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EDUCATION AND DEBATE: Robert Szabo and Roger V Short How does male circumcision protect against HIV infection? BMJ 2000; 320: 1592-1594 [Full text]

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One-sided picture

Dennis Harrison   (9 June 2000)

Read this paper

James Gregory   (9 June 2000)

Implications for adults, rather than infants

Name and address removed   (9 June 2000)

Irresponsible and misleading

Christopher Price   (10 June 2000)

Writer seriously questions HIV study recommendations

John Sawkey   (10 June 2000)

Data not enough

L G Shah   (11 June 2000)

Acculturation vs. medical indoctrination

Theron L Gibbons   (11 June 2000)

Misuse of the Medical Circumcision Literature: Psychological Factors

George Hill   (11 June 2000)

Another silly article probably written on April's fool day

Jacqueline Maire   (11 June 2000)

Re: One-sided picture

Guy Cox   (11 June 2000)

What has happened to peer review?

David J Wilson   (12 June 2000)

Infant Circumcision not Warranted by Study

Lawrence Barichello   (12 June 2000)

Nothing new under the sun

Pierre Delaurent   (12 June 2000)

Re: Re: One-sided picture

Dennis Harrison   (12 June 2000)

One-third were already infected

Hugh Young   (12 June 2000)

CIRCUMCISION OF CHILDREN: CRIMINAL ASSAULT

G Boyle   (12 June 2000)

Re: Re: One-sided picture

David Wilson   (12 June 2000)

Re: Re: One-sided picture

Gary L Harryman   (12 June 2000)

Circumcision: Not The Way To Prevent AIDS

Tony Shale   (13 June 2000)

More of the One-sided picture

Guy Cox   (13 June 2000)

Re: More of the One-sided picture

David Wilson   (13 June 2000)

Re: More of the One-sided picture

Steve Wilder   (14 June 2000)

Re: More of the One-sided picture

Dennis Harrison   (14 June 2000)

Re: More of the One-sided picture

Gary L Harryman   (14 June 2000)

Circumcision Complication Rate

Erick L Gustavson   (14 June 2000)

Why wait till puberty?

John Smith   (14 June 2000)

Re: More of the One-sided picture

John Antonopoulos   (15 June 2000)

Re: Solidarity with Victoria

Brian Morgan   (16 June 2000)

Down under = below the belt

Jacqueline Sonnendrücker   (17 June 2000)

To the circumcisers of all backgrounds, religions, colours and creeds.

Julie Filliatre   (17 June 2000)

Penis epithelium

Peter Morrell   (18 June 2000)

A superstitious rite

John Dalton   (18 June 2000)

Solidarity with Victoria

Rio Cruz   (19 June 2000)

Dangerous Recommendation

Amber Craig   (19 June 2000)

Prepuce:Anatomy and Functions

Rio Cruz   (20 June 2000)

Mass Circumcision: Crime Against Humanity?

Jerry Warner   (21 June 2000)

The Ghosts of Abraham Wolbarst and Aaron Fink

George Hill   (22 June 2000)

Questions

M van der Veer   (25 June 2000)

Study of FGM and AIDS

Brian A Waldman   (26 June 2000)

A Procrustian Solution

Jerad Lee   (26 June 2000)

An Anonymous Missive

M van der Veer   (3 July 2000)

Circumcisers: Penis Paracites

Eileen Marie Wayne   (10 July 2000)

ETHICAL IMPLICATIONS OF MALE CIRCUMCISION AND HIV IN DEVELOPING NATIONS

Adrian Viens   (11 July 2000)

Ethical Nightmare

Sadira Bolt   (17 July 2000)

A little bit of science wouldn't have gone amiss

Robert S Van Howe   (19 July 2000)

Warped!

Kevin Elks   (22 July 2000)

Male circumcision and protection against HIV infection.

R T D Oliver   (22 August 2000)

Not all male circumcisions are the same.

Judith E Brown   (4 January 2001)

Cultural imperialism should be recognised for what it is

John D Dalton   (28 May 2001)

Safe Circumcisions in Africa ? When ?

Jean-Jacques, A. GUILBERT   (30 April 2007)

One-sided picture 9 June 2000
Dennis Harrison, Concerned citizen Vancouver, British Columbia Send response to journal: Re: One-sided picture	Szabo and Short present a one-sided picture of circumcision. In stating that male circumcision protects against sexually transmitted diseases such as syphilis and gonorrhoea, the authors are ignoring substantial evidence to the contrary. Laumann et al. concluded on the basis of a nationally representative probability sample that "circumcision provides no discernible prophylactic benefit and may in fact increase the likelihood of STD contraction."(1) Similarly, when the authors assert that neonatal circumcision has a low incidence of complications, they seem to be disregarding studies that have found complication rates of 2 to 10 percent(2) and 55 percent.(3) Griffiths et al. found that childhood circumcision "has an appreciable morbidity."(4) References: 1. Laumann EO, Masi CM, Zuckerman EW. Circumcision in the United States: Prevalence, Prophylactic Effects, and Sexual Practice. JAMA 1997;277:1052-1057. 2. Williams N, Kapila L. Complications of Circumcision. Brit J Surg 1993;80:1231-1236. 3. Patel H. The problem of routine infant circumcision. Can Med Assoc J 1966;95:576-581. 4. Griffiths DM, Atwell JD,Freeman NV. A prospective survey of the indications and morbidity of circumcision in children. European Urology 1985;11:184-7.
Read this paper 9 June 2000
James Gregory Send response to journal: Re: Read this paper	http://www.cirp.org/library/disease/HIV/vanhowe4/ Circumcision and HIV infection: review of the literature and meta-analysis R. S. Van Howe MD FAAP Department of Pediatrics, Marshfield Clinic, Lakeland Center, USA "Summary: Thirty-five articles and a number of abstracts have been published in the medical literature looking at the relationship between male circumcision and HIV infection. Study designs have included geographical analysis, studies of high risk patients, partner studies and random population surveys. Most of the studies have been conducted in Africa. A meta-analysis was performed on the 29 published articles where data were available. When the raw data are combined, a man with a circumcised penis is at greater risk of acquiring and transmitting HIV than a man with a non-circumcised penis (odds ratio (OR)=1.06, 95% confidence interval (CI)=1.01-1.12). Based on the studies published to date, recommending routine circumcision as a prophylactic measure to prevent HIV infection in Africa, or elsewhere, is scientifically unfounded." In the developed world (1) the USA has one of the highest circumcision rates and the highest HIV rates and (2) the Scandinavian coutries have the lowest circumcision rates and the lowst HIV rates. Circumcision is still a procedure in search of validation.
Implications for adults, rather than infants 9 June 2000
Name and address removed, on author's request on 25 September 2008 Send response to journal: Re: Implications for adults, rather than infants	This article fails to point out that the implications discussed are for adults, not infants. While this may seem obvious to some, it will be overlooked by others. Male infant circumcision is a human rights violation in most parts of the world, however, adults can choose to have preventive amputations based on risk factors (ie, mastectomy). As no infant is at-risk for developing HIV through intercourse, the relevance of these findings is limited to adults, and should be clearly stated as such.
Irresponsible and misleading 10 June 2000
Christopher Price, Writer Self-employed Send response to journal: Re: 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.
Writer seriously questions HIV study recommendations 10 June 2000
John Sawkey, Retired teacher/principal . Currently a writer. Home Send response to journal: Re: Writer seriously questions HIV study recommendations	I would like to comment on the article "How does male circumcision protect against HIV infection?" by Robert Szabo and Roger V. Short. I find the conclusions reached by these Australian researchers incredible. It is difficult to believe that intelligent individuals would reach such preposterous conclusions that mass circumcisions would eliminate or prevent a variety of diseases including the spread of the HIV virus. It is clearly another study designed to promote and legitimize circumcision. It is an attempt to save the albatross of which so many males have become victims over the decades. The practice of circumcision is rapidly declining and falling into disrepute. The end of this dehumanizing and barbaric practice is long overdue. One can only conclude that the study is a catharsis providing the authors with a means to vindicate their own circumcision. Intact males do not have the need to validate their wholeness. Perhaps the authors of the study would state why they did not carry out their study in the USA or Israel where the majority of men are circumcised. Why didn't they research why circumcision has not prevented the spread of AIDS in these two countries? And if it did, how great an effect did it have? Recently, the Center for Disease Control in Atlanta stated that the USA had the greatest rate of increase and most rapid spread of AIDS in the developed nations, surpassing many European countries where circumcision rates are only a fraction of what they are in the USA. Several studies in the state of New York and a recent study done by the University of Chicago found no correlation between the spread of AIDS and circumcision. Several years ago, an Israeli newspaper reported that a hooker spread AIDS to thousands of men, in Israel where most men are circumcised. Circumcision should have prevented large numbers of these men from getting the AIDS virus, as we are told by the Australian researchers. Perhaps the researchers would explain why circumcision hasn't prevented the spread of AIDS in Israel, if circumcision is such an important factor, as we are lead to believe? Would not warning males to take precautionary measures be more effective and logical? Do Robert Szabo and Roger Short really believe that millions of males should be circumcised and lose vital erogenous tissue in order to prevent a few cases of AIDS? Are they suggesting that all teenage or adult males will be promiscuous, become drug users or engage in practices which may put them at risk of contacting AIDS? Males who engage in practices which put them at risk - in whatever situation - are aware of the risks that they are taking. If they are not, would not logic dictate that an effective education program is more desireable than mass amputations? We are plagued by studies which seek to legitimize circumcision. For years we were told that circumcision would prevent prostate cancer. Today it is the second leading cause of death in Canada and the USA. Circumcision would prevent penile cancer, we were told. Today statistics in the USA have shown that penile cancer is an age related disease and is also found in circumcised men even though they were circumcised as infants. Urinary tract infections are deadly for males, but easily treated in females. These are just a few examples of scare tactics used to persuade parents into circumcising their sons. All very convincing - but none of them legitimate. For more than a century males have become victims of a practice for which there were plenty of excuses - but no valid medical reasons. It is not circumcision which needs to be studied, but rather the advocates of circumcision and why their desire to mutilate another's genitals never ceases. We live in a civilized and democratic society where most of us have the intelligence to decide what is in our own best interests. If we decide to engage in practices which may put our lives at risk - so be it . How many decisions are these researchers prepared to make on our behalf? How many body parts need to be amputated? We do not need some totalitarian grand daddy researchers making decisions for us. In a democracy each individual has the right to choose what he wants to do with his/her own body, not Robert Szabo nor Roger Short. Sincerely, John Sawkey Box 578, Yorkton, Saskatchewan Canada S3N 2W7 John Sawkey is a retired teacher/ principal.
Data not enough 11 June 2000
L G Shah, Primary Care Physician India Send response to journal: Re: Data not enough	Dear Sir, The conclusion is hasty. What needs to be done is study of incidence in large population eg. muslim community in Indian Subcontinent. Here neonatal and 1st year of life circumcision is almost compulsory for followers of Islam. Regarding sexually transmitted disease, one does see enough incidence in circumcised men. Therefore more data is needed. Thanks. No conflict of interest.
Acculturation vs. medical indoctrination 11 June 2000
Theron L Gibbons, Head Writer Elucid Press Send response to journal: Re: Acculturation vs. medical indoctrination	This article does not take into consideration international statistics regarding HIV transmission and cultural behaviors. Nobody seems to like to admit it in the medical community, but monogomy is still the best protection against all forms of sexually transmitted diseases, including HIV. The penis is as much a transmission point for disease as is the vagina. Separating the issue by gender and using surgery in place of education about behavioral choices is ludicrous. Examples that support this are culturally definable. The US has the highest circumcision rate, and the highest HIV growth rate of any country in the industrialized west. HIV is currently spreading quite quickly through our 50-70 year old generation, these people being of a group who are nearly 90 percent circumcised. In contrast, our high school youth, less of whom are being circumcised with each year that passes, are at a lower risk of contracting HIV than they have been in nearly a decade -- primarily because they are educated on disease prevention and are making safe personal decisions when engaged in sexual relations. In Eastern industrialized countries, a stronger support of culture vs cutting exists. Japan has an incredibly low incidence of HIV. They are as a nation uncircumcised, but as a culture support monogomous behavior. Thailand, another island culture that is uncircumcised, was sitting at around 85 percent of the population being HIV positive two years ago. They as a culture support sex from roughly the onset of puberty, multiple sex partners, and have a strong prositution market. In using a global view, one obvious corolary becomes apparent: Individual behavior and cultural attitudes about sex, and not the practice of circumcision, is the key to limiting the spread of HIV.
Misuse of the Medical Circumcision Literature: Psychological Factors 11 June 2000
George Hill, Retired Send response to journal: Re: Misuse of the Medical Circumcision Literature: Psychological Factors	To the Editor: Misuse of the Medical Circumcision Literature: Psychological Factors Male circumcision removes about 1/2 of the skin and mucosa from the penis.1 This lost skin is actually specialized mucosa that contains a concentration of erogenous nerve endings1 that provide sexual ecstasy to the owner of the foreskin when they are stimulated by sexual activity. Persons who have lost body parts to surgery must grieve the loss of their function.2 Men who have lost their prepuce to circumcision must grieve their loss of function and erogenous pleasure.3 Men who have failed to grieve their loss of sexual ecstasy usually are in denial of their loss. Men who are in denial of their loss use a variety of mental gymnastics to avoid feeling the pain of their loss. Male medical doctors who are circumcised are not immune from this phenonenon.4 Such medical doctors tend to misuse the medical literature to justify their loss.4 Goldman states: "Among physicians, support for circumcision has been based on supposed 'rational' factors, but as psychiatrist Wilhelm Reich wrote, 'Intellectual activity has often a structure and direction that it impresses one as an extremely clever apparatus precisely for the avoidance of facts, as an activity which distracts from reality'. This appears to have been the case in those advocating circumcision. Science has been adopted as the great arbiter between fact and fiction. This systematic approach to evaluating experience is of value, especially as research has shown that a surprising number of adults do not reason logically. The scientific method is designed to help protect the scientific community and the public against flawed reasoning, but it is the flawed reasoning of supposedly reputable scientific studies that has contributed to the confusion on the circumcision issue.4 "One reason that flawed studies are published is that science is affected by cultural values. A principal method of preserving cultural values is to disguise them as truths that are based on scientific research. This 'research' can then be used to support questionable and harmful cultural values such as circumcision. This explains the claimed medical 'benefits' of circumcision."4 Goldman concludes: "Defending circumcision requires minimizing or dismissing the harm and producing overstated medical claims about protection from future harm. The ongoing denial requires the acceptance of false beliefs and misunderstandings of facts. These psychological factors affect professionals, members of religious groups and parents involved in the practice. Cultural conformity is a major force perpetuating non-religious circumcision, and to a greater degree, religious circumcision. The avoidance of guilt and the reluctance to acknowledge the mistake and all that that implies help to explain the tenacity with which the practice is defended."4 There have been many claims made for circumcision through the more than a century of its medicalization.5 The benefit claimed is the disease most feared at the moment. In the 19th century when the cause of mental disease was unknown, circumcision was claimed to prevent mental illness which supposedly was caused by masturbation. At the time of the first World War, circumcision was claimed to protect against venereal disease. In the 1930-50 era, when cancer was the dread disease, claims were made that circumcision offered protection against cancer. All these claims have been disproved.6 Editors of medical journals seem to be unaware of the psychological impact of circumcision on medical doctors and frequently allow such articles written by circumcised male doctors 7-12 to slip through the peer review process. The opinion piece by Szabo and Short13 seems to be of this genre. It appears to be a psychological manifestation of the circumcised male.4 Turning to the merits of the work, Szabo and Short claim that most men are infected with HIV through the penis.13 However they offer no supporting citation. In reality, the path of entry of HIV has never been established. Dezzuti states that "the data suggest that the in vivo mucosal epithelial barrier protects against HIV transmission."14 Short and Szabo claim that keratinization of the glans penis in the circumcised male provides protection against HIV infection.13 This is a much repeated claim but there is no evidence to support it.6 This claim originated with a letter by a noted circumcisionist that was published in the New England Journal of Medicine in 1986.6,15 Short and Szabo suggest that the presence of Langerhans cells in the mucosa make it susceptible to penetration by HIV and that circumcision would remove the Langerhans cells and offer protection against HIV.13 Cold and Taylor, however, state that: "Circumcision has been justified by some because it removes the Langerhans' cells of the prepuce and therefore supposedly decreases the risk of HIV infections. This theory is flawed, as even after circumcision, there is residual penile mucosa of the glans, and there are Langerhans' cells in the penile shaft epidermis. Surgical removal of the Langerhans cells in all mucosa and skin to prevent infections is not feasible, nor rational. In addition, the aggressive circumcision campaign in the USA has not prevented sexually transmitted infections, including HIV. Therefore, Langerhans cells of the prepuce should be understood as normal mucosal immune cells, rather than a pathological entity requiring excision."16 While the entry path of the HIV has never been definitely established much attention has been focused on genital ulcer disease (GUD) which is caused by pre-existing STD, usually syphilis and chancroid, as probable points of entry.17 Female sex workers in Africa continue to ply their trade even with GUD.18 Short and Szabo propose that circumcision would somehow prevent GUD and stop HIV transmission. Circumcision cannot prevent or cure GUD. Nor can it stop the female sex workers from having sex with GUD. Only antibiotics can do this. Short and Szabo repeat the medical myth that the prepuce is prone to tearing during sexual intercourse.13 In reality in the intact complete non-circumcised male, the penile shaft moves within its sheath during sexual intercourse. The rolling/sliding lubricating action of the moist prepuce makes the intact non-circumcised penis much less susceptible to trauma such as tearing or abrasions.6,16 Lauman et al. report that 77% of U.S. born men are circumcised.19 This has not prevented the United States from having the highest incidence of STD infection amongst the industrial nations.20 In spite of the high incidence of male circumcision in the U.S., the incidence of HIV infection in the U.S. is more than 6 times that of the U.K.21 Two meta-analyses of the medical literature regarding HIV and male circumcision have been published.22,23 De Vincenzi and Mertens found that: "[the] major criticism of most of the studies preformed to date is the lack of attention given to potential confounding factors, which could be related to both circumcision status and risk of sexually transmitted infections, such as sexual behaviour or differences in hygienic practices, or differential use of specific health facilities….As the safety, expected benefits, feasibility and acceptability of mass circumcision are all questionable, neither public-health interventions nor intervention studies appear to be defensible options before there is stronger evidence from observational studies in different settings that show lack of male circumcision may be a genuinely independent risk factor for the transmission of HIV." Van Howe is even more emphatic. Van Howe conducted a statistical meta-analysis of all published data. Base on the published data, Van Howe concluded: "A meta-analysis was performed on the 29 published articles where data were available. When the raw data are combined, a man with a circumcised penis is at greater risk of acquiring and transmitting HIV than a man with a non-circumcised penis (odds ratio (OR)=1.06, 95% confidence interval (CI)=1.01-1.12). Based on the studies published to date, recommending routine circumcision as a prophylactic measure to prevent HIV infection in Africa, or elsewhere, is scientifically unfounded." " Recently, the African cultural practice of "dry sex" has been identified as a confounding factor in the study of HIV transmission.24 Nevertheless, not a single one of the more than 40 studies on which Short and Szabo13 rely control for this confounding factor. Short and Szabo propose child circumcision as an immediate step to prevent HIV infection.13 However, children are legally incompetent persons who are unable to grant consent for invasive surgical procedures.25 Male circumcision is a violation of the child's legal right to bodily integrity. Furthermore, lawyers note that, since minors are unable to grant consent for such a non-therapeutic amputation of healthy tissue, child circumcision is probably unlawful assault.26 Short and Szabo have made numerous errors of fact which suggests that they are more interested in promotion of circumcision than the advancement of medical science or the prevention of HIV infection. Promotion of circumcision as an alternative to safe sexual practices could easily create a false sense of security in the minds of circumcised men. Such behavior is irresponsible from a public health standpoint and should not be condoned. At the present time, the notion that circumcision can prevent the transmission of HIV remains an unproven hypothesis. Medical decisions should not be based on such dubious evidence. NOCIRC of Lousiana P. O. Box 88 Port Allen, Louisiana 70767-0088 USA E-mail to iconbuster{at}eatel.net References: 1 Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996;77:291-295. 2 Maguire P, Parks CM. Coping with loss: surgery and loss of body parts. BMJ 1998; 316(7137):1086-1088. 3 Denniston GC. An Epidemic of Circumcision. Paper presented at the Third International Symposium on Circumcision, University of Maryland, College Park, Maryland, May 22-­25, 1994. http://www.nocirc.org/symposia/third/denniston3.html 4 Goldman R. The psychological impact of circumcision. BJU International 1999; 83, Suppl. 1:93-102. / 5 Gollaher DL. From ritual to science: the medical transformation of circumcision in America. Journal of Social History 1994;28(1):5-36. 6 Fleiss P, Hodges F, Van Howe RS. Immunological functions of the human prepuce. Sex Trans Inf 1998;74:364-367. 7 Wiswell TE, Smith FR, Bass JW. Decreased incidence of urinary tract infections in circumcised male infants. Pediatrics 1985, 75: 901-903. 8 Schoen EJ. The status of circumcision of newborns. N Engl J Med 1990; 322: 1308-1311. 9 Schoen EJ. Is it time for Europe to reconsider newborn circumcision (letter)? Acta Paediatr Scand 1991;80;573-5. 10 Schoen EJ. Benefits of newborn circumcision: Is Europe ignoring medical evidence? Arch Dis Child 1997;77:358-60. 11 Moses S. Bailey RC, Ronald AR. Male circumcision: assessment of health benefits and risks. Sex Transm Infect 1998:74:368-73. 12 Halperin DT, Bailey RC. Male circumcision and HIV infection: 10 years and counting. Lancet 1999;354:1813. 13 Szabo R. Short RV. How does male circumcision protect against HIV infection? BMJ 2000,320:1592-94. 14 Dezzutti CS. Mechanisms of HIV Transmission through Epithelial Cell Barriers. 12th World AIDS Conference. Geneva, June/July 1998 [abstract 278/32124. 15 Fink AJ. A possible explanation for heterosexual male infections with AIDS. N Engl J Med 1986;315:1167. 16 Cold CJ, Taylor JR. The prepuce. BJU International 1999;83 Suppl. 1:34-44. 17 Pepin J, Quigley M, Todd J, et al. Association between HIV-2 infection and genital ulcer diseases among male sexually transmitted disease patients in The Gambia. AIDS 1992;6:489-493. 18 Kaul R, Kimani J, Nagelkerke NJ, et al. Risk factors for genital ulcerations in Kenyan sex workers. The role of human immunodeficiency virus type 1 infection. Sex Transm Dis 1997;24(7):387-92. 19 Laumann, EO, Masi CM, Zuckerman EW. Circumcision in the United States. JAMA 1997; 277(13):1052-1057. 20 Tanne JH. US has epidemic of sexually transmitted disease. BMJ 1998;317:1616. 21 World Health Organization. The Current Global Situation of the HIV/AIDS Pandemic. World Health Organization. Geneva: (3 July 1995). 22 de Vincenzi I, Mertens T. Male circumcision: a role in HIV prevention? AIDS 1994;8(2): 153-160. 23 Van Howe RS. Circumcision and HIV infection: review of the literature and meta-analysis. Int J STD AIDS 1999;10:8-16. 24 Baleta A. Concern voiced over "dry sex" practices in South Africa. The Lancet 1998;352:1292. / 25 Lynn E. Lebit. Compelled Medical Procedures Involving Minors and Incompetents and Misapplication of the Substituted Judgment Doctrine. Journal of Law and Health 1992;7:107-130 (1992). 26 Gregory J Boyle, J Steven Svoboda, Christopher P Price, J Neville Turner. Circumcision of Healthy Boys: Criminal Assault? J Law Med 2000; 7;301-310.
Another silly article probably written on April's fool day 11 June 2000
Jacqueline Maire, retired nurse, ETHIC (End The Horror of Infant Circumcision) Vancouver Send response to journal: Re: Another silly article probably written on April's fool day	Incredibly funny those Australians and no short (no pun intended) of ideas to get some publicity!!! Circumcision, a condom for life against AIDS ... Ha! Ha! Who is gullible enough to swallow that one? (again no pun intended). To verify this statement, let's all the intact white male population above the age of 25 get circumcised and live the life of promiscuity, at random, preferably in Africa. Then let's have some real statistic, based on facts. Cowardly attacking newborn to promote such an insane theory is nothing short (again no pun intended) of criminal. The clowns who promote and endorse these beliefs won't be around to verify their stories themselves ..., no more than the avid ablationists who promoted circumcision against kleptomania, tuberculosis, cancer, are here today to see how ridiculous they were. Meantime they make money Money MONEY. Show me one of those jerks (no pun intended) riding a bus, living in the poorest section of town, lining up at the food bank ... I tell you: circumcision is MONEY. The sad part ... those unfortunate babies who have no say in the matter, mutilated in their beautiful bodies by unscrupulous doctors with no respect for human rights. Shame to B.M.J. for printing such hogwash and make civilization take a back seat just because troubled scientists are making fun of babies and their parents. Parents should be aware that M.D. stands for Morally Disabled, more often than they care to know.
Re: One-sided picture 11 June 2000
Guy Cox, Senior Lecturer University of Sydney Send response to journal: Re: Re: One-sided picture	Your correspondent Harrison is effectively misquoting the excellent and thorough study carried out by H. Patel (CANADIAN MEDICAL ASSOCIATION JOURNAL,95: 576-581) in claiming that it reports a complication rate for infant circumcision of 55%. Patel's study recorded in detail the postoperative history of 100 infant circumcisions. I quote: "Slight bleeding, consisting mainly of oozing, occurred in 31 ..... In four there was moderate bleeding, sutures being necessary in one of them. .... In no case was bleeding so severe as to require a blood transfusion." Clearly the line at which 'complications' can be cited is flexible, but few would refer to postoperative oozing as a complication. Patel reported eight minor infections only one of which required antibiotic treatment. In only one case - secondary phimosis following inadequate removal of the prepuce complicated by postoperative infection - was further intervention needed. Hence we have one need for suturing, one antibiotic case, and one case requiring surgical intervention (the latter two may have been the same infant) - a complication rate of 2% or 3% by the criteria used in other studies. Patel also points out that no deaths occurred at Kingston General Hospital over a 10-year period from circumcisions of infants (6753 operations) or older children (589 operations). Thus infant circumcision remains a safe procedure. The risk of serious complications when it is carried out as a medical (rather than ritual) procedure remains almost too low to estimate. In Australia there were two deaths attributable to circumcision in the period 1960-66. (IOW Leitch, 1970. Circumcision, a continuing enigma. Australian Pediatric Journal, 6, 59-65). 840,000 boys were born in that time and if we (conservatively) assume a circumcision rate of 70% this translates to a death rate of one in 290,000 circumcisions. Over the same period 78 Australians died from carcinoma of the penis (Leitch, op cit.), a condition which affects only uncircumcised men. Assuming that at that time the Australian population contained 2.25 milion uncircumcised men (30% of a male population of 7.5 million) we find that the risk of death from penile carcinoma is 1 in 28,800 in a seven-year period or approximately 1 in 2,900 in a lifetime. Hence the risk of death, from cancer alone, in being uncircumcised is 100 times higher than the risk of death from being circumcised. While AIDS is making headlines at the moment, it is as well to remember that the prophylactic value of circumcision against penile carcinoma has been well known for at least 50 years.
What has happened to peer review? 12 June 2000
David J Wilson, Patent Agent Medlen & Carroll, LLP Send response to journal: Re: What has happened to peer review?	In response to Robert Szabo and Roger V Short's very skewed article "How does male circumcision protect against HIV infection?", one has to ask what has happened to peer review of articles and to the integrity of the publishing entity. Szabo and Short disregarded a substantial body of scientific evidence that throws into serious doubt their speculative conclusions. Unfortunately, this article has been picked up by press service organizations and has been disseminated as the medical establishment's vindication of circumcision as a method to reduce or inhibit HIV transfer. In fact, many large studies have shown the exact opposite to be true. By publishing an article that suggests the lack of a foreskin offers any protection from HIV, the BMJ has taken an irresponsible action that may lead to reduced condom use and reduced safe sex practices by circumcised men thus increasing their risk of HIV infection. Additionally, the money that Szabo and Short would like to spend on circumcisions would be better spent on education programs and condom distribution, which could result in benefits quickly. The foreskin has been demonized to cause or contribute to a surprising long list of medical and psychological conditions, all of which have been disproved. HIV transmission is the latest in this long list. However, by choosing HIV as the current disease to be benefited by circumcision, the authors may actually be contributing to the spread of HIV. The BMJ should take pains to ensure this doesn't happen again.
Infant Circumcision not Warranted by Study 12 June 2000
Lawrence Barichello, Executive Director, Intact Intact Send response to journal: Re: Infant Circumcision not Warranted by Study	I have no objection to any young man of the age of majority having his foreskin removed if he perceives that this will prevent some disease that he feels he is at risk of developing, just as some healthy women have their breasts removed because they are worried that they might get breast cancer. This recent study does not, however support *infant* circumcision as a desireable procedure to prevent AIDS, and in fact, the authors contradict themselves in saying so. By the time today's infants reach the age of sexual activity, AIDS may cease to exist or may be curable, or, as the authors mention, HIV blockers may have been developed which prevent the spread of the disease much more effectively than they suppose circumcision does. Circumcising infants is also dangerous because it makes unwarranted assumptions about the infants behaviour fifteen or twenty years in the future: After all, the circumcised infant may grow up to marry his high- school sweetheart and not be in any danger whatsoever of contracting HIV. In any of the above scenarios, the infant has been circumcised against his will and contrary to his human rights-and his full sexual sensitivity has been sacrificed for nothing. What if he would have preferred to have an intact penis? What if his lover prefers the advantages of a foreskin? Infant female mastectomy would also be an effective prophylactic against breast cancer. But, then, wouldn't that be contrary to a little girl's human rights? Lawrence Barichello Executive Director, Intact lawrence@intact.ca http://www.intact.ca
Nothing new under the sun 12 June 2000
Pierre Delaurent, retired engineer Vancouver, Canada Send response to journal: Re: Nothing new under the sun	Those two researchers Szabo and Short remind me of a research done by a professor of sort somewhere in Europe. He had trained fleas to jump, then cut their legs and told them to jump. They did not. Conclusion they had become deaf ... As well intentioned as the researchers are, their conclusion is faulted. Less is never better than more. And until they give me proof: a) of their circumcised state and b) that they have intercourse with multiple HIV+ partners, I won't believe their speculations. Neither professionanal nor lay men should. One thing that those researchers promoting circumcision against AIDS fail to say is: what is the percentage of circumcised men in the 10+ million people sexually infected with AIDS worldwide? I bet they don't say it because it is widely over 50%.
Re: Re: One-sided picture 12 June 2000
Dennis Harrison Send response to journal: Re: Re: Re: One-sided picture	As Guy Cox correctly points out, weighing the risks of surgery is not an exact science. One thing, however, is clear: in societies where genital mutilation is socially sanctioned, the harms associated with performing this surgery are underreported. It is in the nature of human society to bring pressure to bear against anyone who would discredit an established practice. Cox's claim that the "prophylactic value of circumcision against penile carcinoma has been well known for at least 50 years" is not recognized by the American Cancer Society, which advises: "circumcision is not of value in preventing cancer of the penis." 1. ( http://www2.cancer.org/ezineCFML/dsp_storyIndex.cfm?fn=/001_11051998_0.html)
One-third were already infected 12 June 2000
Hugh Young, Private Pukerua Bay, New Zealand Send response to journal: Re: One-third were already infected	Drs Szabo and Short make much of the circumcised men who did not contract HIV during the course of the Uganda study 1. Why do they not mention the one-third of circumcised candidates (29 out of 79) who were already infected, and therefore excluded from it? 2 They make much of the mucosa of the foreskin, yet the much greater area of the vagina is also lined with mucosa and Langerhans' cells. Why are women not infected at a much greater rate than men? Their small histological study was conducted entirely on men aged 60 and over. Would the keratinsation of their glanses be the same as that of younger men? Circumcision is nearly universal in Ethiopia, yet HIV/AIDS is rampant there. How do Drs Szabo and Short explain this? Circumcision does not take place in a social vacuum, and here as everywhere, correlation need not mean causation. Religion, sexual practice and circumcision are all interlinked, and those links need to be untangled before it can be concluded that any correlation between circumcision and HIV infection is causal. Circumcision is a quick fix of slight efficacy if any, but one that will promote a false sense of security and do irreparable damage to real safe-sex campaigns. The lethal sexism of promoting a prophylaxis against HIV infection that protects men (if it does) while leaving women defenceless - compared to condoms, which protect both equally - ought to be an outrage to women and fair-minded men everywhere. We should be very suspicious of new claims for medical benefits of circumcision in view of its tawdry history as a panacea against masturbation, epilepsy, club foot, paralaysis and tuberculosis, to name but a few. Prevention of HIV infection is only the latest in a long list of bad reasons to circumcise. Clearly, something else is going on. That is what really needs to be investigated. Hugh Young Pukerua Bay, New Zealand 1. Quinn TC, Wawer MJ, Sewankambo N, et al., for the Rakai Project Study Group. Viral load and heterosexual transmission of immunodeficiency virus type 1. N Engl J Med, 2000;342:921-9. 2. The Rakai Study: Risk Factors for Heterosexual Transmission. Commentary by Laurence Peiperl, MD, HIV InSite Journal Club, April 14, 2000. Discussion of study by Quinn et al., New England Journal of Medicine, March 2000.
CIRCUMCISION OF CHILDREN: CRIMINAL ASSAULT 12 June 2000
G Boyle, Professor of Psychology Bond University, Gold Coast, Australia Send response to journal: Re: CIRCUMCISION OF CHILDREN: CRIMINAL ASSAULT	Szabo and Short claim that male circumcision reduces the transmission of HIV/AIDS. This proposition is based on a study in Uganda. Yet, in Ethiopia, where the circumcision rate is high, there is also a high rate of HIV/AIDS infection. Why are these "researchers" so selective in their reporting? What motivates them psychologically to push their pro- mutilation opinions? Are they perhaps both circumcised men who seek to employ the well-known Freudian defence mechanisms of denial and rationalisation to reduce their own feelings of penile inadequacy? Studies based on idiosyncratic African samples are not applicable to the industrialised world, where modern standards of hygiene and education apply. Why did Szabo and Short fail to examine the epidemiological evidence in the industrialised world? In the USA where most males are circumcised, the HIV/AIDS infection rate is many times higher than in Europe (where most males are intact). A recent meta-analysis based on no fewer than 29 separate studies (VanHowe) showed that circumcision if anything increases the risk of HIV infection. Why do Szabo and Short fail to cite this reference in their paper? Why are they so selective? As concluded by Boyle, Svoboda, Price & Turner (2000), in their article entitled "Circumcision of Healthy Boys: Criminal Assault?" JOURNAL of LAW & Medicine, Vol. 7, 301-310, there are legal grounds now indicate that "enforced or involuntary circumcision must now be considered as an assault causing grievous bodily harm (genital mutilation). Doctors contemplating the circumcision of healthy unconsenting minors should be warned that they are likely to face prosecution in the future. Recently, a young man was paid about $360,000 (Australian) in an out of court settlement--from the doctor who circumcised him in infancy, for the resultant physical, sexual and psychological harm.
Re: Re: One-sided picture 12 June 2000
David Wilson, Patent Agent Medlen & Carroll Send response to journal: Re: Re: Re: One-sided picture	In regards to Dr. Cox's response wherein he states that penal cancer is unheard of in circumsised men and indicates that he believes that circumcision is preventative of penal cancer, I quote the American Cancer Society's position on circumcision and penal cancer. "Circumcision is the removal of a part or all of the foreskin at birth or later on in life. This practice has been suggested as conferring some protection against cancer of the penis by contributing to improved hygiene. However, the penile cancer risk is low in some uncircumcised populations, and the practice of circumcision is strongly associated with socio-ethnic factors which in turn are associated with lessened risk. The consensus among studies that have taken these other factors into account is that circumcision is not of value in preventing cancer of the penis. It is important that the issue of circumcision not distract the public's attention from avoiding known penile cancer risk factors -- having unprotected sexual relations with multiple partners (increasing the likelihood of human papillomavirus infection) and cigarette smoking." and "In the past, circumcision has been suggested as a strategy for preventing penile cancer. This suggestion is based on studies that reported much lower penile cancer rates among circumcised men than among uncircumcised men. However, most researchers now believe those studies were flawed, because they failed to consider other factors that are now known to affect penile cancer risk. For example, some recent studies suggest that circumcised men tend to have certain other lifestyle factors associated with lower penile cancer risk -- they are less likely to have multiple sexual partners, less likely to smoke, and more likely to have good personal hygiene habits. Most public health researchers believe that the penile cancer risk among uncircumcised men without known risk factors living in the United States is extremely low. The current consensus of most experts is that circumcision should not be recommended as a strategy for penile cancer prevention." Based on the foregoing, Dr Cox's statements are erroneous and misleading. The removal of healthy tissue from infants in anticipation of acquiring cancer has no precedent in medical science. Additionally, penal cancer is easily treatable if detected early. Therefore, instead of advocating circumcision to prevent penal cancer, the prudent choice would be to advocate education programs and promote self exams.
Re: Re: One-sided picture 12 June 2000
Gary L Harryman, retired Send response to journal: Re: Re: Re: One-sided picture	I have no competing interests Guy Cox claims -- "....carcinoma of the penis, a condition which affects only uncircumcised men." That statement is quite simply false. Surely Cox knows you cannot prevent cancer of the glans or any other part of the penis by amputating the prepuce any more than cancer of the tongue could be prevented by amputating the lips. Then Cox finishes his letter with -- "While AIDS is making headlines at the moment, it is as well to remember that the prophylactic value of circumcision against penile carcinoma has been well known for at least 50 years." Evidently Cox stopped reading the medical literature at that point because according to the American Cancer Society (ACS) data, we have known that statement to be false for the last 40 years. This headline-generating "The-male-foreskin-causes-AIDS" scare is just the latest myth capping 150 years of equally outrageous myths and lies regarding the pleasure-producing penile foreskin that has been perpetrated by members of the medical community with a hidden sexual, or anti-sexual agenda. Obviously Cox, Szabo, and Short are not interested in science, but in politics. And just as obviously, it is politics with a hidden agenda. Dragging out past lies to prove current lies is a crafty old politician's trick. Its use exposes an intent to deceive. If we are going to cite cancer rates in this "The-male-foreskin- causes-AIDS" dialogue, let's get some perspective from the source. The ACS does not have separate data on labia and foreskin cancer. However, I have just copied the following table directly from the American Cancer Society web site: Total Est. New Cancer Cases and Deaths, United States, 1999 Cancer Sites New Cases Deaths Vagina & other genital 2,300 600 Vulva 3,300 900 Testis 7,400 300 Penis & other genital 1,400 200 From this data, and depending on how the numbers are skewed, it appears that women are either three or four times more likely to get genital cancer than men. Does this mean that Cox, Szabo, and Short will soon be recommending that women be surgically altered at birth to protect them from cancer? Of course not. Is it because they know they would be justly garroted before sunset by feminists? Or is it because they have no interest in amputating female genitalia? Why then do they make such absurd suggestions regarding little boy's penises? Is it just because the boys cannot defend themselves? Or is it because they know men will not defend little boys? Whatever the hidden agenda of the "The-male-foreskin-causes-AIDS" crowd, torturing numbers to justify mutilating little boy's penises is not medical science, it is quackery -- shameful perverse sadistic quackery. The male foreskin has been blamed for every disease du jour for 150 years. Is it fair to ask why?
Circumcision: Not The Way To Prevent AIDS 13 June 2000
Tony Shale, layman not of relevance Send response to journal: Re: Circumcision: Not The Way To Prevent AIDS	In what I consider an illogical position, a professor of medicine at the University of Melbourne in Australia claims there’s mounting evidence that male circumcision can prevent the spread of the virus that causes AIDS. Roger Short, M.D., says an analysis of 40 studies shows that circumcised males are two to eight times less likely to become infected with HIV because the surgery removes many of the receptor cells in the penis where the virus can penetrate. He argues that it’s best to circumcise babies, but adds that since it would be about 20 years before infants become sexually active, it might be more effective to do the surgery during a boy’s teenage years, according to a paper published in the British Medical Journal. This doesn’t make sense to me at all since here in America most men who get AIDs are circumcised. How does he explain that? And circumcising teenage boys would result in pain, bleeding and psychological trauma that isn’t necessary. Short says that of the estimated 50 million people infected with HIV worldwide, about half are men. Of these, about 70 percent have become infected through their penises and 30 percent through anal sex. I don’t see how being circumcised makes any difference because AIDS is caused by a specific sexually-transmitted virus and people who are exposed are those who get the disease. This is usually through high-risk sexual behavior where the skin can be ruptured. To protect against AIDS, we need to educate men and women to use condoms and practice safe sex. There are also new spermicides and ointments coming onto the market to help prevent sexually transmitted diseases. It’s flawed logic to think circumcision will prevent the spread of AIDS. I certainly can’t see putting all boys through the trauma of circumcision based on this faulty line of reasoning.
More of the One-sided picture 13 June 2000
Guy Cox, Senior Lecturer University of Sydney Send response to journal: Re: More of the One-sided picture	My previous posting generated a number of responses which perhaps do not require detailed responses, but I must comment on the striking claim made by David Wilson, PhD: "For example, some recent studies suggest that circumcised men tend to have certain other lifestyle factors associated with lower penile cancer risk -- they are less likely to have multiple sexual partners, less likely to smoke, and more likely to have good personal hygiene habits." If circumcision really makes men less likely to smoke and more faithful to their partners there would seem to be an overwhelming case in favour of the operation. Sadly, I fear this isn't so. One can bring up confounding factors as much as one likes - that there are other contributory factors is not in doubt - but the fact remains that men circumcised in infancy do not contract this most unpleasant disease at any statistically measurable rate. So far as I know there has been just one report in the medical literature of one man circumcised in infancy contracting penile carcinoma (VF Marshall, 1953, Typical carcinoma of the penis in a male circumcised in infancy. Cancer, 6, 1044-1045). It is almost exclusively a disease of the uncircumcised. This applies in Scandinavia just as much as in the USA, UK or Australia. (I do not believe that comparing countries is a very fruitful exercise, but nevertheless if one compares countries which are culturally similar but differ in circumcision rate, such as UK vs Australia or Bali vs Java, the rate of penile carcinoma accurately reflects the proportion of circumcised men in the population.)
Re: More of the One-sided picture 13 June 2000
David Wilson, as above Send response to journal: Re: Re: More of the One-sided picture	In regards to Dr. Cox's response to the American Cancer Society's position on circumcision and penal cancer, Dr. Cox has misinterpreted the ACS statement. By analogy, just as certain groups of people tend to buy certain styles of automobiles (families may have a preference for minivans, for instance), certain groups of people may select to circumcise their children. Those same groups of people may show other life style preferences that limit their exposure to penal cancer "compounding factors" including practicing better hygiene and not smoking. This correlation may be especially true if the reason these people chose to circumcise was because they believed it to be more hygienic. The ACS did not state, as Dr. Cox claims, that circumcision prevents one from taking up smoking or makes one less promiscuous. Dr. Cox's gross misinterpretation of the ACS statement is gratuitous. Additionally, the incidence of penal cancer in circumcised men is well documented in the literature. See, for example: Ross BS, Levine VJ, Dixon C, Ashinoff R. Squamous cell carcinoma of the penis in a circumcised man: a case for dermatology and urology, and review of the literature. Cutis. 1998 Jan;61(1):41-3. Review. Kanik AB, Lee J, Wax F, Bhawan J. Penile verrucous carcinoma in a 37- year-old circumcised man. J Am Acad Dermatol. 1997 Aug;37(2 Pt 2):329-31. Review. Cold CJ, Storms MR, Van Howe RS. Carcinoma in situ of the penis in a 76-year-old circumcised man. J Fam Pract. 1997 Apr;44(4):407-10. Review.
Re: More of the One-sided picture 14 June 2000
Steve Wilder, Software Developer Stanford University Send response to journal: Re: Re: More of the One-sided picture	Guy Cox really doesn't understand cause and effect. To propose that circumcision prevents people from getting cancer is as silly as saying that circumcision prevents people from smoking. Circumcision serves as an indicator for smoking, social class, and affluence. While the risk of damage to the penis from cancer is very slight, circumcision damages the penis in 100% of all cases.
Re: More of the One-sided picture 14 June 2000
Dennis Harrison Send response to journal: Re: Re: More of the One-sided picture	The idea that circumcision protects against cancer of the penis may have originated with Abraham L. Wolbarst.(1) A member of the American Society of Sanitary and Moral Prophylaxis, Wolbarst argued that adult masturbators should be sterilized and forbidden to marry.(2) He also believed that circumcision protects against epilepsy.(3) The American Cancer Society advises that circumcision is not of value in preventing cancer of the penis. (1) Wolbarst A. Circumcision and penile cancer. Lancet 1932;1:150-3. (2) Wolbarst A. Persistent masturbation. JAMA 1932;90:154-5. (3) Wolbarst A. Universal circumcision as a sanitary measure. JAMA 1914;62:92-7. (4) http://www.cirp.org/library/disease/cancer/vanhowe1/
Re: More of the One-sided picture 14 June 2000
Gary L Harryman, As above Send response to journal: Re: Re: More of the One-sided picture	Well, there he goes again. No matter how many times a lie is stated, it will never become the truth. "...but the fact remains that men circumcised in infancy do not contract this most unpleasant disease at any statistically measurable rate. So far as I know there has been just one report in the medical literature of one man circumcised in infancy contracting penile carcinoma (VF Marshall, 1953, Typical carcinoma of the penis in a male circumcised in infancy. Cancer, 6, 1044-1045). It is almost exclusively a disease of the uncircumcised." If Mr.Cox would read again what I previously posted, but will repeat here -- The American Cancer Society states in plain language that it does not separate out the locations of penile cancers. Never has. Therefore, from the ACS data one could just as honestly state that --"All of the 400 cases of penile cancer in 1999 occured in circumcised males." Since penile cancer is a disease of old men, and since the circumcision fad in the US did not begin in earnest until the 1940's and reached its apex in the late 1980's one would have to assume that almost all 60 and 70-year old men alive in the US today are intact. Therefore, one would expect most of the cases of penile cancer in the US to be in intact men. And one can also expect to see an ever-increasing ratio of circumcised men to get penile cancer until the year 2050 when 90% of the penile cancer cases will be circumcised men. For Cox to suggest that this phenomenon has anything to do with the foreskin per se is more dishonest claptrap. More incantation of the 150- year legacy of shame and myths and lies regarding the magical powers of routine neonatal penis mutilating. Since Mr. Cox is obviously learned enough to know these things, perhaps he would now like to explain to us what his real agenda is for falsly claiming circumcision prevents cancer and AIDS.
Circumcision Complication Rate 14 June 2000
Erick L Gustavson, Human Rights Activist Send response to journal: Re: Circumcision Complication Rate	I would like to emphasise that a procedure carried out with no pathology ( indications ) is immoral AND illegal. The complication rate for those penile reductions is at a rate of 100%. In order for a procedure to be termed as surgery, a known immediate and long-term benefit to the patient must have pathology. A qualifying point of interest would be: When the ablated tissue is sold to Organogenisis, the pirated tissue MUST be certified as pathalogen free and free of contaminates, such as some type of pain relief. A logical question would then come to mind: If the ablated, pirated tissue is pathology free, why was it ablated in the first place? My next question would be: How do companies like Revlon, Estee' Lauder, Apligraf and Organogenisis purchase "donated" tissue from an infant? What ever happened to the Uniform Anatomical Gift Act? Besides a genital mutilation, assault and battery, and Slavery come to mind. Erick L. Gustavson egustav435@erols.com
Why wait till puberty? 14 June 2000
John Smith, Dental student Liverpool Send response to journal: Re: Why wait till puberty?	Dear Author I wonder why the author assumes that circumcision at the age of puberty would be most effective as practicsed by Muslims. Doesn't the author think this would be vary barbaric and not all teenagers would agree to it - at the same time creating many major ethical problems. Would it not be more sensible to circumsize EVERY male born on the eigth day, or abit later if the baby is jaundice; like the Jewish religion practices
Re: More of the One-sided picture 15 June 2000
John Antonopoulos, President Circumcision Information Resource Centre, Montreal, Canada Send response to journal: Re: Re: More of the One-sided picture	One of the most frequently trotted-out health myths relating to infant male circumcision is that cancer of the penis (one of the rarest of cancers in developed nation settings in any case, rarer even than male breast cancer) affects virtually no circumcised males. Yet in 1993, Christopher Maden et al. reported that of 110 men diagnosed with penile cancer between January 1979 and July 1990, 22 (or 20%) had been circumcised as infants, 19 later in life. So much for circumcision and penile-cancer immunity. With the advent of increasing bathing facilities in homes in Denmark, the incidence of penile cancer in that country (having a virtually non- circumcised male population) has decreased to an incidence lower than that in the U.S. (which has a majoritarily circumcised male population). In this same journal, in 1995, Frisch, Friis, Kjear and Melbye stated: "[T]he declining incidence of penis cancer in Denmark [from 1940 to 1990] cannot reasonably be attributed to an increased practice of neonatal circumcision...During the period under study, the proportion of Danish dwellings having a bath increased gradually from 35% in 1940 to 90% in 1990. It seems plausible that better penile hygiene resulting from this improvement in sanitary installations might have contributed to the observed trend." [2] As for the once-current claim that removal of the prepuce in males lowers the risk of cervical cancer in female partners, the American Academy of Pediatrics Task Force on Circumcision, having plowed laboriously through forty years of literature on circumcision, does not even mention cervical cancer in connection with circumcision, in its most recent 1999 statement.[3] [1] Maden C, Sherman KJ, Beckmann AM, et al. History of circumcision, medical conditions, and sexual activity and risk of penile cancer. Journal of the National Cancer Institute 1993;85(1):19-24. http://www.cirp.org/library/disease/cancer/maden/ [2] Frisch M, Friis S, Kjear SK, Melbye M. Falling incidence of penis cancer in an uncircumcised population (Denmark 1943-90). British Medical Journal 1995;311(7018):1471. http://www.cirp.org/library/disease/cancer/frisch/ [3] American Academy of Pediatrics Task Force on Circumcision. Circumcision policy statement. Pediatrics 1999;103(3):686-693. http://www.cirp.org/library/statements/aap1999/
Re: Solidarity with Victoria 16 June 2000
Brian Morgan, Freelance Journalist Cardiff Send response to journal: Re: Re: Solidarity with Victoria	I hate to jump in on a debate with which I have only a slight connection - having being circumcised as a baby 60 years ago, and neither suffering any grief nor thinking to ask my parents why they had this done to me before sadly they shuffled off their own mortal coils, but I do have to question one of Rio Cruz's points - about the perfection of the human form and after millions of years of evolution that no part of it might be redundant. I'm not suggesting the prepuce is redundant for one moment, I don't know enough about the argument - but I was always told in my biology classes that the vermiform appendix really is a redundant organ which we share with rabbits who make good use of it as well as their prepuces, as possibly other mammals may do too.
Down under = below the belt 17 June 2000
Jacqueline Sonnendrücker, Retired R.N. Vancouver, Canada Send response to journal: Re: Down under = below the belt	Cox, Short, Szabo and many others are not above unscrupulous bluffs and blenches to promote themselves. They are succeeding! like arsonistes watching the fire they started or street urchin coming back to look at their graffitis ... I bet they're jumping up and down and wetting their underwear with excitement. Who is to blame for this neurotic behaviour? No one else but the Medical Profession! If doctors in high position want to regain the confidence of the public at large, they'll need to get a psychological profile of each candidate to the Hippocratic Oath and make careful assessment of men and women who think that an M.D. certificate is a ticket to act out all of their sadistic impulses. Of course, it takes courage to impose such regulations. In the name of the children, find it! Many nurses and midwives have, a long time ago ... Hello sisters! Jacqueline Sonnendrücker, Retired R.N.
To the circumcisers of all backgrounds, religions, colours and creeds. 17 June 2000
Julie Filliatre, member of ETHIC Vancouver Send response to journal: Re: To the circumcisers of all backgrounds, religions, colours and creeds.	To the circumcisers of all backgrounds, religions, colours and creeds. Look at your handa Remember! "First do no harm" ... Their purpose is to comfort, to reassure What are they holding? A knife ... it will hurt ... Remember! "First do not harm" ... Retracting, slicing, are you sure Of what you are doing? The blood will spurt ... Look at your hands Remember! "First do no harm" ... A frail baby new, intact, pure Why is he crying? Why do you want to hurt? Look at your hands Remember! "First do no harm" ... Is circumcision a cure For your hatred within? Is it your way to blurt Out the unspeakable truth The pain of your own youth? Look at your hands Remember! "First do no harm" ... When are you going to understand? Look at your hands. Julie Filliatre, ETHIC End The Horror of Infant Circumcision No competing interest
Penis epithelium 18 June 2000
Peter Morrell, Hon Research Associate, History of Medicine Staffordshire University Send response to journal: Re: Penis epithelium	Sir, Szabo and Short say: "A keratinised, stratified squamous epithelium covers the penile shaft and outer surface of the foreskin. This provides a protective barrier against HIV infection. In contrast, the inner mucosal surface of the foreskin is not keratinised and is rich in Langerhans' cells, making it particularly susceptible to the virus. This is particularly important because during heterosexual intercourse the foreskin is pulled back down the shaft of the penis, and the whole inner surface of the foreskin is exposed to vaginal secretions, providing a large area where HIV transmission could take place.” [1] But, puzzlingly, they then conclude: "There is controversy about whether the epithelium of the glans in uncircumcised men is keratinised; some authors claim that it is not, but we have examined the glans of seven circumcised and six uncircumcised men, and found the epithelia to be equally keratinised. In circumcised males only the distal penile urethra is lined with a mucosal epithelium. However, this is unlikely to be a common site of infection because it contains comparatively few Langerhans' cells." [1] Having initially read only the letters, and while thinking of this debate, it occurred to me that mucus membrane surfaces seem to be the prime sites of infection, allergy, inflammation and major ‘entry points’ where the organism succumbs to infective agents. I think that Szabo and Short have answered their own question: the previously delicate epithelium of the glans and prepuce of the penis does indeed become more thickened and sclerotized after circumcision, and is thus no longer such a vulnerable entry point for infective agents, as is the mucosa of glans and prepuce of the uncircumcised penis. The cellular composition and properties of the epithelium clearly must become changed, due to the drying influence of the air and the sclerotizing influence of abrasion against clothing after circumcision - forces to which the epithelium of the uncircumcised penis are quite simply never exposed. This must be the very heart of this matter. What better explanation is there for the observations given? Future research on this matter should therefore focus on this aspect - far more detailed comparison studies of penis epithelium taken from circumcised and uncircumcised men. I feel sure this line of inquiry will lead to new findings concordant with the view that penis epithelium as an infective route is fundamentally reduced by circumcision. As for the arguments for and against circumcision, which have raged in these columns, they are only relevant should this altered aspect of penis epithelium be substantially confirmed through future research. Clearly, if the weight of evidence moves in favour of circumcision as a method of reducing infectivity via the penis, then its value as a therapeutic aid might well be boosted - at which point the strong ethical considerations will have to be reassessed in that light. Sources [1] How does male circumcision protect against HIV infection? Robert Szabo, Roger V Short, BMJ 10 June 2000; http://www.bmj.com/cgi/content/full/320/7249/1592
A superstitious rite 18 June 2000
John Dalton, Researcher and Archiver NORM-UK Send response to journal: Re: A superstitious rite	Szabo and Short have concluded the male child circumcision should be seriously considered as an additional means of preventing HIV. I do not intend to comment on whether or not they have a valid argument for the circumcision of consenting adults, but they have certainly not made a case for circumcising unconsenting children who are not sexually active. Furthermore, there are certain failings of the article which should not have escaped the attention of the peer reviewer. A Medline search for relevant literature was conducted by Szabo and Short but they present no full listing of the search results. An objective review of the literature would have shown that there was no consensus that male circumcision protects against HIV.1 One metanalysis showed circumcised men to be more at risk of HIV than those with the normal, intact penis.2 No evidence is presented by Szabo and Short to confirm their claim that HIV enters the body through CD4 and CCR5 receptors on Langerhans' cells located in the penis. As such their proposed mechanism for prevention of HIV by male circumcision is little more than supposition. It is unacceptable for Szabo and Short to claim that circumcision has a low incidence of complications on the basis of a booklet favouring circumcision which has had no peer review. Although a complication rate as low as 0.06 per cent has been claimed for circumcision, rates as high as 55 per cent3 have also been reported. A detailed literature review4 of the complication rate for circumcision concluded that a realistic rate of significant complications lies in the range 2-10 per cent. It seems possible that any programme of child circumcision cause more serious complications than it would prevent cases of HIV. We believe that we live in an enlightened age. What is most surprising is that we still believe that we should ward off disease by cutting children's genitals. Publishing the opinion of Szabo and Short will do more to perpetuate non-therapeutic circumcisions of unconsenting children in North America and Australia than it will for the prevention of HIV in Africa. References 1. de Vincenzi I, Mertens T. Male circumcision: a role in HIV prevention? AIDS 1994;8(2):153-160. 2. Van Howe RS. Circumcision and HIV infection: review of the literature and meta-analysis. IntJ STD AIDS 1999;10:8-16. 3. Patel H. The problem of routine infant circumcision. Can Med Assoc J 1996;95:576-581. 4. Williams N, Kapila L. Complications of Circumcision. Brit J Surg 1993; 80: 1231-1236.
Solidarity with Victoria 19 June 2000
Rio Cruz, Former University Professor, retired Send response to journal: Re: Solidarity with Victoria	13 June 2000 To the Editor: Szabo and Short's opinion piece in the BMJ1 places them in splendid solidarity with Victorian notions of sex and hygiene,2 together with tribal initiation rituals. They are completely isolated from their major peer medical organizations,2,3 not one of which endorses routine infant circumcision as a prophylactic measure despite 150 years of pressure brought to bear by circumcisers. Szabo and Short continue in this proud tradition. In order to accept that circumcision is a really swell idea, we first have to believe that nature made this huge, enormous, boondoggle design error in human anatomy that requires removal by force. This is a huge leap of faith given the fact that not just humans, but all of Mammalia, has evolved over millions of years to end up with a prepuce. Every single warm-blooded, fur-bearing, lactating critter on the face of the planet has a foreskin...both male and female. Every man, every woman, every bull, bitch and skunk has a prepuce. But for some reason known only to religious types, and medicalized capitalism, the only mammal to be benefited by summarily putting this omnipresent organ through the surgical Veg-O-Matic is the human male mammal. The history of medicalized circumcision is a fascinating study in Victorian medicine and anti-sexuality.4 Suffice it to say, amputating the normal prepuce of human beings started in the Engilish-speaking countries as an anti-masturbation measure. It didn't work, of course. But circumcisers have learned that the pretexts for penile pruning are seemingly inexhaustible. Simply by playing on the fears of the culture they can keep the practice going...and the income flowing. So, at the turn of the 20th century better penile hygiene was the big issue, in the 30s--during the beginning of the penile cancer scare--Abraham Wolbarst concocted studies to "prove" circumcision prevented penile cancer.5 In the 50s, prevention of cervical cancer came into vogue, the 60s brought sexually transmitted diseases as the rationale, urinary tract infections in the 80s6,7 and, perhaps the most dreaded of all, AIDS in the 90s. If it looks like circumcision is an operation in search of a disease, that's because it is. Every single claim for legitimate medical benefit justifying the routine practice of this amputation has been disproved.8 But still the cutting goes on. One reduced penis every 26 seconds in the United States. The single most common surgery performed in America. And this is in sharp contrast with the rest of the world9 where over 80% of the male population is left whole and intact--including all of Europe, non-Muslim Asia and Latin America--their genitals as nature designed them before the collective wisdom of Szabo and Short and other pro-circumcision proponents had "a better idea." RIO CRUZ 1. Szabo R. Short RV. How does male circumcision protect against HIV infection? BMJ 2000,320:1592-94. 2. Guidelines for Circumcision. Australasian Association of Paediatric Surgeons. Hersion, QLD, 1996. 3. Position Statement, Australian College of Paediatrics. Parkville, VC, 1996. 4. Moscucci O. Clitoridectomy, Circumcision, and the Politics of Sexual Pleasure. In: Sexualities in Victorian Britain. Eds: Andrew H. Miller and James Eli Adams. Indiana University Press, Bloomington and Indianapolis 1996: 63-65 (ISBN 0-253-33066-1). 5. Fleiss PM, Hodges F. Neonatal circumcision does not protect against cancer. BMJ 1996;312:779-780. 6. Wiswell TE, Smith FR, Bass JW. Decreased incidence of urinary tract infections in circumcised male infants. Pediatrics 1985, 75: 901-903. 7. Wiswell TE, Roscelli JD. Corroborative evidence for the decreased incidence of urinary tract infection in circumcised male infants. Pediatrics 1986;78:96-99. 8. Fleiss P, Hodges F, Van Howe RS.Immunological functions of the human prepuce. Sex Trans Inf 1998;74:364-367. 9. Wallerstein E. Circumcision: the uniquely American medical enigma. Urologic Clinics of North America 1985;
Dangerous Recommendation 19 June 2000
Amber Craig, parent, volunteer for NOCIRC Send response to journal: Re: Dangerous Recommendation	Dear Editors: These authors are making a very dangerous and unethical recommendation. They are suggesting a massive amputation campaign in hopes of reducing the spead of HIV. Unless there is conclusive evidence that circumcised males never contract HIV or develop AIDS, the authors are being very short sighted and misleading in their recommendations. Clearly, the large population of circumcised males with HIV and AIDS in America shows that circumcision does not make males immune to HIV. Therefore, promoting an amputative surgery that may or may not slightly reduce the risk of HIV transmission is simply offering a dangerous and false sense of protection to males practicing risky behavior. If circumcision carried no risks, if there was no pain in removal of the foreskin, and the foreskin provided no benefit to a male, then a massive amputation campaign on minor children might not be the controversy it is today. However, circumcision always exposes males to surgical risks, causes extreme pain, and permanently alters a male's genitals. Therefore, recommending mass circumcision of minor males to provide an illusion of protection against HIV is unethical. Amber Craig
Prepuce:Anatomy and Functions 20 June 2000
Rio Cruz, Former University Professor, retired Send response to journal: Re: Prepuce:Anatomy and Functions	Prepuce: Anatomy and Functions Oh dear, I see as how Brian Morgan put words in my mouth when he said, "but I do have to question one of Rio Cruz's points - about the perfection of the human form and after millions of years of evolution that no part of it might be redundant." I've searched and searched through my letter and have been unable to find where I ever mentioned the "perfection of the human form," let alone the suggestion that "no part of it might be redundant." I was, however, gratified that Mr. Morgan did not, for one moment, suggest that the prepuce is redundant. This is in sharp contrast with most serial circumcisers who insist, despite all evidence to the contrary, that the human prepuce is a redundant, vestigial piece of flesh whose ablation only enhances the male form. For those seeking biological justification for their amputation fetish, the following may not be of help: The male prepuce is the primary covering for the glans and inner mucosal lining. Just as with the clitoris and inner labia of women, these structures are normally internal organs shielded by the foreskin from abrasion, drying, and callusing, and keeping them uncontaminated by dirt. The foreskin comprises approximately half of the smooth muscle sheath called the dartos fascia; most of the erotogenic nerve endings on the penis, including the densely innervated Ridged Bands; specialized epithelial Langerhans cells, an immune system component; thousands of coiled fine-touch receptors, lymphatic vessels, the loss of which interrupts the lymph flow within a part of the body's immune system; the frenulum, a sensitive tethering structure on the underside of the penis rich in erotogenic nerves; the pheromone producing apocrine glands; 50% or more of the total penile skin, which when amputated, radically desensitizes and immobilizes the remaining shaft skin.1 The sub-preputial moisture contains lytic material (lysozyme).2 Lee-Huang has documented the anti-HIV action of lysozyme in vitro.3 The prepuce offers protection against genital warts. Men with intact prepuces tend to get fewer genital warts.4 When they do get genital warts they tend to form on the distal tip, the part least protected by the foreskin.4 Since genital warts are caused by human papiloma virus (HPV), there is evidence of protection against HPV. The foreskin also offers an abundance of other immunological functions.5 The foreskin gives the penis the ability to "glide."5 If unfolded and spread out flat, the adult foreskin measures 15 to 20 square inches, the size of a postcard. All this specialized skin gives the natural penis the anatomically unique ability to smoothly "glide" within itself - which allows non-abrasive intercourse without drying out the vagina.5-7 It also contains several feet of blood vessels, including the frenular artery8 and portions of the dorsal artery, the loss of which interrupts normal blood flow to the shaft and glans of the penis, potentially reducing its growth and damaging its erectile function; an estimated 240 feet of microscopic nerves including portions of the dorsal nerve; and, perhaps most importantly, between 10,000 and 20,000 specialized erotogenic nerve endings of numerous types, which can discern slight motion, subtle changes in temperature, and fine gradations in texture. Does all this sound like vestigial, superfluous tissue? But not to worry. Circumcisers will ignore this and all other evidence that may dissuade them from targeting their favorite organ to mutilate. Especially if it's attached to an infant that can neither fight back nor give consent. RIO CRUZ, PhD Cold CJ, Taylor JR. The prepuce. BJU Int 1999;83 Suppl. 1:34-44. Prakash S, Raghuram R, Venkatesan, et al. Sub-preputial wetness - Its nature. Ann Nat Med Sci (India) 1982; 18(3): 109-112. Lee-Huang S, Huang PL, Sun Y, et al. Lysozyme and RNases as anti-HIV components in beta-core preparations of human chorionic gonadotropin. Proc Natl Acad Sci U S A 1999;96(6):2678-2681. Cook LS,Koutsky LA,Holmes KK. Clinical presentation of genital warts among circumcised and uncircumcised heterosexual men attending an urban STD clinic. Genitourin Med 1993;69:262-264. Fleiss P, Hodges F, Van Howe RS. Immunological functions of the human prepuce. Sex Trans Inf 1998;74:364-367. Warren J, Bigelow J. The case against circumcision. Br J Sex Med 1994; Sept/Oct: 6-8. O'Hara K, O'Hara J. The effect of male circumcision on the sexual enjoyment of the female partner. BJU International 1999;83 Suppl 1, 79-84. Persad R, Sharma S, McTavish J, et al. Clinical presentation and pathophysiology of meatal stenosis following circumcision. Br J Urol 1995; 75(1): 91-3.
Mass Circumcision: Crime Against Humanity? 21 June 2000
Jerry Warner, Banking/Financial Services N/A Send response to journal: Re: Mass Circumcision: Crime Against Humanity?	Jerry W. Warner 10010 Karen Drive Baton Rouge, Louisiana 70815 USA To the Editor: Mass Circumcision: Crime Against Humanity? Szabo and Short propose mass intentional systematic involuntary non-therapeutic circumcision of large population groups of healthy non-consenting pubescent boys as a measure to stem the epidemic of AIDS.1 Male circumcision removes the prepuce of the male penis. Taylor et al. report that circumcision removes large amounts of specialized skin and mucosa.2 Cold and Taylor. report that: "The prepuce is primary, erogenous tissue necessary for normal sexual function."3 Mutilation is the act of making imperfect by excising or removing parts or to deprive of a limb or essential part.4 The prepuce is an essential part for normal sexual function.3 Certainly, circumcision is mutilation and has long been so identified in the Australian literature.5 Circumcision causes physical harm.2-3 Circumcision also causes mental and emotional harm.6-8 The Netherlands Institute of Human Rights has determined that non-therapeutic circumcision of male children is a human rights offence under several instruments of international law.9 The Australian Code of Medical Ethics10 tells doctors to: "Treat your patients with compassion and with respect for their human dignity."10 Violations of patients' human rights and injuries to their persons and psyche do not show compassion or respect for human dignity. The measure proposed by Szabo and Short1 thus appears to be a rather serious violation of the Australian Code of Medical Ethics.10 Furthermore, the International Law Commission's U.N. Draft Code Part of Crimes Against the Peace and Security of Mankind (1996)11 defines Crime Against Humanity in part at Article 18(k) as: "...inhumane acts which severely damage physical or mental integrity, health or human dignity, such as mutilation and severe bodily harm."11 Short and Szabo's proposed mass programme of involuntary child circumcision1 comes perilously close to the definition of crime against humanity, thus easily could be construed as a crime against humanity. Mass involuntary non-therapeutic circumcision of non-consenting youths cannot be contemplated seriously. Szabo and Short seem to have made their proposal without first giving consideration to the moral, ethical, and legal constraints that limit the practice of medicine. The BMJ previously has taken a strong stand against child circumcision12-14 and in favour of full implementation of the UN Convention on the Rights of the Child (1989).15 One, therefore, finds it amazing that such a proposal1 could be entertained in these pages.             JERR Y W. WARNER Szabo R. Short RV. How does male circumcision protect against HIV infection? BMJ 2000,320:1592-94. Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996;77:291-295. Cold CJ, Taylor JR. The prepuce. BJU Int 1999;83 Suppl. 1:34-44. The American Heritage Dictionary of the English Language. Boston: Houghton Mifflin Company, 1992 (ISBN 0-395-44895). Morgan WKC. Penile Plunder. Med J Aust 1967;1:1102-1103. Cansever G. Psychological effects of circumcision. Brit J Med Psychol 1965;38:321-31. Goldman R. The psychological impact of circumcision. BJU Int 1999;83 Suppl. 1:93-103. Rhinehart J. Neonatal circumcision reconsidered. Transactional Analysis Journal 1999; 29(3):215-221. Jacqueline Smith. Male Circumcision and the Rights of the Child. In: Mielle Bulterman, Aart Hendriks and Jacqueline Smith (eds.), To Baehr in Our Minds: Essays in Human Rights from the Heart of the Netherlands. Netherlands Institute of Human Rights, University of Utrecht, Utrecht, Netherlands, 1998. Australian Medical Association. Code of Medical Ethics (1996). Australian Medical Association. Deakin, ACT, 1996. International Law Commission. Draft Code of Crimes Against the Peace and Security of Mankind (1996), Report A/48/10. In: Yearbook of the International Law Commission, vol. II(2), 1996. The case against circumcision. [editorial]BMJ 1979; 6172: 1163-1164. Gordon A, Collin J. Saving the normal foreskin. [editorial] BMJ 1993; 306: 1-2. Warren J, Smith FD, Dalton JD, et al. Circumcision of children. BMJ 1996;312:377. Lansdown G, Waterston T, Baum D. Implementing the UN Convention on the Rights of the Child. [editorial] BMJ 1996;313(7072).
The Ghosts of Abraham Wolbarst and Aaron Fink 22 June 2000
George Hill, Retired Airline Pilot N/A Send response to journal: Re: The Ghosts of Abraham Wolbarst and Aaron Fink	Letters Editor BMJ BMA House Tavistock Square London To the Editor: The Ghosts of Abraham Wolbarst and Aaron Fink The possible role of male circumcision in the prevention of penile cancer, as introduced by Guy Cox, is not germane to the discussion of the possible prevention of HIV transmission by systematic, indiscriminate, and involuntary male circumcision, as proposed by Szabo and Short.1 Nevertheless, certain parallels exist between the origin of the circumcision-prevents-cancer hypothesis and the circumcision-prevents-HIV hypothesis that deserve to be illuminated. Both hypotheses were first advanced by one of two now deceased circumcised male American doctors, Abraham Wolbarst and Aaron Fink,2-3 who both were previous ardent promoters of universal male circumcision.4-5 Both cancer and AIDS were dread diseases at the time that their respective hypothesis was first proposed. Both hypotheses have been disproved,6-7 yet both hypotheses still have male adherents in the English speaking nations where male neonatal circumcision was formerly frequent. Goldman8 and Rhinehart9 report that some circumcised males carry emotional baggage related to their trauma and loss by circumcision. Van der Kolk reports that some traumatized persons have a compulsive need to reenact the trauma and to re-victimize others.10 Circumcision causes certain loss of sensory function.11 Fitzgerald and Parkes report that one must grieve the lost of sensory function or go into denial.12 These subjective factors may have influenced Wolbarst and Fink to promote circumcision.8 It must now be noted that the American Academy of Pediatrics, in sharp contrast to previous practice, passed over many male doctors and chose a female, Carol Lannon, to chair its most recent task force on circumcision.13 Under Dr Lannon's objective evidence-based scrutiny with the aid of an epidemiologist of a half-century of medical controversy, all of the medical myths that are used to support and rationalize male circumcision were stripped away. In the end, the task force could not document a single medical reason to support the practice of male circumcision.13 In spite of the lack of documentation of the two theories, the ghosts of Abraham Wolbarst and Aaron Fink continue to haunt the medical literature. Although strong counter-evidence exists6-7 and despite the dubious origin of these hypotheses, a few male doctors in the English speaking nations, where male circumcision was once culturally acceptable, continue the persistent advocacy of universal male circumcision to prevent cancer and HIV infection1,14-20. There is grave danger that this incessant drum beat for mass circumcision will mislead unwary public health authorities into abandoning proven methods of disease control for the still unfounded, self-defeating Fink hypothesis. This would be a recipe for disaster. George Hill NOCIRC of Lousiana P. O. Box 88 Port Allen, Louisiana 70767-0088 USA E-mail to iconbuster{at}eatel.net References Szabo R. Short RV. How does male circumcision protect against HIV infection? BMJ 2000;320:1592-4. Wolbarst AL. Circumcision and penile cancer. Lancet 1932;1:150-3. Fink AJ. A possible explanation for heterosexual male infection with HIV [letter]. N Engl J Med 1986;315:1167. Wolbarst AL. Universal circumcision as a sanitary measure. JAMA 1914;62:92-7. Fink AJ. Circumcision: A Parents Decision for Life. Menlo Park: Kavanaugh Publishing Company, 1988. Cold CR, Storms MR, Van Howe RS. Carcinoma in situ of the penis in a 76-year-old circumcised man. J Fam Pract 1997;44:407-10. Van Howe RS. Circumcision and HIV infection: review of the literature and meta-analysis. Int J STD AIDS 1999;10:8-16. Goldman R. The psychological impact of circumcision. BJU Int 1999;83 (Suppl. 1):93-103. Rhinehart J. Neonatal circumcision reconsidered. Transactional Analysis Journal 1999;29:215-21. van der Kolk BA. The compulsion to repeat the trauma: re-enactment, revictimization, and masochism. Psychiatr Clin North Am 1989;12:389-411. Cold CJ, Taylor JR. The prepuce. BJU Int 1999;83 (Suppl 1):34-44. Fitzgerald RG, Parkes, CM. Blindness and loss of other sensory and cognitive functions. BMJ 1998;316:1160-3. American Academy of Pediatrics Task Force on Circumcision. Circumcision Policy Statement. Pediatrics 1999;103:686-93. Schoen EJ. Neonatal circumcision and penile cancer: evidence that circumcision is protective is overwhelming. BMJ 1996;313:46. Schoen EJ. Benefits of newborn circumcision: Is Europe ignoring medical evidence? Arch Dis Child 1997;77:358-60. Moses S, Bailey RC, Ronald AR. Male circumcision: assessment of health benefits and risks. Sex Transm Infect 1998;74:368-73. Moses S, Nagelkerke NJ, Blanchard J. Analysis of the scientific literature on male circumcision and risk for HIV infection. Int J STD AIDS 1999;10(9):626-8. Halperin DT, Bailey RC. Male circumcision and HIV infection: 10 years and counting. Lancet 1999;354:1813-5. Schoen EJ, Wiswell TE, and Moses S. New Policy on Circumcision-Cause for Concern. Pediatrics 2000;105:620-3. Schoen EJ, Oehrli M, Colby Cd, Machin G. The highly protective effect of newborn circumcision against invasive penile cancer. Pediatrics 2000;105(3):E36.
Questions 25 June 2000
M van der Veer, N/A Retired Send response to journal: Re: Questions	Guy Cox, referring to H. Patel's study, says: " Patel's study recorded in detail the postoperative history of 100 infant circumcisions. I quote: "Slight bleeding, consisting mainly of oozing, occurred in 31 ..... In four there was moderate bleeding, sutures being necessary in one of them. .... In no case was bleeding so severe as to require a blood transfusion." Later, he reports: "Patel also points out that no deaths occurred at Kingston General Hospital over a 10-year period from circumcisions of infants (6753 operations) or older children (589 operations). " My questions are: If Patel took the time to review the record over a 10 year period (7342 subjects) to ascertain the death rate due to circumcision, why did he choose to study, in detail, the postoperative histories of only 100? And, what were the selection criteria? Looks, at first glance, like another case of those attempting to excuse circumcision using their favorite tactic of selective winnowing.
Study of FGM and AIDS 26 June 2000
Brian A Waldman Send response to journal: Re: Study of FGM and AIDS	What always strikes me about these ridiculous "studies" is that there is some connection between AFRICA and the rest of the world. And the study always tries to connect African MALE circumcision to AIDS. Given that this continent is one of the few places where FEMALE circumcision is practised and AIDS is rampant, why don't they try to do similar "research" - if, indeed, that is what it can be called - on the relationship of FGM and AIDS? The initial answer seems clear. I suspect that societies that practice female circumcision had VERY strict moral codes and that the incidence of AIDS there would be lower than "normal" - especially for Africa where the disease is rampant. Blinding themselves to the moral issues I've mentioned - which, I note the so-called "researchers" did in the case of MALE circumcision - a lower AIDS pathology in FGM-practicing regions would cause our "researchers" to have to conclude and publish that ... "FEMALE CIRCUMCISION DRASTICALLY REDUCED THE INCIDENCE OF AIDS!" Would they publish such a finding? As a previous poster implied ... not unless they were prepared to be skewered at sunrise by the virulent feminist groups - a fate they would justly deserve. Still, it begs the question - even from a curiosity point-of-view, why isn't such a "study" being done? It isn't like we'd have to start doing female circumcisions in America to obtain the statistics.
A Procrustian Solution 26 June 2000
Jerad Lee, Retired Send response to journal: Re: A Procrustian Solution	I haven't heard such Draconian recommendations for the African HIV epidemic as proposed by Szabo and Short since Procrustes chopped off the legs of victims in order to make them fit his beds. Based on the generalizations of numbers, the pro-circumcision cabal wants their favorite amputation inflicted on all males in a random, mass application. What we are told is that since some unnamed, unidentified males within a population may have a greater chance of contracting AIDS if their penis hasn't been foreshortened, then all members of that population should live out their lives with a partial penis in order to protect them against something they do not have...nor may ever have. Based on such logic, the mass amputation of women's breasts should be standard in order to save some from breast cancer. AIDS is the result of unsafe sexual practices, not the status of one's penis...or vagina. It's notable that all studies coming out of Africa--conducted mainly by those of white, European extraction--focus only on the male member, never the female. The paternalistic sexism of these studies is glaringly apparent. So is the unethical application of a surgery to all members of one gender based solely on some general manipulation of numbers. The waste of time and resources by these circumcision advocates is something the greater AIDS research community should take note of. Jerad Lee, MD, PhD
An Anonymous Missive 3 July 2000
M van der Veer, N/A Retired Send response to journal: Re: An Anonymous Missive	I received the following missive, anonymously, from someone with a rather different view of the brouhaha over the recent recommendations made by Szabo and Short regarding circumcision. Being unsure of whether or not it was meant as satire, and since I've a haunting feeling its sentiments may be widely shared among those who circumcise, I thought I'd bring it to the attention of readers. (It certainly does seem to suggest that Circumcision is not without merit as a subject of psycho-sexual study - and that perhaps this aspect of it ought to be more widely investigated and discussed.) A Modest Proposal To Szabo and Short Gentlemen: Bravo! Bravo! Wonderful! It was with the most fascinated interest that I read your splendid recommendation that circumcision be initiated, world-wide, as a prophylactic to the acquisition of AIDS. Indeed, chill- laden quivers of delight caressed my spine for long minutes after my first reading! However, if I may be so bold, may I modestly suggest what I believe to be a long overdue revision to the tremblingly delightful procedure of circumcision itself? To wit: In all cases, instead of limiting removal of tissue to mere excising of the foreskin, shift the site of ablation to the juncture of the groin and penis - and sever, with clean, surgical finality, this desease- seeking, lust laden, terrible wand of iniquity. I'm sure you'll agree standardization on this slight but eminently feasible modification will result not only in a fabulous decrease in AIDS, but also harbors the awesome potential for wiping out almost all STDs contracted by males across our globe - as well as truly going that rare extra mile in ameliorating the current catastrophic but still increasing population crisis. If you concur, may I further suggest that this newly revised procedure be applied first to those pioneers who would implement it? Indeed, what finer example could be set by these future, far-sighted geniuses (who, like you, will have so unselfishly put the betterment of mankind before any trivial, personal consideration) than to be its progenitors, destined for immortality in the annals, not only of our own civilization, but those of other, supplanting species to come? Yours in Swiftian admiration, A True Believer
Circumcisers: Penis Paracites 10 July 2000
Eileen Marie Wayne, Eye Surgeon Office & Hospital Send response to journal: Re: Circumcisers: Penis Paracites	Circumcisers: Penis Parasites Circumcision: Sexual Act of Surgical Sadism The AIDS & Circumcision Connection Thousands of circumcised men are dying of AIDS. Perpetrating circumcision as a preventive for AIDS is a willful act of misrepresentation. It is a disgrace and discredit to the medical profession. Cut Before the Victim is of Age to Refuse Sexual surgery on non-consenting, tethered, protesting infants, under the leal age of informed consent or refusal is a violation of the patient’s legal rights. Amputating healthy erogenous sexual tissue is genital surgical abuse. Cut Before the Victim Knows the Lubricating, Gliding, and Erogenous Sexual Benefits Inform the public about the immunologic, lubricating, gliding, and erogenous sexual benefits of the foreskin. Once a man and his mate experience the erogenous pleasure of his God-given foreskin, they will never consent to a mortal circumciser cutting it off. http://www.InformedConsent.com/Circumcision.html Circumcision: A Sexual Act of Surgical Sadism The most treacherous and pervasive penis parasite is the circumciser. The circumciser gives pain and takes pleasure. The British Journal of Psychiatry and Bizarre Behavior can have a field day with the perversion that is circumcision. History will look with contempt upon the circumciser. They bring shame upon their children and their children’s children. Stop the surgical sexual violence of our newborns. Take the circumcisers hands off. Eileen Marie Wayne, M.D. Founder, InformedConsent.com Foundation, Inc. http://www.InformedConsent.com" EileenWayneMD@InformedConsent.com
ETHICAL IMPLICATIONS OF MALE CIRCUMCISION AND HIV IN DEVELOPING NATIONS 11 July 2000
Adrian Viens Send response to journal: Re: ETHICAL IMPLICATIONS OF MALE CIRCUMCISION AND HIV IN DEVELOPING NATIONS	Editor - Szabo and Short (1) in their recent article on the role of male circumcision on HIV transmission raises important substantive questions with respect to developing nations. Although in developed nations (such as the United States and Canada) the incidence of male circumcision as a routine intervention has recently decreased for various medical and ethical reasons, its possible use in developing nations to combat HIV transmission is uncertain. Current antiviral drugs such as reverse transcriptase inhibitors and protease inhibitors, along with proposed AIDS vaccines are too expensive for many developing nations with a high prevalence of HIV infection. In developing nations where debt repayment or militarization often greatly exceeds health expenditures, it is tremendously unrealistic to expect that a cure or treatment for HIV will be successful in these countries. A good example is the prevalence of tuberculosis in developing nations. Although a treatment for tuberculosis has been around for approximately 40 years and its administration is relatively cheap, we continue to see the increased prevalence of tuberculosis infection around the world. We need to examine other alternative modalities of treatment, such as male circumcision, to reduce HIV transmission in developing nations. However, is it morally justifiable to have two standards with regard to the acceptance of male circumcision in developing versus developed nations? If we think that there are sufficient medical and ethical reasons to limit the routine use of circumcision, should not the same standards be held in developing nations? Pragmatically, I do not know if this is so clear. In developed nations, we see routine male circumcision as unnecessary because a slight increased risk of urinary tract infection and penile cancer does not justify removing the foreskin. However, in developing nations where prevention strategies such as education and condoms are not widely used (2), the existence of epidemiological evidence that shows a lower incidence of HIV infection in circumcised men (3), and minimal governmental expenditures on health care, male circumcision may be a medically and ethically viable option in helping to reduce HIV transmission in these nations. References: 1. Szabo R, Short RV. How does male circumcision protect against HIV infection? BMJ 2000;320:1592-4. 2. Quinn TC, Wawer MJ, Sewankambo N, Serwadda D, Li C, Wabwire-Mangen F, et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. N Engl J Med 2000;342:921-9. 3. Halperin DT, Bailey RC. Male circumcision and HIV infection: 10 years and counting. Lancet 1999;354:1813-5. Adrian Viens 35 Ormskirk Avenue, Suite 514, Toronto, Ontario, Canada M6S 1A8
Ethical Nightmare 17 July 2000
Sadira Bolt, Pediatrician Send response to journal: Re: Ethical Nightmare	I was greatly perplexed by Adrian Viens’ dithering suggestion that perhaps, in the case of developing countries, circumcision may be a medically and ethically viable option in helping to reduce HIV transmission eventho the forced amputation of the male and female prepuce is seen as unnecessary and unethical in developed countries. What we know about the hypothetical relationship between HIV transmission and circumcision status is tenuous and contradictory at best and the data suspect at worst. Under such circumstances, how could applying mass, forced, sexually diminishing amputations on only the male population of a given country possibly be, under any concept of ethics or sexism accepted by rational people, an ethical and non-sexist consideration? The logical slight of mind, let alone the moral gymnastics required of such a suggestion, fit well into the medical/ethical nightmares witnessed in our recent history. We have only to look at the Tuskegee experiments and the festivities of the Third Reich for instruction. All serious AIDS researchers and indeed, the thrust of the recent conference in Durban, agree that education is the key to solving the AIDS pandemic, not universal, involuntary amputations. HIV acquisition is the result of unsafe sexual behaviour. If Mr. Viens or anyone else ever develops a surgical technique that will amputate poor behaviour choices from willing volunteers, he may have something of interest. Sadira Bolt, MD, MPH
A little bit of science wouldn't have gone amiss 19 July 2000
Robert S Van Howe Send response to journal: Re: A little bit of science wouldn't have gone amiss	To the Editor - We read with interest the opinion piece by Szabo and Short.[1] While a number of studies suggest an association between the foreskin and HIV infection, a simple tallying of studies is both unscientific and misleading.[2,3] Systematic review using meta-analysis has demonstrated a significant degree of between-study heterogeneity, which calls into question the validity of the summary results. Analysis suggests that men who engage in high-risk behaviors may be placed at further risk by having a foreskin, but in the general population circumcision status is not a significant risk factor.[4,5] Based on the number of factors that influence sexual behavior and the susceptibility to HIV, it is irresponsible to focus blame on normal anatomy. The authors report finding Langerhans cells in the preputial mucosa. This is nothing new: all mucosal tissues have Langerhans cells. The authors failed to report the concentration of these cells in comparison to other mucosal tissues, their concentration in the glans, the foreskin remnant and circumcision scar in circumcised men, the presence of associated T-cell infiltration, and how their findings in elderly cadavers correlate to sexually active 20- to 30-year-old men in Africa. The authors presumptively state "the inner surface of the foreskin ... and the frenulum ... must be regarded as the most probable sites for viral entry of primary HIV infections in men;" however, without quantitative comparative data their statements are pure speculation. To date, the only reports of preputial Langerhans cells have been in specimens from neonates[6,7] and elderly cadavers. If normal genital mucosa is at risk, the concentration of Langerhans cells in these tissues is essential information in determining which normal genital tissue needs to be removed. We need to know the concentration in healthy men, men with multiple sexual partners, men with genital infections, men with HIV, and men of differing races and ages before any recommendations can be made. Because the infectivity of Langerhans cells may be linked to inflammatory T-cells,[8] their presence also needs to be documented. Finally, citing a pro-circumcision tract, the authors dismiss the complications of circumcision as having a "low incidence." In contrast, the rate of immediate complications in the United States is between 3.1%[9] and 9%,[10] and another 5% can later expect to develop meatal stenosis,[11] a common cause of obstructive renal failure.[12] Although it has never been directly measured, a higher rate of complications is believed to follow circumcisions performed in the developing world, where circumcision has been linked to tuberculosis,[13] tetanus,[14] penile amputation,[15] and death.[16] HIV transmission is heavily dependent on certain sexual behaviors, not anatomy. The authors have not provided any new information to alter this fact, but have taken the discussion off on a needless tangent. Although medicalized ritualistic circumcision appears to be an easy answer, as popularized by some Western researchers, this surgery is unproven and does not address the core behavioral issues that have fueled this pandemic. As a result, it will not alter the course of AIDS in Africa. Robert S. Van Howe, MD Minocqua, Wisconsin USA Christopher J. Cold, MD Marshfield, Wisconsin USA Michelle R. Storms, MD Hazelhurst, Wisconsin USA 1. Szabo R, Short RV. How does male circumcision protect against HIV infection? BMJ 2000; 320: 1592-4. 2. Greenland S. Quantitative methods in the review of epidemiological literature. Epidemiol Rev 1987; 9: 1-30. 3. Hedge LV, Olkin I. Vote-counting methods in research synthesis. Psychol Bull 1980; 88: 359-69. 4. Van Howe RS. Circumcision and HIV infection: review of the literature and meta-analysis. Int J STD AIDS 1999; 10: 8-16. 5. O'Farrell N, Egger M. Circumcision in men and the prevention of HIV infection: a "meta-analysis" revisited. Int J STD AIDS 2000; 11: 137- 42. 6. Hussain LA, Lehner T. Comparative investigation of Langerhans' cells and potential receptors for HIV in oral, genitourinary and rectal epithelia. Immunol 1995; 85: 475-84. 7. Weiss GN, Sanders M, Westbrook KC. The distribution and density of Langerhans cells in the human prepuce: site of a diminished immune response? Isr J Med Sci 1993; 29: 42-3. 8. Pope M, Frankel SS, Mascola JR, Trkola A, Isdell F, Birx DL, Burke DS, Ho DD, Moore JP. Human immunodeficiency virus type 1 strains of subtypes B and E replicate in cutaneous dendritic cell-T-cell mixtures without displaying subtype-specific tropism. J Virol 1997; 71: 8001-7. 9. O'Brien TR, Calle EE, Poole WK. Incidence of neonatal circumcision in Atlanta, 1985-1986. South Med J 1995; 88: 411-5. 10. Sutherland JM, Glueck HI, Gleser G. Hemorrhagic disease of the newborn: breast feeding as a necessary factor in the pathogenesis. Am J Dis Child 1967; 113: 524-33. 11. Van Howe RS. Variability in penile appearance and penile findings: a prospective study. Br J Urol 1997; 80: 776-82. 12. Eke FU, Eke NN. Renal disorders in children: a Nigerian study. Pediatr Nephrol 1994; 8: 383-6. 13. Annobil SH, Al-Hilfi A, Kazi T. Primary tuberculosis of the penis in an infant. Tubercle 1990; 71: 229-30. 14. Bennett J, Schooley M, Traverso H, Agha SB, Boring J. Bundling, a newly identified risk factor for neonatal tetanus: implications for global control. Int J Epidemiol 1996; 25: 879-84. 15. Özdemir E. Significantly increased complication risks with mass circumcisions. Br J Urol 1997; 80: 136-9. 16. Phillips K, Ruttman T, Viljoen J. Flying doctors, saving costs. S Afr Med J 1996; 86: 1557-8.
Warped! 22 July 2000
Kevin Elks, Business Owner Dover Send response to journal: Re: Warped!	Dear Sirs, I am appalled at the advocating of Male Genital Mutilation (circumcision) to reduce the risk of contracting HIV or Aids. It is totally irresponsible to even suggest such a thing. This suggestion of gaining protection by cutting off a pefectly healthy and useful pleasure sensor like the foreskin has grave negative effects. When this skin is removed it reduces sensitivity by at least 50%, the glans dry out and through abrasion on clothing will keratenize loosing even more sensitivity. The older you get the worse the effects. This makes sex more aggressive and prolonged to the point where the woman will often become 'dry', the vagina will sustain abrasion and often become sore. My wife suffered many bouts of 'Thrush' a fungal infection over the many years of marriage. When I spent years of stretching what skin was left to the point of having enough coverage to protect and moisten the glans both myself and my wife noticed a marked difference to the functionality and gentle pleasure the foreskin can provide. As a result she has not suffered with this type of infection in the last five years. What effect could the aggressive and prolonged sex act of the circumcised man have when HIV is concerned? Australian research has shown that condoms are more likely to split when a circumcised male is involved than an intact male. The circumcised male will be so de-sensitised that he will be reluctant to use a condom if it was at all avoidable. The only safe way to prevent HIV is an impermeable barrier such as a condom and it is irresponsible to say anything to discourage their use. What about the insanitary conditions that this form of mutilation may be carried out? There are deaths in the developed rich country's of the world through circumcisions, we know that there are many deaths in Africa due to this practice. I fail to understand the obsession that some people have to cut off sexual bits from defenceless children that cannot chose. Yours disgusted, Kevin Elks.
Male circumcision and protection against HIV infection. 22 August 2000
R T D Oliver, Professor of Medical Oncology St Bartholomew's Hospital Send response to journal: Re: Male circumcision and protection against HIV infection.	Dear Sir Re Male circumcision and protection against HIV infection Recently Szabo and Short in an educational article (BMJ 2000;320:592- 94) have suggested that the increased number of Langerhans' cell on the surface of the foreskin explains why circumcised men are less likely to become HIV infected. The authors failure to mention an issue that has long dogged debate on the protective effect of circumcision on incidence of cervix cancer and now increasingly prostate cancer 1,2, i.e. how much are improved hygiene and affluence are confounding variables to the benefits of circumcision. This is exemplified by the lower incidence of cervix cancer in educated high caste women in India whose husbands were not circumcised than in the less educated Muslim women with circumcised husbands 3. Undoubtedly the increased numbers of Langerhans' cells with HIV receptors in the foreskin may well contribute to an increased susceptibility to HIV. Evidence that nutritional status and other STDs also plays a role in acquisition of HIV Infection prompted us to examine the role of the foreskin in the occurrence of HIV infection in a series of new patients 83 (40 of whom i.e. 48% HIV positive) attending a Urethritis clinic at East and West Drakefontein Gold Mines Carltonville, Gauteng South Africa as part of a study of the impact of HIV/STD on serum PSA 2 . The miners, after signing informed consent, received a questionnaire and were examined in relationship to ascertaining circumcision status including whether the glans penis was visible and retractability of foreskin. In addition a limited history of sexual activity was recorded. As expected the frequency of HIV was significantly lower in those who were circumcised (Table). Possibly more interesting was that the small subgroup circumcised after puberty seemed to have some benefit in reducing the incidence of HIV. Even more interesting in light of Szabo & Short's hypothesis about the increased numbers of Langerhan's in the foreskin, was the observation that contrary to what might be expected if their hypothesis was correct, the HIV frequency was less in men with long foreskins that were difficult to retract than in those with short easily retractable short foreskins. Clearly this observation is based on too small a sample size to be totally confident in the results. However these observations added to those on the role of hygiene versus circumcision in reducing cervix cancer 3 from India do suggest that further studies in this issue could well help to clarify Szabo and Short's hypothesis and need to be done before implementation of widespread use of circumcision in an attempt to reduce spread of HIV infection. Furthermore work needs to be done on the influence of circumcision after puberty as performing such a procedure after the first STD infection could be a more effective approach than total population based circumcision. Yours sincerely RTD Oliver, JC Oliver, R Ballard. Table ______________________________________________________ No. of cases HIV sero positive ______________________________________________________ Circumcised: All 20 29%a pre puberty 9 22% post puberty 12 33% Non-circumcised: All 62 55%b Exposed glans/ 31 61%c easy retraction Long foreskin/ 31 48%d difficult retraction ______________________________________________________ a v b chi2 = 4.33 p=.037, c v d chi2 =1.04 p=0.308 References: 1. Ross R, Shimizi H, Paganini-Hill A, Honda G, Henderson B. Case- control studies of prostate cancer in blacks and whites in southern California. J Natl Cancer Inst 1987;78(5):869-74. 2. Oliver J, Oliver R, Ballard R. Influence of circumcision and sexual behaviour on PSA levels in patients attending a sexually transmitted disease (STD) clinic. Prostate Cancer and Prostate Diseases 2000;In press. 3. Gajalakshmi C, Shanta V. Association between cervical and penile cancers in Madras, India. Acta Oncologica 1993;32(6):617-620.
Not all male circumcisions are the same. 4 January 2001
Judith E Brown Send response to journal: Re: Not all male circumcisions are the same.	EDITOR - We are currently investigating male circumcision in central Kenya, so we found helpful Szabo and Short's discussion of the mechanisms that may link an intact foreskin with heightened risk of HIV infection. They offer two possibilities: (a) Langerhans' cells with HIV receptors on the inner surface of the foreskin, and (b) a vascularised frenulum susceptible to trauma during intercourse.1 We must not assume, however, that we all know what "circumcision" is. When Tanzanian researchers compared men's self reports of their circumcision status with clinical observations, agreement was only 81%. When they asked the same men on two different occasions whether they were circumcised; agreement between the men's own first and second reports was 77-90%.2 Several African investigators, in performing genital examinations, have added to the categories "circumcised" and "uncircumcised" a third category, such as "partially circumcised" or "functionally uncircumcised".3 In our area, on the eastern slopes of Mt. Kenya, men uniformly report that they were circumcised during adolescence. Three very different procedures are practiced, though, varying by ethnic sub-group and by the person doing the circumcision. Two of the procedures (one performed by hospital nurses and the other by traditional circumcisers) produce identical results after healing, but they employ quite different surgical techniques and remove different parts of the foreskin. The third procedure, also a traditional technique, removes the tip of the foreskin and leaves the rest as an appendage on the ventral side of the penile shaft. Besides questions and clinical exams, detailed knowledge of local languages and customs is essential to determine exactly what parts of the foreskin were removed and which are left attached. These different circumcision procedures raise new questions about risks of infection. Does a partial foreskin put the man as much at risk as a complete foreskin? When part of the foreskin remains, are Langerhans cells still present? Is the frenulum still susceptible to trauma? What if the inner surface of the prepuce is scraped, while the outer surface is left intact? Is it possible that certain styles of circumcision, rather than offering some protection, actually constitute an added risk of infection? More answers are needed before we can recommend male circumcision as a risk-reducing intervention. Judith E Brown medical anthropologist Chogoria Hospital, PO Box 35, Chogoria, Kenya Kenneth D Micheni nursing finalist Elizabeth MJ Grant consultant in community health James M Mwenda nursing tutor Francis M Muthiri nursing tutor Angus R Grant general practitioner 1. Szabo R, Short RV. How does male circumcision protect against HIV infection? Brit Med J 2000;320:1592-4. 2. Urassa M, Todd J, Boerma JT, Hayes R, Isingo R. Male circumcision and susceptibility to HIV infection among men in Tanzania. AIDS 1997;11:73-80. 3. Moses S, Bailey RC, Ronald AR. Male circumcision : assessment of health benefits and risks. Sex Trans Inf 1998;74:368-73.
Cultural imperialism should be recognised for what it is 28 May 2001
John D Dalton, Researcher and Archiver NORM-UK Send response to journal: Re: Cultural imperialism should be recognised for what it is	Th e-letter from Judith E Brown serves as a reminder of the cross-cultural problems associated with research of the kind presented by Short and Szabo. Western researchers have a clear idea of what they understand by "circumcision", but do not appreciate that "circumcision" in other parts of the world may refer to many differing procedures with differing characteristics and effects. The effects of one practice may not, indeed probably do not, read across to the others. While some of those looking at the effects of circumcision on HIV in Africa are no doubt innocents drawn unwittingly into the fray, many "researchers" are seeking to use African data of spurious relevance to proselytise for their own form of "circumcision" in their own culture. The recent Los Angeles Times article Spreading Islam With His Scalpel (Monday, May 21, 2001) shows that circumcisers consider they have a role in expanding the political and economic influence of their countries. Medical research should not be subverted by those with similar ambitions.
Safe Circumcisions in Africa ? When ? 30 April 2007
Jean-Jacques, A. GUILBERT, former professor public health CH - 1205 Geneva Send response to journal: Re: Safe Circumcisions in Africa ? When ?	From a UN Title : The circumcision surgery has serious risks if performed in unhygienic settings by poorly trained providers or with inadequate instruments, as often happens in Africa. According to ONUSIDA and to WHO "The risks involved in male circumcision are generally low" (with no reference to corresponding research reports) while admitting that “Information on traditional practices is required” and recognizing that "high complication levels have been observed when the circumcision is undertaken in unhygienic settings by poorly trained providers or with inadequate instruments". WHO recognizes that "Health services in many developing countries are weak and (that) there is a shortage of skilled health professionals". It recognizes that “the safety of male circumcision depends on the setting, equipment and expertise of the provider”. It therefore recommends that “Supervision systems for quality assurance should be established along with referral systems for the management of adverse events and complications” and "that the training (in standardized procedures) and certification” of providers should be rapidly implemented” in the public and private sectors. Any observer of the African scene knows that the expression “rapidly” is only an example of the xylographic headquarters’ style and is of no practical consequence in the field. "quotes" :from WHO/UNAIDS News Release/10, of March 28, 2007, and from Conclusions and Recommendations, WHO/UNAIDS Technical Consultation, Montreux, 6-8 March 2007 (embargoed: 28 march 2007) JJ.Guilbert, M.D., Ph.D.(educ), D.Hc. 30 April 2007 Competing interests: None declared