Tight foreskin
BMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i4639 (Published 05 October 2016) Cite this as: BMJ 2016;355:i4639
All rapid responses
I am unclear what Ms Gupta is trying to achieve by quoting word for word a statement from the WHO website.
It is about time the oft-repeated claim, ‘There is compelling evidence that male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 60%.’ is abandoned as misleading.
Even if one ignores the many and considerable methodological flaws in the studies from which this figure is derived, it is a relative reduction; the absolute decrease in HIV infection is only 1.3%, which is not statistically significant. See, for example:
http://www.salem-news.com/fms/pdf/2011-12_JLM-Boyle-Hill.pdf.
I recently contacted the WHO about this. Their response? Silence.
In any case, all this is a diversion started by Ms Gupta from the subject of the original article which is about ‘tight foreskin’. Incidentally, this is a dubious concept: either the foreskin is retractable or it is not.
Competing interests: No competing interests
We thank all the rapid responders for their interest in the article.
In response to JK Anand:
The dorsal slit procedure is still sometimes performed in the emergency setting to treat paraphimosis but rarely seen electively nowadays. Our data on retractability is based on a Cochrane database meta-analysis performed in 2014 by Moreno and colleagues. Paraphimosis may occur in other mammals and is not uncommon in dogs.
In response to A Newson:
Your wording is more accurate and the line would be better phrased: "At age 3 years, 90% of boys have a partially retractile foreskin; this rises being fully retractile in up to 95% of 16-17 year olds". Thanks for your comment.
In response to O Bratt:
No good evidence exists with regard to phimosis in adults and advice is extrapolated from paediatric studies (level 1a) including teenagers. Men with symptomatic phimosis should be offered the option to see a urologist if symptoms persist
Competing interests: No competing interests
In my previous two responses what I had mentioned about foreskin and HIV, was from WHO and CDC publications respectively1,2.
I've asked the scientists in ICMR who have worked on male circumcision in prevention of HIV. They've done qualitative studies and found that acceptability for male circumcision was very low in Indian Population 3,4,5.
References:
1. http://www.who.int/hiv/topics/malecircumcision/en/ as accessed on 27/10/2016.
2. https://www.cdc.gov/hiv/pdf/prevention_research_malecircumcision.pdf
3. Sinha A, Chandhiok N, Sahay S, Deb S, Bharat S, Gupta A, Bhatt S, Kanthe V,
Kumar B, Joglekar N, Paranjape R, Mehendale S. Male circumcision for HIV
prevention in India: emerging viewpoints and practices of health care providers.
AIDS Care. 2015;27(9):1196-8. doi: 10.1080/09540121.2015.1039957. PubMed PMID:
26001127.
4. Sahay S, Nagarajan K, Mehendale S, Deb S, Gupta A, Bharat S, Bhatt S, Kumar
AB, Kanthe V, Sinha A, Chandhiok N. Community and healthcare providers'
perspectives on male circumcision: a multi-centric qualitative study in India.
PLoS One. 2014 Mar 10;9(3):e91213. doi: 10.1371/journal.pone.0091213. PubMed
PMID: 24614575; PubMed Central PMCID: PMC3948789.
5. Chandhiok N, Gangakhedkar RR. The new evidence on male circumcision: an Indian
perspective. Reprod Health Matters. 2007 May;15(29):53-6. PubMed PMID: 17512375.
FOOTNOTE: (The summary of two references from Pubpdf is provided below:)
MALE CIRCUMCISION FOR HIV PREVENTION IN INDIA: EMERGING VIEWPOINTS AND PRACTICES OF HEALTH CARE PROVIDERS.
AIDS Care 2015 22;27(9):1196-8. Epub 2015 Dec 22.
Anju Sinha, Nomita Chandhiok, Seema Sahay, Sibnath Deb, Shalini Bharat, Abhilasha Gupta, Sripad Bhatt, Vidisha Kanthe, Bijesh Kumar, Neelam Joglekar, Ramesh Paranjape, Sanjay Mehendale
A compelling case for promoting male circumcision (MC) as an intervention for reducing the risk of heterosexually acquired HIV infection was made by dissemination of the results of three studies in Africa. The WHO/UNAIDS recommendation for MC for countries like India, where the epidemic in concentrated in high-risk groups, advocates MC for specific population groups such as men at higher risk for HIV acquisition. A multicentre qualitative study was conducted in four geographically distinct districts (Belgaum, Kolkata, Meerut and Mumbai) in India during June 2009 to June 2011.
COMMUNITY AND HEALTHCARE PROVIDERS' PERSPECTIVES ON MALE CIRCUMCISION: A MULTI-CENTRIC QUALITATIVE STUDY IN INDIA.
PLoS One 2014 10;9(3):e91213. Epub 2014 Dec 10.
Seema Sahay, Karikalan Nagarajan, Sanjay Mehendale, Sibnath Deb, Abhilasha Gupta, Shalini Bharat, Shripad Bhatt, Athokpam Bijesh Kumar, Vidisha Kanthe, Anju Sinha, Nomita Chandhiok
Although male circumcision (MC) is recommended as an HIV prevention option, the religious, cultural and biomedical dimensions of its feasibility, acceptability and practice in India have not been explored till date. This study explores beliefs, experiences and understanding of the community and healthcare providers (HCPs) about adult MC as an HIV prevention option in India.
This qualitative study covered 134 in-depth interviews from Belgaum, Kolkata, Meerut and Mumbai cities of India.
Competing interests: No competing interests
Quoting WHO on Male circumcision for HIV prevention:
There is compelling evidence that male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 60%. Three randomized controlled trials have shown that male circumcision provided by well trained health professionals in properly equipped settings is safe. WHO/UNAIDS recommendations emphasize that male circumcision should be considered an efficacious intervention for HIV prevention in countries and regions with heterosexual epidemics, high HIV and low male circumcision prevalence.
Male circumcision provides only partial protection, and therefore should be only one element of a comprehensive HIV prevention package which includes: the provision of HIV testing and counseling services; treatment for sexually transmitted infections; the promotion of safer sex practices; the provision of male and female condoms and promotion of their correct and consistent use.
(http://www.who.int/hiv/topics/malecircumcision/en/ as accessed on 27/10/2016)
I will answer Dr. Anand's question (asked on 26/10/2016) after talking to scientists who have worked on male circumcision in prevention of HIV.
Competing interests: No competing interests
This is a response to Gupta of ICMR (The Indian Council of Medical Research) and colleagues who appear convinced of the value of the little snip to save mankind from the depredations of HIV. The colleagues referred to include a Municipal Medical Officer of Health and a professor of community medicine.
Two questions to these authors:
Is the Indian Council of ICMR convinced of the value? If so, has the Govt of India been so advised by the ICMR? If not, why not?
Has the Delhi Municipal Corporation been so advised? If not, why not?
I await, patiently, the replies.
Competing interests: Uncircumcised
It is unfortunate that Neeru Gupta takes the opportunity to respond to an article on tight foreskin with a digression to try to propagate the mistaken view that circumcision significantly reduces the rate of HIV acquisition. She does this by reference to a document produced by the CDC. This theory has been thoroughly debunked in a paper by Robert S Van Howe: https://www.researchgate.net/publication/271841897
Competing interests: No competing interests
Raja and colleagues puzzle me.
1. They speak of circumcision. No mention of dorsal slit. In the days of my youth, very very long ago (as a surgical houseman - I was not a patient) a dorsal slit was an option.
Has it fallen out of favour? Considering the rich neurological endowment of the prepuce, it ought not to be consigned to history books.
2. Their patient is, I guess, a hypothetical patient. Non-retractability is only of a few months duration. Clearly infection is the cause.
3. The authors describe a very high rate of full spontaneous retractability of the prepuce in children. Hard to believe. I appreciate the risk of being accused of indecency if you go around pushing the foreskin back in symptomless children. So, I do not recommend a survey. It should be possible though, to study the records of circumcision at various ages to see how many teenage boys have been circumcised for other than religious reasons.
4. Our cousins - eg, the Chimpanzees and Orang Utans - must possess a prepuce. Have the veterinarians of the British zoos come across cases of paraphimosis?
I would be grateful for replies to the above comments.
Competing interests: No competing interests
According to the Centers for Disease Control and Prevention (https://www.cdc.gov/hiv/pdf/prevention_research_malecircumcision.pdf):
Several types of research have documented that male circumcision significantly reduces the risk of men contracting HIV through penile-vaginal sex.
Compared with the dry external skin surface of the glans penis and penile shaft, the inner mucosa of the foreskin has less keratinization (deposition of fibrous protein) and a higher density of target cells for HIV infection. Some laboratory studies have shown the foreskin is more susceptible to HIV infection than other penile tissue, although others have failed to show any difference in the ability of HIV to penetrate inner compared with outer foreskin surface. The foreskin may also have greater susceptibility to traumatic epithelial disruptions (tears) during intercourse, providing a portal of entry for pathogens, including HIV. In addition, the microenvironment in the preputial sac between the unretracted foreskin and the glans penis may be conducive to viral survival. Finally, the presence of other sexually transmitted diseases (STDs), which independently may be more common in uncircumcised men, increase the risk for HIV acquisition.
Competing interests: No competing interests
Is the opening statistic, "At age 3 years, 90% of boys have a fully retractile foreskin; this rises to 95% of 16-17 year olds.1 2" also partly in error - the first part seems too high a level - it does not tally with my prior reading or the sources listed. A more accurate line might be, "At age 3 years, 90% of boys have a partially retractile foreskin; this rises being fully retractile in up to 95% of 16-17 year olds.1 2". Could the authors check and respond? Many thanks.
Competing interests: No competing interests
Response to Dr. Gabriel Symonds: Seeing is believing
I do not disagree with Dr. Symonds, but I humbly want to bring to his kind notice to the findings of a paper by Dinh et al which is published in March, 2015 in PLos Pathogens. To gain insight into female-to-male HIV sexual transmission and how male circumcision protects against this mode of transmission, they visualized HIV-1 interactions with foreskin and penile tissues in ex vivo tissue culture and in vivo rhesus macaque models utilizing epifluorescent microscopy. In summary, the results of the paper suggest that the inner foreskin and glans epithelia may be important sites for HIV transmission in uncircumcised men1.
Reference:
1. Dinh MH, Anderson MR, McRaven MD, Cianci GC, McCoombe SG, Kelley ZL, Gioia CJ, Fought AJ, Rademaker AW, Veazey RS, Hope TJ. Visualization of HIV-1 interactions with penile and foreskin epithelia: clues for female-to-male HIV transmission. PLoS Pathog. 2015 Mar 6;11(3):e1004729. doi: 10.1371/journal.ppat.1004729.
Competing interests: No competing interests