Foresight
Can recent studies about the health benefits of circumcision be trusted?
by Paul Festa
August 20, 2007
It's said that a little knowledge is a dangerous thing, and there's nothing like a conversation about male circumcision and sexual health to prove the point.
Consider my contribution to the problem. Every time the subject of circumcision has arisen, whether at a wedding, a funeral or a bris, I've always brought up the study they did showing that the female partners of uncircumcised men were significantly more likely to wind up with cervical cancer. I long ago forgot, if I ever knew, who did the study, or when, but nobody ever asks. In casual chit-chat — most people's source of medical information — "they" is an authority beyond dispute.
Whoever was behind the research, it served admirably as a conversation stopper. If I were debating a circumcision opponent (which describes most of my friends and acquaintances under fifty), the words "cervical cancer" would fry their argumentative circuits; you could almost smell their liberal pieties about respecting the integrity of the human body being incinerated by their liberal pieties about men's responsibility for protecting their partners' sexual health. As the circumcision opponent fell mute, I'd go on to explain the study results, how nearly all cervical cancers were caused by varieties of the human papillomavirus, or HPV, and that the research demonstrated that intact foreskin played a role in transmitting the lethal virus.
In fact, the research linking HPV infection to intact foreskin is highly controversial and its conclusions muddy. A paper in August's British Journal of Infection looked at sixteen papers on this subject, found serious methodological problems with most of them and concluded from the salvageable data that there was "no significant association between genital HPV infection and circumcision status." So whether or not circumcisions are protecting men and their sex partners from viral infection, I've apparently been spreading something else to my conversation partners over the years: medical misinformation.
The link between circumcision and sexually transmitted disease is a hot topic this year, and, according to circumcision opponents, misinformation is playing a key role in the debate. Three papers published in 2007 claimed to demonstrate that male circumcision significantly reduced female-to-male AIDS transmission in South Africa, in Kenya, and in Uganda. The studies instantly became a rallying cry for circumcision proponents around the world, and not just on behalf of African populations. In New York, the health department said it may recommend adult circumcision as a way to help slow the spread of AIDS there.
"The efficacy of male circumcision in reducing female to male HIV transmission has now been proven beyond reasonable doubt," the World Health Organization and the United Nations' AIDS program declared this year.
But circumcision opponents fault the African studies on methodological grounds. They say the African subjects and theresearchers studying them had a so-called expectation bias that influenced the results. While researchers told both the circumcision and control groups to practice safer sex, the circumcision group was told to abstain from sex altogether or use condoms while their circumcisions healed, a period of safe sex that study critics say would likely skew the rates of HIV infection. And because the studies were concluded early, after eighteen months, critics say the effect of that lead-time bias would be magnified.
Circumcision opponents complain more generally that the procedure has attached itself to medical justifications with some promiscuity over the years. When circumcision was first promoted in English-speaking countries in the nineteenth century, it was as a prophylaxis against masturbation, which in turn was thought to cause such disorders as TB, epilepsy, insanity and hip dysplasia.
"Male circumcision has long been an operation in search of a disease," wrote members of the group Doctors Opposing Circumcision in the May 12th edition of The Lancet.
In the twentieth century, as claims about masturbation and mental illness started sounding quaint and then downright wacky, circumcision transformed itself into a shield against STDs, urinary tract infections and cancer. "A clear pattern has emerged," wrote circumcision opponents introducing a study in the November 2005 Journal of the Royal Society for the Promotion of Health. "Any incurable disease that happens to be the focus of national attention at any given time will be used by U.S. circumcision advocates as an excuse for the continued imposition of mass circumcision."
Controversy in scientific research is hardly unique to the subject of male circumcision, but the procedure itself does pose unique challenges to the investigator. The first of these is determining who is actually circumcised. In some studies, researchers simply asked participants — or their female partners — if the penis in question was intact or not. But circumcision skeptics say asking doesn't cut it. Bob Van Howe, co-author of a recent study showing that circumcision removes the most sensitive parts of the penis, cites research showing that both men and women are wrong about the circumcision status of the penis between five and thirty percent of the time. (I found this statistic implausible until I asked my mother whether my father — to whom she'd been married for eighteen years and with whom she'd had two children — was circumcised. She didn't know.)
Even after figuring out who's cut and uncut, the researcher confronts epidemiologically significant cultural and religious questions that can turn painstakingly designed studies into the equivalent of a leaky condom. In Africa, as elsewhere, Muslim men are more likely to be circumcised and less likely to be HIV-positive. Is that because their circumcision is protecting them, or because of the way religion and ritual affect their sexual behavior and genital hygiene? In England, circumcision rates among older men are class-determined. Are HIV rates among the gentry low because they're missing a prepuce, because of the sex practices of the English upper class, or because of the education and health care they can afford? In the U.S., Hispanics are less likely to be circumcised than African-Americans, and less likely to be HIV-positive. Again, is that a function of cultural affiliation and sexual behavior, or of foreskin?
In Africa, circumcision research faces even knottier challenges. One study published this year showed that sub-Saharan African adolescents and virgins were significantly more likely to infected with HIV if they were circumcised, probably because they were infected by the instruments used to circumcise them. But among circumcised adults, HIV rates were lower. Instead of indicating that foreskin was the culprit in spreading HIV, the study authors suggested, this lower HIV prevalence may simply be because a significant number of men who were circumcised as boys in Kenya, Lesotho and Tanzania didn't survive their circumcisions long enough to be studied.
So is it any surprise that circumcision studies are so frequently at odds with each other? From the studies I've reviewed for this story, I could use peer-reviewed scientific evidence to support the notion that circumcision results in higher rates of infection with herpes type 2, or lower rates of herpes type 2, or higher rates of infection but lower incidents of herpes outbreaks. I could argue that circumcision helps prevent HPV and anogenital and cervical cancer or that it has no effect. I could argue that the West has an obligation to help Africa get circumcised or that it has an obligation to leave African penises alone.
But even if the medical establishment arrived at an undisputed consensus, I'll keep thinking about the well intentioned parents — and doctors — in the nineteenth century who circumcised millions of boys to protect them from hip dysplasia. Doesn't that history give us a special obligation to be cautious?
Circumcision proponents say that amounts to tainting them by association with yesterday's crackpots. "One can find absurd statements about almost anything if one searches for them," said Robert Bailey, professor of epidemiology at the School of Public Health at the University of Illinois at Chicago, and the principal investigator for the Kenya study. "There is a lunatic fringe advocating for or against nearly every medical treatment ever proposed."
But the nineteenth century argument linking circumcision, masturbation and epilepsy didn't belong to the lunatic fringe. It belonged to the medical establishment. Respected researchers in major medical journals and textbooks urged doctors to amputate the foreskin of men and boys to prevent them from jerking off and contracting the debilitating disorders, physical and otherwise, that masturbation was thought to cause.
How will future generations judge today's medical establishment on the question of circumcision? Surely scientific research today is more rigorous than it was in the nineenth century. In the coming century, it will be more rigorous still. Personally, if I'm ever in the position of deciding whether an infant is going to have the most sensitive part of his penis cut off in exchange for potential health benefits later in life, the full range of what They have been telling us over the last 150 years is going to raise one hell of a red flag. ©2007 Paul Festa and hooksexup.com