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It not a joke!!! It is the truth!!!

Giving people what they want: violence and sloppy eating

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Snip, snip, the scissors go...
mini me + poo
Last week, there were a number of stories in the media, for example:

Men who want to lower their chances of contracting HIV should be circumcised, the world's leading health experts said yesterday.

Having the foreskin removed lowers the risk of catching the virus by 60 per cent, they said.

(The Metro, London 29th March 2007)

So why not circumcise all men?

The later paragraphs in this story gave some reasons that weren't in all the ones I saw:

.. an additional important intervention to reduce the risk of heterosexually acquired HIV infection in men..

So, not enough on its own, not relevant to the bulk of infections acquired in the UK, and of marginal benefit to women (if fewer men have HIV, fewer women will have HIV+ partners, but if yours is, circumcision doesn't help you) but even so, worth trying?

In the UK, the large NATSAL surveys show no difference in STI rates between 'cut' and 'uncut' men, but a 60% reduction in risk sounds a lot - it's about what people are hoping for from a vaccine against HIV, should one be developed - and it comes from three randomised control trials in Africa (you circumcise some men, but not others, and see what happens to them over time) but...

  • It's a relative reduction. The absolute reduction was about 1.8% - over the course of the trials, the risk was about 4.8% (uncut) and 3.0% (cut)

  • The level of complications was about 1.5% - and these were circumcisions performed in the best conditions they could arrange. Complications vary from serious blood loss and infections, to impotence and loss of the penis.

So in order to get about a 1.8% reduction in HIV cases in that time, 1.5% of men had problems, some serious. If somewhere decided to circumcise every man and boy, the complications would increase (these countries have higher priorities for their health budgets than paying for first world standards of circumcision!)


  • The trials were all cut short (sorry! 'terminated early') and this will mask any delaying effect. Imagine that all circumcision did was delay catching HIV by a year, on average. Stopping a three year trial after two years would show a substantial reduction in relative risk - you'd miss all the cut men who caught HIV in the third year! I'd expect at least a decade's follow-up before anyone should consider recommending it in this way.

So it's not particularly surprising to find out that the people running the trials had long track records of favouring circumcision.

And it gets worse: in order to maximise what benefit there is, you'd need to do this in infancy, but there are serious consent issues - you're performing an unecessary operation with possibly some major complications on someone who can't give consent themselves in the hope that, fifteen or so years later, there might be some benefit.

If they turn out to be gay or bisexual, it will be of no benefit. If a medical advance happens in another prevention technology, there may be no benefit. And if they ask you for advice, you're still going to say 'use condoms'!

As I say, by the end of the session on this at CHAPS, the person presenting the 'might be worth trying' argument was looking seriously beleagured.

TMI disclaimer: I have a foreskin, and I'm very happy with it. There would need to be a serious reason for me to want to lose it and as you might guess, I'm not booking any surgery soon.

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Ah. The problems with the science media, I just want to throttle them sometimes. Extrapolating from a reasonable suggestion to an excessive one just by removing a few words. The recommendation isn't useful for countries with low rates of HIV/AIDS. However in areas where the virus is endemic, it could have a major impact. The WHO recommendation, in particular, notes that it's only useful for "Countries with high rates of heterosexual HIV infection and low rates of male circumcision." Neither of which applies to the U.K.

I'm not even convinced of its use in high prevalence countries: I suspect it is indeed a delaying effect.

To be perfectly honest, I don't want to like the studies much either, because one of the major scientists on the more recent end of the project is someone who I do not have a great deal of respect for. However, I find the combined weight of the biological arguments, the observational studies, and the RCTs relatively convincing in the high prevalence settings. Not absolutely, and it certainly will be interesting to see what happens a few years down the line. I would be much less supportive of the recommendation if it was proposing mandating circumcision, but since the current proposal is to make safe circumcision more available I think it will be interesting to see how things go. And you're right, it could be a delaying effect, although my instinct would be that in the early stages circumcision would actually increase risk, and that as keratinization of the glans epithelium progresses, and healing of the surgical site becomes more complete, risk would stabilize at some baseline lower level.

My real worry is that despite the promises of education, that men may see this as a quick fix, and yet another reason not to use condoms. Mind you, in a lot of these areas condoms aren't available or acceptable anyway, but will this just make that worse?

Aren't there statistics showing a lower rate of cervical and vaginal cancer in women in countries which have religious circumcision? I just heard this and don't know where the stats would be. Having said that my grandmother and Capt Ex's mother both had cancer of the womb and one was Jewish and one Moslem. I suppose the lower indcidence could also be due to other factors.

many thanks, i've heard the circumcision line trotted out a number of times, but it sounded a bit farfetched for a number of reasons, any chance of a link to the study?

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