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The CDC Botches Circumcision

Should genital cutting be recommended?

by Norm Cohen


Sometimes we get the wrong answer; always we are left with the wrong question.

Routine circumcision is the wrong question. Not only is it the wrong answer to disease prevention, it is also the wrong question about disease prevention.

The US Centers for Disease Control and Prevention (CDC) released a draft in December 2014 of the first federal guidelines on circumcision(1), claiming that the benefits of the procedure “outweigh the risks,” a position that runs counter to medical advice in many other countries.(2)

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The CDC suggested that parents of newborn males and all uncircumcised men who are at risk of becoming infected with HIV should receive “comprehensive counseling” on circumcision and even advised similar counseling of sexually active teens who haven’t undergone the procedure.

In response, here are some valid questions to ask:
  • Why is circumcision recommended over more effective alternatives?
  • Why is the prevalence of HIV infection 2.5 times higher in the United States, where about 75% of sexually active men are already circumcised, than it is in Western Europe, where less than 10% of sexually active men are circumcised?(3)
  • Why do 10 African countries have a prevalence of HIV infection that is greater in circumcised men?(4)
Circumcision is the only case in modern medicine where the routine removal of normal tissue is still recommended for disease prevention. The most private and personal organ of a boy’s body is the only target for routine preventative surgery.

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The response to a risk of disease must be proportional, and routine circumcision is not a proportional response. It is extraordinary to recommend tissue reducing surgery on infants to prevent avoidable, behavior-based diseases that only occur in adults. The infant is subject to immediate risks from the surgery without any immediate benefits.

The CDC admits that circumcision provides no benefit to homosexual men.(5) The men who are at most risk from HIV (homosexuals) have not been found to be protected by circumcision. The men who are targeted by the recommendations are the ones at least risk from HIV (heterosexuals). These men are also the ones most in need of preventing an unwanted pregnancy through the use of a condom.
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Norm Cohen, Director
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Condoms eliminate the alleged need for circumcision and, unlike circumcision, protect women too. The ethnic group with the highest circumcision rate in the US is African Americans, and this group also has the highest rate of heterosexually transmitted HIV.(6)

The CDC devoted only 119 words out of 18,336 words in the body of its technical report to the effects of circumcision on sexual function and penile sensation.(7) It ignored entirely the functions of the foreskin and why some men find having a foreskin to be beneficial.

The foreskin is the primary sensory tissue of the penis.(8) It has been found on every mammal, both male and female, for the last 65 million years. The foreskin covers and protects the head of the penis. The protective and lubricating effects of having a mobile sheath of living tissue as part of one’s genitals should be self-evident to anyone not circumcised. Circumcision removes the foreskin, alters the appearance and sensation of the penis, and creates a visual and functional deficit that lasts a lifetime.


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continued:

The foundation of the CDC’s recommendations lays in three infamous “randomized controlled” trials (RCTs) designed and conducted by men who wanted to promote circumcision and performed on men in Africa who wanted to be circumcised.(9) These short-term trials were not representative of men in Africa or in the United States and were not controlled for condom use, virus exposure, and other relevant behaviors.

The results of the RCTs from Africa are so inapplicable to HIV infection in the United States that it took the CDC over 7 years after the studies were published to propose related recommendations. In the meantime, Europe, Japan, China, and South America never took the results seriously.

The claim that circumcision produced a 50 to 60% reduction in HIV incidence is misleading because this is a relative risk reduction, not an absolute risk reduction. The men in the African studies lowered their total risk of HIV infection by only 1.3% if they got circumcised.(10) This means that for 98.7% of the men, circumcision made no difference.

When experimental errors and other factors are considered, the research findings have no significance. The studies lasted less than 5% of a man’s sexual life and found during that time, circumcision failed to prevent half of all HIV infections.

With repeated exposures over the course of a man’s lifetime, circumcision cannot prevent infection. Partial prevention of a deadly virus that one is repeatedly exposed to is not prevention. It is a dangerous illusion. Kenya has the fourth largest HIV epidemic in the world, and 85% of men there were circumcised as children.(11)

Circumcision is remarkably ineffective and inconsistent in preventing disease. Finding a slight health benefit in favor of circumcision does not mean that boys should be circumcised, that insurance should pay for it, or that parents should be allowed to decide. No amount of research, either well-designed or biased from the start, can determine public policy. Science alone doesn’t and can’t dictate prevention measures, insurance coverage, or human rights.

It is biologically plausible that the removal of the inner labia of girls would also serve to prevent disease. The unlikelihood of receiving research funding to pursue this hypothesis illustrates the limitation science actually has in guiding public policy.

Medicine has a shocking history of using poor research methods to reach bad conclusions that are ideological props for the status quo. Circumcision is culturally and religiously motivated and will always be. The amount of “scientific” research on circumcision that originates in the US compared to the non-existent research on the nature and function of the foreskin is indicative of a bias in finding, funding, and filtering results that support the cultural and religious status quo.

The CDC’s guidelines are discredited by its mix of cultural norms with recommendations that are contrary to international medical opinion. Pediatricians from 16 European countries accused the American Academy of Pediatrics (AAP) of cultural bias after it released its 2012 pro-circumcision policy statement.(12)

Most studies of HIV prevention measures have been done in the US or Europe. The circumcision studies were not and could not be conducted or repeated in the US due to their inherent ethical violations by the researchers who endangered sex partners not in the study.

The medical profession has a long history of denying the risks of harm from medical procedures while exaggerating the risks of harm from other sources and from no intervention. Its history of denying procedural pain in infants is an example of this.

Complications from circumcision are always underreported. The AAP has admitted that the true complication rate is not known.(13) Infant circumcision is often performed by inexperienced medical residents, and infants cannot speak up to complain of complications. 100% of the immediate and long-term complications, which every year include death and penis amputation, would be prevented if circumcision was avoided.

Expressing the risks of genital cutting as an absolute percentage is misleading. Serious complications in at least 0.2% of the 1.1 million boys circumcised annually means that 2,200 boys every year are immediately negatively impacted by circumcision long before any benefit could accrue.(14)

The most common documented long-term complication of circumcision is meatal stenosis, a narrowing of the urinary opening. It occurs in 5% to 20% of circumcised boys, risks causing kidney problems, and requires more surgery to correct.(15)

All benefits of routine circumcision are hypothetical. Hypothetical benefits are not the same as real benefits. In the vast majority of men, no benefits will accrue at all because they will never be exposed to the infections circumcision is claimed to prevent. There are less expensive and less risky alternatives to disease prevention and treatment.

AIDS never became widespread among heterosexuals in the United States. Less than 1 in 10 HIV infections in the US are transmitted heterosexually.(16) The number of heterosexually transmitted HIV infections in men is 3,300 per year.(17) The risk of a man in the US getting infected by an HIV positive woman is 1 in 2,500 exposures.(18)

There is no AIDS crisis here, and there never will be. The number of new HIV infections worldwide peaked in the late 1990s and has been declining since.(19) Nevertheless, since 1995 circumcision’s last stand in the medical world has been calls for worldwide circumcisions to prevent AIDS.

The US has the highest HIV rate and the highest circumcision rate in the Western world. Every country in Western Europe has a lower rate of HIV and a vastly lower rate of circumcision.(20) Over 500,000 circumcised American men have been infected with HIV from unprotected sex since HIV was discovered.(21)

No studies of men in the United States have been able to demonstrate a correlation between HIV infection and the presence of a foreskin. The foreskin has never been the primary site of HIV infection for men in the United States.

Circumcision is among the least effective means of preventing sexually transmitted diseases. Over 750 males in the US would supposedly have to be circumcised to prevent 1 HIV infection.(22) In those who allegedly would benefit, this benefit would disappear over the course of repeated exposures to HIV.

The CDC’s guidelines contravene long-standing CDC recommendations about the use of condoms as the essential component to safe sex and pregnancy prevention. The CDC has taken a cynical and pessimistic approach to condom use and implicitly condones unsafe sexual practices. It leaves the impression that condoms are the secondary instead of primary means of preventing transmission. Meanwhile, no other AIDS prevention organization in the US is recommending that males get circumcised.

Condoms provide cost-effective, symmetric, and near-perfect protection to both partners, as well as pregnancy protection. Circumcision does not protect women and claims about protecting men never come close to the success rate of condoms. An HIV infected man who isn’t wearing a condom is about 8 times as likely to infect a woman as an infected woman is to infect a man.(23)

What use is circumcision to a man who wears a condom when he has sex? Recommending circumcision is not a complementary strategy in the fight against AIDS; it’s a competitive strategy. The CDC gives youth the impression that condoms are an optional form of disease control. The guidelines provide a confusing and contradictory message that will inevitably encourage risk-taking among young men and put women at additional risk.

Parents have no interest in circumcising their sons to inspire risky sexual behavior. Parents are just not going to go there with their newborns, and they are not going to get their older boys circumcised in case their sons might have unprotected sex!

The CDC is culturally biased in recommending a procedure so closely tied to custom and religion. Furthermore, the CDC’s recommendation that its target audience—physicians—be paid by Medicaid and insurance companies for a non-therapeutic surgery to protect against a man’s risk-taking behavior is profiteering from fear-mongering and is unethical.

The CDC’s cultural dislike of the foreskin, its lack of critical analysis, and its confused approach to disease prevention are examples of the agency’s misplaced priorities in protecting public health. The recommendations will be ignored by all except for current circumcision advocates.

NOCIRC of Michigan is working for a world of genital integrity where a boy can be born unmolested by genital cutting. We believe that sex and medical research should both be chaperoned by common sense. The genitals of children must be treated with the highest integrity and ethical standards.

“Should circumcision be recommended?” is the wrong question about how to improve public health, and the CDC has provided all of us with the wrong answer.

Norm Cohen
Director




Footnotes


1 Centers for Disease Control and Prevention, “Recommendations for Providers Counseling Male Patients and Parents Regarding Male Circumcision and the Prevention of HIV Infection, STIs, and other Health Outcomes,” December 2, 2014, http://www.regulations.gov/contentStreamer?documentId=CDC-2014-0012-0003&disposition=attachment&contentType=pdf

2 Frisch M, et. al, “Cultural bias in the AAP’s technical report and policy statement on male circumcision,” Pediatrics March 2013; 131: 796-800, http://pediatrics.aappublications.org/content/early/2013/03/12/peds.2012-2896.full-text.pdf

3a UNAIDS, “UNAIDS report on the global AIDS epidemic 2013,” p. A6, http://www.unaids.org/sites/default/files/media_asset/UNAIDS_Global_Report_2013_en_1.pdf

3b Xu F, Markowitz LE, Sternberg MR, Aral SO, “Prevalence of circumcision and herpes simplex virus type 2 infection in men in the United States: The national health and nutrition examination survey (NHANES), 1999-2004,” Sexually Transmitted Diseases 2007;34(7):479-484, http://journals.lww.com/stdjournal/Fulltext/2007/07000/Prevalence_of_Circumcision_and_Herpes_Simplex.11.aspx

3c Frisch M, Friis S, Kjaer SK, Melbye M, “Falling incidence of penis cancer in an uncircumcised population (Denmark 1943-90),” British Medical Journal, 1995;311(7018):1471, http://www.bmj.com/content/311/7018/1471

4 Mishra, Vinod, Amy Medley, Rathavuth Hong, Yuan Gu, and Bryant Robey, February 2009, “Levels and Spread of HIV Seroprevalence and Associated Factors: Evidence from National Household Surveys,” DHS Comparative Reports No. 22. Calverton, Maryland, USA: Macro International Inc., p. xii, https://www.dhsprogram.com/pubs/pdf/CR22/CR22.pdf

5 Centers for Disease Control and Prevention, “Background, Methods, and Synthesis of Scientific Information Used to Inform the ‘Recommendations for Providers Counseling Male Patients and Parents Regarding Male Circumcision and the Prevention of HIV infection, STIs, and other Health Outcomes’,” p. 15, December 2, 2014, http://www.regulations.gov/contentStreamer?documentId=CDC-2014-0012-0002&disposition=attachment&contentType=pdf

6a Mor Z, Kent CK, Kohn RP, Klausner JD, “Declining rates in male circumcision amidst increasing evidence of its public health benefit,” PLoS ONE September 2007; 2(9): e861, http://journals.plos.org/plosone/article/asset?id=10.1371%2Fjournal.pone.0000861.pdf

6b Centers for Disease Control and Prevention, “HIV/AIDS among African Americans,” updated July 2015, United States Department of Health and Human Services, Atlanta, Georgia, http://www.cdc.gov/hiv/group/racialethnic/africanamericans/

7 Centers for Disease Control and Prevention, “Background, Methods, and Synthesis of Scientific Information Used to Inform the ‘Recommendations for Providers Counseling Male Patients and Parents Regarding Male Circumcision and the Prevention of HIV infection, STIs, and other Health Outcomes’,” p. 26, December 2, 2014, http://www.regulations.gov/contentStreamer?documentId=CDC-2014-0012-0002&disposition=attachment&contentType=pdf

8 Sorrells ML, Snyder JL, Reiss MD, Eden C, Milos MF, Wilcox N, Van Howe RS, “Fine-touch pressure thresholds in the adult penis,” British Journal of Urology International, April 2007; 99: 864-9, http://onlinelibrary.wiley.com/enhanced/doi/10.1111/j.1464-410X.2006.06685.x/

9a Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A, “Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: The ANRS 1265 Trial,” PLoS Medicine, November 2005; 2(11): e298, http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0020298

9b Bailey RC, Moses S, Parker CB, Agot K, et. al., “Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial,” Lancet, February 2007; 369: 643-56, http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)60312-2/fulltext

9c Gray RH, Kigozi G, Serwadda D, Makumbi F, et. al., “Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial,” Lancet, February 2007; 369: 657-66, http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)60313-4/fulltext

10 Van Howe RS, Storms MR, “How the circumcision solution in Africa will increase HIV infections,” Journal of Public Health in Africa, February 2011; 2: e4, http://www.publichealthinafrica.org/index.php/jphia/article/view/jphia.2011.e4/html_9

11 Centers for Disease Control and Prevention, “Progress in Voluntary Medical Male Circumcision Service Provision — Kenya, 2008–2011,” http://www.cdc.gov/mmwr/pdf/wk/mm6147.pdf

12 Frisch M, et. al, “Cultural bias in the AAP’s technical report and policy statement on male circumcision,” Pediatrics March 2013; 131: 796-800, http://pediatrics.aappublications.org/content/early/2013/03/12/peds.2012-2896.full-text.pdf

13 American Academy of Pediatrics Task Force on Circumcision, “Technical Report, Male Circumcision,” September 2012, Pediatrics, 130, no. 3, p. e772, http://pediatrics.aappublications.org/content/130/3/e756

14 Van Howe, RS, “A CDC-requested, Evidence-based Critique of the Centers for Disease Control and Prevention 2014 Draft on Male Circumcision: How Ideology and Selective Science Lead to Superficial, Culturally-biased Recommendations by the CDC,” January 2015, Academia.edu, p. 17, https://www.academia.edu/10553782/A_CDC-requested_Evidence-based_Critetting">https://www.academia.edu/6992015/Incidence_of_Meatal_Stenosis_following_Neonatal_Circumcision_in_a_Primary_Care_Setting

15 Van Howe RS, “Incidence of meatal stenosis following neonatal circumcision in a primary care setting,” January 2006, Clinical Pediatrics, 45: 49-54, https://www.academia.edu/6992015/Incidence_of_Meatal_Stenosis_following_Neonatal_Circumcision_in_a_Primary_Care_Setting

16 Centers for Disease Control and Prevention, “HIV Surveillance Report, 2014,” November 2015, vol. 26, p. 18, http://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-report-us.pdf

17 ibid, p. 18

18 Boily M-C, Baggaley RF, Wang L et. al., “Heterosexual risk of HIV-1 infection per sexual act: systematic review and meta-analysis of observational studies,” Lancet Infectious Diseases, February 2009, vol. 9, no. 2, p. 118–29, http://www.thelancet.com/pdfs/journals/laninf/PIIS1473-3099%2809%2970021-0.pdf

19 UNAIDS, “Global HIV prevalence has leveled off,” 20 November 2007, Joint United Nations Program on HIV/AIDS and World Health Organization, Geneva, Switzerland, http://www.who.int/mediacentre/news/releases/2007/pr61/en/

20 Wikipedia contributors, "List of countries by HIV/AIDS adult prevalence rate," Wikipedia, https://en.wikipedia.org/w/index.php?title=List_of_countries_by_HIV/AIDS_adult_prevalence_rate&oldid=693791229

21 Calculated using a 75% circumcision rate for cumulative data from the Centers for Disease Control and Prevention, November 2015 “HIV Surveillance Report, 2014; vol. 26, p. 22, http://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-report-us.pdf

22 A 1.3% heterosexual risk-reduction x 10% heterosexual incidence in the US = .13%. The number needed to treat is calculated as 1 / .13% = 769 boys.

23 Padian NS, Shiboski SC, Glass SO, Vittinghoff E, “Heterosexual Transmission of Human Immunodeficiency Virus (HIV) in Northern California: Results from a Ten-Year Study,” American Journal of Epidemiology, August 1997, Vol 146, Issue 4, p 350-7, http://aje.oxfordjournals.org/content/146/4/350.full.pdf+html
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