beausoleil

I was curious about the HIV - circumcision - Uganda thing. It struck me that circumcision is a custom dependent on parental circumstances that might themselves tend to lead children towards less risky lifestyles in later life. A quick search turned up this, which may of course be biased but suggests there is a case to answer...

Position Statement on the Use of Male Circumcision to Limit HIV Infection

<a href="http://www.nocirc.org/statements/hiv_statement2001.html" target="_blank">http://www.nocirc.org/statements/hiv_statement2001.html</a>

Reading it led me to wonder if any national health body recommends circumcision to combat HIV.

Turning to this paper...

Male circumcision and HIV acquisition and transmission: cohort studies in Rakai, Uganda. Rakai Project Team.

<a href="http://www.cirp.org/library/disease/HIV/gray1a/" target="_blank">http://www.cirp.org/library/disease/HIV/gray1a/</a>

As a non-medic scientist, the abstract shouts at you that it might be Muslim vs non-Muslim that is making the difference, not circumcised vs uncircumsized. When non-Muslims are examined, no effect is found from circumcision.

The authors seem to agree somewhat here...

<a href="http://www.cirp.org/library/disease/HIV/quinn1/" target="_blank">http://www.cirp.org/library/disease/HIV/quinn1/</a>

" In our representative population in Rakai, we found that circumcision was associated with a reduced rate of HIV-1 acquisition; this was particularly true for circumcision performed before puberty. However, this effect was mainly due to the lower incidence of HIV-1 among Muslims, who constitute the largest group of circumcised males. Circumcision was not significantly protective among non-Muslim men or in couples in which both partners were HIV-1-negative. (1) The 30 African epidemiologic studies mentioned by Bailey are mainly cross-sectional investigations with inconsistent findings and inadequate control for potential confounding. These observational data are difficult to interpret, and clinical trials are needed before circumcision can be promoted as a means of preventing HIV infection. "

Dr Rick

Here's a brief review of some of the international medical literature on circumcision over the past 36 months. These recent studies speak directly to some of the older, and at the times they were made appropriate but nonetheless now out-dated, criticisms along the lines of "there is no good evidence" that circumcision has any benefit.

Again, the debate is still unsettled, but it now hinges upon whether or not the demonstratable benefits of the procedure outweigh its risks and potential for harm.

From Sweden, a study documenting the protective effects of circumcision against penile carcinomas:
Scand J Urol Nephrol 2000. Etiology of squamous cell carcinoma of the penis. Dillner J, von Krogh G, Horenblas S, Meijer CJ. Microbiology & Tumor Biology Center, Karolinska Institute, Stockholm, Sweden.

From Spain, the decreased risk of cervical cancers in women and the decreased risk of human papilloma virus infections in men associated with male circumcision:
N Engl J Med. 2002 Male circumcision, penile human papillomavirus infection, and cervical cancer in female partners. Castellsague X, Bosch FX, Munoz N, Meijer CJ, Shah KV, de Sanjose S, Eluf-Neto J, Ngelangel CA, Chichareon S, Smith JS, Herrero R, Moreno V, Franceschi S; The International Agency for Research on Cancer Multicenter Cervical Cancer Study Group. Servei d'Epidemiologia i Registre del Cancer, Institut Catala d'Oncologia, Hospitalet de Llobregat, Barcelona, Spain.

...ditto from India:
J Indian Med Assoc 2000 Epidemiology of cancer of the cervix: global and national perspective. Shanta V, Krishnamurthi S, Gajalakshmi CK, Swaminathan R, Ravichandran K. Cancer Institute (WIA), Chennai.


From Uganda, evidence that circumcision protects against HIV aquisition:
AIDS 2000 Male circumcision and HIV acquisition and transmission: cohort studies in Rakai, Uganda. Rakai Project Team. Gray RH, Kiwanuka N, Quinn TC, Sewankambo NK, Serwadda D, Mangen FW, Lutalo T, Nalugoda F, Kelly R, Meehan M, Chen MZ, Li C, Wawer MJ. Johns Hopkins University, School of Hygiene and Public Health, Department of Population and Family Health Sciences.

...and the same from other parts of sub-Saharan Africa:
AIDS 2001 Male circumcision and HIV infection in four cities in sub-Saharan Africa. Auvert B, Buve A, Lagarde E, Kahindo M, Chege J, Rutenberg N, Musonda R, Laourou M, Akam E, Weiss HA; Study Group on the Heterogeneity of HIV Epidemics in African Cities.

From Turkey, an exploration of the mechanisms by which neonatal circumcision protects against urinary tract infections:
Pediatr Nephrol 2001 Circumcision for the prevention of significant bacteriuria in boys. Nayir A. Department of Pediatrics, Pediatric Nephrology Division, Istanbul Faculty of Medicine, University of Istanbul, Tarik Zafer Tunaya sok 2/6, Gumussuyu-Istanbul, 80040 Turkey.

From Tanzania, the association of syphillis with the lack of circumcision:
Sex Transm Infect 2001 Risk factors for active syphilis and TPHA seroconversion in a rural African population. Todd J, Munguti K, Grosskurth H, Mngara J, Changalucha J, Mayaud P, Mosha F, Gavyole A, Mabey D, Hayes R. National Institute for Medical Research, Mwanza, Tanzania.

From the USA, a study linking lack of circumcision to gonorrhea:
Sex Transm Infect 2000 Circumcision and STD in the United States: cross sectional and cohort analyses. Diseker RA 3rd, Peterman TA, Kamb ML, Kent C, Zenilman JM, Douglas JM Jr, Rhodes F, Iatesta M. Kaiser Permanente Research Department, Nine Piedmont Center, 3495 Piedmont Road, NE, Atlanta, GA 30305-1736, USA.

I'm off for my holiday; thanks to all those who, even if they had strong feelings on the subject, were rational and civil.

Rick

[ August 22, 2002: Message edited by: rbochnermd ]</p>

Gurdur

Not wholly at you, but also at others, some far worse. The circumcision debates seem extremely and inappropriately emotional, given the low morbidity rate.

Heh, were you bitterly attacking the linguistic community, I would doubtlessly feel personally attacked too (unless you kept your attacks to American transformational grammarians).

It's a mite disingeneous to bitterly attack the entire medical profession in exaggerated terms, and then not to see it as also being an attack on rbochnermd, since he's a member of it.

Again you make what seems to be a personal attack on rbochnermd.
Yes, he's proud of being a medical doctor.
Good on him.
It wasn't easy for him to become one, and he helps people.
No, he's never expressed pride, to my knowledge, at representing the "medical imdustry".
Do you see the difference ?

heh, maybe you should consider toning it down a wee bit; I'm sure rbochnermd - as you do yourself - has as a first imperative the well-being of people.
The argument here is what best serves that well-being, not whether it exists.

So I guesss the entire "medical industry" as you slightingly put it is not completely at fault in your eyes then ?

Flattery it ain't; call it parody.

Very seriously; everything I see indicates to me that rbochnermd has the well-being of people at heart very strongly - as you seem to too.

I suggest you keep that in mind when disagreeing with him over the best means to serve that well-being.

[ August 22, 2002: Message edited by: Gurdur ]</p>

ybnormal

<a href="http://www.math.missouri.edu/~rich/MGM/primer.html#intro" target="_blank">source</a>

From the Third International Symposium on Circumcision
University of Maryland, May 22-25, 1994:

Look at these hands.

These hands have taken a newborn baby from his mother's safe warm breast and his father's sheltering arms, and these hands have tied this baby to a cold hard platter and served him up to the circumciser.

These hands have readied the scalpel, even as they caressed the brow of the terrified baby as he struggled for freedom and searched my eyes for compassion he did not find.

A tortured being has sucked frantically on this finger in a hopeless effort to end the agony as his flesh -- his birthright -- is ripped from him and thrown in the garbage.

These hands have removed the diaper painfully adhered to the feces-covered wound between his chubby legs.

These hands have shielded my ears from his screams.

Nurses of America, I did not become a nurse to hurt babies, and neither did you.

In 1992, with over 20 other nurses at St. Vincent Hospital in Santa Fe, New Mexico, I gave notice to my employers and declared I would no longer be an accomplice in the atrocity that is infant circumcision.

I have reclaimed my tattered soul and begun the process of becoming whole again.

I am a conscientious objector in the war against our infant brothers and sons, and it feels wonderful.

Nurses of America, wipe the blood from your hands and join me!

Mary Conant, RN

[Mary Conant is one of the 24 heroic Conscientious Objectors to Circumcision nurses at St. Vincent's Hospital, Santa Fe, New Mexico, and co-founder of Nurses for the Rights of the Child]

beausoleil

How odd. This is the paper I linked above. The authors themselves later agreed their conclusion was incorrect, as I pointed out there. The observed effect was so obviously due to the social differences between Muslims and non-Muslims it's hard, as an outside scientist, to see how it got published.

Meanwhile,

Laumann EO, Masi CM, Zuckerman EW. Circumcision in the United States. Prevalence, prophylactic effects, and sexual practice. JAMA 1997;277(13):1052-57.

As reported here

<a href="http://www.reproline.jhu.edu/english/6read/6issues/6network/v18-3/nt1832a.html" target="_blank">http://www.reproline.jhu.edu/english/6read/6issues/6network/v18-3/nt1832a.html</a>

found that, for the USA:

" a nationally representative sample of 1,511 men and 1,921 women between the ages of 18 and 59, showed that there was no evidence of a prophylactic role for circumcision in regard to sexually transmitted diseases (STDs). In fact, circumcised men were slightly more likely to have had both a bacterial and a viral STD in their lifetime."

Moving on to cervical cancer in partners, here's a stinging critique of the NEJM paper...

<a href="http://www.circumstitions.com/Cancer-cervNEJM.html" target="_blank">http://www.circumstitions.com/Cancer-cervNEJM.html</a>

Once again, the population from which most of the circumsised men was drawn is drastically different from that in which the uncircumsised men are drawn.

The evidence about penile cancer seems similarly flawed...

<a href="http://www.circumstitions.com/Cancer.html" target="_blank">http://www.circumstitions.com/Cancer.html</a>

Now I'm no expert, but the studies I've seen so far where like populations have been compared (non-Muslims in Uganda, men in the USA) show no evidence of a benefit from circumcision.

On a wider scale, medical research about the benefits of this or that procedure or drug anecdotally has a poor record of being tainted by the interest of researchers - the whole ADHD thing a while back for instance. I'm not getting reassured from this debate. If I went to a doctor I'd hope to get a balanced view, but I'm not sure I would.

But I just don't get what doctors have invested in circumcision - it's not like they're short of work, is it?

[ August 23, 2002: Message edited by: beausoleil ]</p>

tronvillain

Well, as is obvious from that Saskatchewan memo and British Columbia circumcision rates, it is simply not true to suggest that doctors in general do have something invested in circumcision.

beausoleil

I guess I don't mean doctors in general - I'm sure as a whole the medical profession is just and neutral. I can see how someone unscrupulously (or even unconsciously - researchers are only human) might gain funding by favouring a drug, for instance, but not by favouring a procedure.

eldar1011

Well, since I am intact and expecting our first child, I tend to be drawn to this topic. I am relieved that we are expecting a daughter, however.

A son would have caused some problems as I am not in favor of circumcision, yet my wife's family is Jewish.

The only thing I wanted to add is that I'm glad to see this one excerpt from Rick's posts:


That pretty much says everything I need to know about circumcision, particularly the last sentence. A relatively small benefit could not justify inflicting this procedure on my child without his consent.

Dr Rick

That is why we try to use clinical studies, and not anecdotes, to guide medical decisions. Good clinical studies are subjected to internal institutional reviews if they involve directed therapies, are blinded, peer-reviewed before being published, subjected to critiques after publication through correspondence, and then verified or refuted by further studies from other institutions and groups. The medical literature is in a constant state of change because of this process.

<strong> I hate to use up this much bandwidth, but to help better understand the studies, the entire abstract and follow-up correspondence has been posted at the bottom of this reply. Notice that the authors found:

• a protective effect for circumcision in the group as a whole
• a protective effect for circumcised male partners compared with uncircumcised male partners of HIV+ females
• a protective effect for women of circumcised male partners with low HIV loads compared to women of uncircumcised male partners with low HIV loads
• that the small number of circumcised non-Muslims in the study did not allow them to make a statistically significant conclusion about this sub-group (ie. there are no confidence intervals or p-values for them).
• the protective effects were significant only for prepubertal and not postpubertal circumcision
• The observed effect was not due to the social differences between Muslims and non-Muslims; rather the authors note that cultural differences and the lower rates of HIV in the Muslim population compared with the non-muslim population confounded more definitive conclusions.

Notice in the follow-up correspondence that:

• there is no admission that anything they concluded was incorrect
• the authors re-iterate the protective effect they found for prepubertal circumcision, particularly in high-risk (discordant) couples
• the authors found neither a statistically significant protective effect for circumcison in non-muslims, nor a statistically significant lack of effect in this sub-group
• the low HIV acquistion rate in the circumcised muslim group was due mostly to the low prevalence of HIV in this population. In other words, populations with low rates of infection are going to have low rates of transmission no matter what preventive measures are tested, which may potentially confound any study.

The authors of the study concluded in both the abstract and correspondence that more study was warranted, and that is just what was done and published in the following year:

AIDS 2001 Male circumcision and HIV infection in four cities in sub-Saharan Africa. Auvert B, Buve A, Lagarde E, Kahindo M, Chege J, Rutenberg N, Musonda R, Laourou M, Akam E, Weiss HA; Study Group on the Heterogeneity of HIV Epidemics in African Cities.
Here, a different study methodology was used, but the results confirmed the protective effects of circumcision. So now we have two good studies from two different groups using two different methods published in a peer-reviewed journal demonstrating the protective effects of circumcision, and if you do a review of the literature, as I did, you will find several others. By no means is this the end, as more studies are in progress, but for now the best evidence shows that circumcision, or at least prepubertal circumcision, has a protective effect against HIV acquisition.

Now, let's look at what happens when we get study results that are not in agreement, as often happens in medicine:

<strong> ...Well, I guess we can't, since you linked to an article that reports the results second-hand with no specifics about the study population, methods, or statistical analysis, so we'll just have to address the issue of discordant medical literature in general.

It's rare to have medical studies that agree with each other 100% The reasons for this are many, and they include selection bias, sampling differences, sampling of different groups witrh varying disease rate prevalences, retrospective results instead of prospective ones, and many more. That's why reading lots of studies from a variety of places and researchers is a good thing. For instance, some studies have found no relation between good diabetic control and preservation of kidney function, but other studies have, and on comparison it appears that the latter used better methods and statistical evaluations, so now doctors encourage diabetics to control their blood sugars well. If a better study comes along that shows otherwise, we'll have to change our practices, again. That's exactly what happenened with hormone-replacement therapy this year. For a long time, the available evidence demonstrated benefit from estrogen-replacement therapy in post-menopausal women, but a newer, and now to-date the best study on the subject came out this Spring showing just the opposite. Literally, overnight, our practices changed. The results were rushed into the lay-press to alert the public and emailed to doctors all-over advising us of the findings so that we could act upon them quickly, and hundreds-of-thousands of women were taken off their therapy. The old studies are still out-there and can be accessed online and in my textbooks that were published more than one year ago, but the recent one was conducted much better than those and now guides us.

Nothing in medicine or science is carved in stone; what we think we knew yesterday often turns out wrong tomorrow.

Going back to the issue of circumcision, a current literature search will reveal that the preponderance of evidence in the better studies demonstrates a protective effect against syphillis and gonorrhea by circumcision. No, not every article ever written on the subject will say that, just as not every article on diabetes favors controlling blood sugars. Nonetheless, the more recent and better studies demonstrate a protective benefit from circumcision; in other words, the recent studies demonstrating a benefit are overall superior to the older ones that did not.

<strong> ...from a non-peer reviewed anti-circ site.
If the authors had submitted their critique to a peer-reviewed journal, it would have been reviewed and the researchers would have had an opportunity to respond to the criticisms. In the forum these critics chose, they can pretty much trash the study, and no rebuttal will be allowed.

This is not a good way to objectively evaluate medical studies. I wouldn't want my doctor to rely on such one-sided forums for his continuing education.

The current best evidence in the peer-reviewed literature suggests a link between lack of circumcision and cervical cancer, even though the evidence presented on anti-circ sites may not.


<strong> ...from yet another anti-circ site. And their argument is not that circumcison doesn't protect against penile cancer but that it is too uncommon to justify circumcision

<strong> You haven't shown us that you've seen any studies at all, just second-hand reports from some not-so objective sources:

And look at what they are relying upon: studies from 1975, 1973, 1962, and 1958. I can't locate any of them online or in my hospital library. Did you really read them? If so, how did you find them? Were they printed on papyrus?

<strong> You're probably not likely to get an especially balanced view from an anti-circ site, either. But if you really want to be absolutely sure to get an opinion that's consistent with yours, just seek out a doctor that hasn't read anything in the past 3 years. The rest of us hold a variety of opinions, and those of us who know what we are talking about will tell you that the evidence shows some benefits from circumcision, though that evidence is not enough for us to offer a "blanket" recommendation one way or the other

From Gray et. al: "Male circumcision is associated with reduced HIV acquisition. METHODS: HIV acquisition was determined in a cohort of 5507 HIV-negative Ugandan men, and in 187 HIV-negative men in discordant relationships. Transmission was determined in 223 HIV-positive men with HIV-negative partners. HIV incidence per 100 person years (py) and adjusted rate ratios (RR) and 95% confidence intervals (CI) were estimated by Poisson regression. HIV-1 serum viral load was determined for the seropositive partners in HIV-discordant couples. RESULTS: The prevalence of circumcision was 16.5% for all men; 99.1% in Muslims and 3.7% in non-Muslims. Circumcision was significantly associated with reduced HIV acquisition in the cohort as a whole (RR 0.53, CI 0.33-0.87), but not among non-Muslim men. Prepubertal circumcision significantly reduced HIV acquisition (RR 0.49, CI 0.26-0.82), but postpubertal circumcision did not. In discordant couples with HIV-negative men, no serconversions occurred in 50 circumcised men, whereas HIV acquisition was 16.7 per 100 py in uncircumcised men (P = 0.004). In couples with HIV-positive men, HIV transmission was significantly reduced in circumcised men with HIV viral loads less than 50000 copies/ml (P = 0.02). INTERPRETATION: Prepubertal circumcision may reduce male HIV acquisition in a general population, but the protective effects are confounded by cultural and behavioral factors in Muslims. In discordant couples, circumcision reduces HIV acquisition and transmission. The assessment of circumcision for HIV prevention is complex and requires randomized trials.

Bailey comments on the association between circumcision and reduced rate of acquisition of HIV-1 in male subjects in our study of couples discordant for HIV-1 status. Although circumcision was strongly associated with reduced acquisition of HIV-1 in these highly exposed couples, additional analyses suggest that generalization to the whole population is complicated by confounding. (1) In our representative population in Rakai, we found that circumcision was associated with a reduced rate of HIV-1 acquisition; this was particularly true for circumcision performed before puberty. However, this effect was mainly due to the lower incidence of HIV-1 among Muslims, who constitute the largest group of circumcised males. Circumcision was not significantly protective among non-Muslim men or in couples in which both partners were HIV-1-negative. (1) The 30 African epidemiologic studies mentioned by Bailey are mainly cross-sectional investigations with inconsistent findings and inadequate control for potential confounding. These observational data are difficult to interpret, and clinical trials are needed before circumcision can be promoted as a means of preventing HIV infection.

Fremont-Smith questions the proportion of subjects with undetectable viral loads in our study on the basis of a comparison with a subgroup analysis from the Multicenter AIDS Cohort Study (2) and a previous report that plasma HIV-1 RNA levels tend to be higher in sub-Saharan Africa. (3) Unfortunately, these studies cannot be directly compared with ours. Both studies referred to by Fremont-Smith used plasma, whereas we used serum. HIV-1 RNA levels in plasma are 30 to 80 percent higher than those in serum, (4) so specimens with low levels of HIV-1 RNA in plasma may have undetectable levels in serum. Prolonged periods between collection, processing, and storage in our study may also have lowered viral detection, since the greatest decrease in RNA levels occurs within the first six hours after collection. However, the overall results remain internally valid, since the methods of sample preparation and assay were consistent throughout the study. Our estimate of the risk of transmission per log (base 10) increment in viral load is nearly identical to the risk observed in a study of mother-to-infant transmission (5) and in a study of heterosexual transmission in Zambia (6); this consistency further supports the validity of our measurements of viral levels."

Well, now I really am off for St Maarten.

Bye

Rick

[ August 23, 2002: Message edited by: rbochnermd ]</p>

Dr Rick

Studies have shown that this is more likely than any medical information to influence your decision; if you were circumcised, chances are your son would be, too.

Either way, unless perhaps you're posting from sub-Saharan Africa, it probably wouldn't make a difference in the kid's health or happiness.

Congratulations on your future daughter, by the way.

Rick

[ August 23, 2002: Message edited by: rbochnermd ]</p>