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The kindest cut?

ResearchBlogging.orgThe best way to prevent sexually transmitted infections is the proper use of condoms. That being said, it’s not the only way to prevent STI’s. Abstinence is one way, but it involves an amputation of sorts—the removal of a critical human behavior. Another amputation (of sorts) that prevents STIs is circumcision. Male circumcision has been found in several good studies to reduce the rate of HIV transmission, and now a study out of Uganda shows a significant decrease in rates of genital herpes infections (HSV-2), human papilloma virus (HPV) infection (the strains that cause penile, cervical, and anal cancer), but no decrease in syphilis infection.

This study complements the our knowledge on the benefits of circumcision to prevent disease. The authors emphasize that circumcision alone is not sufficient, but may be a useful adjunct to prevent serious STIs. In fact, STI’s tend to travel together, and ulcerative diseases such as herpes increase transmission of HIV.

Now people get a little touchy about male circumcision. Despite the lack of data to show negative effects, there is a reasonable question to be asked as to whether the removal of the foreskin, whatever benefit may accrue, is worth any loss of sexual pleasure that may result. This is a tough outcome to study. Most males are circumcised as infants and know no different. However, a small study was published in the Journal of Urology a few years back that asked an interesting question: if you circumcise an adult male, what differences will he report? In the study published, they found that men reported decreased erectile function, decreased penile sensitivity, but increased satisfaction.

The study has its limitations of course, but what it did not find was a group of terribly unhappy men.

The science is quite clear; circumcision effectively prevents the transmission of a number of important diseases, and used in congress with condoms has a great potential to reduce the plagues killing millions of people yearly. What has yet to be answered is whether the human cost of circumcision, whatever that may be, justifies its use.

References

Aaron A.R. Tobian, M.D., Ph.D., David Serwadda, M.Med., M.P.H., Thomas C. Quinn, M.D., M.Sc., Godfrey Kigozi, M.B., Ch.B., M.P.H., Patti E. Gravitt, Ph.D., Oliver Laeyendecker, M.S., M.B.A., Blake Charvat, M.Sc., Victor Ssempijja, B.Stat., Melissa Riedese (2009). Male Circumcision for the Prevention of HSV-2 and HPV Infections and Syphilis The New England Journal of Medicine, 360 (13), 1298-1309

FINK, K., CARSON, C., & DEVELLIS, R. (2002). Adult Circumcision Outcomes Study: Effect on Erectile Function, Penile Sensitivity, Sexual Activity and Satisfaction The Journal of Urology, 167 (5), 2113-2116 DOI: 10.1016/S0022-5347(05)65098-7

Posted in: Science and Medicine

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27 thoughts on “The kindest cut?

  1. Jules says:

    Is there a cost to male circumcision? Let’s see: you reduce your chances of STDs, and your sex life improves? Hardly a human cost, if you ask me, at least, compared to female “circumcision”.

    In terms of reproductive health, it’s a rather tacky debate: men have to pick between their health and their pleasure. Women get the lovely choice between their health and the life/death of a possible human being (and all of the social implications linked to it).

  2. Bald Ape says:

    I don’t see how the study applies in developed countries like the US.

    Theoretically, studies like this may actually decrease the odds of uncircumsized teens in the US from contracting STD’s. Simply put, if these results hold up to scrutiny (and it seems likely that they will), I will tell my uncircumsized son that it is *especially* important to use a condom. If this increases the chances of him always using a condom from 95% to 99%, then I’ve effectively cut his risk of STD by 80% (significantly better than what circumsicion itself is claimed to do). Conversely, is it not conceivable that a well-educated, circumcized teenager, aware of these studies, may feel that his risks of contracting STD are a bit lower, and so he can have sex “just this once” without a condom?

    Unless and until concrete (and substantial) health benefits, massively outweighing the risks, are demonstrated for circumcision in developed countries, isn’t it most accurate to regard it as a cosmetic surgery? If so, and if all (or most) of the benefits can be achieved with a later-in-life surgery anyway, why not just leave it up to the kids?

  3. overshoot says:

    Oh, Lordy! Not enough that Dr. Hall opened the case of grenades, you had to pull all of the pins to see if they worked!

    Pardon me, Dr. Lipson, but I’m heading for the bunker now until the shrapnel stops rattling around.

  4. overshoot says:

    Sorry about the prior post — wrong tab.

  5. John Snyder says:

    WHO data on the effectiveness of circumcision in reducing HIV transmission in Africa prompted the New York DOH, a couple of years ago, to consider encouraging men in the city to undergo the procedure. In fact, the data was so promising that the idea was to have the procedure performed for free at public health clinics. Needless to say, the plan has met stiff resistance (sorry).

    As a pediatrician, I am frequently asked about the issue as it pertains to newborns, for whom the procedure is most often performed. The American Academy of Pediatrics revised it’s position in 1999, based on the fact that circumcised boys have a ten-fold reduction in the risk of urinary tract infections in the first year of life. UTI’s can be associated with significant complications in young infants, so this is not trivial. However, because the ten-fold reduction is from a small to a really small number (0.1 down to 0.01%), no formal recommendation was made. As stated in the AAP policy on circumcision:

    “Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision.”

    Interestingly, although the impact on HIV infection is discussed in the AAP statement, the data they used is old and inconclusive. It may be time for the AAP to revisit the issue.

  6. David Gorski says:

    Oh, Lordy! Not enough that Dr. Hall opened the case of grenades, you had to pull all of the pins to see if they worked!

    Pardon me, Dr. Lipson, but I’m heading for the bunker now until the shrapnel stops rattling around.

    Clearly, Dr. Lipson thought things were getting a bit too dull around here. :-)

  7. yeahsurewhatever says:

    This is a great demonstration that “preventive medicine” is not necessarily “ethical medicine”.

    What level of benefit makes it ethical to perform unnecessary surgery on an infant?

    Suppose it was discovered, beyond any doubt, that cutting off an infant’s pinky toes would definitely increase their eventual lifespan by 10 years, but that the benefit was eliminated if the procedure was done at a later age. Toe-cutting then becomes medically justifiable?

    Have any studies been done on the potential health benefits of female genital mutilation? What’s that you say? There couldn’t be any? How do you know?

    What if a study discovered that in Rwanda, the Hutu genocide of Tutsis decreased the rate of HIV transmission in that country. Suddenly it was a good thing to do?

    There is no medical justification for genital mutilation on non-consenting patients, male or female.

  8. ImperfectlyInformed says:

    “Despite the lack of data to show negative effects” — really, another biased selection of the literature? It’s worth noting that circumcision, like all medical surgery, may have complications, which could, in rare situations lead to death (http://www.cps.ca/english/statements/FN/fn96-01.htm). The source, which is dated, doesn’t have a number. Wikipedia throws out a couple numbers; for death, one source has 1/500 000 and another has 1/5 625.

    STIs, particularly HIV, are a major problem in developing nations and less of a problem in the developed world. Conveniently, then, the vast majority of circumcisions occur in the developing world — without anesthesia, under traditional settings (doi:10.2471/BLT.08.057752). Problem solved!

    Out of curiosity, was that sexual satisfaction?

    One would also wonder if the hyping of circumcision might lead to negligence in the use of condoms. My intuition tells me that there is a vanishingly small benefit in reducing STIs for circumcision when a condom is used.

  9. ImperfectlyInformed says:

    After trolling PubMed and reading around, I found that a couple freely-accessible recent articles expressing the respective positions in the debate:

    http://www.cfp.ca/cgi/content/full/53/12/2096 YES
    http://www.cfp.ca/cgi/content/full/53/12/2097 NO

    The most interesting references appear in the rapid responses of the NO article. References contesting the STI and UTI benefits are presented; the UTI is interesting since the claim is that the original studies were never replicated.

    This study presents hard data on complications: http://pediatrics.aappublications.org/cgi/content/full/118/5/1971

    Two recent negative cost-benefit reviews: http://rsh.sagepub.com/cgi/content/abstract/125/6/259
    http://mdm.sagepub.com/cgi/content/abstract/24/6/584

    Ultimately, of course, it’s a personal decision for parents, who should be provided all information.

  10. Joybobington says:

    I need to disagree with Mr. Lipson’s interpretation of the latest study.

    The Uganda study is based on the same data from an old study that showed that circumcision decreases the odds of catching HIV.

    Although, both HIV and HPV have the same transmission vector, exchange of bodily fluids, Herpes is transmitted through sores on the skin.

    It makes no sense to assume that circumcision can reduce the chances of aquiring HIV/HPV as well as Herpes.

    The only way the data is makes sense is if Circumcised males in Uganda are more likely to belong to different social/economic/religious groups than uncircumcised males.

    In which case, the differences in HIV/HPV rates can be explained due to differences in lifestyles with circumcision being coincidental not causative.

    Any study on the health effects of circumcision will be plagued by methodological flaws due to the social and religious character of circumcision. For example, try comparing STD rates among circumcised and uncircumcised Jews in Israel; it can’t be done as it’s a defining characteristic of the social group.

  11. storkdok says:

    I’m waiting for Consult/Dr. Christopher Cold to show up. Got the popcorn ready…

  12. addiejd says:

    Maybe I should just get my appendix taken out now. Because, you know, it could get infected, sometime, maybe, in the future, possibly, and I could get appendicitis and it could burst. It’s not like I use the thing anyway.

    Or a double mastectomy. I don’t plan on having children, so it’s not like I need my breasts anyway. Best to remove them now while they’re still cancer-free, just in case. It’s not like I have a genetic predisposition, but breast cancer is way more common than penile cancer, and if penile cancer is a good enough excuse to cut off someone’s foreskin, which is a perfectly functional body and useful body part as opposed to my 34 DDs, which won’t be feeding anyone anytime ever.

  13. qetzal says:

    Although, both HIV and HPV have the same transmission vector, exchange of bodily fluids, Herpes is transmitted through sores on the skin.

    IIRC, herpes can be transmitted even when the infected partner has no overt skin lesions, so I don’t think your argument holds up.

    (For all I know, it could still be true that circumcision correlates with social/economic/religious group, and that this is the actual driver for different infection rates. But I don’t think you can make that case based on HPV.)

  14. Diane says:

    I am of the opinion that
    1. male circumcision is probably disease preventing;
    2. female circumcision is completely useless and harmful;
    3. all infants should be prevented from experiencing pain of the imposed surgical kind.
    http://dolor.blogspot.com/2009/03/interesting.html

  15. Necator says:

    Joybobington, I believe there is a plausible mechanism for circumcision reducing the spread of HIV:

    HIV initially infects antigen presenting cells (APCs), which carry the virus back to a lymph node where it infects CD4+ T cells (helper T cells). The APCs have the necessary receptor for viral binding. The foreskin seems to have a relatively high quantity of APCs. Thus, removing the foreskin mechanically removes a number of cells that can serve as viral entry points.

    In any case, I’m confused as to why this is being promoted as an adjunct to condom use. I haven’t read all the studies, but I have read the big ones–and there was no indication that condoms were being used at significant rates in these African studies. It seems unlikely, given the mechanism by which circumcision reduces HIV transmission, that if a condom were used properly circumcision would have any effect on HIV transmission during vaginal sex.

    Perhaps the most interesting thing about the circumcision debate is that removing the female analog of the foreskin, the clitoral hood, is considered mutilation–the thought horrifies and repulses most Americans. Maybe this analogy can help people clarify their own opinions about the issue of circumcision. I, for one, would not consider removing a girl’s clitoral hood until she were a woman and were making this choice of her own volition. And I think I’d hesitate to remove it from a neonate at a parents request even if there were demonstrable medical benefits. (Note: I am not speaking about more extreme forms of female “circumcision”/mutilation where more than the clitoral hood is removed.) In any case, I think this illustrates how hard it is to remove prejudice (which may just be familiarity and acceptance with one procedure over another, in this case) from one’s thoughts on the matter.

  16. qetzal says:

    Suppose it was discovered, beyond any doubt, that cutting off an infant’s pinky toes would definitely increase their eventual lifespan by 10 years, but that the benefit was eliminated if the procedure was done at a later age. Toe-cutting then becomes medically justifiable?

    Absolutely!

  17. Peter Lipson says:

    Although, both HIV and HPV have the same transmission vector, exchange of bodily fluids, Herpes is transmitted through sores on the skin.

    HIV and HPV are transmitted via skin-to-skin contact. No skin breakdown is required. HIV is not transmitted via intact skin.

    It makes no sense to assume that circumcision can reduce the chances of aquiring HIV/HPV as well as Herpes.

    In fact, it is a plausible hypothesis, was tested and found to be likely representative of reality.

    This post is not an argument for or against circumcision. What this study and many others show is that in certain populations circumcision clearly prevents the transmission of certain STIs. It is not the only method, nor is it necessarily one that should be implemented.

    What some comments show is that people who are opposed to the practice, rather than arguing on the merits, sometimes deny the facts.

  18. ImperfectlyInformed says:

    Can you say cognitive dissonance, Peter?

    Those wondering what I’m talking about can refer to my comments above and compare with Peter’s statement “that some comments show is that people who are opposed to the practice, rather than arguing on the merits, sometimes deny the facts”.

    I daresay there’s some irony here.

  19. Mark Crislip says:

    “Herpes is transmitted through sores on the skin.”
    Not true.

    the majority of people with HSV do not know and the diseases is reactivated and passed on subclinically.

    There is something about STD’s that leads to repeated exposure, so there does not have to be high infectivity.
    ===

    one of many

    Reactivation of genital herpes simplex virus type 2 infection in asymptomatic seropositive persons.

    Wald A, Zeh J, Selke S, Warren T, Ryncarz AJ, Ashley R, Krieger JN, Corey L.

    N Engl J Med. 2000 Mar 23;342(12):844-50.

    PMID: 10727588

  20. Joybobington says:

    I take back part of my comment. It was 3 a.m. etc.

    Ok, the two studies referred to, are based on the same set of data; which again, compared circumcised versus uncircumcised males without factoring out social/economic/religious factors. Again, Catholic Ugandans will circumcise at different rates than Muslim Ugandans or Protestant Ugandans.

    Since these groups will tend to have sex within the group, have different sexual practices, different beliefs about condoms (particularly Catholics), etc. etc. etc.

    What we need is a study in Western European countries, with homegenous populations, whose secular nature would make circumcision optional, not a part of the cultural identity. For example, a country like Finland with good medical records.

    Until those studies are done, we can’t make conclusions about the effects of said study.

  21. desiree says:

    but how on earth do you weigh risks to an infant against risks to an adult?
    do we know the risk of death or permanent injury to babies from circumcision? how about a reasonable estimate of the number of adult lives that could be saved (here in the US) by circumcision?

    i can’t possibly know where i stand on the issue without the numbers.

  22. snfraser says:

    “The science is quite clear; circumcision effectively prevents the transmission of a number of important diseases” is an incredibly misleading, or at least ambiguous, statement.

    In this particular study (Aaron et al.), reduction of HSV-2 infection was modest, with a 95% CI Hazard ratio = .72 ranging from .56 to .92. So, it could be even more modest, or nearly quite good.

    This amounts to preventing about 40-45 cases (I did not look at raw data, just compared percents and roughly calculated prevented cases based on size of the control and intervention group) in a sample 3393. There were roughly 300 cases of HSV-2 seroconversion in total.

    There was no effect for syphilis.

    The most promising finding was for HPV. Of course, with an effective vaccine for HPV, one might want to compare the cost/benefit of the vaccine to circumcision.

  23. Eric Jackson says:

    Touchy subject indeed.

    The science has received some criticism, that I’ve read, though I’ve by no means looked into it in depth. Most of these seem to focus on the fact that there are radically different social factors that play in between the two populations examined, and that this is not suitably controlled for in the examination of the data. Again, I have not examined the studies in detail. The preponderance of followup studies seem to indicate that the benefits may be far more modest, particularly in developing countries, than is portrayed by the ones done in Africa.

    The reduction in HIV transmission rate, if I recall, was hypothesized to be about the reduction in available CD4+ cells. While HIV is commonly known to primarily affect Th-cells, the site of initial infection is usually other CD4+ cells, notably Langherhans Cells, which are present in high numbers in the human foreskin, and macrophages. One professor of immunology I took a course from about a year ago was of the belief that the macrophage ability to cross the blood brain barrier is a major contributing factor to the neurological symptoms in late stage AIDS. She also stated that the now somewhat famous CCR5-d32 mutation conferred very strong resistance to HIV infection, simply by preventing initial macrophage infection.

    It does evoke a rather visceral since of revulsion in quite a good proportion of men who are not circumcised, though there is a fair body of medical literature on those who undergo the procedure later in life report little change in function, and an experience that though different, is no worse. Still, it’s an incredibly intimate, personal area of a person’s body, and as such it provokes quite a bit of, for lack of a better word, ‘nutty’ behavior, focusing on it to an extreme and senseless degree. There’s the vitriolic pro-circumcision crowd out there, who advocate it to an extreme, and refuse to listen to anything that says the procedure isn’t the greatest thing conceived of in human history.

    There are those on the other side of course, who proclaim quite vocally that it is nothing short of brutal, excruciating mutilation, inexcusable on all moral and medical levels, including a subset who have received the procedure and go through quite odd and painful seeming means to ‘reverse’ it.

    It’s one of those issues that even if the science were conclusively and unanimously for, which it clearly does not seem to be, would be resolved. It simply touches people in far too personal way.

  24. yeahsurewhatever says:

    Dr. Lipson, your statements are becoming increasingly ridiculous and defensive.

    “This post is not an argument for or against circumcision.”

    Of course it is. To present information selectively and uncritically is to endorse it. To endorse a study which finds that there is a “statisticlly aggregate medical benefit to society” as a result of an unethical procedure is to endorse the unethical procedure.

    “What some comments show is that people who are opposed to the practice, rather than arguing on the merits, sometimes deny the facts.”

    So argue the merits. The evidence is insufficient to recommend the procedure, and there is still an ethical question that you’re dodging and which does not depend in any way on the possible benefits of performing the surgery, which everyone agrees is unnecessary.

    Are you saying that it’s okay to perform any procedure on a patient, even if they’re not in a state where they can meaningfully achieve informed consent, provided that the procedure benefits society at large, and doesn’t kill the patient? Because it sounds to me like you’re trying to imply something remarkably similar to that!

    Francis Galton invented a word to refer to this line of reasoning. Eugenics.

    Your rationale here was used to sterilize the mentally retarded and criminal element in Indiana in 1907, and that was the example that Hitler used for his sterilization of Jews starting in 1933. It was even referred to, by the Germans and everyone else in the world, as the “Indiana procedure”. Indiana was the first place in the world to ever have such a sterilization law. The US Supreme Court even upheld it as constitutionally valid, and Justice Oliver Wendell Holmes remarked that “three generations of imbeciles are enough”, reflecting that the intention of the law was to raise the average intelligence of society. There’s much more backstory, even involving Alfred Binet and his IQ test, but it’s not relevant to this discussion.

    Now, circumcision is not sterilization, but the logic you offer justifies both equally and without differentiation, and thus can’t be sufficient. I perceive the mistake to be the fact that “society at large” is not the patient being treated, and medical practitioners have no oath to keep to society at large. This seems to create a subtle conflict of interest between medicine and “public health”, which — to be sure — is a distinct entity which is not directly founded upon medicine.

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