Because Sometimes More is More

 

stinkerandmommy asked
How does it decrease it? It really stumps me.

(This question is in regards to claims that circumcision offers partial protection against HIV acquisition).

Let me preface by saying that my knowledge on this issue isn’t in depth. I’m far from being an expert on immunology or experimental science, and as such I don’t feel confident in taking a strong position on the scientific aspects of this issue. What I know is that there appears to be a prevailing view in the international public health community that circumcision can lower HIV acquisition rates among men who have sex with women. I think it’s important to be fair-minded in addressing this potential benefit, while also looking at it in the proper context.

From a biological point of view, this protection theorized to occur because the mucosal membrane of the inner foreskin is particularly vulnerable to HIV infection, and circumcision removes a large portion of that tissue, while causing the remaining portion to become keratinized and therefore less receptive to the HIV pathogen. (The rub, of course, is that this alteration has a significant effect on penile sensation and functioning as well). On a more technical level, the foreskin contains a large number of Langerhans Cells, which have a specific purpose of “sampling” potential pathogens by carrying them inside the body from the surface of the mucosal membrane — as a proactive part of the immune system. In the case of HIV, the virus defeats these cells, causing this mechanism to backfire.

There is some debate surrounding the recent studies that have established HIV prevention as a major part of the circumcision debate. For one, this research was conducted on African populations, which apparently differ significantly from other populations in terms of the epidemiology of the disease. Infection rates among those populations are much, much higher, and primary means of transmission is through heterosexual genital contact. By contrast, in Western populations HIV is predominately transmitted sexually from male to male, and through blood contamination. There are also legitimate concerns over how circumcision status will affect condom use, given that circumcised individuals might overestimate the limited extent of the protection offered by circumcision.

When it comes to circumcision and HIV in Africa, I think the people there should be able to make this decision as autonomously as possible, so I try to stay out of their business. I also recognize that the stakes are much different for them, given an infection rates that tops 20% in some regions. If circumcision can help alleviate this crisis to a significant extent, then I could see myself accepting even the circumcision of children as a justifiable measure. By the way, current circumcision campaigns in Africa tend to focus on adult males, which is ethically less problematic (though not completely so). 

The non-therapeutic circumcision of children in Western countries is where I take a stand against the HIV argument. Because elective adult circumcision is widely available in these countries, the imperative to surgically alter infants for the benefit of STI immunity is minimal. As I mentioned earlier, HIV rates in in the United states are 20-30 times lower than in the populations this research was conducted on. They are also higher than the rates in most of the countries you would expect them to be similar — Canada, United Kingdom, Australia, France, etc., despite the fact that circumcision rates in the United States are already much higher. The other argument is the progress being made in treating AIDS, which is extremely likely to be more fully realized by the time today’s generation of newborns reaches sexual maturity.

14 Adults Have Been "Cured" of HIV

The 14 patients were part of a group of 70 examined at the Pasteur Institute in Paris. They all began receiving anti-retroviral (ARV) medications between 35 days and 10 weeks of contracting the virus. The patients then stayed on the drugs for an average of three years, but all eventually stopped. ARV drugs can keep HIV in check, but can’t totally remove it from your system. And typically, when you stop taking the drugs, the virus re-emerges. Except, that hasn’t happened with these 14 patients. The early treatment is similar to the treatment of the Mississipi baby who was cured. She had ARV drugs administered just 30 hours after being born.

In countries where daily personal hygiene is possible and routine, there are no, or at least only highly doubtful, verifiable medical advantages of circumcising a child. Even if the removal of the foreskin could minimize the man’s risk of contracting H.I.V. or reduce his female partners’ risk of developing cervical cancer, this does not justify the circumcision of children. Whatever risks might exist for an uncircumcised man and his partners, they would not become relevant until the man is sexually active. For young boys, there are no medical benefits. On the contrary, circumcision carries all the risks inherent in any surgery.

We heard two disturbing comments from people regarding the tremendous financial interests behind the mass circumcision efforts. A professor from the Office of the President’s National AIDS Control Council, who has stopped by Intact America’s booth every year for the last three years, says he doesn’t support circumcision, but then added, “Even if you know you’re doing something wrong… you have to because of the financial support.”

Four cereal;: FOLLOW UP ON MY CIRCUMCISION POST

teapot-:

Let me give you some background. My family and I were having a discussion on the pros and cons of circumcision and I brought it up as a pro. They then proceeded to tell me I’m wrong (I quote “No, you’re wrong, you made that up”) and that circumcision makes absolutely zero difference in terms of…

I don’t think there’s anything wrong with discussing the potential benefits of circumcision from a scientific point of view, so it’s a shame that you caught flak for it. You didn’t discuss circumcision of children specifically (as opposed to voluntary adult circumcision), which is where the topic becomes controversial. It’s also slightly curious to encounter a family where an older generation opposes the practice more than the younger, since it’s usually the other way around.

The issue that I have with researching circumcision in hopes of finding health benefits is that it’s happening within a problematic cultural context. I don’t think we, as a society, relate to circumcision in a rational way. I think we’d rather continue circumcising for very subjective reasons, and that we’re only too happy to look for additional justifications. An example that I have to offer to illustrate this view is a hypothetical situation where a parent is offered an unspecified pediatric surgery with the same theoretical HIV prevention benefits as circumcision. I feel that the overwhelming majority of parents would defer the surgery because of concerns over surgical trauma and risks, and the reality that their child isn’t yet at risk for STIs. “We’ll take a rain check,” or “We’ll cross that bridge when we get there,” are the type of response that I would expect to see.

On a concrete level, I doubt that the potential benefit of partial HIV immunity justifies the risks and cons of circumcising children in places like the United States. Just as you said, biomedical advances offers us a constantly improving knowledge of health and sexuality, which includes the damage and harm caused by circumcision. In 1996 we learned about the high degree of innervation and specialization within the tissue destroyed by circumcision. In 2007 we found out about the extent of relative sensitivity loss attributed to circumcision. Last year we learned more about the subjective negative impact on the sex lives of circumcised males and their partners. As you’re probably aware, there is also growing ethical concerns within medical and legal communities, as well as among the general public. On the flip side, the limited HIV protection offered by circumcision present diminishing benefits to children (in a population such as the United States’) who won’t be at risk for another ~15 years.

Two more men allegedly cured of HIV

gaywrites:

Two more men seem to have been cured of HIV through bone marrow transplants, according to news out of the International AIDS Conference. 

This is in addition to Timothy Brown, who earlier underwent similar treatment that seemed to have removed HIV from his body. Researchers are preparing to study other HIV-positive people who have undergone bone marrow transplants to look for similar results. 

The two men who were being treated at Brigham and Women’s Hospital in Boston for cases of cancer at different times. One of the men is in his 20s and was infected at birth, while the other man is in his 50s, and has been infected with HIV since the early 1980s. After each receiving bone marrow transplants, the men also remained on their antiretroviral medication regimens, according to NBC News. 

Within eight months of their respective transplant surgeries, it was discovered that the patients’ cells were replaced by cells from the HIV-negative bone marrow donors. The men also now show no signs of HIV in their DNA or RNA. Levels of HIV antibodies have also decreased. 

Amazing. 

That the relationship between circumcision and transmission of HIV is at the very least unclear is illustrated by the fact that the US combines a high prevalence of STDs and HIV infections with a high percentage of
routine circumcisions.15 The Dutch situation is precisely the reverse: a low prevalence of HIV/AIDS combined with a relatively low number of circumcisions.

I’ve been reading a decent amount of scholarly information on circumcision later, so I thought I might as well start dropping in some interesting tidbits. This one is from <http://knmg.artsennet.nl/Publicaties/KNMGpublicatie/Nontherapeutic-circumcision-of-male-minors-2010.htm>.

There may be a case that male circumcision reduces HIV risk in sexually active adults, but the decision about whether to have this procedure should be left until the person is old enough to make his own informed healthcare choices.

Dr. Geoff Hinchley via (CMAJ)

Circumcision Propaganda Exposed by 14 year old boy

restoringtally:

A 14 year old boy researched circumcision for a school assignment. He learned that circumcision cuts nerve endings and results in a reduction of pleasure. His research points out that the propaganda for the African circumcision campaign does not make full disclosure of the effects of circumcision. As many studies have shown, male circumcision removes erogenous tissue and often results in a noticeable reduction of sexual pleasure.

What impressed me about this letter, is the author’s ability to think critically and analytically, even despite discouragement from the teacher. I think this quote really sums up the matter:

I plead with those who are campaigning for circumcision to tell us both the advantages and disadvantages. It is our right to know about these things before we make a decision.”

This is a really expressive drawing, but the 300 deaths number seems a bit exaggerated. Generally speaking, I feel that it&#8217;s important to make accurate, realistic claims, especially when the core arguments against circumcision are already compelling enough.

This is a really expressive drawing, but the 300 deaths number seems a bit exaggerated. Generally speaking, I feel that it’s important to make accurate, realistic claims, especially when the core arguments against circumcision are already compelling enough.

As discussed in Chapter 12, male circumcision is considered to have a protective effect for HIV infection, in part because of physiological differences that increase the susceptibility to HIV infection among uncircumcised men. As Table 14.10 shows, the relationship between HIV prevalence and circumcision status is not in the expected direction. Circumcised men have a slightly higher HIV infection rate than men who are not circumcised (22 percent compared with 20 percent).

Swaziland Demographic and Health Survey, 2006-2007 

Intact America petition to WHO and UNAIDS

I am not endorsing this petition 100% because I have only a basic understanding of how circumcision might affect HIV transmission. I am also cognizant of the fact that in places where the infection rate is as high as a quarter of the population, the imperative to curtail the spread of the disease may trump all other considerations.

At the same time, it does seem like the science behind circumcision and HIV epidemiology is incomplete and politicized. I am concerned that the other side of the discussion (effects on sexual experience, including perceived risk/reward balance) are not fully presented, which is why I am signing the petition. 

restoringtally:

Intact News: WHO recommends intact for men who have sex with men and transgender people
World Health Organization guideline Prevention and treatment of HIV and other sexually transmitted infections among men who have sex with men and transgender people was recently published. Pages 32 on in the WHO Guidelines recommend intact over circumcised, citing a lack of  evidence for male circumcision preventing HIV and STI acquisition in MSM  and transgender people. Current research in this area is of a  “very  low quality,” and there is a lack of research for MSM practicing  insertive versus receptive anal intercourse.

restoringtally:

Intact News: WHO recommends intact for men who have sex with men and transgender people

World Health Organization guideline Prevention and treatment of HIV and other sexually transmitted infections among men who have sex with men and transgender people was recently published. Pages 32 on in the WHO Guidelines recommend intact over circumcised, citing a lack of evidence for male circumcision preventing HIV and STI acquisition in MSM and transgender people. Current research in this area is of a  “very low quality,” and there is a lack of research for MSM practicing insertive versus receptive anal intercourse.

It is extremely offensive for someone to say it is ethical to cut off a normal part of my penis without my consent because they think I am too stupid or too irresponsible or too lazy to practice safe sex," he said. "Whether you are circumcised or not, you always need to use a condom when you have sex outside of a long-term relationship, so why cut off a part of your penis that feels good?

Jeff Brown, proponent of SF circumcision ban.

(Source: edgeboston.com)