HIV Infection and Circumcision: Cutting through the Hyperbole

By Van Howe, Robert S.; Svoboda, J. Steven et al. | The Journal of the Royal Society for the Promotion of Health, November 2005 | Go to article overview

HIV Infection and Circumcision: Cutting through the Hyperbole


Van Howe, Robert S., Svoboda, J. Steven, Hodges, Frederick M., The Journal of the Royal Society for the Promotion of Health


Abstract

The objective of this study was to determine whether the justifications given for promoting mass circumcision as a preventive measure for HIV infection are reasonable and whether mass circumcision is a feasible preventive measure for HIV infection in developing countries.

The medical literature concerning the practice of circumcision in the absence of medical indication was reviewed regarding its impact on HIV infection and related issues. The literature was analysed with careful attention to historical perspective.

Our results show that the medical literature supporting mass circumcision for the prevention of HIV infection is inconsistent and based on observation studies. Even if the two ongoing randomised controlled trials in Africa show a protective benefit of circumcision, factors such as the unknown complication rate of the procedure, the permanent injury to the penis, human rights violations and the potential for veiled colonialism need to be taken into account. Based on the best estimates, mass circumcision would not be as cost-effective as other interventions that have been demonstrated to be effective.

Even if effective, mass circumcision as a preventive measure for HIV in developed countries is difficult to justify.

Key words

Circumcision; HIV infection; informed consent; medical history; prophylaxis

INTRODUCTION

The explosion of publicity accorded to the HIV/ AIDS pandemic can in part be attributed to the lack of clear understanding of the disease mechanism and the apparently inescapable mortality attributed to the acquisition of HIV. The public's awareness and fear of HIV have resulted in changes in sexual behaviours such as increased condom use, which has been less comprehensive and long-lasting than originally expected.1 Regrettably, some have capitalised on the fear generated by the HIV/AIDS pandemic to promote personal or political agendas.2-5 In the medical establishment, this has been manifested in the scientifically dubious promotion of male circumcision as a preventive measure for HIV infection.2

HISTORY OF CIRCUMCISION PROMOTION

This is not the first time that circumcision has been promoted as a panacea for an incurable disease. As a medical procedure, circumcision was first introduced in the nineteenth century in English-speaking countries as a means of preventing and 'curing' masturbation, which was then believed to cause everything from epilepsy, insanity, tuberculosis, spinal paralysis, to hip dysplasia.6 As the germ theory of disease developed and the understanding of disease processes improved, the true aetiologies of the illnesses for which circumcision was believed to hold the cure were elucidated. During the Cold War, mass involuntary circumcision of the newborn was implemented in the USA, giving the practice a cultural foothold.6 New medical-sounding justifications, however, were sought to justify its continued use as a routine neonatal surgery since the traditional justifications for preventing masturbation and 'nervous diseases' were no longer as persuasive to the public or the medical profession. The prevention of cancer, sexually transmitted diseases (STDs) and urinary tract infections were each in turn invoked to justify infant male circumcision, although the medical evidence supporting such claims ranged from paltry to imaginary.

A clear pattern has emerged: any incurable disease that happens to be the focus of national attention at any given time will be used by US circumcision advocates as an excuse for the continued imposition of mass circumcision. In the 1870s, epilepsy was the focus of national attention, so circumcision advocates claimed that circumcision could cure and prevent epilepsy.6 In the 1940s, STDs were the focus of national attention, so circumcision advocates claimed that circumcision could cure and prevent the spread of STDs.6 Likewise in the 1950s, cancer was the focus of national attention, and again circumcision advocates claimed that circumcision could cure and prevent a variety of cancers including penile cancer, cancer of the tongue, prostate cancer, rectal cancer and cervical cancer. …

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