March 5, 2012

The Pros and Cons of Circumcision: Part 1

Can male circumcision really reduce HIV transmission risk by 60% or more? And how can circumcision be used to battle the AIDS epidemic in sub-Saharan Africa?

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Male circumcision is a tricky topic. An important religious rite to some, a life-saving preventative health service to others, and a controversial, abusive practice to others still–the topic of removing foreskin continues to invoke heightened emotions in cultures around the world. Today, in Part 1 of The Pros and Cons of Circumcision, we’ll be discussing the recent public health implications of circumcision in sub-Saharan Africa in the battle against HIV/AIDS.

Recent studies in sub-Saharan Africa have found that being circumcised reduced male participants’ risk of contracting HIV from female sex partners by as much as 63%. The effect of circumcision on AIDS transmission in these populations has been known to medical science since 1989, when medical anthropologists observed that the cultural groups in Africa where circumcision was not commonly practiced had the highest HIV infection rates. This represents excellent news for public health efforts aimed at reducing the rate of AIDS in these populations, but also raises several concerns.

Wait, what?

Does it all sound too good to be true? Well, it is–if you’re thinking about it the way I was initially.

First let’s talk a bit about the mechanics of male circumcision and HIV transmission. Circumcision is believed to reduce risk of HIV transmission because the inside of the foreskin is a mucous membrane that contains a copious number of Langerhans cells, giving viruses such as HIV a greater surface area through which to enter and infect the host.  By removing this mucous membrane, circumcision reduces the AIDS virus’ chances to successfully infect a host.

Think of it as the difference between opening your mouth when a sick person sneezes in your face, and keeping it closed. Makes a degree of sense, right?

But next, it is extremely important to note that the studies in question are not suggesting that getting circumcised reduces every man’s chance of contracting HIV, or that you should pursue circumcision as a way to reduce your risk of AIDS. That really is too good to be true.

The studies’ results only apply to MSW (men who have sex with women) in sub-Saharan Africa. Now, while this might sound faulty (“Well if it works for them, why won’t it work for me? The mechanics are the same, right?”), I humbly beseech you to hang on a minute.

When you think about the way that research studies are conducted, you have to remember that the results really only apply to the individuals that participated in the study. And even then, it doesn’t apply to all of them, or to any circumstances/situations that weren’t represented in the study. This is why research suggests things, and demonstrates trends, but never provides concrete proof.

So please, don’t assume from this article that being or getting circumcised will magically protect you from contracting HIV or STIs if you have unprotected sex. In fact, studies on American MSM (full study available here) have repeatedly shown circumcision to have no protective effect against STIs or HIV, and possibly even increase MSM’s chances of contracting STIs. Condom use is the only thing that has consistently been shown to have a protective effect against HIV and most STIs in all populations. For reals.

So while the studies’ findings may not have implications for American males, they still represent exciting progress in the fight against HIV/AIDS in sub-Saharan Africa, where such innovations are desperately needed.  However, due to the high cost and lack of access to the surgery, wide-scale circumcision has previously not been an option for these populations.

Assembly Line Circumcision

But an innovative, new device might be the key to breaking these barriers: the PrePex makes the procedure safe, easy, painless, and bloodless. A sterile environment is not required for the procedure, and a small number of staff can circumcise hundreds of men a day with it. This assembly-line method of circumcision makes Prepex unprecedented for ease of use and maximum accessibility. Invented in 2009, the device was only recently approved by the FDA.

First, the PrePex size selector is used to determine which size rings and ElastiRing will be used for each individual. Next, a trained practitioner marks along the outside of the foreskin where it will be removed, and the Inner Ring is placed around the glans of the penis, beneath the foreskin. An elastic band (ElastiRing) then secures the foreskin tightly (but not painfully) into a groove along the surface of the Inner Ring. The ElastiRing compresses the foreskin, stopping the flow of blood to the measured amount of skin secured above the ElastiRing. After 7 days, the foreskin will be dead, much like a clamped umbilical cord, and can be removed like a fingernail with safe, blunt scissors.

The Effect

Due to a combination of biological, economic and cultural factors, AIDS disproportionately affects heterosexual women in sub-Saharan Africa, where women represent 59% of adults living with AIDS, and young women are two to six times as likely to be infected as their male peers.

Although the PrePex does not affect individual women’s risk directly, reducing the number of male adults living with AIDS will have an important impact of decreasing overall transmission risk for all adults, and represents an important step toward ultimately eliminating the HIV/AIDS epidemic in sub-Saharan Africa.

Despite these exciting public health implications, there is a dark side to the research findings about circumcision in sub-Saharan Africa. Misinterpretation of the findings is leading rural men in sub-Saharan Africa to engage in unprotected sex, which drastically increases their risk of contracting HIV, regardless of their circumcision status. In fact, due to such misinterpretations, it is believed that the public health message promoting the so-called “circumcision solution” will ultimately increase the rate of HIV infection in sub-Saharan Africa.

Such misinterpretations and subsequent health effects highlight the incongruences between public health messages and public health practice, as well as the cultural difficulties inherent in the battle against HIV in sub-Saharan Africa. That is why it is important for readers to seek information and do their own research on research studies and health practices, and make sure you’re getting the whole picture when it comes to your health.

Next time, in The Pros and Cons of Circumcision: Part 2, we’ll be exploring the possible sexual consequences of circumcision, in terms of pleasure and satisfaction.

Burke Denning is an MPH student at Indiana University, and is currently interning at the Kinsey Institute. Her studies are centered around the promotion of holistic sexual health and education that seeks to improve quality of life, and expands beyond the prevention and treatment of disease, dysfunction and unintended pregnancy.