Szabo and Short's claim,1 using a selective bibliography and
speculation for foundation, that circumcision represents an effective new
strategy for combatting AIDS is highly irresponsible, particularly when a
rise in unprotected gay sex is being reported on both sides of the
Atlantic.2 It is likely to discourage even further the practice of safe
sex by circumcised men who are liable, as a result, to believe that their
circumcision is all the protection they need. Indeed, Halperin (commenting
on the article cited by them) was quoted in an interview to the
Californian newspaper, The Bay Area Reporter, on Nov 24, 1999 as saying
"If I were a top [insertive partner in anal intercourse], and I didn't
like to use condoms, I would consider getting circumcised".
Their article is also misleading, relying on selection, and
misrepresentation, of the corpus of the literature, and on highly flawed
and tendentious studies out of Africa whose authors, with clear cultural
bias, ignore the confounding factors, and also the failure of circumcision
to prevent the HIV pandemic in the United States that is on a par with the
incidence documented in sub-Saharan Africa. In sharp contrast, the largely
uncircumcised Europe has rates one quarter of the US.3
Szabo and Short assert that circumcision "also protects against other
sexually transmitted infections, such as syphilis and gonorrhoea";
however, they conspicuously fail to cite Laumann et al4, who found
"circumcision status does not appear to lower the likelihood of
contracting an STD. Rather, the opposite pattern holds. Circumcised men
were slightly more likely to have had both a bacterial and a viral STD in
their lifetime."
The theory that Langerhans' cells provide the mechanism for infection
by HIV has yet to be properly substantiated, and appears to suffer from
the fallacy of 'post hoc, propter hoc' by suggesting that infected
Langerhans' cells are the cause, rather than simply the result of HIV
infection.
Szabo and Short's bald assertion that the keratinised, stratified
squamous epithelium of the penile shaft "provides a protective barrier
against HIV infection" is without a scintilla of substantiation or
evidence; and the loss of specialised nerve-endings in the prepuce6 along
with the desensitisation of the circumcised glans and foreskin remnant by
keratinisation is likely
to make circumcised men even less willing to suffer the further
desensitisation of a condom.
Equally, their suggestion that neonatal circumcision is "easy to
perform, and has a low incidence of complications" cites a populist
pamphlet, which is notorious for its highly selective and discredited5
propagandising of neonatal circumcision, and fails to reflect more
scholarly assessments of the complications.6, 7, 8, 9
Routine circumcision might justly be seen as a remedy still looking
for a disease process, which is why a succession of scare tactics (each
then soundly refuted) has cynically been used over the decades. Szabo and
Short are thus in a long and discreditable line of those who, typically
coming from countries where routine circumcision is prevalent, seek to promote this damaging
mutilation as a panacea for the latest illness 'de nos jours' by preying
on current popular fears.
References
1 Szabo R, Short RV. How does male circumcision protect against HIV
infection? BMJ 2000;320:1592-1594.
2 Dodds JP, Nardone A, Mercey DE, and Johnson AM. Increase in high
risk sexual behaviour among homosexual men, London 1996-8: cross
sectional, questionnaire study. BMJ 2000; 320: 1510-1511.
3 World Health Organization. Global Programme on AIDS: The Current
Global situation of the HIV/AIDS Pandemic, Quarterly Report. 3 July, 1995.
4 Laumann EO, Masi CM and Zuckerman EW. Circumcision in the United
States, prevalence, prophylactic effects, and sexual practice; JAMA
1997;277(13):1052-1057.
5 Dewan P. Book lacks scientific evidence. Australian Medicine
1999;11(11):18 (Review of "In Favour of Circumcision" by Brian Morris).
6 Taylor R, Lockwood AP and Taylor AJ. The prepuce: specialized
mucosa of the penis and its loss to circumcision. Br J Urol 1996;77(2):291
-295.
7 Patel H. The problem of routine circumcision. Canadian Medical
Association Journal 1966;95:576-81.
8 Kaplan GW. Complications of circumcision. Urol Clin N Amer
1983;10:543-549.
9 Williams N, Kapila L. Complications of circumcision. Br J Surg
1993;80:1231-1236.
Rapid Response:
Irresponsible and misleading
Szabo and Short's claim,1 using a selective bibliography and
speculation for foundation, that circumcision represents an effective new
strategy for combatting AIDS is highly irresponsible, particularly when a
rise in unprotected gay sex is being reported on both sides of the
Atlantic.2 It is likely to discourage even further the practice of safe
sex by circumcised men who are liable, as a result, to believe that their
circumcision is all the protection they need. Indeed, Halperin (commenting
on the article cited by them) was quoted in an interview to the
Californian newspaper, The Bay Area Reporter, on Nov 24, 1999 as saying
"If I were a top [insertive partner in anal intercourse], and I didn't
like to use condoms, I would consider getting circumcised".
Their article is also misleading, relying on selection, and
misrepresentation, of the corpus of the literature, and on highly flawed
and tendentious studies out of Africa whose authors, with clear cultural
bias, ignore the confounding factors, and also the failure of circumcision
to prevent the HIV pandemic in the United States that is on a par with the
incidence documented in sub-Saharan Africa. In sharp contrast, the largely
uncircumcised Europe has rates one quarter of the US.3
Szabo and Short assert that circumcision "also protects against other
sexually transmitted infections, such as syphilis and gonorrhoea";
however, they conspicuously fail to cite Laumann et al4, who found
"circumcision status does not appear to lower the likelihood of
contracting an STD. Rather, the opposite pattern holds. Circumcised men
were slightly more likely to have had both a bacterial and a viral STD in
their lifetime."
The theory that Langerhans' cells provide the mechanism for infection
by HIV has yet to be properly substantiated, and appears to suffer from
the fallacy of 'post hoc, propter hoc' by suggesting that infected
Langerhans' cells are the cause, rather than simply the result of HIV
infection.
Szabo and Short's bald assertion that the keratinised, stratified
squamous epithelium of the penile shaft "provides a protective barrier
against HIV infection" is without a scintilla of substantiation or
evidence; and the loss of specialised nerve-endings in the prepuce6 along
with the desensitisation of the circumcised glans and foreskin remnant by
keratinisation is likely
to make circumcised men even less willing to suffer the further
desensitisation of a condom.
Equally, their suggestion that neonatal circumcision is "easy to
perform, and has a low incidence of complications" cites a populist
pamphlet, which is notorious for its highly selective and discredited5
propagandising of neonatal circumcision, and fails to reflect more
scholarly assessments of the complications.6, 7, 8, 9
Routine circumcision might justly be seen as a remedy still looking
for a disease process, which is why a succession of scare tactics (each
then soundly refuted) has cynically been used over the decades. Szabo and
Short are thus in a long and discreditable line of those who, typically
coming from countries where routine circumcision is prevalent, seek to promote this damaging
mutilation as a panacea for the latest illness 'de nos jours' by preying
on current popular fears.
References
1 Szabo R, Short RV. How does male circumcision protect against HIV
infection? BMJ 2000;320:1592-1594.
2 Dodds JP, Nardone A, Mercey DE, and Johnson AM. Increase in high
risk sexual behaviour among homosexual men, London 1996-8: cross
sectional, questionnaire study. BMJ 2000; 320: 1510-1511.
3 World Health Organization. Global Programme on AIDS: The Current
Global situation of the HIV/AIDS Pandemic, Quarterly Report. 3 July, 1995.
4 Laumann EO, Masi CM and Zuckerman EW. Circumcision in the United
States, prevalence, prophylactic effects, and sexual practice; JAMA
1997;277(13):1052-1057.
5 Dewan P. Book lacks scientific evidence. Australian Medicine
1999;11(11):18 (Review of "In Favour of Circumcision" by Brian Morris).
6 Taylor R, Lockwood AP and Taylor AJ. The prepuce: specialized
mucosa of the penis and its loss to circumcision. Br J Urol 1996;77(2):291
-295.
7 Patel H. The problem of routine circumcision. Canadian Medical
Association Journal 1966;95:576-81.
8 Kaplan GW. Complications of circumcision. Urol Clin N Amer
1983;10:543-549.
9 Williams N, Kapila L. Complications of circumcision. Br J Surg
1993;80:1231-1236.
Competing interests: No competing interests