Thursday, January 31, 2008

Circumcision in America

By Debra S. Ollivier
First published by Salon (1998). Reposted with permission.
Read more from Ollivier here at Salon.

PART ONE

When I told people that our newborn son would not be circumcised, I didn't realize that a tiny but vital part of his penis would touch off deeply held convictions about cultural mores, aesthetics, psychology, hygiene, father-son relations, American identity and thousands of years of biblical traditions. In fact, I hadn't given penises much thought since my teenage years, when every penis was a circumcised penis and the only issue of overriding concern as the tentative probings of adolescence bloomed into full-blown sexuality was: "How does this thing work?" Years later, I was given a detailed, hand-etched poster called "Penises of the Animal Kingdom"; in this vast forest of mammalian genitalia the only thing more striking than the banality of man's penis next to that of the 20-foot gray whale was the fact that all of them, including man's, were intact. Aside from this brush with reality, however, the mushroom leitmotif of the circumcised penis remained the unequivocal, unquestioned status quo of my youth and of all my peers. It was the uncircumcised penis, with its strange fleshy retractability, that was somehow freakish, a slightly vestigial aberration, like being born with a tail or a set of gills.

Years of living in Europe and being married to a French (intact) Catholic changed all that. Because only Jews and Arabs practice routine circumcision in Europe -- in fact, the United States is the only country in the industrialized world to practice it across the board -- I eventually grew so accustomed to the intact penis that a circumcised one now looks startlingly bereft. Still, when I told people in the States that our son would not be circumcised it was as if, in keeping his little foreskin intact, I was committing a perfidious impropriety: refuting both my Jewish and American identity and, in so doing, robbing my son of both. For all those who expressed their convictions, however -- the astonished Jewish relative, the slightly repelled girlfriend, the perturbed American husband -- a number of questions hung in the air, unanswered. Why, exactly, do we circumcise? How did circumcision evolve from a strictly Jewish and Muslim ritual to a standard medical procedure performed on a vast majority of American males, irrespective of religion? Why is the United States the only Western nation in the world to practice it routinely, despite overwhelming evidence debunking medical claims and enduring myths? More important, what exactly is the foreskin, what happens when we remove it and why do we continue to opt for circumcision?

It doesn't take much to realize that nature didn't intend the foreskin and the penis to be separated at birth. Try retracting the foreskin of a newborn's penis and you're struck by the steadfast, tenacious grip it has on the glans, or head. The foreskin is sealed to its bounty like a silo, and only slowly, over the years, yields to full retractability. But it's far more than just a sheath. The foreskin contains thousands of highly sensitive sensory receptors called Meissner corpuscles, which are more abundant there than in any other part of the penis. Richly endowed with a profusion of blood vessels, it also has a ridged band of peripenic muscles that protects the urinary tract from contaminants, and an undersurface lined with mucocutaneous tissue found nowhere else on the body, which contains ectopic glands that produce natural emollients and antibacterial proteins similar to those found in mother's milk. With its frenar ridges and its thousands of nerve endings, the foreskin not only protects the glans, which in an intact male is extremely sensitive, it also accounts for roughly one-third of the penis' sexual perceptivity. In short, evolution has seen to it that the penises of all mammals come protected in a remarkably fine-tuned and responsive foreskin.

After nine months of infinitely complex and elegant work at literally becoming whole persons, however, the majority of American newborn males have their foreskins removed. [Editor's Note: The CDC reported the rate of male circumcision dropped from 56% in 2006 to 32% in 2009. Today the majority of newborn American males remain intact.] Curiously, in a culture where the rights of every living thing are vigorously endorsed by the vox populi, most parents opt neither to view nor to question the mechanics of this procedure. Dr. Hiram Yellen, one of the two inventors of the Gomco Clamp, a tool used in circumcision, describes the standard procedure for circumcision in the following passage:
"... the prepuce is put on a stretch by grasping it on either side of the median line with a pair of hemostats. No anesthesia is used. A flat probe, anointed with Vaseline, is then inserted between the prepuce and the glans ... In cases where the prepuce is drawn tightly over the glans, a dorsal slit will facilitate applying the cone of the draw stud (the bell) over the glans. After anointing the inside of the cone, it is placed over the glans penis ... The prepuce is then pulled through and above the bevel hole in the platform and clamped in place. In this way the prepuce is crushed against the cone causing hemostasis. We allow this pressure to remain five minutes, and in older children slightly longer. The excess of the prepuce is then cut with a sharp knife."
Within minutes, three feet of veins, arteries and capillaries, 240 feet of nerves and more than 20,000 nerve endings are destroyed; so are all the muscles, glands, epithelial tissue and sexual sensitivity associated with the foreskin. Finally, what nature intended as an internal organ is irrevocably externalized.

Perhaps for parents who don't watch a circumcision (the majority don't; the minority that do wish they hadn't), the reality here -- the strapping, forcing, cutting, bleeding, stripping, slicing and creating of immeasurable pain -- is a little like the Bomb: something you'd rather not think about unless you absolutely, positively must. But the fact remains that millions of American newborns routinely undergo this procedure, and most parents don't really know why. How did this come to pass?

Research into circumcision's history suggests that it dates back to around 3000 B.C., when it was performed in ancient Egypt as a mark of slavery and as a religious rite. Aside from Jews and Muslims, however, people considered circumcision to be a repugnant form of genital mutilation, and both the Greeks and Romans passed laws forbidding its practice. Thus, for a few millennia at least, most men worldwide enjoyed the virtues of an intact penis. In fact, routine circumcision didn't take off in America until the Victorian era, and didn't reach cruising altitude until the Cold War years, when technology, medicine and big business came together in the interest of institutionalized birthing.

The systematic removal of the foreskin owes its ubiquity in America to one man named Dr. Lewis Sayre, once known as the "Columbus of the prepuce" by his colleagues. In 1870, Sayre drew a correlation between the foreskin and an orthopedic malady in a young boy. Through a series of bizarre medical experiments, Sayre and his colleagues eventually determined that links existed between the foreskin and a vast range of ailments that included gout, asthma, hernias, epilepsy, rheumatism, curvature of the spine, tuberculosis and elephantiasis. But what drove circumcision deeper into the bedrock of pediatric medicine was the strident belief that masturbation, thought to be the root of everything from bed-wetting to intractable forms of insanity and mental retardation, could be "cured" with circumcision.

Dr. Peter Charles Remondino, a well-known physician, public health official and champion of universal circumcision, typified the Zeitgeist. Remondino wrote that the foreskin, which he referred to as an "unyielding tube" and "a superfluity," made the intact male "a victim to all manner of ills, sufferings ... and other conditions calculated to weaken him physically, mentally, and morally; to land him, perchance, in jail, or even in a lunatic asylum."

Dr. John Harvey Kellogg, a well-known fundamentalist health reformer and medical journalist (his 1888 "Plain Facts for Old and Young" included roughly 100 pages dedicated to "Secret Vice [Solitary or Self Abuse]") who went on to create the world's preeminent corn flake, was more direct in his approach. "A remedy for masturbation which is almost always successful in small boys is circumcision," he wrote. "The operation should be performed by a surgeon without administering an anesthetic, as the brief pain attending the operation will have a salutary effect upon the mind, especially if it be connected with the idea of punishment. In females, the author has found the application of pure carbolic acid to the clitoris an excellent means of allaying the abnormal excitement."

As astonishing as it may seem, Kellogg's views were shared by most prominent practitioners of the time. In Robert Tooke's popular book "All About the Baby," published in 1896, circumcision is recommended for preventing "the vile habit of masturbation." And Dr. Mary Melendy, author of "For Maidens, Wives and Mothers," wrote that masturbation "lays the foundation for consumption, paralysis and heart disease ... It even makes many lose their minds; others, when grown, commit suicide." Appealing to parents who might question the protracted afflictions associated with masturbation, Melendy warned, "Don't think it does no harm to your boy because he does not suffer now, for the effects of this vice come on so slowly that the victim is often very near death before you realize that he has done himself harm."

Circumcision was not only bound up with deeply irrational fears about masturbation at the turn of the century; it was also tied to sociocultural changes as vast waves of immigration flooded American cities. Circumcision became a mark of social class that distinguished gentrified, "real" Americans from the "insalubrious" immigrant masses at a time when cleanliness was synonymous with godliness. Eventually, circumcision staked its claim on the American male and his problematic penis, and became so accepted as the norm that by the early 1900s standard medical textbooks depicted the normal penis without its foreskin. In this highly charged atmosphere, American parents who chose not to circumcise their sons were almost criminally negligent, if not freakishly nonconformist.

By the Cold War era, roughly 90 percent of American males were systematically circumcised at birth. It was simply something you did -- a medical procedure as unquestioned as the cutting of the umbilical cord -- and so deeply entrenched in America that it was upheld as standard practice long after the theories by which it was justified were debunked. People had long forgotten that circumcision was not based on any supreme medical imperative but rather on the fantastically phobic mores of a Victorian society, and the medical establishment did little to clear the smoke on what had become a profitable business. Was this a perception/reality problem, or a morality/reality problem?

It wasn't until the '70s -- after French obstetrician and natural-birthing pioneer Frederick Leboyer's "Birth Without Violence," after extensive studies discrediting longstanding medical claims, after lawsuits that forced hospitals to obtain parental consent before circumcising, and after millions of foreskins had been left on the cutting-room floor -- that Americans (and Jews all over the world) began questioning circumcision.

By 1975, the American Academy of Pediatrics (AAP) had reversed its pro-circumcision stance in "Standards and Recommendations for Hospital Care of Newborn Infants," by stating: "there is no absolute medical indication for routine circumcision of the newborn." And in 1984, it published "Care of the Uncircumcised Penis," which, clearly supporting the intact penis, concluded by saying, "The foreskin protects the glans throughout life." But despite a slow decline in the circumcision rate, accompanied by a new awareness of the rights of newborns -- and despite rigorous campaigning against circumcision by doctors worldwide, in the form of international symposiums, in-depth studies, human rights legislation, information resource centers and more -- circumcision remains the most commonly performed neonatal surgical procedure in America. And in this, America stands alone.


PART TWO

Why is the most "advanced" nation in the industrialized world alone in practicing a disturbing archaism from less enlightened times? In "The Saharasia Connection," Dr. James DeMeo, who calls circumcision "an ancient blood ritual ... that has absolutely nothing whatsoever to do with medicine, health, or science in practically all cases," puts forth this hypothesis: "The fact that so many circumcised American men, and mothers, nurses, and obstetricians are ready to defend the practice in the face of contrary epidemiological evidence is a certain giveaway to hidden, unconscious motives and disturbed emotional feelings about the penis and sexual matters in general."

It remains to be seen to what extent "unconscious motives" are responsible for the perpetuation of circumcision today. However, "emotional feelings about the penis" may very well be knit into the fabric of certain long-standing myths that persist in the United States despite logical or empirical evidence to the contrary. After much verbal intercourse with friends over the years about near misses and close calls with the intact penis, it seems evident that three persistent myths or biases dominate.

The mother of all myths, now locker-room gospel, is that a circumcised penis is more hygienic than an intact one. This comes as no surprise in a culture where the art of sterilization is so pervasive that certain foods have a half-life that probably exceeds that of plutonium. Still, doctors discredited hygiene as an advantage of circumcision years ago. When I asked our pediatrician what I needed to clean my son's intact penis, he replied: "Common sense." The American Academy of Pediatrics (AAP) put it another way: "Good personal hygiene would offer all the advantages of routine circumcision without the attendant surgical risk." (This, of course, is the case for both sexes: Leave any body part unattended for too long and things get, well, unpleasant.) Yet another doctor posited in "Circumcision: A Medical or Human Rights Issue?" that removing the foreskin for hygiene's sake is like removing one's eyelid for a cleaner eyeball.

Another popular and profoundly baffling myth is that circumcision is painless. Studies indicate that those babies who appear to sleep through a circumcision have most likely slipped into a semicomatose state, and a slew of recent studies on newborns, traumatic experience and sensory perception support this hypothesis.

Equally strange is the cultural bias for the aesthetics of a circumcised penis. In moments of free-associative candor, girlfriends have compared the looks of an intact penis to everything from an elephant trunk to a dachshund. The queerness of it was reinforced by the unsettling feeling that it required at best a refresher course on basic anatomy, at worst a whole new sex education, as if an intact man were some sort of Minotaur. To the extent that the circumcised penis is endorsed largely through culturally determined views about hygiene and aesthetics, one wonders if it's not in some odd way a metaphor for America itself: sleek and streamlined, the way we like our cars and buildings, connoting speed and unimpeded verticality; but also surgical and sanitized, and thus thoroughly modern. By contrast, the intact penis is a little too unruly, too Paleolithic, a little too, well, animal. (If penises could walk and talk, the circumcised penis would be a suit and tie, a clean shave and a shoulder-high salute. The intact penis would be a rumpled shirt, a five o'clock shadow and a finger flipping you the bird.)

Either way, passing judgment on an intact penis in America is like passing judgment on a real nose in a country where rhinoplasty is imposed at birth. Quite simply, most Americans have forgotten that an intact penis is actually the norm, and that for thousands of years the only people who were circumcised were Jews and Muslims.

Which leads me to a word about Jews and the penis. When I mentioned to certain relatives that my son would remain as nature intended him, the conversation, once the shock wore off, went something like this:

"But honey, what about the, er, Covenant of Abraham?"

"What exactly is the connection between the Covenant of Abraham and my son's penis?"

"Well, I'm not sure. Let me put Sam on the phone."

Sam wasn't sure about the God-penis-Covenant connection either. Neither was Ruth. Nor Morley. Nor were any of my Jewish friends or relatives.

In fact, the Covenant was a pact between God and Abraham, an expression of both faith and tribal belonging that set the "chosen people" apart, and which has been passed on to all Jews. Jewish identity, however, is not determined by circumcision nor is it passed through the penis. As most Jews know, Jewish identity is passed through the mother, hence the traditional and immemorial Jewish concern about assimilation through intermarriage. The "Encyclopedia Judaica" reaffirms this: "Any child born of a Jewish mother is a Jew, whether circumcised or not." I'm reminded of a Jewish friend who insisted that his son be circumcised despite the fact that his wife was Catholic. "Circumcision," his rabbi reminded him, "will not make your son Jewish." (His wife's conversion to Judaism, however, would.)

Despite all this, the issue of Jewish identity, in which circumcision is inextricably bound up, remains one of the most complex, thorny and eternally debated subjects around. Volumes have been written on the subject, and everything is up for personal interpretation. With this in mind, and given that a vast number of Jews do not know what the Covenant really is -- their sons are circumcised in hospitals without a bris; they are not Orthodox, and do not keep kosher -- one can only surmise that circumcision is not an act of religious conviction but rather one of deeply entrenched cultural conformity rooted in the deep past. In fact, a cruel irony lingers here: Originally, biblical circumcision involved cutting only the tip of the foreskin (called brith milah), which still left enough foreskin for certain Jewish men to stretch it forward and pass as gentiles. This gave rise to a rabbinical movement called Brith Periah. Much more radical in nature, Brith Periah essentially removed the entire foreskin, making it impossible for Jews to emulate gentiles. Modern circumcision is based on this much more radical procedure of Brith Periah -- a strange medical twist that has leveled the playing fields of the penis among Jews and gentiles alike.

Jew or gentile, to the extent that "God" is behind circumcision and the oft-cited Covenant, one can only wonder: Why ordain the removal of such a fundamental part of the penis? And why the penis? Here the views of Moses Maimonides, a medieval Jewish philosopher, rabbi and figure in the codification of Jewish law, are enlightening in a more universal context. In "Guide to the Perplexed," Maimonides wrote that the commandment to circumcise "has not been prescribed with a view to perfecting what is defective congenitally, but to perfecting what is defective morally." Celebrated for his chastity by the sages, Maimonides elaborates: "With regard to circumcision one of the reasons for it is, in my opinion, the wish to bring about a decrease in sexual intercourse and a weakening of the organ in question, so that this activity be diminished and the organ be in as quiet a state as possible ... The fact that circumcision weakens the faculty of sexual excitement and sometimes perhaps diminishes the pleasure is indubitable. For if at birth this member has been made to bleed and has had its covering taken away from it, it must indubitably be weakened."

Maimonides' views evoke not only the Victorians, the doctrines that underlie female circumcision and the "unconscious motives" Dr. DeMeo wrote about: They also hark back to the forbidden fruits of sex and religion that have festered in the gardens of earthly delight ever since Adam and Eve discovered the apple.

Considering the troubling history of circumcision in light of my own son's corpulent little penis, I'm reminded that it is the choice -- and in some cases, the courage -- of American parents that will determine whether the next generation of American men reclaims what is rightfully theirs to begin with. In this regard it might be the late Dr. Benjamin Spock who stands for conventional wisdom at its best. When asked about circumcision in an interview with Redbook in 1989, he said quite simply, "My own preference, if I had the good fortune to have another son, would be to leave his little penis alone."

Photo courtesy of peaceful parenting mom, Christina King. 
Intact related onesies and tees available at Made By Momma.

Additional resources (scholarly books, articles, websites) on the prepuce, intact care and circumcision at Are You Fully Informed?

Tuesday, January 29, 2008

How Male Circumcision Impacts Your Love Life

By Dr. Christiane Northrup
First printing: 2004; Posted with permission.



Circumcision, the surgical removal of the male prepuce (foreskin), usually during the first few days after birth, is an emotionally charged subject that most people are reluctant to discuss openly, let alone objectively.



I know. As an obstetrician-gynecologist, I've performed hundreds of circumcisions, and I've been on the front lines of the circumcision debate for more than 25 years.



Though I've provided information on circumcision for expectant couples for years, it long ago became clear to me that the decision about whether or not to circumcise a boy is made from an emotional not a rational place. Still, the tide is turning as more and more people, both within and without the medical profession, rethink the entire subject.



In the spirit of science and compassion, I urge you to read this article with an open mind. It may well change the entire way you view circumcision.



A Risky, Painful, and Unnecessary Procedure
 
The sad truth is that throughout most of the 20th century, the American medical community has focused on finding reasons to remove the foreskin of newborn males instead of acknowledging Mother Nature's wisdom in including this highly sensitive tissue. Happily, more and more individuals are questioning circumcision's necessity and acknowledging its potential harm. Since 1980, the national circumcision rate has dropped by 30 percent, and an increasing number of physicians are finding the courage to refuse to perform the procedure.




This is precisely what happened in England, a nation formerly obsessed with circumcision. In the 1940s, following the release of information that supported leaving male babies fully intact, England's circumcision rate plummeted almost overnight to less than I percent. Similar information is beginning to gain ground here in the United States, so I'd like to share it with you.



To start with, babies feel pain the same way adults do. But the prevailing wisdom at medical schools has long been that newborns can't feel pain and therefore don't experience it during their circumcisions.


When I was a medical student, this is what I heard from my professors as well, although common sense told me it wasn't true. I watched placid newborns begin to scream and gasp in pain as the circumcision procedure began. Fortunately, it is finally accepted as a medical fact that circumcision is extraordinarily painful for newborns, who are born with full nocioceptive (pain sensing) ability.



Furthermore, routine newborn circumcision has no health benefit. Though a wide variety of health advantages have been attributed to circumcision--decreases in the incidence of cervical cancer, AIDS, sexually transmitted diseases, and male urinary tract infection--the most up-to-date research has refuted all these justifications. In fact, the American Academy of Pediatrics issued a policy statement in 1999 saying there is not sufficient scientific data to recommend routine newborn circumcision. Given this, the number of insurance companies willing to pay for the procedure is also decreasing.



Though circumcision is relatively easy to perform, like any surgical procedure it has risks. The most common complication is hemorrhage, which is reported in as many as 2 percent of cases. Though rare, more disastrous complications can and do occur: "degloving" of the penile skin, which requires skin grafts and results in loss of sensation; destruction of the penis; and death from hemorrhage or infection.



Because there are no proven benefits for the procedure in the first place, these complications are all the more tragic. As respected obstetrician and gynecologist George Denniston points out, "Circumcision violates the first tenet of medical practice: 'first, do no harm.' According to modern medical ethics, parents do not have the right to consent to a procedure that is not in their son's best interest. The removal of a normal, important part of the male sexual organ is not in their son's best interest."



Intact is the Norm


The vast majority of the world's men, including most Europeans and Scandinavians, are intact. And before 1900, circumcision was virtually non-existent in the United States as well--except for Jewish and Muslim people, who've been performing genital cutting for hundreds of years for religious reasons.



Believe it or not, circumcision was introduced in English-speaking countries in the late 1800s to control or prevent masturbation, similar to the way that female circumcision was promoted and continues to be advocated in some Muslim and African countries to control women's sexuality. As the absurdity of this position became apparent, new justifications, such as the prevention of cervical and penile cancers, received the blessing of the medical establishment. But these are justifications that science has been unable to support. Nor is there any scientific proof that circumcision prevents sexually transmitted diseases.



Also contrary to popular belief, the intact penis requires no special care. Many parents get hung up about how to "clean" the intact penis in an infant. Some are even told to retract the foreskin. This can cause pain and scarring, and it isn't necessary. The foreskin often does not retract naturally until a child is older--sometimes not until he is a teenager--but a boy can easily stretch and retract his foreskin gently over several months' time.



The Pleasures of Natural Sex
 
I've always felt that the male foreskin, one of most richly innervated and hyper-elastic pieces of tissue in the male body, is there for a reason. Until recently, I didn't know exactly what that reason was. But now, thanks to Kristen O'Hara's well-researched book, Sex as Nature Intended It, I finally understand the reasons for the design of the penis and foreskin and how this design ensures optimal penile function, including this organ's ability to satisfy the female sexually. Most American women have not personally experienced the sensation of sex with an uncircumcised man because the majority of men in this country, especially those born before 1980, have been circumcised. But Kristen O'Hara's long-ago affair with an uncircumcised man was the spark that touched off years of research, the result of which is her eye-opening book. Consider the following:




The primary pleasure zones of the natural (intact) penis are located in the upper penis, which includes the penis head, the foreskin's inner lining, and the frenulum--the hinge of skin that connects the foreskin to the head of the penis. When a male is circumcised, some of the most erotically sensitive areas of the penis are removed: the foreskin that normally covers the head of the penis (the glans) and some or all of the frenulum.



The frenulum contains high concentrations of nerve endings that are sensitive to fine touch. The glans was designed by nature to be covered all the time except during sexual activity. Upon erection, both foreskin layers unfold onto the upper penile shaft, leaving the highly innervated frenulum, glans, and inner lining exposed and readied for sexual activity. This is one of reasons why the penile tip is the focus of sexual excitement.



New scientific evidence shows that highly erogenous tissue equivalent to the female clitoris is located in the core of the penis, beneath the corona (the hook-like head of the penis) and coronal tip. This sensitive tissue extends all the way down the length of the penile shaft to the pubic mound, where it branches and continues into the pelvis and onto the pelvic bone in a manner analogous to the anatomy of the female clitoris. Though the penis contains nerves that are sexually excited by pressure, its tip contains the greatest density of these nerves and is therefore the most sexually responsive part, just as the tip of the clitoris is the most sensitive part. And like the tip of the female clitoris, the tip of the penis is sexually stimulated by the pleasurable sensations created by the massaging actions of the movement of the foreskin upon it during intercourse.



During intercourse, these exquisitely sensitive nerves of the upper penis both excite a man sexually and control the rhythm of penile thrusting. "When the natural penis thrusts inward, the vaginal walls brush against the erotically sensitive nerves of the glans, the foreskin's inner lining, and the frenulum, causing these nerves to fire off sensations of pleasure;" writes O'Hara. "The inward thrust of the penis keeps these pleasure sensations ongoing, but after these nerves have fired, the penis senses a reduction in pleasurable feelings, so it stops its inward thrust and begins its outward stroke in search of stronger sensations.



"During the outward stroke, the foreskin's outer layer slides forward to cloak the nerves of its inner lining, while the inner lining itself covers the frenulum" she continues. "Once covered, these nerves are allowed to rest from stimulation until the next inward thrust. As the foreskin moves forward on the shaft, it bunches up behind the coronal ridge, and may sometimes roll forward over the corona, depending upon the length of the stroke. This applies pressure to the interior tissue of the corona and coronal ridge where nerves that are excited by pressure send a wave of sexual excitement throughout the upper penis. The natural penis receives pleasure sensations from one set of sensory nerves on the inward thrust and a different set of nerves on the outward stroke. It can maintain a continuous stream of highly pleasurable sensations by maintaining the right rhythm."



And intriguingly, because the area of sexual sensation is so localized in the tip, the penis only has to travel a short distance to excite one set of nerves or another. In other words, it doesn't have to withdraw very far to receive pleasure on the outward stroke. This allows the penis to stay deep inside the vagina, keeping the man's pubic mound in close and frequent contact with a woman's clitoral area, which increases her pleasure and a sense of closeness.



As part of the research for her book, Ms. O'Hara surveyed approximately 150 women--enough to make the study statistically reliable. Here's how one survey respondent described sex with a natural partner:



"Sex with a natural partner has been to me like the gentle rhythm of a peaceful but powerful ocean--waves build, then subside and soothe. It felt so natural, as if it were filling a deep need within me, not necessarily for the act of sex, but more in order to experience the rhythm of a man and woman as they were created to respond to each other."



The Sexual Consequences of Male Circumcision
 
After circumcision, the exposed head of the penis thickens like a callus and becomes less sensitive. And because erotically sensitive areas of the penis have been removed, the circumcised penis must thrust more vigorously with a much longer stroke in order to reach orgasm through stimulating the less sensitive penile shaft. In her study of women who have had sexual experiences with both natural and circumcised men, O'Hara notes that respondents overwhelmingly concurred that the mechanics of coitus were different for the two groups of men. Seventy-three percent of the women reported that circumcised men tended to thrust harder, using elongated strokes; while intact men tended to thrust more gently, to have shorter strokes, and to maintain more contact between the mons pubis and clitoris.




O'Hara's research makes the following sexual comparisons between the natural and circumcised penis.
 
The natural penis may be more comfortable for the vagina than the circumcised penis. The coronal ridge of the natural penis is more flexible; O'Hara likens it to the resiliency of Jell-O. The circumcised penile head is considerably harder--overly firm and compacted like an unripe tomato. This is because circumcision cuts away 33-50 percent of penile skin. As a result, the skin of the penile shaft can get stretched so tightly during an erection that it pulls down on the skin covering the glans, compressing the tissue of the penis head. The abnormally hardened coronal ridge can then be very uncomfortable to vaginal tissue during intercourse.




Women sometimes experience a scraping feeling with each outward stroke and even report discomfort after intercourse or even the next day. The brain makes pain-relieving endorphins that may partially block any discomfort during intercourse itself. As a gynecologist, I can tell you that painful intercourse is a very common symptom in women, many of whom blame themselves or who feel that something is wrong with their sexual response.



The give of the natural penis, by contrast, allows for more bend and flex of the organ in the vagina, adding to a woman's pleasure and comfort. The abundant skin of the natural penile shaft further cushions the force of the coronal ridge in the vagina. In addition, the mobile skin of the penis is "grasped" by the ridges of the vaginal mucosa and held in place. The bunching and unbunching of penile skin during intercourse enhances a man's pleasure, but it also excites the woman. As one of O'Hara s survey respondents reported: "What I noticed was that my natural man got a lot of pleasure from deliberate, slow insertion and backing out because his foreskin would fold back and forth, which would excite me also."



Circumcised sex may cause the vagina to abnormally tense up and decrease its lubrication. Women report more problems with lubrication when having sex with circumcised men, possibly because of irritation from the harder tip and involuntary tensing against it, and also because the longer stroke length tends to remove lubrication from the vagina. Often an artificial lubricant is necessary.



Intercourse may also be painful for the circumcised man because his penis scrapes against the ribbed structure of tensed-up vaginal walls and becomes over stimulated from constant pressure. The degree of discomfort, if any, will depend upon the tightness of the man's shaft skin, the vigor of his thrusting, the duration of intercourse, and the amount of lubrication.



Circumcision may cause a man to work harder to achieve orgasm, resulting in emotional and physical distancing from his partner. When a circumcised man has sex, he may have to concentrate intensely on the erotic sensations he is receiving while simultaneously blocking out any uncomfortable sensations. Survey respondents often reported that their circumcised partners seemed to have to work too hard to achieve orgasm. And because of the erotic tissue that has been removed, he can't enjoy the sensations leading up to orgasm or his partner's responses.



O'Hara makes a compelling argument that circumcised intercourse may frustrate the primordial subconscious that seems to know "real sex ain't this way." She also suggests that each circumcised experience has the potential to buildup negative memory imprints so that over time, repeated sexual encounters with the same partner may lead to negative feelings between the two that carry over into everyday life. If this sounds like an extraordinary leap, consider the question that O'Hara asks in her book: "Other things being equal, which couple is more likely to stay together--one enjoying delicious, satisfying sex or one whose sexual pleasure is being compromised in many ways?"



The Solution: Foreskin Restoration
 
Fortunately, there are alternatives for men (and their partners) who want to experience natural sex. This quiet revolution, called Foreskin Restoration, can be achieved through plastic surgery or non surgical methods. The latter work on the principle that skin stretches and grows under pressure just like abdominal skin when it stretches to accommodate pregnancy. According to O'Hara, whose husband stretched his foreskin over the course of several years, their sex life is better than ever, and neither can believe the difference that foreskin restoration has made. Many other men and women attest to this improvement as well. 



For more information, the following resources can be helpful.



National Organization of Restoring Men (NORM) Web site: http://www.norm.org



The Joy of Uncircumcising! A restoration manual and more, by Jim Bigelow, Ph.D. (Contact UNCIRC, POB 52138, Pacific Grove, CA 93950).



Restore Yourself! A Handy Kit for Circumcised Men from NOCIRC of Michigan Web site: www.RestoreYourself.com


TLC Tugger site: www.tlctugger.com/



Non-Surgical Foreskin Restoration, a Canadian Web site with a great deal of information: http://infocirc.org/top.htm
 

What about Religious Circumcision?
 
I am not Jewish (or Muslim), but I can assure you that many are rethinking circumcision. As a matter of fact, two of the most well-researched and eloquent books on the harmful nature of circumcision have been written by Jewish men. For more information, I urge you to read Circumcision: The Hidden Trauma by Ronald Goldman, Ph.D., (Vanguard, 1997), Circumcision: An American Health Fallacy by Edward Wallerstein (Springer Publishing, 1980) and watch CUT: Slicing Through the Myths of Circumcision. For additional information on the Jewish perspective, see these links. For the Christian perspective, see these links. For circumcision within Islam visit
http://www.quranicpath.com/misconceptions/circumcision.html and http://www.quran.org/khatne.htm.

 

I hope this has been an eye-opening article. I realize that circumcision may not have been the topic uppermost on your mind before you opened your issue [of Men's Health] this month, but it's my mission to bring you timely, life-enhancing information. My hope is that you'll weigh it and then make the wisest choice for yourself and your family.


For more on how male circumcision impacts women's sexual health, see the articles on this page.


For additional information on the prepuce, intact care, and circumcision see, Are You Fully Informed?

Wednesday, January 23, 2008

FGM / MGM: A Visual Comparison

By Joseph Lewis
Read more from Lewis at Joseph4GI

I've taken the pictures from the recent NY news report, and the blog commentary on the Turkish Circumcision Palace, to create a second visual comparison.

Now, what kind of ignorance, denial and double-think does it take to insist that the following pictures are NOT the same thing?



Just what is it that makes them "different?"

Indeed, the sexes of these individuals may be "different."


But isn't the principle of taking a helpless individual and forcefully cutting his/her genitals the EXACT SAME PRINCIPLE?


And, do the ages of the individuals really matter?

Is the equality situation immediately self-evident?

Or do people continue to delude themselves with double-think?


Question circumcision.


The principle of forcefully cutting up a person's genitals is the same, no matter what age, no matter what sex.


For more information on the prepuce organ ('foreskin' or 'hood') and circumcision, see scholarly resources (books, sites, articles) at Are You Fully Informed?

Tuesday, January 8, 2008

International AIDS Conference: Circumcision Does Not Protect Against HIV Infection

Presentation at the 16th International AIDS Conference in Toronto
By Danny Kucharsky


HIV prevalence is not lower in populations that have higher male circumcision rates, according to findings from a study of African countries presented in Toronto at the 16th International AIDS Conference (AIDS 2006).

The study, which examined the association between male circumcision and HIV infection in 8 Sub-Saharan African countries, contradicts the findings of previous research and the opinion of several prominent personalities active in the fight against AIDS, such as former US President Bill Clinton and Bill Gates (founder and CEO of Microsoft).

While three studies have suggested male circumcision has a protective effect against sexually transmitted infections (STI), including HIV infection, the evidence is inconclusive, said investigator Vinod Mishra, MD, director of research, ORC Macro, Calverton, Maryland. "We're just questioning that push," he said of the optimism displayed by Clinton and others.

The study used demographic findings from recent demographic and health surveys in Burkina Faso, Cameroon, Ghana, Kenya, Lesotho, and Malawi, and AIDS indicator surveys from Tanzania and Uganda. The surveys were conducted from 2003 to 2005 and sample sizes ranged from 3,300 men in Lesotho to 10,000 men in Uganda.

In survey fieldwork in each country, men aged 15 to 59 gave blood for anonymous HIV testing. Information on circumcision status and on STI/STI symptoms was based on men's responses to questions in survey interviews.

Prevalence of male circumcision ranged from a high of 96% in Ghana to a low of 21% in Malawi. Among the other countries, circumcision rates were 84% in Kenya, 89% in Burkina Faso, and 25% in Uganda.

HIV prevalence was lower among circumcised than intact men only in Kenya (11.5% among intact men vs 3.1% among circumcised men). A small, statistically insignificant difference was also seen in Burkina Faso (2.9% vs 1.7%, respectively) and Uganda (5.5% vs 3.7%).

In each of the other countries, there was either no difference in HIV rates between circumcised and intact men, or circumcised men were more likely to be HIV-positive than intact men. For example, in Lesotho, HIV was seen in 23.4% of circumcised men compared with just 15.4% of intact men.

"If anything, the correlation [between circumcision and HIV infection] goes the other way," in most of the countries studied, Dr. Mishra said during his presentation on August 15th.

When adjusted for sociodemographic and behavioral factors, the difference in HIV infection was not statistically significant in any country, Dr. Mishra said.

In Kenya, and to a lesser extent, in Ghana, Malawi, Tanzania, and Uganda, circumcised men were less likely than intact men to report having had an STI, or STI symptoms, in the 12-month period prior to the survey (2.1% vs 5.4%, respectively). The relationship was reversed in Cameroon (8.0% vs 2.5%) and Lesotho (12.1% vs 7.5%).

With other factors controlled, the theorized "protective" effect of male circumcision was statistically significant only in Tanzania.

In addition, "circumcised men tend to have more lifetime sex partners, so there's some [high-risk] behaviors that go with circumcision status," he said.

A study limitation is that it was based on self-reported information on circumcision status and STI/STI symptoms. It also lacks data on age at circumcision and degree of circumcision, which might influence susceptibility to HIV infection.

However, Dr. Mishra said the study is consistent with other research that has failed to find a protective effect of male circumcision on HIV and STIs (sexually transmitted infections).


[Presentation title: Is Male Circumcision Protective of HIV Infection? Abstract TUPE0401]


Related resources on HIV and circumcision:

Dr. Dean Edell and others discuss HIV and circumcision (the U.S. has the highest numbers of HIV positive persons of any developed nation, and the U.S. also has the highest numbers of sexually active adult circumcised men). Circumcision does not prevent HIV.

For additional information on circumcision, the prepuce organ ('foreskin') and intact care see: Are You Fully Informed?

~~~~

Wednesday, January 2, 2008

Circumcision, HIV and Sexually Transmitted Infections in the U.S. Navy



PREVALENCE OF CIRCUMCISION AND ITS ASSOCIATION WITH HIV AND SEXUALLY TRANSMITTED INFECTIONS IN A MALE U.S. NAVY POPULATION

Anne G. Thomas, Ph.D.
Ludmila N. Bakhireva, M.D., M.P.H.
Stephanie K Brodine, M.D.
Richard A. Shaffer, Ph.D.

Naval Health Research Center 
P.O. Box 85122
San Diego, CA 92186-5122

Graduate School of Public Health Division of Epidemiology and Biostatistics San Diego State University
San Diego, CA 92182-4162

Report No. 04-10, was supported in part by Cooperative Agreement DAMD17-93-V 3004 between the U.S. Army Medical Research and Material Command, Fort Detrick, Maryland, and the Henry M. Jackson Foundation for the Advancement of Military Medicine, Rockville, Maryland, and the Army Reimbursable Work Unit #6916. The views expressed in this article are those of the authors and do not reflect the official policy or position of Department of the Navy, Department of Defense, or the U.S. Government. Approved for public release; distribution unlimited.

This research has been conducted in compliance with all applicable federal regulations governing the protection of human subjects in research.

Abstract

Objectives: To determine circumcision prevalence and its association with HIV and STI in a male United States military population.

Design: Case-control study of HIV-infected U.S. military personnel (n = 232) from 7 military medical centers and male U.S. Navy controls (n = 516) from an aircraft carrier.

Methods: Cases and controls completed similar self-administered HIV behavioral risk surveys. Case circumcision status was abstracted from medical charts while control status was reported on the survey. Cases and controls were frequency matched on age. Multiple logistic regressions were constructed separately to evaluate the role of circumcision in the acquisition of HIV and STI.

Results: Cases (84.9%) and controls (81.8%) reported similar proportions of circumcision. Prevalence of circumcision among United States-born men was higher (85.0%) than those born elsewhere (58.1%). After adjustment for demographic and behavioral risk factors, lack of circumcision was not found to be a risk factor for HIV (OR = 0.9; 95% CI, 0.51–1.7) or STI (OR = 1.08; 95% CI, 0.52–2.26). The odds of HIV infection were 2.6 higher for irregular condom users, 5 times higher for those reporting STI, 6.2 times higher for those reporting anal sex, 2.8–3.2 times higher for those with 2- 7+ partners, nearly 3 times higher for Blacks, and 3.5 times higher for men who were single or divorced/separated.

Conclusions: Although known HIV risk factors were found to be associated with HIV in this military population, there was no significant association with male circumcision. Randomized clinical trials currently underway should shed more light on this pressing topic.


Introduction

With an estimated 5 million new infections, 3 million deaths, and 40 million prevalent infections in 2003, reducing the incidence of HIV infection remains a critical, worldwide goal. In recent years, several studies conducted among sub-Saharan African male populations report circumcision to be associated with reduced risk of HIV infection [1–5]. Compelling evidence from studies conducted among sub-Saharan African populations of circumcision’s protective effect against HIV acquisition, is now considered substantial enough that many are advocating for male circumcision as one component of a comprehensive HIV prevention package [5,6].

Whether circumcision of male infants should be recommended as a method of HIV prevention in developed countries such as the United States remains the subject of heated controversy. Thus far, the majority of studies investigating the association of circumcision and HIV have been conducted among Sub-Saharan African populations, which differ substantially from developed nations in terms of HIV risk factors, sexual practices, and medical care availability.

Ulcerative sexually transmitted infections (STIs), such as genital herpes, syphilis, and chancroid, known risk factors for HIV infection [2,7–11], are more prevalent among sub-Saharan African populations, the same populations with low levels of circumcision. This may be a major source of residual confounding in the HIV–circumcision association.

Relatively few studies have been conducted in the United States or other developed nations investigating the association between circumcision status and STI acquisition, and, to our knowledge, none have been of large enough scale to report any significant finding regarding an association with HIV acquisition. With respect to STI acquisition, these studies have yielded inconsistent results, with several showing a protective effect of circumcision [11–13] while others found an increased risk for STIs among circumcised males [14].

In addition to STI acquisition, several studies among western populations have shown circumcision to have a strong protective effect against urinary tract infections (UTIs) among male infants [15–17] and penile cancer in middle-aged and older men [18– 20]. However, there is still controversy surrounding the practice of male circumcision, as opponents argue that the medical benefits do not outweigh the risks, and that the neonatal procedure causes unnecessary pain, reduced penile sensitivity, and violates the human rights of the unconsenting child [14,21–23]. This case-control study describes the prevalence and demographic determinants of circumcision in a U.S. military population and the association of circumcision and HIV/STI acquisition.

Methods

Study population

HIV seropositive case participants in this case-control study were male, active- duty U.S personnel from all branches of the military recruited from 7 military medical referral centers throughout the United States as a part of a larger case-series study. Enrollment and study procedures are described elsewhere [24,25]. All cases had documented HIV seroconversion and completed a self-administered behavioral risk factor questionnaire.

Control participants from a general Navy aircraft carrier population completed similar questionnaires. Controls were assumed to be HIV seronegative. U.S. Department of Defense policy stipulates that all military personnel undergo predeployment HIV screening and test negative.

Case and control participants had to meet two criteria for inclusion in this study. First, their circumcision status had to be available. Case circumcision status was abstracted from previously collected medical data, with 51.2% (294/574) having this information available. The control population was limited to those who answered the circumcision question (yes/no) on the self-administered survey (93.3%; 859/ 921). Second, using a combination of survey questions, cases and controls had to be categorized as having had sex during their reporting time frame (286 cases and 801 controls).

Case participants reported behaviors occurring within their seroconversion window (SCW), the time between the last negative and first positive HIV test. To reduce variability in the length of the SCW, and recall bias, only cases with a SCW of 3 or less years (median = 1 year) were included (n = 234). Providing comparable reporting time frames controls were asked to report their behaviors within last 12 months.

The Institutional Review Boards of participating institutions approved both studies; all participants provided informed consent.

Data collection

Case participants’ data collection occurred between February 1997 and June 2001. Demographic characteristics, sexual risk behaviors, and STI history were assessed. Circumcision status for cases was abstracted from medical records obtained during the case study.
Circumcision and HIV/STI association 6

The control survey was conducted in April 2002 during a “safety stand-down,” a period of time when all personnel at a military command engage in safety training rather than performing their regular jobs. Controls were administered a questionnaire comparable to that of the cases, with the deletion of questions not applicable for an HIV- seronegative population, and the addition of questions regarding circumcision status, HIV testing, and supplemental condom use questions.

Demographic characteristics, including age, ethnicity, country, and state of birth (U.S.-born), marital status, education, and rank were collected. HIV risk behaviors, including number of sexual partners, engaging in anal or group sex, geographic location of sex (U.S. or foreign), STI history, and condom use during vaginal, anal, and oral sex were collected.

Statistical analysis

Since cases were significantly older than controls, and age was thought to be associated with both HIV risk and prevalence of circumcision, frequency matching on age was performed. Eight strata were created with matching ratios varying from 1:1 to 1:4 depending upon the number of available controls. The final sample comprised 232 cases and 516 frequency matched controls.

Comparisons of demographics and sexual risk behavior by case status were performed using analysis of variance (ANOVA) and chi-square tests. Circumcision prevalence was compared using chi-square tests.

Unconditional logistic regression was used to examine the effect of circumcision on HIV infection after adjustment for demographic, and sexual behavior risk variables. Accounting for age frequency matching, 7 dummy variables were created and included in all models. For model building purposes, all demographic and sexual risk behavior variables univariately associated with HIV were initially included in the models. The final logistic regressions included variables that remained significantly (p ≤ .05) associated with HIV status. Likewise, multivariate logistic regression models were used to examine the independent association between circumcision status and STI history.

Potential participation biases were examined through demographic comparisons of men with (participants) and without (nonparticipants) circumcision status available using ANOVA and chi-square tests. All statistical analyses were performed using SAS (Release 9.0, SAS Institute, Inc., Cary, NC, 2002).


Results

Among the cases, availability of circumcision status differed greatly by participation site (p < 0.001). However, after adjusting for site, there were no significant demographic differences between cases who had (n = 294; 51.2%) and did not have (n = 280; 48.8%) their circumcision status available. Furthermore, among the controls, no demographic differences were found between those who reported their circumcision status (n = 859; 93.3%) and who did not (n = 62; 6.7%).

The proportion of circumcised men did not significantly differ between cases (84.9%) and controls (81.8%). Case participants were more likely to be Black, single or divorced, and have some college or a bachelor’s degree or higher, and be of E4-E6 military ranks than the controls (Table 1).

The prevalence of circumcision among this U.S. military population was particularly high (more than 85%) for birth-years 1945-1964 and 1970-1979, with a decline during 1965-1969 (77.1%) and the 1980s (74.2%) (Table 2). Prevalence of circumcision differed dramatically by ethnicity, with the highest prevalence among whites (92.4%) and the lowest among Hispanics (44.1%). There was a significantly higher proportion of circumcised men among those born in the United States (85.0%) as compared with men born in other countries (58.1%). There were some regional differences, with the highest prevalence of circumcision among men born in the Midwest (90.2%) and Northeast (86.8%), followed by the West (85.0%) and the South (82.0%).

Case and control participants differed significantly with respect to sexual risk characteristics (Table 3). A higher proportion of cases did not use condoms regularly (91.0%), had sex in either a foreign country or both a foreign country and the United States (27.6%), reported anal sex (72.8%), group sex (29.5%), had more sexual partners (almost 75% had 3 or more partners), and had higher prevalence of STIs (22.8%), as compared with controls.

In multivariate logistic regression analysis (Table 4), lack of circumcision was not found to be associated with HIV (OR = 0.90; 95% CI, 0.51–1.70) after controlling for significant demographic and sexual risk covariates. These data confirmed an association between HIV and inconsistent condom use (OR = 2.60; 95% CI, 1.36–4.98), recent history of STI (OR = 5.04; 95% CI, 2.46, 10.32), and anal sex (OR = 6.24; 95% CI, 3.98– 9.78). Having multiple sexual partners was also associated with increased risk of being HIV positive, with OR = 2.83 (95% CI, 1.21–6.59) for those with two partners, OR = 3.88 (95% CI, 1.98–7.63) for men with 3-6 sexual partners, and OR = 3.24 (95% CI, 1.60–6.58) for those who had 7 or more sexual partners. Demographic characteristics associated with HIV-infection included Black ethnicity (OR = 2.97; 95% CI, 1.81–4.87), single marital status (OR = 3.51; 95% CI, 1.85–6.63), and being divorced/separated (OR = 3.53; 95% CI, 1.62–7.70).

No statistically significant association was found between circumcision status and history of STI either univariately or multivariately (data not shown). For the entire group, odds of having a history of STIs among uncircumcised men were not different from those for circumcised men (OR = 1.08; 95% CI, 0.52–2.26) after adjusting for age, ethnicity, marital status, history of anal sex, and condom use. Similarly, no associations were observed when the circumcision–STI association was examined separately among HIV cases and controls.

Discussion

This case-control study of the role of circumcision status in HIV acquisition among a U.S. military population provides evidence that lack of male circumcision is not a risk factor for HIV or STI acquisition in this population, with no significant association found either univariately or after adjustment for demographic and sexual risk factors. In fact, the direction of the association indicated lack of circumcision to be protective for HIV infection, although without statistical significance. Known HIV risk factors, including: having multiple partners, inconsistent condom use, history of STI, anal sex, and demographic characteristics of Black ethnicity and single or divorced marital status, were strongly associated with HIV status in this population.

During the past 20 years in the United States, overall rates of male circumcision have declined; in part due to changes in attitudes, and in part due to changes in the country’s ethnic distribution. Caucasians have the highest prevalence of circumcision in the United States, whereas Hispanics and Blacks report significantly lower rates.

Differences in changes by ethnicity and geography are evident, with the West experiencing the most dramatic decline, from 64% to 37% [26], attributed largely to the increasing Hispanic population. However, circumcision rates have increased in the Midwest and South, and among Blacks [12,14]. Given the heavy burden of HIV among U.S. Black and Hispanic populations, and the lower rates of circumcision among these racial/ethnic groups [26], it was anticipated that an association between circumcision and HIV would be found, hence a possible means to reduce the burden of HIV/AIDS in these communities. The findings of this study indicate that it is unlikely that lack of circumcision is contributing to the ethnic disparity in HIV rates in the United States.

The few case-control studies conducted among high-risk populations in Africa showed mixed results for circumcision as a risk factor for HIV [27–29]. This study’s findings of no significant association between circumcision status and both HIV and STI contradict a number of studies, finding an association, conducted principally among African populations [30,31]. However, one case-control study of a general population in Senegal [32] also found a protective effect for lack of circumcision on HIV status.

Studies of HIV or STI and circumcision status conducted in developed nations have yielded contradictory findings [12,13,33]. Results from cross-sectional and cohort analyses of the project RESPECT study group, U.S. sexually transmitted disease clinic- based populations, showed slightly elevated risk for gonorrhea and syphilis among uncircumcised men, while there was essentially no risk difference found for chlamydial infection. Biological and mechanical mechanisms for increasing risk through microabrasion and the inherent infectiousness of the organisms may explain these findings.

An analysis of data from the 2000 British National Survey of Sexual Attitudes and Lifestyles (Natasal), found an overall circumcision rate of 15.8% with no statistically significant difference in cumulative STI incidence by circumcision status [34]. Although the British population has relatively low rates of circumcision, and the United States has moderately high rates, the British population’s circumcision rates likewise differ by ethnicity and country of origin. However, the associations were opposite those seen in the United States, with ethnic minority men in Britain more likely to report circumcision, as were men born outside the country. Considering “developed” countries as monolithic in terms of the role of circumcision in STI and HIV risk may be misleading. Nonetheless, there are similarities in sanitary conditions and relative access to healthcare.

Differences in the various study findings may be due to uncontrolled confounding by religion [35,36], hygiene practices, restrictive social rules limiting partners outside of marriage, or differences in sexual practices and risk behaviors [7,37,38], rather than circumcision, per se. Basic health and sanitation conditions, as well as access to healthcare in the United States, are generally better and more comprehensive than in many African nations, which can greatly influence the role of circumcision, or lack thereof, in HIV transmission.

In our study, while there were differences in the method of circumcision reporting between cases and controls, and differences in the rates of available circumcision status, no differences in demographics were seen after adjustment for participation location. Site-specific history-taking practices, and differences in clinical report forms account for reporting differences, not biases, with respect to patient characteristics. Some reporting bias could be present due to differences in clinician versus self-report data, although the direction of the bias is unclear [39]. The rates of circumcision found among the cases (85%) and controls (81%) are quite similar to the rates reported by the Centers for Disease Control and Prevention [26].

As discrepant evidence regarding the role of male circumcision in HIV/STI transmission has surfaced and societal perceptions of circumcision have changed, the policy of the American Academy of Pediatrics (AAP) regarding routine neonatal circumcision in the United States was reassessed. In 1999, the AAP Task Force on Circumcision issued a policy statement recognizing the existing scientific evidence demonstrating medical benefits of neonatal circumcision, and yet concluded that the data remain insufficient to recommend routine neonatal circumcision; thus leaving the decision up to parents with the guidance of their pediatrician.[20]

This study adds weight to the evidence that lack of circumcision is not a risk factor for HIV in the general population of a developed country. Although known HIV risk factors such as inconsistent condom use, history of STI, multiple partners, and anal sex were found to be associated with HIV in this military population, there was no significant association with male circumcision. Randomized clinical trials currently underway should shed more light on this pressing topic.


References

1. Weiss HA, Quigley MA, Hayes RJ. Male circumcision and risk of HIV infection in sub-Saharan Africa: a systematic review and meta-analysis. AIDS 2000; 14:2361–2370.

2. Cameron DW, Simonsen JN, D'Costa LJ, et al. Female to male transmission of human immunodeficiency virus type 1: risk factors for seroconversion in men. Lancet 1989; 2:403–407.

3. Auvert B, Buve A, Lagarde E, et al. Male circumcision and HIV infection in four cities in sub-Saharan Africa. AIDS 2001;15(suppl 4):S31–S40.

4. Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. Rakai Project Study Group N Engl J Med 2000; 342:921–929.

5. Halperin DT, Bailey RC. Male circumcision and HIV infection: 10 years and counting. Lancet 1999; 354:1813–1815.

6. Bailey RC, Plummer FA, Moses S. Male circumcision and HIV prevention: current knowledge and future research directions. Lancet Infect Dis 2001; 1:223–231.

7. Moses S, Bailey RC, Ronald AR. Male circumcision: assessment of health benefits and risks. Sex Transm Infect 1998; 74:368–373.

8. Simonsen JN, Cameron DW, Gakinya MN, et al. Human immunodeficiency virus infection among men with sexually transmitted diseases: experience from a center in Africa. N Engl J Med 1988; 319:274–278.

9. Nasio JM, Nagelkerke NJ, Mwatha A, Moses S, Ndinya-Achola JO, Plummer FA. Genital ulcer disease among STD clinic attenders in Nairobi: association with HIV-1 and circumcision status. Int J STD AIDS 1996; 7:410–414.

10. Newell J, Senkoro K, Mosha F, et al. A population-based study of syphilis and sexually transmitted disease syndromes in north-western Tanzania. 2. Risk factors and health seeking behaviour. Genitourin Med 1993; 69:421–426.

11. Parker S, Stewart A, Wren M, Gollow M, Straton J. Circumcision and sexually transmissible disease. Med J Aust. 1983; 2:288–290.

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16. Shaw KN, Gorelick M, McGowan KL, Yakscoe NM, Schwartz JS. Prevalence of urinary tract infection in febrile young children in the emergency department. Pediatrics 1998; 102:e16.

17. Herzog LW. Urinary tract infections and circumcision. A case-control study. Am J Dis Child 1989; 143:348–350. Circumcision and HIV/STI association 15

18. Schoen EJ, Oehrli M, Colby C, Machin G. The highly protective effect of newborn circumcision against invasive penile cancer. Pediatrics 2000; 105:e36.

19. Maden C, Sherman KJ, Beckmann AM, et al. History of circumcision, medical conditions, and sexual activity and risk of penile cancer. J Natl Cancer Inst 1993; 85:19–24.

20. American Academy of Pediatrics. Task Force on Circumcision: Circumcision Policy Statement. Pediatrics 1999; 103:686–693.

21. Harrison DC. Male circumcision and HIV infection. Lancet 2000; 355:926; 927 [author reply].

22. Grossman EA, Posner NA. The circumcision controversy: an update. Obstet Gynecol Annu 1984; 13:181–195.

23. Hodges FM, Svoboda JS, Van Howe RS. Prophylactic interventions on children: balancing human rights with public health. J Med Ethics 2002; 28:10–16.

24. Brodine SK, Shaffer RA, Starkey MJ, et al. Drug resistance patterns, genetic subtypes, clinical features, and risk factors in military personnel with HIV-1 seroconversion. Ann Intern Med 1999; 131:502–506.

25. Brodine SK, Starkey MJ, Shaffer RA, et al. Diverse HIV-1 subtypes and clinical, laboratory and behavioral factors in a recently infected US military cohort. AIDS 2003; 17:2521–2527.

26. Centers for Disease Control and Prevention/National Center for Health Statistics. Trends in circumcisions among newborns. 2003: http://www.cdc.gov/nchs/products/pubs/pubd/hestats/circumcisions/circumcisions
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27. Carael M, Van de Perre PH, Lepage PH, et al. Human immunodeficiency virus transmission among heterosexual couples in Central Africa. AIDS 1988; 2:201–205.

28. MacDonald KS, Malonza I, Chen DK, et al. Vitamin A and risk of HIV-1 seroconversion among Kenyan men with genital ulcers. AIDS 2001; 15:635– 639.

29. Sassan-Morokro M, Greenberg AE, Coulibaly IM, et al. High rates of sexual contact with female sex workers, sexually transmitted diseases, and condom neglect among HIV-infected and uninfected men with tuberculosis in Abidjan, Cote d'Ivoire. J Acquir Immune Defic Syndr Hum Retrovirol 1996; 11:183–187.

30. Nasio J, Nagelkerke N, Mwatha A, Moses S, Ndinya-Achola J, Plummer F. Genital ulcer disease among STD clinic attenders in Nairobi: association with HIV-1 and circumcision status. Int J STD AIDS 1996; 7:410–414.

31. Gray RH, Kiwanuka N, Quinn TC, et al. Male circumcision and HIV acquisition and transmission: cohort studies in Rakai, Uganda. Rakai Project Team. AIDS 2000; 14:2371–2381.

32. Pison G, Le Guenno B, Lagarde E, Enel C, Seck C. Seasonal migration: a risk factor for HIV infection in rural Senegal. J Acquir Immune Defic Syndr 1993; 6:196–200.

33. Donovan B, Bassett I, Bodsworth NJ. Male circumcision and common sexually transmissible diseases in a developed nation setting. Genitourin Med 1994; 70:317–320.

34. Dave SS, Johnson AM, Fenton KA, Mercer CH, Erens B, Wellings K. Male circumcision in Britain: findings from a national probability sample survey. Sex Transm Infect 2003; 79:499–500.

35. Bailey RC, Neema S, Othieno R. Sexual behaviors and other HIV risk factors in circumcised and uncircumcised men in Uganda. J Acquir Immune Defic Syndr 1999; 22:294–301.

36. Grosskurth H, Mosha F, Todd J, et al. A community trial of the impact of improved sexually transmitted disease treatment on the HIV epidemic in rural Tanzania: 2. Baseline survey results. AIDS 1995; 9:927–934.

37. Mertens TE, Carael M. Sexually transmitted diseases, genital hygiene and male circumcision may be associated: a working hypothesis for HIV prevention. Health Transit Rev 1995; 5:104–108.

38. de Vincenzi I, Mertens T. Male circumcision: a role in HIV prevention? AIDS 1994; 8:153–160.

39. Diseker RA, III, Lin LS, Kamb ML, et al. Fleeting foreskins: the misclassification of male circumcision status. Sex Transm Dis 2001; 28:330– 335.


Tables















PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES)

Naval Health Research Center P.O. Box 85122
San Diego, CA 92186-5122

SPONSORING/MONITORING AGENCY NAMES(S) AND ADDRESS(ES)

Chief, Bureau of Medicine and Surgery Code M2
2300 E St NW
Washington DC 20372-5300




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