I looked at your website (http://www.circumstitions.com/), which in its own words advocates the “struggle for genital integrity and against the involuntary genital modification of children of any sex.” I’ve also noticed that you have posted comments similar to this one on other sites that discuss the use of circumcision in HIV risk reduction. It’s clear that the issue is very important to you, and I appreciate your interaction with my post.

Since your website explains that it “does not pretend to be ‘balanced,’” you are obviously aware that some of your views are controversial. For myself, I don’t have a strong position on circumcision itself, but I am interested in anything that shows promise in reducing the spread of HIV/AIDS. From this perspective, I’d like to respond to some of your points. While I realize that you are unlikely to change your position, I think a response could be helpful to other readers.

1. First, I think it’s important to emphasize that the use of circumcision as a prevention strategy – with the understanding that it reduces but by no means eliminates the risk of transmission of HIV from women to men – has been supported by the WHO and UNAIDS. I very much doubt that these international authorities would be duped by research as faulty as you suggest this is. I’m not saying these organizations are infallible, but since I have not seen opposition to the strategy, or criticism of the research behind it, coming from similarly authoritative sources, it seems reasonable to trust that the studies’ findings are reliable.

2. I agree that the use of circumcision raises concerns about its effects on sexual behavior. I think this is very much on the minds of the strategy’s advocates. Prominant supporters of the strategy (e.g. the WHO) are taking great pains to emphasize that circumcision reduces, but by no means eliminates, the risk of HIV transmission from women to men. Also worth looking at is this article from a Ugandan paper (http://allafrica.com/stories/200806300440.html), which cites a study that found “no evidence to suggest that circumcised men engaged in increased risk behavior after the procedure.”

3. Regarding the effects on women: while I can understand the scenario you’re suggesting, I think we must also take into account the fact that the fewer men who have HIV, the fewer women will be infected by male partners. So any benefits of circumcision would apply indirectly to women.

4. You criticise these studies for not being double-blind or placebo-controlled. Forgive me if I’m not fully understanding your argument, but I don’t see how tests of a surgical procedure could meet either of these standards. I can’t imagine how you could produce the equivalent of a placebo for circumcision. So I don’t think this argument can fairly be used against the studies.

5. This approach doesn’t “ignore” non-sexual transmission: it’s a legitimately targeted approach – the same is true for strategies like ABC. No one is saying this should be the only AIDS prevention method. Obviously things like mother-to-child transmission have to be addressed in other ways.

6. Some of your points I can’t respond to, because I don’t know the sources of your information.

TO SUM UP, let me say that I’m certainly no expert on this issue. I have, however, tried to use reliable information sources in everything I’ve written on the matter. Not having encountered counter-information from sources of comparable reliability, I don’t see any pressing need to doubt the validity of the use of circumcision as part of a comprehensive HIV/AIDS prevention strategy. I’m inclined to think that every little bit helps. If I find anything to change my mind, I’ll post it.

Again, Hugh, thanks for your interaction with this post. And if anyone else has comments on this issue, feel free to jump in!

Best wishes,
h.e.g.

It’s inevitable that men are going to get circumcised so that they can have sex without condoms, and they’re going to pressure women to accept that. Circumcision disempowers women, who are already at greater risk.

But there are worse problems. The flaws in the research are manifold:

* Not double-blinded
* Not placebo-controlled
* Significant drop-out rate – 5 times as many as were known to be infected. (And if you had endured a painful and marking operation “to protect against AIDS” and then got tested elsewhere – as they were encouraged to do, because it was considered “unethical” to tell them they were HIV+ – would you go back to the people who had done that to you?)
* Non-sexual transmission ignored
* Non-identical treatment of controls and experimental group
* One of the three trials used a method that removed significantly less tissue than the others, yet the “protection” was the same.

In several African countries, the HIV rate is higher among circumcised men than non-circumcised, according to the National Demographic and Health Surveys.

Something very funny is going on.