I am resending the text of this interesting article, although there are
some graphics is you access via the link in my previous message.


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http://chronicle.com/weekly/v51/i38/38a01201.htm
From the issue dated May 27, 2005


Battle Over the Knife
Medical researchers debate the wisdom -- or folly -- of mass-circumcision
campaigns as a way to prevent HIV transmission in Africa

By DAVID GLENN

During the past century and a half, various medical scholars have asserted
that male circumcision has many benefits. Here, in ascending order of
plausibility, are some of the ailments that circumcision has been believed
to prevent:

Insanity. Paralysis. Bed-wetting. Excessive masturbation. Impotence.
Tuberculosis. Prostate cancer. Syphilis. Cervical cancer (in circumcised
men's sex partners). Penile cancer.

Some of those claims were serious. (The last two hypotheses are still
posited by a minority of researchers.) Others were sheer quackery. In
1891, at the height of one wave of anti-foreskin zealotry, Peter Charles
Remondino, a prominent physician in San Diego, encouraged insurance
companies to charge higher rates to uncircumcised men: "A circumcised
laborer in a powder mill or a circumcised brakeman or locomotive
engineer," he wrote, "runs actually less risk than an uncircumcised tailor
or watchmaker." Dr. Remondino also announced that he had cured an
asylum-bound mentally ill man by removing his foreskin.

Since 1989, a new claim has been added to the circumcision wars -- a claim
with extremely high stakes. Circumcision, some scientists believe, gives
men significant protection from acquiring HIV during heterosexual
intercourse. Some proponents of that theory are urging countries with high
rates of HIV infection to establish mass campaigns to circumcise infant
boys -- and even adult men.

"The evidence appears quite compelling," says Robert C. Bailey, a
professor of epidemiology and biostatistics at the University of Illinois
at Chicago, who is leading an ambitious study of circumcision in western
Kenya. "If it holds up, this could have a huge impact."

But skeptics warn that mass-circumcision campaigns could do far more harm
than good. Some medical anthropologists fear an explosion of unsanitary
ritual circumcisions in Africa. Dirty knives, they say, could themselves
spread AIDS and other diseases. They also worry that circumcised men and
their sexual partners will overestimate the protection that circumcision
offers, and therefore act recklessly.

"Before one does a prevention program that appears to be as radical as
this one would be," says Ralph Bolton, a professor of anthropology at
Pomona College, "we need to ask a hell of a lot of questions and have
really good data. Going around lopping off the foreskins of adult men in
Africa is potentially both politically and medically risky."

During the past decade, at a series of contentious international seminars,
the two sides have fought each other to a stalemate. But that stalemate
may be about to break, one way or the other: By the end of 2007, three
carefully designed, randomized studies currently under way in Africa will
be completed. If all goes well, those studies -- one of which is Mr.
Bailey's -- should provide strong evidence about the protection, or lack
thereof, that circumcision offers.

Will the fractious world of AIDS prevention, which is already consumed by
debates over condoms, abstinence, marriage, and sex education, be prepared
to digest the studies' implications? "I've long maintained that if we just
gave Africans money for AIDS prevention and let them use their wisdom and
discretion, they'd do well," says Edward C. Green, a senior research
scientist at the Harvard School of Public Health and author of Rethinking
AIDS Prevention: Learning From Successes in Developing Countries (Praeger,
2003). Mr. Green fears that the circumcision studies' findings -- no
matter which way they fall -- will not be left to Africans' discretion,
but will instead be thrown into a hornet's nest of politicized debates
among Western donors.

The Missing Link

The notion of a circumcision-HIV link has been the subject of speculation
since nearly the beginning of the AIDS epidemic, almost 25 years ago. But
it received its first serious push in 1989, when a team of scholars
published a study in the British medical journal The Lancet that found
that male customers of HIV-positive female prostitutes in Nairobi, Kenya,
were 8.2 times more likely to acquire the virus if they were
uncircumcised.

That study was relatively small -- only 422 men were involved -- and did
not identify any causal mechanisms. It gave rise to a number of
epidemiological studies that demonstrated strong correlations between
various African regions' circumcision rates and the prevalence of HIV.
(Skeptics point out that if you use the same method to look at the
developed world, the map gives you the opposite picture: The United
States, which has a much higher circumcision rate than Western Europe,
also has a far higher heterosexual HIV rate.)

Scientists also began to identify potential biological mechanisms that
explain the pattern. The foreskin contains a dense concentration of
Langerhans cells -- a type of epidermal cell, named for the 19th-century
German physician Paul Langerhans, that is highly receptive to the HIV
virus. (Women's cervices also contain a high proportion of these cells.)

Other studies suggest that uncircumcised men are more susceptible than
their circumcised peers to certain complications of herpes, syphilis, and
other sexually transmitted diseases. Uncircumcised men, according to this
line of argument, are likely to have higher numbers of genital sores and
ulcers, which in turn can make them more vulnerable to HIV infection.

By the end of the 1990s, some proponents of the theory believed that the
evidence was strong enough to warrant large-scale circumcision campaigns.
"In populous regions such as South Asia, where a large population of men
are uncircumcised," Mr. Bailey and a co-author wrote in The Lancet in
1999, "the number of infections attributable to lack of male circumcision
could soon reach into the millions. In the face of such compelling
evidence, we would expect the international health community to at least
consider some form of action."

Belief and Beyond

Not all scholars found the evidence so compelling. Observational "map"
studies, they pointed out, are probably not as simple as they appear.

African circumcision rates are highest, for example, in countries where
Islam is practiced (although there are also numerous smaller non-Muslim
groups in Africa that practice ritual circumcision). And Islam, in turn,
is possibly itself a causal factor in AIDS prevention, if, as is widely
surmised, Muslim men are more conservative sexually than their non-Muslim
peers. So, if HIV rates are lower in Muslim regions of Africa, is that due
to men's physiognomy or their behavior?

Skeptics also point to other factors that might cloud the epidemiological
studies of the early 1990s. One such factor is cross-regional variations
in hygiene practices. Another is variations in viral load. For instance,
if the Nairobi prostitutes in the 1989 study had extremely high HIV
levels, according to the skeptics, then their customers' rate of infection
might not be representative of the typical risks faced in ordinary sexual
encounters.

A third factor is smaller-scale cultural differences. People in some
regions of Africa use powders and other agents to dry the vagina before
sex. That practice, which adherents believe increases sexual pleasure, is
known to increase the risk of HIV transmission. This sort of regional
custom might also complicate the maps drawn in early epidemiological
studies.

A medical-literature review completed in 2003 by the Cochrane
Collaboration, a well-regarded international program for the evaluation of
medical evidence, found that most existing studies of circumcision and
AIDS had not adequately dealt with such potentially confounding variables.
"There are not yet sufficient grounds to believe that male circumcision,
as a preventive strategy for HIV infection, does more good than harm," the
report concluded.

Some skeptics also began to raise questions about the laboratory studies
suggesting that foreskin tissue is highly vulnerable to HIV. Robert S. Van
Howe, a clinical instructor at Michigan State University's College of
Human Medicine and a prominent opponent of circumcision in all cases save
as an adult religious ritual, says such studies have been misinterpreted.
Langerhans cells, he says, are highly receptive to HIV only when the
surrounding tissue is inflamed (typically because of an existing sexually
transmitted disease). Aggressively treating gonorrhea and other low-level
sexual infections, he says, is far more cost-effective than circumcision
is likely to be.

Dr. Van Howe also points out that some of the most promising AIDS vaccines
are not injected directly into the bloodstream but instead administered
topically on the mucosal glands. Men with foreskins, he says, have much
more tissue for the reception of such vaccines.

"Coming from an epidemiological perspective," says Nandi L. Siegfried,
lead author of the Cochrane paper, "I'd say that we've made a lot of bad
decisions in the past based on simple observational studies. I think we
owe it to society to develop the best possible evidence before we make
policy." She now works at the Cochrane project's center, in Oxford,
England.

Because of doubts like Dr. Siegfried's, three teams of scientists began in
2000 to design random-assignment studies, which should throw more light on
the dynamics of circumcision and HIV infection. The trials are taking
place in South Africa, Uganda, and Kenya.

"It became obvious that we really needed clinical trials to nail this down
much more conclusively," says Illinois's Mr. Bailey.

His experiment, in Kisumu, Kenya, a city of 400,000 people on Lake
Victoria, involves about 2,800 sexually active, HIV-negative adult men
from the Luo ethnic group, which does not normally practice circumcision.
Half of the men are randomly assigned to be circumcised; their HIV status
will be monitored for two years and compared with that of the
uncircumcised control group. All 2,800 participants are being offered
intensive safe-sex counseling, and they are all eligible to receive free
health care of any sort -- notably including treatment for gonorrhea and
other sexually transmitted diseases -- at Mr. Bailey's clinic. (At the end
of the study, the members of the control group will be offered free
circumcision, if they would like.)

Most Kisumu residents do not have such steady access to health care and
safe-sex counseling. So will the experience of the 1,400 newly circumcised
subjects actually be representative of what a mass-circumcised Kenya might
look like? "That's a challenge for clinical trials generally," Mr. Bailey
says.

"As a matter of good clinical practice and as a matter of distributive
justice, if circumcision is found to be effective, we wouldn't advocate
just introducing circumcision into health facilities around Africa," he
says. "Rather, we would strongly advocate for making circumcision part of
a complete package of male reproductive health services, which would
include treatment of sexually transmitted infections and counseling about
safe sex behaviors. In fact, circumcision could become a real opportunity
to access young men, who are at high risk and who normally don't come in
to health facilities very often."

Men are still being enrolled in Mr. Bailey's project -- it is near the
2,400 level -- and he hopes to release results in late 2007. His study is
being financed by the U.S. National Institute of Allergy and Infectious
Diseases and by the Canadian Institute for Health Research.

Culture and Prevention

What will happen -- and what should happen -- if the three randomized
trials show a strong causal relationship between circumcision and lower
HIV rates?

Mr. Bailey says large-scale circumcision campaigns should be considered,
even if the protective effect of circumcision turns out to be only
moderate. "Imagine if we had a vaccine that was 50-percent effective," he
says. "I think a lot of people would scramble to roll out such a vaccine
very rapidly."

But it is not clear how well such an intervention might be received in
communities that have traditionally spurned circumcision.

"This is ultimately contingent on the last word from the populations that
are going to be affected by these kinds of interventions -- African
communities and the individuals in them," says James P. Stansbury, an
assistant professor of anthropology at the University of Florida, who has
written on the AIDS-prevention debate. "Really, that's where it rests. And
it's very difficult to generalize, anthropologically and ethnographically,
about Africa. That's something that's been done altogether too much." Even
within a single ethnic group that shares a common religious heritage, Mr.
Stansbury says, the acceptability of male circumcision can vary widely.

Some opponents of circumcision say they will condemn the practice no
matter what the randomized trials show. A recent essay by Robert Darby, an
independent scholar in Australia who wrote A Surgical Temptation: The
Demonization of the Foreskin and the Rise of Circumcision in Britain
(University of Chicago Press, forthcoming in July), suggests that even if
a strong causal connection is found (a prospect he doubts), mass
circumcision of infants would still be unethical and unwarranted. An
infant-circumcision campaign in Africa, he argues, would involve
"amputations performed on nonconsenting children showing no signs of
injury or disease."

"If a 15-year-old boy were shown a condom and a Gomco clamp," Mr. Darby
continues, "there would not be much doubt which he would choose."

"If African men are well informed about what they will lose when their
foreskin is removed -- if they are adult, mature, informed men -- that's
no concern of mine," says Leonard B. Glick, a professor emeritus of
anthropology at Hampshire College and author of Marked in Your Flesh:
Circumcision From Ancient Judea to Modern America (Oxford University
Press, forthcoming in June). "We're talking about the rights of infants
not to have surgery imposed on them until they reach an age where they can
decide for themselves."

Mr. Stansbury worries that zealots on either side of the debate will
someday behave like cultural imperialists, imposing a single attitude
toward circumcision worldwide. "I'm not even certain how to respond" to an
argument like Mr. Darby's, he says. "Cross-culturally you find the full
continuum, from seeing circumcision as heinous mutilation all the way to
seeing it as an important part of becoming a man."

As a pragmatic matter, he says, "if a particular community doesn't buy
into circumcision, it's simply not going to succeed." But if other groups
are receptive, he says, then circumcision campaigns might well be worth
trying.

Risky Business

In a 1997 essay, James P.M. Ntozi, who was then a population researcher at
Makerere University, in Uganda, wrote that while he was skeptical about
the circumcision theory, any intervention that might succeed in "reducing
the suffering of the people and preventing the infection of HIV should be
tried." He added, however, that Western scientists and donors should be
sensitive to each community's beliefs about male circumcision. For
example, he noted, in some regions of Uganda, circumcised men are highly
stigmatized.

"In a region highly sensitive to previous colonial exploitation and
suspicious of the biological-warfare origin of the virus," he wrote,
"failure of circumcision is likely to be a big issue. Those recommending
it should know how to handle the political implications."

Another concern is that circumcision campaigns would lead to moral hazard
-- that is, that newly circumcised men would take advantage of their new
level of safety by behaving in sexually risky ways.

"Clearly, one of the great risks is that people will think condoms are no
longer necessary," says Pomona's Mr. Bolton, who organized a panel on
circumcision and HIV at the April meeting of the Society for Applied
Anthropology. "I think this is a tremendous issue, and I don't think it's
being addressed."

"It concerns me that the 'C' in the ABC message" -- abstain, be faithful,
use condoms -- "may start to become circumcision rather than condoms,"
says Susan C. McCombie, an assistant professor of anthropology at Georgia
State University who has studied AIDS in Uganda. "I worry about the rural
young woman with no education who learns that circumcision protects
against AIDS and says, 'OK, this guy is circumcised, so he's safe, I can
have sex with him.' I think that's a real possibility." There is no
evidence whatsoever, she adds, that circumcision prevents male-to-female
HIV transmission; whatever protective effect there is benefits only men.

Mr. Green, of Harvard, is not dissuaded by such worries. Concerns about
moral hazard exist in almost any public-health intervention, he says. "But
you never hear that argument about one thing, and that's condom use.
Condoms clearly give people a false sense of security that they're safer
than they actually are."

Condoms' weaknesses should be more broadly publicized, he says, but he
would never argue that condoms should be removed entirely from the
AIDS-prevention arsenal. Likewise, he says, with circumcision: Even if the
practice leads some people to behave more recklessly, on balance it is
probably a useful intervention.

In the Kenya study, Mr. Bailey and his colleagues are aware of the
concerns about moral hazard. They are asking participants how many sexual
partners they have and how often they use condoms. If the researchers see
signs that the circumcised men begin to behave less carefully, they will
report those changes in their findings.

Whatever the randomized trials' outcome, the debate will inevitably be
viewed through the lens of the condom-versus-abstinence argument within
the Bush administration.

"I think one of the reasons that this project is being pushed is for
political reasons," says Mr. Bolton. "It's clear that we are moving toward
faith-based disbursement of American funds. We're moving away, and have
been moving away, from condom promotion."

But Mr. Green, who supports promotion of abstinence and monogamy and is
relatively skeptical of both the efficacy and likelihood of condom use, is
not so sure how circumcision fits into the usual policy quarrels. "It's
not at all clear that religious conservatives would go along with
circumcision as an intervention," he says, reflecting on his recent work
in Uganda. "Just as liberals tend to draw a line and say condoms only,
conservatives sometimes say abstinence only. So I'm not really sure how
this fits into the culture wars."

http://chronicle.com
Section: Research & Publishing
Volume 51, Issue 38, Page A12


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University of Washington
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