Ellsworth

From: BarryBE@AOL.com
Date: Sun, 16 Jun 1996 19:58:04 -0400
Message-ID: <960616195804_136272319@emout07.mail.aol.com>
To: fgm-l@bitsy.hollyfeld.org, Karen.E.Kun-1@tc.umn.edu
Subject: requested information
Sender: owner-fgm-l@hollyfeld.org
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reply-to: fgm-l@bitsy.hollyfeld.org

Karen E. Kun recently cited Moses' review of published studies on a relationship between circumcision status and HIV transmission, and requested further information on the subject, and on any medical associations that have criticized routine male circumcision.

Moses et al. developed their original conclusions from geographical data without examining a single patient (Moses S, Bradley JE, Nagelkerke NJ, Ronald AR, Ndinya Achola JO, Plummer FA. Geographical patterns of male circumcision practices in Africa: association with HIV seroprevalence. Int J Epidemiol 1990; 19: 693-7.). They failed to confirm circumcision status or to take recognized factors such as age of first coitus, chastity, and monogamy into account. This is obviously a grave oversight, as circumcision status is often misreported, and sexual prectices have a great bearing on HIV transmission.

Of the ten studies to date that are not marred by serious methodological flaws, only three found an association of HIV transmission with uncircumcised status, while five found no connection, and two found higher levels of HIV transmission among circumcised men. In an independent review of studies on the relationship between circumcision status and HIV transmission, Isabelle de Vincenzi and Thierry Mertens, (of the European Centre for the Epidemiological Monitoring of AIDS, and The London School of Hygiene and Tropical Medicine), concluded that relatively few studies have been carried out and those that have present conflicting results. The major criticism of most of the studies performed 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 behavior or differences in hygienic practices or differential use of specific health facilities ... 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. (Male circumcision: a role in HIV prevention?, Isabelle de Vincenzi and Thierry Mertens, AIDS 1994, 8:153160)

In an excellent example of self-promotion in the world of academic medicine, Moses later led a review of the literature on the subject (Moses S, Plummer FA, Bradley JE, Ndinya-Achola JO, Nagelkerke NJ, Ronald AR. The association between lack of male circumcision and risk for HIV infection: a review of the epidemiological data. Sex Transm Dis 1994; 21: 201-10.) in which each of the authors were part of at least one of the studies reviewed that claimed a positive connection between circumcision and HIV status. Not surprisingly, they confirm their own conclusions, and then go on to suggest that consideration be given to male circumcision as an intervention to reduce HIV transmission. Dr. Frank Plummer, who co-authored both papers with Moses, has claimed that Male circumcision, if it could be universally implemented, would be a very effective [AIDS] prevention. (Scientists Discover Circumcision is Key: AIDS Clues Turn Tide, Winnipeg Free Press 7/23/95)

The promotion of circumcision as an AIDS prevention strategy defies common sense. American men in the age groups hit hardest by AIDS are about 90% circumcised. Disseminating the notion that circumcision confers protection from AIDS is likely to lead the public to forego recognized methods of HIV prevention,such as condom use, with potentially disastrous effects.

That American medical associations such as ACOG (Gynecology,) AAP (Pediatrics,) and the AMA (American Medical Association), have condemned FGM while waffling on male circumcision is no surprise, since their members perform most of the one million infant male circumcisions done in the United States every year. Selections from The Canadian Peadiatric Society's position statement follows:

There is no medical indication [justification] for circumcision during the neonatal period....The more immediate hazards of circumcision include infection, which may be minor, or which could lead to gangrene or, general sepsis, severe haemorrhage, mutilative deformity of, the penis, or rarely, a procedural misadventure requiring, partial amputation of the penis....Later complications include the excoriation of the exposed edges of the glans from a diaper dermatitis, or a similar lesion at the urethral meatus, resulting in stenosis in some cases. The narrowed passage may produce obstructive uropathy and its more serious consequences...There seems to be little basis for prescribing routine circumcision because of a fear of cancer of the uncircumcised prepuce developing in a septuagenerian. It is an infrequently encountered lesion, easy to detect and unlikely to spread. This remote possibility of a curable condition of very old age stands in sharp contrast to the established hazards of neonatal circumcision...The claim that circumcision is associated with a reduced prevalence of venereal diseases [including HIV] in the adult male, or a decreased frequency of cervical carcinoma in the sexual partner, has not been established as a cause-and-effect relationship...Although the desire for conformity has sometimes influenced a parent's or doctor's decision, intended to ensure that the newborn infant in question will grow up to have genital resemblance with his father and brothers, any important conformity must now be considered in relation with the peer group in a society with a rapidly diminishing demand for circumcision...If paediatricians are showing leadership in curtailing the numbers of mutilative operations of questionable benefit, it is likely that uninformed parents may turn to their family physician or obstetrician to perpetuate such an obsolete operation. Therefore, discussion of this subject should be encouraged among all who may deal with parents, both among the medical and nursing professions...In the search for ways in which to stem the rising cost of health care, the removal of such an unnecessary procedure as a routine practice can be calculated as a major saving in terms of direct charges - professional fees, nursing and other hospital services and supplies, and sometimes the length of hospital stay - and secondary costs resultingfrom any recognized clinical complications.

A blind reliance on medical opinion, which is often contradictory and divided, is unwarranted in evaluating male circumcision. Over the past century, circumcision has been promoted by American doctors as a cure for tuberculoses (S.G.A. Brown, MD, A Plea for Circumcision, Medical World 1897;15:124-125; Editor, Medical Record. Circumscisus, Medical Record, 1896;49:430), epilepsy (Steele, MD. Importance of Circumcision, Medical World,1902;20:518-519; Abraham L. Wolbarst, MD. Universal Circumcision, Journal of the American Medical Association, 1914;62:92-97), and paralysis (Charles E. Fisher, MD. Circumcision, A Hand-Book On The Diseases of Children And Their Homeopathic Treatment. Chicago: Medical Century Co. 1895. 875; Steele, MD. Importance of Circumcision, Medical World,1902;20:518-519). Many of the same doctors who promoted circumcision also endorsed and performed clitoradectomies with similar justifications.

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