In deference to Jack riddler who posted it in another thread.
(from an earlier thread just like this one)
The "cleanliness" propaganda is a perennial in justifying this involuntary mutilation of infants, and it really angers me. Because in my case, and in the case of the majority of American males thus mutilated, the religious mythology played no role. Our parents were duped by the health propaganda.
Want to cut down on infections? Teach males from an early age about how they should keep their penis clean. A few years later, teach them about condoms.
But just as we would not tolerate a health junta that preemptively removed everyone's highly dangerous and apparently useless appendix, or (in some future) that neutralizes the brain sections most likely to cause people to commit violence, so too can it not be justified in ethical or logical terms to practice foreskin amputation as a preventive health measure. This is rightly a question of one's freedom, one's right to maintain one's body as nature bestowed it, and thus the question is legitimately left to young adults to decide.
On the last go-around on DU with the issue of involuntary infant foreskin amputation, there was talk of the study held in by Auvert et al. on South African men who were paid to be the guinea pigs. This study's conclusions that circumcision will serve to prevent AIDS made waves around the world, and were picked up uncritically by prominent cheerleaders like Bill Clinton. However, these conclusions may be deconstructed as wishful at best, merely by reading it carefully.
Here we go:
Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: The ANRS 1265 Trial
Bertran Auvert1,2,3,4*, Dirk Taljaard5, Emmanuel Lagarde2,4, Joëlle Sobngwi-Tambekou2, Rémi Sitta2,4, Adrian Puren6
1 Hôpital Ambroise-Paré, Assitance Publique—Hôpitaux de Paris, Boulogne, France, 2 INSERM U 687, Saint-Maurice, France, 3 University Versailles Saint-Quentin, Versailles, France, 4 IFR 69, Villejuif, France, 5 Progressus, Johannesburg, South Africa, 6 National Institute for Communicable Disease, Johannesburg, South Africa
Background
Observational studies suggest that male circumcision may provide protection against HIV-1 infection. A randomized, controlled intervention trial was conducted in a general population of South Africa to test this hypothesis.
Methods and Findings
A total of 3,274 uncircumcised men, aged 18–24 y, were randomized to a control or an intervention group with follow-up visits at months 3, 12, and 21. Male circumcision was offered to the intervention group immediately after randomization and to the control group at the end of the follow-up. The grouped censored data were analyzed in intention-to-treat, univariate and multivariate, analyses, using piecewise exponential, proportional hazards models. Rate ratios (RR) of HIV incidence were determined with 95% CI. Protection against HIV infection was calculated as 1 - RR. The trial was stopped at the interim analysis, and the mean (interquartile range) follow-up was 18.1 mo (13.0–21.0) when the data were analyzed. There were 20 HIV infections (incidence rate = 0.85 per 100 person-years) in the intervention group and 49 (2.1 per 100 person-years) in the control group, corresponding to an RR of 0.40 (95% CI: 0.24%–0.68%; p < 0.001). This RR corresponds to a protection of 60% (95% CI: 32%–76%). When controlling for behavioural factors, including sexual behaviour that increased slightly in the intervention group, condom use, and health-seeking behaviour, the protection was of 61% (95% CI: 34%–77%).
Conclusion
Male circumcision provides a degree of protection against acquiring HIV infection, equivalent to what a vaccine of high efficacy would have achieved. Male circumcision may provide an important way of reducing the spread of HIV infection in sub-Saharan Africa. (Preliminary and partial results were presented at the International AIDS Society 2005 Conference, on 26 July 2005, in Rio de Janeiro, Brazil.)
Competing Interests: The authors have declared that no competing interests exist.
Academic Editor: Steven Deeks, San Francisco General Hospital, San Francisco, California, United States of America.
Citation: Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, et al. (2005) Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: The ANRS 1265 Trial. PLoS Med 2(11): e298 doi:10.1371/journal.pmed.0020298
Received: June 29, 2005; Accepted: September 26, 2005; Published: October 25, 2005
Full article here:
http://medicine.plosjournals.org/perlserv/?request=get-...Emphasis above (bold) mine: Study was suspended at interim stage because the doctors chose to declare victory and offer circumcision to the control group. What's interesting is that in the earlier study by Bailey et al., the difference in infection rates between control and intervention groups tended to converge the longer the study went.
In assessing any such study we must consider both the set-up of the study and the selection process for the control and intervention groups, about which the study presents quite a bit of obfuscation, as we shall see.
The selection mechanisms of the two groups are given their most exhaustive summary in the following flowchart:
The key piece of information otherwise is surely this: "During the study, 20 and 49 participants acquired HIV infection in the intervention and control groups, respectively, corresponding to incidence rates (95% CI) of 0.85 per 100 py (0.55–1.32) and 2.1 per 100 py (1.6–2.8) in the intervention and control groups, respectively."
While the 20 and 49 are presumably hard figures for the numbers who tested HIV+ (what's the false positive rate again?), the 0.85 and 2.1 per annum figures and high-low ranges for the rates are interpretative statistics. 1.34 percent of the “intervention group” ultimately test positive, as opposed to 3 percent of the control group.
So, what do we know about this study, just from what its authors present?
Six authors come together to conduct the study. It required an unspecified number of staff, including other doctors, nurses and lab personnel. It ran for two years. That's substantial funding and time, so let's not pretend there was no pressure felt to come up with results that were conclusive.
They recruited 3,483 South African men. "The recruitment of participants took place in the general population from July 2002 to February 2004." Recruitment within an impoverished population was at least partly induced by payment: "The participants received a total of 300 South African Rand as compensation (1 South African Rand ~ 0.12 Euro)." The doctors randomized the men into two groups. They excluded 146 from the study who tested HIV+ (although this group still came in for the followups). Thus they created a control group of 1598 and an intervention group of 1493.
What came next was surely the most dramatic moment in the study. To the men in the "intervention group," the doctors offered the option of having the foreskin amputated. (Thus this is hardly a double-blind study!) The study notes that participants were "informed that the impact of MC on the acquisition of sexually transmitted infections (STIs), including HIV, is not known." But we can imagine how many of them believed it must be a good bet, otherwise one might logically think the study would not be held.
On the other hand, one may legitimately doubt the men were told the simple fact that the foreskin carries one-half of the skin surface and one-half of all the nerve endings in the penis.
What other persuasive means may have been applied is unclear, but 1339 men accepted the procedure. (Ninety-three did not, but seem to still be counted in the "intervention group," and their number rises to 96 at a later stage; this probably has to do with some of the missing coming back, rather than magical foreskin regeneration. No accounting is given for why the control and “intervention” groups seem to each be contaminated with men who should be placed in the other group.)
This is a serious commitment on the part of the experimenters. They haven't just located groups of amputated and unamputated; they have in fact carried out a massive amputation action just to get their experiment going. Implicitly, the doctors already believe in the high likelihood of the benefits of circumcision, or are themselves likely to pick up such a belief in the process of carrying out an act of social engineering on a mass scale. If they don't find some benefit to circumcision, then they may have persuaded 1339 men to have their foreskins cut off at great pain and for no benefit.
Furthermore, the write-up gives little consideration to the psychological impact that the amputation may have had on the recipients. Obviously they would have felt pain for a few days and then the strange sensation of not having the foreskin would persist for weeks or months. Might this experience have affected their behavior, including their sexual behavior, compared to the control group, including in subtle ways that aren't measured by survey-type questions?
Participants were asked about their sexual behaviors at the follow-ups, but the study fails to provide breakdowns of the hard figures by group (e.g., for incidence categorized by the number of sexual partners in control and intervention groups), except for a vague statement that sexual activity was slightly higher in the intervention group. "When controlling for behavioural factors, including sexual behaviour that increased slightly in the intervention group, condom use, and health-seeking behaviour, the protection was of 61% (95% CI: 34%–77%)."
Accordingly the table compiling information on sexual and other behaviors fails to break down figures into control and "intervention" groups:
http://medicine.plosjournals.org/perlserv/?request=slid... Right at the bottom of this chart, however, we have the interesting information that 21 out of the 69 HIV+ cases found in both groups (30 percent!) "attended a clinic for a health problem with the genitals" in the 12 months before the point at which they were found to be HIV+, as opposed to only 276 out of 4575 (6%) of those who remained negative.
Now this is a study of the effects of a procedure conducted on the genitals. Furthermore, having a different infection or other "problem with the genitals" is known as a huge factor in HIV transmission, as the study itself notes. So you would think the study has an interest in knowing how the genital procedure it is testing works out in preventing a "problem with the genitals," as a likely contributing factor to preventing HIV infection.
Given the poverty and relatively low health-coverage in South Africa, we can also assume the number of those who had a problem but did not visit a clinic for it was higher. This could be the most important factor in explaining the incidence of HIV+ among men in the test, regardless of circumcision, and for this reason I can't think of a more important stat to see broken down by control and "intervention" groups. This breakdown is missing, however.
Various numbers of men go missing from both groups at the follow-ups, anywhere from 40 to more than 100 at each stage, and 16 are found to have died (the causes are unspecified and said to be unrelated to HIV or to "MC," although we are told the missing were generally visited at home to inquire as to why they weren't showing up).
"Even though some participants were lost during the follow-up, and the loss to follow-up rate was greater than the event rate, the impact of missing participants on the overall results of this study is likely to be small..." (emphasis mine). Honestly, do you expect them to ever say otherwise? They continue: "not only because the loss to follow-up was small for a cohort study conducted in a general population, but also because those who were late for at least one follow-up visit were protected by MC just as the other participants. The reason for this loss to follow-up was a result of participants moving from the area or being unreachable, and not a result of HIV infection." (In the case of unreachable, how does one know the true reason?!)
Finally, by the time of the follow-up at 21 months, the doctors had found a total of 20 men testing HIV+ positive at one of the follow-ups in the "intervention group," and 49 men in the control group. Once again, it is unclear to me how those who were circumcised in the control group and those who remained uncurcumcised in the "intervention group" were accounted for in all this - maybe I'm missing something and other readers can figure that out.
Rather than continuing the study past the two-year window, these results were judged as so dramatic that victory could be declared immediately. So dramatic, in fact, that it was apparently thought unethical not to try to persuade the control group to also have their foreskins amputated right away: "The Data and Safety Monitoring Board advised the investigators to interrupt the trial and offer circumcision to the control group, who were then asked to come to the investigation centre, where MC was advised and proposed."
The doctors presumably started writing up new grant applications not long after. (I wonder how their funding was looking at the point of suspension? Releasing the accounting books of funded studies should be a requirement for peer review, it occurs to me.)
Interesting is the discussion at the end of how amputation might help reduce infection rates:
"The reasons for this protective effect of MC on HIV acquisition have to be found elsewhere, and several direct or indirect factors may explain this <25>. Direct factors may be keratinization of the glans when not protected by the foreskin, short drying after sexual contact, reducing the life expectancy of HIV on the penis after sexual contact with an HIV-positive partner, reduction of the total surface of the skin of the penis, and reduction of target cells, which are numerous on the foreskin <26>."
Reading that, one wonders, why the rush to amputate? Why was there was no study proposed first to determine the benefits of washing and drying the foreskin soon after sex, which should achieve almost all of these same effects, other than "keratinization of the glans"? (*see below)
"Indirect factors may be a reduction in acquisition of other STIs, which in turn will reduce the acquisition of HIV."
This makes the failure to break down by control and intervention group those HIV+ participants who visited a clinic due to problems with their genitals all the more curious.
"Our study does not allow for identification of the mechanism(s) of the protective effect of MC on HIV acquisition."
But despite this admission of so much that is still unknown, there should be no doubt that the study has discovered something important and urgent, as the sentence immediately following argues:
"The first and obvious consequence of this study is that MC should be recognized as an important means to reduce the risk of males becoming infected by HIV. As shown by our study, MC is useful and feasible even among sexually experienced men living in an area with high HIV prevalence."
Furthermore, those reporting on the study (as in the cheerleading newspaper articles) seriously raise the idea that every uncurcumcised male in the world should have their foreskin amputated to reduce the spread of HIV, even in countries like the United States where the incidence of male-to-female/female-to-male transmission (i.e. predominantly vaginal, as opposed to anal penetration) approaches zero.
Now it is true that HIV transmission in Africa seems to more frequently result from male-female sex than it does in the West, based on the far less complete numbers available for African populations, implying a higher rate of vaginal transmission in Africa.
Therefore I'm curious why the doctors who ran this study and their funders chose to center on the relative lower rates of male genital mutilation in Africa than in the West as an important factor, rather than first considering the higher rates of female genital mutilation - which is known to increase susceptibility to infections? South Africa has banned FGM but does not report on possible rates of the practice, which are no doubt lower than in Muslim African countries.
Thus, finally, the choice of question in the first place reproduces the biases of Western culture and Western religions with regard to male as opposed to female genital mutilation. The crime of female genital mutilation is rightly considered barbaric but generally ignored; even as concerns about male foreskin amputation are dismissed because it is "hygienic" (regardless of evidence) and "traditional." This is obvious in the language employed by the study. Foreskin amputation - which would be an accurate clinical term - is reduced not just to male circumcision but "MC," providing an abbreviation that renders the operation generic, neutral, "scientific."
And an act of mass social engineering involving the irreversible removal of part of one's body (and all based on a hypothesis) is covered by the term, "intervention group" with its implications that something was wrong with having a foreskin, before the Western-funded team arrived to intervene.
Do you know of a study to determine a possible link between female genital mutilation and HIV incidence? In a brief search I was unable to find anything large-scale and Western-funded, like the Auvert study in South Africa, but a few surveys indicate it needs to be taken very seriously. This is where the money would have been better spent!
Check out this article:
http://allafrica.com/stories/200711160852.html Tanzania: The Link Between Female Genital Mutilation And HIV Transmission
Arusha Times (Arusha)
ANALYSIS
17 November 2007
Posted to the web 16 November 2007
Mary Katherine Keown
Arusha
Researchers and activists are linking the feminization of HIV-AIDS in sub-Saharan Africa with another major health affliction for women in the region: female genital mutilation.
Sporadic research data over the past 10 years has correlated dirty cutting equipment, hemorrhages requiring blood transfusions, and injurious sexual intercourse causing vaginal tearing and lesions with rising rates of HIV transmission among women in countries where female genital mutilation (FGM) is still widely practiced.
"Because FGM is coupled with the loss of blood and use is often made of one instrument for a number of operations, the risk of HIV-AIDS transmission is increased by the practice," the New York-based United Nations Population Fund says on its website. "Also, due to damage to the female sexual organs, sexual intercourse can result in lacerations of tissues, which greatly increases risk of transmission. The same is true for childbirth and subsequent loss of blood."
Other organizations, such as the London-based International Community of Women Living With HIV-AIDS and the Washington-based Global Health Council, make similar assertions on the immediate risks of HIV transmission and anti-FGM activists in the region express confidence in the link.
A representative from the Network against Female Genital Mutilation in Moshi believes there is a link between FGM and HIV transmission, and a delegate from the National Union of Djiboutian Women - who asked to remain anonymous - says she believes FGM is the single largest contributing factor to HIV infection in that country, with risks that are immediate, as well as long-term.
Meanwhile, a cross-section of data drawn from a 2006 United Nations report on the global AIDS epidemic, for instance, shows that in several countries in Africa where FGM is common-including Somalia, Sudan, Tanzania and Djibouti-between 55 and 60 per cent of HIV-infected individuals are female.
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* "keratinization of the glans" - also a euphemism, albeit in clinical terms, referring to the tendency of protein to build up over the scar tissue after amputation, further dulling sensation.
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To those fighting the widespread practice of female genital mutilation:
Please don't succumb to divide and conquer. You are absolutely right if you say the clitoral and labial amputations perpetrated on females are incomparably more damaging than the amputation of the male foreskin. It's one of the worst horrors on this planet. But it should not be used as a counterpoint in the propganda to trivialize the practice of foreskin amputation.
.
http://www.bmj.com/cgi/content/full/331/7519/781 In the Auvert study doctors tracked black men while they became infected with HIV. Apparently, the participants were not given or allowed to use condoms because this would have disturbed the experiment. This is reminiscent of the infamous Tuske-gee syphilis study, in which newly discovered penicillin was withheld so that the study could continue.4
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Here's a devastating observation:
http://forum.fathermag.com/circ/106/forum/messages/2552... Bailey was responding to concerns that the circumcised men would not use condoms. In Bailey´s letter, he shares that the intervention group (the circumcised men) reported condom use up from 22% to 36% over the baseline (control) group.(§) That is the exact increase to gain a 61% protective factor. This indicates that the men´s circumcisions played no part in the lower infection rate but instead, the condoms were the protective factor. In the later studies that reported 48% and 52% protective factors, it would indicate that circumcision actually increased the men´s susceptibility to HIV/AIDS.
Additionally, the circumcised group reported that they had reduced their number of sexual partners. The percentage of men with more than two sexual partners decreased from 42% to 33%. This would put them at less risk of contracting HIV/AIDS.
This new information turns the studies completely upside down and appear to strongly suggest that the circumcised men were substantially more likely to contract HIV/AIDS.
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