Because Sometimes More is More
(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.
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>.
Dr. Geoff Hinchley via (CMAJ)
Swaziland Demographic and Health Survey, 2006-2007
Jeff Brown, proponent of SF circumcision ban.