Kapila L. Complications Of Circumcision. BJ Surg.1993;80:1231-1236.
19. Taylor JR, Lockwood AP, Taylor AJ. The prepuce: Specialized mucosa of the penis and its loss to circumcision. British Journal of Urology 1996; 77: 291-295.
20. Cold CJ, Taylor JR. The prepuce. BJU International 1999; 83, Suppl. 1: 34-44.
21. O'Hara K, O'Hara J. The effect of male circumcision on the sexual enjoyment of the female partner. BJU International 1999; 83, Suppl. 1:79-84.
22. Cold CJ, McGrath KA. Anatomy and histology of the penile and clitoral prepuce in primates. In Male and Female Circumcision, Denniston GC, Hodges FM, Milos MF eds. Kluwer Academic/Plenum Publishers, New York, 1999.
23. Somerville MA. Medical interventions and the criminal law: lawful or excusable wounding? 26 McGill L. J. 82 (1980).
24. Somerville MA. Therapeutic and Non-Therapeutic Medical Procedures: What are the Distinctions? Health Law in Canada, vol. 2, no. 4, (1981), pp. 85-90.
25. Brigman WE. Circumcision as Child Abuse: The Legal and Constitutional Issues. University of Louisville School of Law, Journal of Family Law, Vol. 23, No. 3, 1984-85.
26. Queensland Law Reform Commission (Australia). Circumcision of Male Infants. Research Paper. Brisbane, December 1993.
27. Dwyer JG. Parents' Religion and Children's Welfare: Debunking the Doctrine of Parents' Rights, California Law Review, Vol. 82, No. 6, (Dec. 1994).
28. Turner N. Circumcised Boys May Sue. Health Law Update, Melbourne. February 23, 1996.
29. Richards D. Male Circumcision: Medical or Ritual? Journal of Law and Medicine 3:4, May 1996:371-376
30. Dwyer JG. The Children We Abandon: Religious exemption to child welfare and education laws as denials of equal protection to children of religious objectors, 74 North Carolina Law Review 1321-1478 (June 1996).
31. Price C. Male circumcision: an ethical and legal affront. Bulletin of Medical Ethics, May 1997:13-19.
32. Chessler, Abbie J. Justifying the Unjustifiable: Rite V. Wrong. 45 Buffalo Law Review 555 (1997).
33. Povenmire, Ross. Do Parents Have the Legal Authority to Consent to the Surgical Amputation of Normal, Healthy Tissue From Their Infant Children?: The Practice of Circumcision in the United States. 7 Journal of Gender, Social Policy & the Law 87 (1998-99).
34. Jacqueline Smith. Male Circumcision and the Rights of the Child. In: Mielle Bulterman, Aart Hendriks and Jacqueline Smith (eds.), To Baehr in Our Minds: Essays in Human Rights from the Heart of the Netherlands. Netherlands Institute of Human Rights, University of Utrecht, Utrecht, Netherlands, 1998.
35. Van Howe RS, Svoboda JS, Dwyer JG, Price CP. Involuntary circumcision: the legal issues. BJU International 1999; 83, Suppl. 1:63-73.
36. J. Steven Svoboda. Attaining international acknowledgement of male genital mutilation as a human rights violation. In: Male and Female Circumcision: Medical Legal, and Ethical Considerations in Pediatric Practice. George C. Denniston, Frederick Mansfield Hodges, Marilyn Fayre Milos, editors. Kluwer Academic/Plenum Press, Boston, New York, London, Dordrecht, Moscow, 1999. (ISBN 0-306-46131-5)
37. Christopher Price. Male non-therapeutic circumcision: the legal and ethical issues. In: Male and Female Circumcision: Medical Legal, and Ethical Considerations in Pediatric Practice. George C. Denniston, Frederick Mansfield Hodges, Marilyn Fayre Milos, editors. Kluwer Academic/Plenum Press, Boston, New York, London, Dordrecht, Moscow, 1999. (ISBN 0-306-46131-5)
38. David J. Llewellyn. Some thoughts on legal remedies. In: Male and Female Circumcision: Medical Legal, and Ethical Considerations in Pediatric Practice. George C. Denniston, Frederick Mansfield Hodges, Marilyn Faye Milos, editors. Kluwer Academic/Plenum Press, Boston, New York, London, Dordrecht, Moscow, 1999. (ISBN 0-306-46131-5)
39. James L. Snyder. The doctor as expert witness in United States Courts. In: Male and Female Circumcision: Medical Legal, and Ethical Considerations in Pediatric Practice. George C. Denniston, Frederick Mansfield Hodges, Marilyn Fayre Milos, editors. Kluwer Academic/Plenum Press, Boston, New York, London, Dordrecht, Moscow, 1999. (ISBN 0-306-46131-5)
40. Gregory J Boyle, J. Steven Svoboda, Christopher P Price, J Neville Turner. Circumcision of Healthy Boys: Criminal Assault? 7 Journal of Law and Medicine 301 (February 2000).

Compiled by John Dalton, with thanks to Chris Price, Bob Van Howe, George Hill, Frederick Hodges and Dennis Harrison.