A comment on the comments on circumcision

Hmm.  As I have mentioned before, I have recently been very surprised by the vehement response I’ve been getting from commenters pretty much every time I post on anything relating to circumcision.  I’m not quite sure what to do with these responses, because many of them have little or nothing to do with HIV/AIDS, and a lot to do with listing various reasons why circumcision is just about the worst thing ever.
 

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As I have said repeatedly, I don’t feel strongly about circumcision in general.  I’m just not interested in the debate.  I’ve only been bringing it up because the use of circumcision as an HIV risk reduction method is big news in the HIV/AIDS field.  That’s what I’m interested in: HIV prevention.  If circumcision is a useful tool in fighting the spread of HIV/AIDS, then I think that’s great.  There are definitely legitimate concerns about circumcision used this way–largely related to potential misinterpretations that might make people think they’re completely protected from HIV when in fact they aren’t–and these should also be part of the discussion.  But many of the criticisms showing up in recent comments are related to circumcision in and of itself, and especially focus on American/Western circumcision of infants.  This is a different issue, and I don’t think either conversation is helped by mingling or confusing them.

I really don’t want to be in a debate about all this–I’m not anywhere close to qualified–but I do want to mention just a few issues that have been raised in recent comments, in an attempt to re-focus the discussion.

Many (not all) of the commenters who have talked about cricumcision on this site seem to hold the assumption–or at least suspicion–that researchers, doctors, and health organizations that advocate circumcision as an HIV risk-reduction method are really just using HIV as an excuse to promote circumcision in and of itself.

Frankly, I don’t think there’s any basis for this theory or the accusations attached to it.  While I’m increasingly aware that the circumcision debate is hugely important to many people, it needs to be understood that for the vast majority of the world’s healthcare workers, especially in the developing world, especially in sub-Saharan Africa, HIV/AIDS is a much, much bigger issue than circumcision.  In the face of severely limited funding, inadequate infrastructure and personnel, and a host of other problems related to a disease that is killing millions of people every year, HIV/AIDS are looking for something that works.  Surely an organization like, say, UNAIDS is more interested in preventing HIV transmission than in promoting circumcision just for the sake of it.  But implying that HIV/AIDS experts who support circumcision as an element of prevention strategies are doing so out of ulterior and/or malicious motives is both unfair and unhelpful.

I could keep going, but I think I’ve hit the main points.  Let me just add a note on sources.  I’ve tried to be very careful to take any information I reference on circumcision from well-recognized, mainstream medical organizations–eg. UNAIDS, the WHO, the Kaiser Network.  These sources are widely regarded as reputable and about as authoritative as it’s possible to be on something like HIV/AIDS.  Many commentators have posted links to contradictory studies; however, many of these have come from sources that openly declare themselves to be hostile to circumcision.  I’m not saying that necessarily makes them untrustworthy, but it does indicate that they are coming from one very specific perspective.  That’s why I keep citing only a few sources: the are certainly others out there, but these are the best I know of, and they’re primarily concerned about HIV/AIDS, not circumcision as a stand-alone issue.

Let me close by saying that I’m not trying to be unkind or unsympathetic to other concerns.  I just wanted to lay out my position and try to re-focus the conversation on the issues this blog is designed to address.  I also have felt a certain amount of pressure to defend some circumcision-as-prevention advocates who have been getting a lot of criticism (which I believe is unfounded) and almost no defense.  Whatever you think abotu circumcision as a prevention or risk-reduction strategy, let’s at least acknowledge that those who support it are genuinely convinced that it will prevent numerous cases of HIV/AIDS, and are pursuing it for that reason.

Thanks, everyone, for reading, and thanks for commenting.  I’m planning to be a little stricter in monitoring comments related to circumcision–trying to make sure the comments are seriously addressing the HIV/AIDS issue, not just seizing the opportunity to make a point about circumcision, especially circumcision in a completely different context–I do hope discussion will continue.  Let’s just try to keep it productive.

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~ by h.e.g. on August 9, 2008.

10 Responses to “A comment on the comments on circumcision”

  1. I think it’s a huge mistake to be promoting circumcision as a way to fight HIV in Africa, and I genuinely believe that it is being oversold by people whose real motives are to promote either circumcision itself, or anything-but-condoms. Huge amounts of funding and publicity seem to be available for anything which makes circumcision look good, but no-one wants to know about any research which doesn’t make it look good. The Mexico conference rejected every single paper that questioned circumcision.

  2. I don’t think researchers and public health officials promote circumcision as an HIV prevention technique out of any malevolent intent. (I also haven’t followed the comments you’re referring to, although I looked at a few of them.) However, it is true that some public officials at the organizations you mention are not pursuing a strategy based on the scope of the research. For example, from December 2006:


    “These (African) countries should now prepare how to introduce circumcision on a large scale,” UNAIDS chief Dr. Peter Piot told Reuters. “The science is clear.”

    Baby boys should be targeted first but then attention should switch to adolescent boys and adult men, said Piot, who is in New Delhi to meet Indian officials on how they plan to tackle the world’s largest HIV/AIDS caseload.

    This has been the basic strategy being adopted, despite the studies being focused entirely on voluntary, adult circumcision. Circumcising infants is neither, and infant males will not be sexually-active for many, many years. They can be taught responsibility. Also, better prevention may be available by then. It also ignores that medical resources are scarce and must be rationed. If circumcision is so wonderful, starting with infants leaves sexually-active adults at risk now while those not currently at risk are circumcised. So, suggesting nefarious intent may be pushing it, but public health officials are being irresponsible (and unethical). It is at least a bit reasonable to guess that public health officials know that circumcising infants leads to the perpetuation of circumcision as a social norm. Men circumcised as infants generally impose circumcision on their sons. Again, I don’t think it’s any evil intent, but public health officials clearly seek to encourage that norm in Africa. The American approach to neonatal circumcision is driven by this, especially now that parents use HIV prevention as an excuse, despite American HIV transmission consisting primarily of male-to-male sexual contact and IV drug use. Circumcision protects against neither.

    I don’t want to imply that I don’t get your approach to circumcision and HIV or that we must derail this exclusively into circumcision ethics. As long as circumcision is voluntary among informed adults, I don’t care. I think it’s a bit irrational because condoms and monogamy are clearly better. I wouldn’t choose it if I still had the choice. But within that context for intact men and as long as those men voluntarily choosing circumcision for themselves are reminded that circumcision is not the best prevention, it can be another tool. (My suspicion is that circumcision as HIV prevention will be a long-term dud.)

    You closed with this: “…let’s at least acknowledge that those who support it are genuinely convinced that it will prevent numerous cases of HIV/AIDS, and are pursuing it for that reason.”

    I think those who support it are genuinely convinced, and are pursuing it for that reason. Yet, the evidence also demonstrates that many of those individuals have become overzealous in pushing circumcision beyond the scope of the studies. (Infant and adult circumcision are different procedures, and no one studied the effects of neonatal circumcision and HIV prevention.) They sell the other potential benefits at the same time, for example, and play down or ignore the drawbacks. Either they forget “voluntary, adult” or they overstate the reduced risk with words like “vaccine”. No vaccine is 100% effective. Most of the public doesn’t know that. And I’ve seen the response to my view against infant circumcision stated explicitly as “so you want people to die of HIV?”. That is ad hominem you haven’t engaged in, but it exists.

  3. REPLY TO MARK:

    First, let me just note that I edited your comment down to just the first paragraph because the rest appeared to be exactly the same as a comment you left on a previous post (“HIV and circumcision). I cut the repeated material for the sake of space and readability, but it’s still on the previous post.

    You said, “I genuinely believe that it is being oversold by people whose real motives are to promote either circumcision itself, or anything-but-condoms.” As I tried to explain in the main post, the idea that the people doing the research and promoting the strategy care more about getting people circumcised than they do about fighting HIV/AIDS just doesn’t work. As for “anything-but-condoms,” that’s not what’s happening either, at least among the people actually trying to implement the strategy.

    Groups that promote this are going out of their way to make it as clear as possible that condom use is still important. There’s evidence to suggest that not everyone is getting that message, but that’s the result of a communication breakdown, not because condoms are being discouraged. As I’ve said elsewhere, circumcision isn’t being employed because doctors want people to stop using condoms, it’s being employed because so many people aren’t using condoms (either by choice or due to unavailability), despite the best efforts of AIDS experts. It really is a “every little bit helps” approach: if completely preventing HIV transmission isn’t working, then reducing transmission is at least something.

  4. REPLY TO TONY:

    Tony, thanks for your thoughts. I appreciate your interaction with what I wrote. First let me just say that I’m sorry you’ve encountered the kind of hostile reaction you described at the end of your post. It’s amazing the things people say when they feel strongly enough about an issue. I hope I haven’t said anything of a similarly insensitive type, and I apologize if anything I’ve written comes across as a personal attack on anybody. That’s certainly not my intent.

    Just a few thoughts in response to your comment. First, I agree–I think just about everyone agrees–that circumcision isn’t the best bet for prevention. The ABC methods are actively promoted by the very same people involved in circumcision efforts. A lot of people are working really hard to try to drill it into people’s heads that circumcision reduces risk rather than eliminates it. Whether they’re getting through to people is where the big questions come up (and the success of the message probably varies a lot from place to place). I think everyone involved would be much happier if ABC-style prevention methods were more widely used, and the kind of risk-reduction approach of circumcision wasn’t even an issue. I think circumcision is really viewed as a last resort type of stategy: “IF people are going to have unsafe sex no matter what, let’s reduce the risk as much as we can.”

    As for circumcising infants in areas with high HIV prevalence rates, you’re probably right that there’s a hope that it will become more of a cultural norm in certain areas (as it already is among many people groups in Africa). I would guess–and I really am just guessing here–that there’s also a desire to catch children before there’s any risk of them becoming sexually active so it’s just taken care of when that time comes. I can also see an advantage in that whereas it might be hard to convince adult men that they need to keep taking other measures even if they get circumcised, if a child was circumcised educators could just focus on ABC methods, knowing that circumcision would be a sort of back up, if and only if the person didn’t follow their advice. All that being said, you may be right that they’d be better off targetting adults first, as they’re the ones actually facing the risk. I’m just suggesting what the logic might be.

    Again, thanks for your thoughtful response.

  5. It’s hard to believe the researchers are entirely dispassionate about circumcision when, for example, one of the top circumcision-against-AIDS promoters, Daniel Halperin, is on record as thinking his descent from a ritual circumcisor meant “maybe in some small way I’m ‘destined’ to help pass along [circumcision] to people in [other] parts of the world … .” (Cover Story: The Case for Circumcision. By Gordy Slack. The East Bay Express Online. May 19-24, 2000.) Whatever else that it, it’s not science.

    Those of us who enter this debate from the circumcision end (it’s been going about 30 years) are all too familiar with the claims about the many wonders of circumcision, and it seems almost incidental that this time around they are being applied to AIDS.

    In the three studies in which 1-3% of subjects were infected with HIV, and the difference between circumcised and intact (a total of 73 men out of the 10,800 they started with) is inevitably described as “60% reduction”, 673 subjects went walkabout and we have no idea whether they got AIDS or not.

    From our perspective, bad science like this being used to promote circumcision against AIDS is just like the bad science being used to promote circumcision against (in reverse chronological order) UTIs, cervical cancer in partners, penile cancer, STDs and masturbation. When circumcision was first medicalised in the English-speaking world in the late 19th century to “cure”, punish and (unsuccessfully of course) prevent masturbation, medicine was invoked to enforce social conformity, in part because medicine and “science” had become a secular religion.

    Circumcision has always brought a caravan of cultural baggage with it: religion, sex, blood, initiation, purification, and more. These murky underpinnings are not miraculously shed when circumcision is invoked to prevent AIDS. Circumcised reporters have a vested interest in repeating beat-up stories about the virtues of circumcision and not publishing the contrary results. (Example, the Fergusson study of STDs, claiming protection, got headlines worldwide, while the bigger, better Dickson study claiming no protection was buried on page F17.)

    While it would be nice to discuss circumcision and AIDS in a detached way, this is the context in which we find ourselves. And it is these prejudices that come into play when we consider promoting circumcision as a backup way to reduce the spread of AIDS. It won’t work that way. People will inevitably think they have “a vaccine of high efficacy” or a magic bullet and fling caution to the winds.

  6. I agree with you that the context in which one discusses circumcision is very important. Much like Tony, if we are talking about adults, who of their own volition seek out circumcision, I wouldn’t care at all, that is there problem. However, when you shift that to infant or child circumcision then there is a serious ethical problem which is not addressed only because of concerns for political correctness which makes the omission of ethical considerations even worse. Each individual man has the right to choose the risk reduction strategies that they feel work best for them. When it comes to circumcision, like Tony mentions, I can’t see how a rational thinker would choose that, since it can’t work on it’s own, but if it is an adult making that decisions, clearly that is there right.

    In the context of Africa, things get a bit more problematic. Considering the fact that HIV is so prevalent, education and living conditions so poor, and just about every country and agency is operating on the dole, they have a duty to go with the cheapest most effective solution. Cheapest because of of obvious budgetary constraints effective because it is important that when people think prevention, they need to understand what really works. Those who are moderate might present circumcision as complimentary but, it doesn’t really add to the effectiveness of condoms or faithfulness. It isn’t really, as you say, a fail safe because if you neglect to wear a condom and you are unsure of your partner’s HIV status you aren’t really safe.

    Perhaps the biggest problem is that you wouldn’t know that from the popular media or even the study authors. For example, consider this piece in the Washington Post where Robert Bailey, one of the lead researchers of the African studies, claimed: “It’s now the most proven, effective HIV prevention strategy we have for male heterosexuals, so it’s really important that we make this widely available”. Or Bertran Auvert’s claim that circumcision equal to a vaccine of high efficacy. Other researchers linked to these trials have made similarly outrageous claims. “the most proven” or “vaccine” these are dangerous statements that could confuse even more educated people (such as those in developed nations) to say nothing about desperately poor and uneducated people in Africa. Do you see how this message will get confused?

    These words aren’t chosen by accident. When there are editorials, articles, and opinion pieces in the popular press, each word is chosen for a specific effect. It is within the realm of possibility that by describing their work in such overloaded terms the authors intend to drum up popular support for implementation and further funding (it’s always about the money). This popular public support is then used to lean on public officials should they dare to disagree with the objectives. It’s Africa, how could it get any worse they might say. It gets worse when articles, like those referenced above, get reprinted in places like Africa and people start believing those things quoted above. And I assure you there has been no shortage of those articles.

    As for additional methods of risk reduction and HIV prevention? Well just ask Daniel Halperin. It would seem that he believes the bulk of resources need to be shifted away from condoms and education, and we again have the vaccine assertion. This is all truly deplorable marketing that could cost lives.

    Are most NGOs pushing circumcision for circumcision’s sake? Proabably not. Are there some that are? Probably. And now the HIV community has itself in a bit of a pickle. With all the publicity, such as that cited above, if they don’t implement circumcision those most at risk might seek it out on their own which would clearly be undesirable. While the public, like in the US, might sit around asking why aren’t they offering it. If they offer it, as they are starting to do, they risk people abandoning what can really protect them. Add to that the significantly increased cost to NGOs. So it seems they’re damned if they do and damned if they don’t. This is not the atmosphere that is conducive to making rational judgments.

  7. Hugh,

    Thanks for explaining your perspective so clearly. That’s actually very helpful for me.

    Just a couple of thoughts:

    – I don’t think it’s fair to say people will “inevitably…fling caution to the wind.” While the potential for increasing risk behavior is a very widespread and very serious concern about circumcision as a risk-reduction strategy, a lot of people are working very, very hard to prevent it from happening. When it comes to HIV/AIDS, a lot of things have been thought to be inevitable, when it turned out they just needed a chance. A lot of people thought that HIV patients in the developing world would never be able to stick to an antiretroviral regimen, but this has turned out to be totally untrue. My main point here is just that saying something like this will “inevitably” fail simply doesn’t work.

    – However quixotic Daniel Halperin’s feelings about his role in promoting circumcision may be, he’s not the only person involved, and I don’t think it’s fair to extrapolate his comments, whatever they might mean, to the many, many other people and organizations that share his basic opinion..

    – I understand that in your view the studies that show circumcision reducing the risk of HIV trasnmission are “bad science.” All I can say is that I haven’t seen criticism of the studies from sources as highly-regarded as the ones that accept the studies. As far as I can tell, most of the criticism seems to be coming from self-proclaimed anti-circumcision groups. Given the fact that these studies have been published in sources like the “Lancet,” and been endorsed as legitimate research by experts working with organizations like the World Health Organization, I have a hard time believing that there are glaring and crucial problems with the research itself.

  8. Joe,

    Just a note on what you said about what you see as bias and/or over-enthusiasm in the news. First, there has been criticism out there too. Second, the African media is not, as you seem to suggest, blindly lapping this up. There have been more than a few critical articles from various African papers–a good place to look would be allAfrica.com (a news aggregator). Third, however the issue is being discussed in American media, the fact remains that the people who come the closest to setting the agenda on AIDS efforts (WHO, UNAIDS, etc.) are working hard to emphasize the *partial* nature of the risk reduction provided by circumcision.

  9. H.E.G.: Your post highlights the ineffectual nature of any generic internet “activism” campaign. Circumcision is one of many controversial topics (think vaccines, abortion, consumption of animal products, etc…) where activists in the minority position frequently “spam” their message in the comments section of any and all article on the subject, regardless of its content. The goal of such posts is to to spread propaganda rather than engage in intellectual discourse.

    I only became aware that anti-circumcision activists utilize this tactic following the recent announcement that circumcision is even more effective against heterosexual HIV transmission than previously thought (at the 17th International AIDS Conference in Mexico City). A few days ago, I read a blog post where the author elegantly described the difficulty of rolling out a circumcision campaign in areas with deep-rooted cultural opposition to the practice. Of the 750 to 1000 words in the essay, she dedicated one sentence to the possibility that circumcision doesn’t negatively affect sexual pleasure for men. ALL of the comments in response to her excellent article focused on the one blasphemous claim that circumcision doesn’t completely ruin a man’s sex life. None of them even made mention of the the essay’s main point.

    Since then, I’ve seen many more blog posts and articles where it was glaringly clear that the commentors in the anti-circumcision camp hadn’t even bothered to read the article, or at least didn’t care about its message. Instead, a lashing of painfully repetitious anti-circumcision talking points ensued. To receive so many off-topic comments must be mildly irritating to authors who dedicate time and effort to compose such an article. I’m also certain that comment spam provokes a substantial amount of eye rolling from the readers.

    The irony of putting so much effort into a comment spam campaign, such as those in response to you your previous circumcision posts, is that most of the posters overestimate their credibility. Little to no effort is made to support their conclusions with reliable references, and anonymity prevents them from being further pressed to substantiate their claims.

    None of this is to say that these folks shouldn’t be allowed to do this, nor do I mean to imply that anti-circumcision comments aren’t welcome when they are on topic. It is the reader’s right to post whatever they want wherever they want, but it is the blog publisher’s right to scrub such comments from their site, because they are completely unproductive. I recommend a little more vigilance the next time you post on this topic to encourage a more interesting and intellectually honest discourse. Keep up the good work.

  10. h.e.g. Thank you for your thoughtful comments.

    “A lot of people thought that HIV patients in the developing world would never be able to stick to an antiretroviral regimen, but this has turned out to be totally untrue. My main point here is just that saying something like this will “inevitably” fail simply doesn’t work.”
    Sticking to an antiretroviral regimen is a matter of motivation. Getting people to understand the frightfully mixed message, “We want you to be circumcised because of its epidemiological benefits, but your individual protection is too small to justify giving up condoms” is another matter. You don’t have to be an African tribesman to find the difference between “epidemiological” and “personal” hard to follow. There is plenty of anecdotal evidence that people are flocking to be circumcised because they think they will be individually protected, and they will not need to use condoms. The claims that they will not take more risks are based on talk – they say they get the message, but are they going to put it into action? (There are other issues they haven’t addressed: circumcision offers no direct protection to women; we maintain it will make it harder for them to resist men’s insistance on sex without condoms.)

    “- However quixotic Daniel Halperin’s feelings about his role in promoting circumcision may be, he’s not the only person involved, and I don’t think it’s fair to extrapolate his comments, whatever they might mean, to the many, many other people and organizations that share his basic opinion.”
    There is a handful of circumcision promoters at the core (Halperin, Bailey, Gray, Auvert, Weiss, Bailis, Castellsagué, Potts, co-authoring papers and, I suspect, reviewing each other’s work). Bailey admits he has been trying to prove that circumcision prevents HIV for decades. That is not the attitude of a scientist. I think the others (How many actually? We see few other names than those) have just been caught up, swept along, and sometimes misled.

    “- I understand that in your view the studies that show circumcision reducing the risk of HIV trasnmission are “bad science.” All I can say is that I haven’t seen criticism of the studies from sources as highly-regarded as the ones that accept the studies.”
    This is the fallacy of appeal to authority, not regarded as a good way of doing science. (The classic example is Galileo vs the Church.) Look at the studies themselves, then look at the critiques and see if the critiques are wrong. My critique is at http://www.circumstitions.com/HIV-SA.html So far nobody has pointed out any flaws in it. (Nobody has even tried. They are welcome to try because I want my argument to be bullet-proof.) It’s not actually rocket science. They circumcised a group of people, and tested whether they got HIV. Other things being equal, this should detect a causal effect, but there are many ways other things were not equal.
    I call the three RCTs bad science because they
    * were not double-blinded
    * were not placebo-controlled
    * had a 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?)
    * assumed all HIV was transmitted (hetero)sexually
    * didn’t treat the controls and experimental groups identically
    * used a method in one of the three trials that removed significantly less tissue than the others, yet the “protection” conferred 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. Rwanda is one such country, yet they are rolling out a circumcision campaign there. Doesn’t that sound counterproductive to you?

    “As far as I can tell, most of the criticism seems to be coming from self-proclaimed anti-circumcision groups.”
    And that is the fallacy of argument ad hominem (against the person) also called “Give a dog a bad name…” Are you suggesting that people who are opposed to circumcision are disqualified from judging the scientific merit of claims it can prevent HIV? As I say, we have heard all these claims before, for other diseases, and we were right then, so we’re more like the canaries in the coal mine.

    “Given the fact that these studies have been published in sources like the “Lancet,””
    Actually the “Lancet” turned down the Auvert study for ethical reasons (that have never been addressed), and he had to publish in PLoS, an open-source journal. You can see my reply there, and his (inadequate) reply to it. The fact is that they all went to the media prior to publication in scientific journals, regarded as very bad practice in science (it lead to the cold fusion debacle), and they have been running a smooth media campaign.

    “and been endorsed as legitimate research by experts working with organizations like the World Health Organization, I have a hard time believing that there are glaring and crucial problems with the research itself.”
    Wouldn’t you think so, but when it comes to circumcision, which affects so many men so intimately, and is so bound up with so many cultures, their critical faculties are affected. They don’t want to believe they have been damaged in any way, and they have a hard time believing anything ill of circumcision. The World Health Organisation is an arm of the United Nations. Do you have a hard time believing that there are any glaring and crucial problems with the United Nations itself?

    After all, you yourself seem to want to pass on a positive message about circumcision without checking the details yourself. I suggest that many of the “experts working with organisations like the World Health Organisation” have done exactly the same thing.

    Thank you for the chance to engage in this healthy discourse.

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