Snip, snip, the scissors go… (Wednesday, May 18th, 2011)

Every so often, there are stories in the media like this one:

Men who want to lower their chances of contracting HIV should be circumcised, the world's leading health experts said yesterday.

Having the foreskin removed lowers the risk of catching the virus by 60 per cent, they said.

(The Metro, London 29th March 2007)

So why not circumcise all men?

The later paragraphs in this story gave some reasons that weren't in all the ones I saw:

.. an additional important intervention to reduce the risk of heterosexually acquired HIV infection in men..

So, not enough on its own, not relevant to the bulk of infections acquired in the UK, and of marginal benefit to women (if fewer men have HIV, fewer women will have HIV+ partners, but if you're a woman and your partner is HIV+, circumcision doesn't help you) but even so, worth trying?

In the UK, the large NATSAL surveys show no difference in STI rates between 'cut' and 'uncut' men, but a 60% reduction in risk sounds a lot – it's about what people are hoping for from a vaccine against HIV, should one be developed – and it comes from three randomised control trials in Africa (you circumcise some men, but not others, and see what happens to them over time) but…

  • It's a relative reduction. The absolute reduction was about 1.8% – over the course of the trials, the risk was about 4.8% (uncut) and 3.0% (cut)
  • The level of complications was about 1.5% – and these were circumcisions performed in the best conditions they could arrange. Complications vary from serious blood loss and infections, to impotence and total loss of the penis.

So in order to get about a 1.8% reduction in HIV cases in that time, 1.5% of men had problems, some serious. If somewhere in Africa decided to circumcise every man and boy, the complications would increase (these countries have higher priorities for their health budgets than paying for first world standards of circumcision!)

And… the trials were all cut short (sorry! 'terminated early') and this will mask any delaying effect. Imagine that all circumcision did was delay catching HIV by a year, on average. Stopping a three year trial after two years would show a substantial reduction in relative risk – you'd miss all the cut men who caught HIV in the third year! I'd expect at least a decade's follow-up before anyone should consider recommending it in this way.

So it's not particularly surprising to find out that the people running the trials had long track records of favouring circumcision.

And it gets worse: in order to maximise what benefit there is, you'd need to do this in infancy, but there are serious consent issues – you're performing an unnecessary operation with possibly some major complications on someone who can't give consent themselves in the hope that, fifteen or so years later, there might be some benefit.

If they turn out to be gay or bisexual, it will be of no benefit. If a medical advance happens in another prevention technology, there may be no benefit. And if they ask you for advice, you're still going to say 'use condoms'!

Circumcision, just say 'not for everyone'.

TMI disclaimer: I have a foreskin, and I'm very happy with it. There would need to be a serious reason for me to want to lose it and as you might guess, I'm not booking any surgery soon.

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