Review of: The African AIDS Epidemic, by J.C. Caldwell and Pat Caldwell, Scientific American, March 1996

According to American historian Frederick Hodges, a common thread in the hundred-year-old tradition of Western medical circumcision advocacy has been a tendency to take whatever maladies may hold public attention at a particular time, and to hold up circumcision as a preventative or cure for them.¹ Born at a time when the American populace was gripped with a morbid fear of children masturbating, routine neonatal male circumcision has since been encouraged by fears of penile and cervical cancer, sexually transmitted diseases, urinary tract infections, and simply poor hygiene, during the course of the twentieth century.

A related phenomenon---which continues to this day---has been a tendency in the literature to emphasize even the most tentative results in favour of male neonatal circumcision, while at the same time fastidiously avoiding any implication that the amputation of the foreskin could have disadvantages. Popular men's health books abound with myths about the natural penis. American medical journals still publish articles claiming that it is necessary to circumcise boys---but not girls. Circumcision has, after all, become accepted by Western medicine, a system that prides itself on providing the best possible standards of care. There is a human need to find good in all things that we do. The African AIDS Epidemic, by the Australian demographer John C. Caldwell and anthropologist Pat Caldwell, is a remarkable example.

The Caldwell argument is based solely on an observed geographical correlation between male non-circumcision rates and HIV-1 rates in Africa. The region in which most men are not circumcised correlates well with the so-called AIDS belt, the region defined here as that in which some 10% of rural and 23% of urban inhabitants are infected with HIV-1. (The AIDS epidemic in Africa is predominantly a heterosexual problem.) Earlier studies of the correlation had been criticized for having used older data that may be inaccurate; Caldwell assures us that the data is new and reliable, although it is not mentioned whether or not they accounted for certain well-known confounding factors that make such surveys inherently difficult.² In addition, the maps of Africa that accompany the Caldwell article rely on artificial boundaries (national boundaries and the 10 degree North parallel of latitude). This may overstate the actual degree ofcorrelation.

In any case, correlation indicates a statistical relationship only, and does not amount to causation. Caldwell is not sufficiently clear on this point. There is no hard evidence that non-circumcision directly and physically increases the risk of contracting and/or transmitting HIV via heterosexual intercourse. The majority of published studies have, in fact, failed to find any significantincrease in risk amongst the noncircumcised.²

The argument used here is essentially a process of elimination, an attempt to exclude other explanations for the observed distribution of HIV-1. However, the correlation could instead be due to otherfactors not studied or not well understood.

The Caldwells immediately discount the hypothesis that the geographical distribution of AIDS in Africa may be due to the disease having its origins in one particular region. They write: ...the AIDS belt is not circular but elongated, clearly not the pattern of expansion from an epicenter. But this fails to take into account patterns of human migration, which are influenced by complex social factors, environmental factors and topography. An earlier study in Tanzania concluded that the results are consistent with the spread of HIV-1 infection along the main roads. There is no evidence that lack of circumcision is a risk factor in this population.³ Because of this and similar results, the center-of-origin theory remains, in the opinion of many researchers, the most plausible one to date.²

A useful approach would be to test the hypothesis of causation in a random sample of individuals, all factors other than circumcision status being equal. Of the many studies that have attempted to do this, some have reported a statistically significant correlation between non-circumcision and HIV.² Unfortunately, though, circumcision status is highly dependent on cultural background and other factors that are not well understood; so it is difficult ifnot impossible to exclude all sources of bias from such an experiment.

Furthermore, it has been suggested that female circumcision (or infibulation) may be a risk factor for the spread of HIV in sub-Saharan Africa; and male circumcision is invariably present in all societies that practise female circumcision.⁴ Despite great media coverage of the issue in recent years, no mention of female circumcision is to be found in the Caldwell article. Could female and/or male genital mutilations actually increase the risk of disease? This frightening question warrants further study.

The selection and presentation of data is misleading. For example, the graphs on page 66 paint a rather dramatic picture: HIV rates of 2.5%-13% for circumcised men, compared with 29%-53% for intact men! But one must read another part of the text carefully, to realize that the two samples come from two very different ethnic groups in Kenya: The largely circumcised Kikuyu on the one hand, and the largely intact Luo on the other. Cultural background is a significant confounding factor in the correlation between non-circumcision and HIV infection. The most extreme from a range of statistics have presumably been used, in order to make the presentation appear convincing.

In the sidebar text accompanying these graphs, it is written: For uncircumcised men, thorough cleaning of the genitals can be particularly challenging. This may be truer in Africa than in developed countries; but if poor genital hygiene plays a role in increasing HIV risk (possibly mediated by other STDs such as chancroid), improving hygiene standards in Africa is surely the most sensible way to combat that risk. It is, by the way, just as easy for a man to keep his intact penis clean as it is for a woman to keep her intact vulva clean! Men ought to stand up and challenge any suggestions to the contrary.

Finally, there is propaganda:

In rural southwest Tanzania, and surely elsewhere in the AIDS belt, uncircumcised man have not waited for agreement among researchers about the connection between circumcision and AIDS. Based on observations of their community and neighboring ones, they have concluded that they are at greater risk for AIDS than circumcised men. These men are appearing at hospitals in sharply increasing numbers, requesting circumcision for themselves and often for their sons. Clinics that offer adult male circumcision as a protection against AIDS now advertise in Tanzanian newspapers.

Surely an advisable strategy to controlling AIDS in Africa would be to make contraceptives widely available, while at the same time controlling widespread panic! The use of condoms is known to be reliable in reducing HIV risk; to suggest that circumcision could play this role instead is, in the reviewer's opinion, disingenuous inthe extreme.

The foreskin has a protective function, as well as sensory and physiological functions during sexual intercourse.^5,6 All male mammals have been provided with a foreskin, and any man possessed of his prepuce ought to be able to list some of the advantages tohaving it.

Circumcision is fundamentally a social surgery, still in search of a medical need. The answer will not likely be found with HIV and AIDS. Rates of circumcision in the United States are declining precipitously.⁷ When circumcision finally disappears, we will probably find it inconceivable that we ever did such a thing to our children, and readers of Scientific American in the year 2046 will be either amused or perplexed to see mention of the presentarticle, in the column, 50, 100, 150 and 200 Years Ago.

(reviewer:)

(the authors:)

© 1996 Geoffrey T. Falk. Permission is given to copy and distribute this text in its entirety for any noncommercial purpose.

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