Triangle Trade in Foreskins, Part 3
Posted on | July 8, 2009 | 15 Comments
So many great comments were made on both sides of the circumcision issue that I started doing research into the literature and added a part 3.
I view studies that highlight the advantages of male circumcision with the same suspicion that I, and most people, would view a study implying an advantage to female circumcision. But in case you think those don’t exist, they do: Check out this study showing reductions in female HIV rates among circumcised women. Ridiculous!? Not at all. It actually makes sense if the pro-male circumcision camp is correct about the mechanism of risk reduction conferred by male circumcision. The CDC reports on their website that male circumcision reduces risk because the foreskin has the penis’s highest concentration of Langerhans cells (immune system cells that actively protect against HIV until the viral load becomes too great, and then they transport the virus into the body).
Now take a wild guess about where ladies have their highest concentration of Langerhans cells: In their vulvas (all the fun parts outside of the vagina like the labia and clitoral hood). The concentration of Langerhans cells drops off towards the cervix.
A little critical thinking leads to the disturbing conclusion that safely performed female circumcision should give women an HIV risk reduction similar to that given men by safe male circumcision. Don’t worry. The above study was done on already-circumcised women and nobody associated with the study wants to circumcise women and nobody is doing clinical trials on women like the ones they did on men. (So for those keeping score, we’re doing at least one thing right.)
But if we were over in Africa engaged in a principled effort to reduce Langerhans cells to stem an AIDS crisis, wouldn’t we be “saving” everyone by trimming off everyone’s Langerhans cells, not just men’s Langerhans cells. Why do the male circumcisionists hate ladies so much that they’re leaving all their death-inviting Langerhans cells on them? Don’t they deserve the same protection from HIV that we’re blessing the African men with?
To make it perfectly clear. I do not want anyone to begin some effort to “save” the women of Africa; I just want us to stop “saving” the men. I point out this hypocrisy to put a bold question mark by the idea that the African male circumcision movement is an unbiased, principled public health effort. I believe instead that it is a misguided exercise of cultural bias.
Tags: Africa > AIDS > Circumcision > clitoris > foreskins > HIV > STDs > STIs
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15 Responses to “Triangle Trade in Foreskins, Part 3”
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My Book
July 8th, 2009 @ 7:42 pm
Circumcision is a dangerous distraction in the fight against AIDS. There are six African countries where men are more likely to be HIV+ if they’ve been circumcised: Rwanda, Cameroon, Ghana, Lesotho, Malawi, and Swaziland. Eg in Malawi, the HIV rate is 13.2% among circumcised men, but only 9.5% among intact men. In Cameroon, the HIV rate is 4.1% among circumcised men, but only 1.1% among intact men. If circumcision really worked against AIDS, this just wouldn’t happen. We now have people calling circumcision a “vaccine” or “invisible condom”, and viewing circumcision as an alternative to condoms.
ABC (Abstinence, Being faithful, Condoms) is the way forward. Promoting genital surgery will cost African lives, not save them.
It’s not like we’ve actually tried the things that do work. In Malawi for instance, only 57% know that condoms protect against HIV/AIDS, and only 68% know that limiting sexual partners protects against HIV/AIDS. There are people who haven’t even heard of condoms. It just seems really misguided to be hailing male circumcision as the way forward. It would help if some of the aid donors didn’t refuse to fund condom education, or work that involves talking to prostitutes. There are African prostitutes that sleep with 20-50 men a day, and some of them say that hardly any of the men use a condom. If anyone really cares about men, women, and children dying in Africa, surely they’d be focussing on education about safe sex rather than surgery that offers limited protection at best, and runs a high risk of risk compensatory behaviour.
Cameroon http://www.measuredhs.com/pubs/pdf/FR163/16chapitre16.pdf table 16.9, p17 (4.1% v 1.1%)
Ghana http://www.measuredhs.com/pubs/pdf/FR152/13Chapter13.pdf table 13.9 (1.6% v 1.4%)
Lesotho http://www.measuredhs.com/pubs/pdf/FR171/12Chapter12.pdf table 12.9 (22.8% v 15.2%)
Malawi http://www.measuredhs.com/pubs/pdf/FR175/FR-175-MW04.pdf table 12.6, p257 (13.2% v 9.5%)
Rwanda http://www.measuredhs.com/pubs/pdf/FR183/15Chapter15.pdf , table 15.11 (3.5% v 2.1%)
Swaziland http://www.measuredhs.com/pubs/pdf/FR202/FR202.pdf table 14.10 (21.8% v 19.5%)
July 24th, 2009 @ 2:36 am
Amen, Colesberry. I just stumbled upon your blog, so I haven’t read your other posts on the subject. Forgive me if I don’t, however, because the word itself makes me dry heave. Why anyone would do this to their child or themselves in the absence of some rare, debilitating condition (and then just enough to rectify it), is absolutely beyond me. All of northern Europe seems to being doing fine with its foreskins and lowest HIV rates in the world. Why isn’t simple cleanliness and education good enough for the rest of us? Answer: it is.
August 25th, 2009 @ 5:45 pm
So, if these Langerhans cells actually help fight HIV (until there is just too much to fight off)…then wouldn’t it make sense that men with intact penises with a small number of sex partners would have a smaller chance of getting HIV than circ. men with the same number of partners…. so, shouldn’t we be sticking to the whole safe sex theory instead of encouraging parents to mutilate their sons.
–mother of a 3 month old intact little boy
August 25th, 2009 @ 6:53 pm
S. Jones,
I think you made a great choice to leave your son intact. And yes, I agree that a cultural commitment to safe sex is a much better idea that encouraging genital mutilation. The CDC is on the verge of recommending circumcision as an operation for infant boys, against the tide of pediatrician groups which have withdrawn their endorsement of circumcision. I’m shocked that the tide is turning back.
Thanks for commenting.
August 26th, 2009 @ 12:08 pm
Thanks for daring to talk about this issue in your blog — I wish more people did. I work with Intact America, an organization devoted to protecting the rights of baby boys, and we too are shocked at the tide turning back towards circumcision. It seems as if the ethics of the issue are being neglected entirely, in favor of African studies that have no relevance to the issue being debated here in the U.S. — studies involving consenting adult heterosexual males. Another study just released confirms that circumcision does not protect gay men from the AIDS virus… and yet the suggestion is still on the table.
Thanks again for your attention to the subject, it’s very much appreciated.
–
Jennifer Konig
Senior Project Manager, Intact America
August 27th, 2009 @ 12:35 am
This week, Karim and colleagues published an article in The Lancet, ‘HIV Infection and Tuberculosis in South Africa: An Urgent need to escalate the public health response.’ The South African government has responded favorably to this and other articles in the same issue of The Lancet, despite their critical stance against the ANC government and its former health minister.
The authors’ views on male circumcision, likely to become official policy in the near future, will not get a sympathetic hearing from many on this blog. They are at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60916-8/fulltext
On a separate topic, the DHS data from all of subsaharan Africa, not selected countries, tend to suggest a protective effect of male circumcision. Lesotho, often cited to show the contrary, does not, except in hospitals, practice circumcision, but only partial removal of part of the foreskin.
Robert Davis
August 29th, 2009 @ 6:45 pm
The FGM link was working only days ago, but not any more! This is probably not a coincidence. Someone out there recognized the strength of your argument and had the website shut down. The lecture on the FGM/HIV connection was held in July 2005, in Rio de Janeiro. It would be great if someone would post a cached copy of the abstract, before it is lost. Indeed, we may ask: Don’t women deserve the same protection from HIV that we’re blessing the African men with?
August 30th, 2009 @ 8:09 am
Very strange indeed. I’ll look through the lit on my next trip to the library.
September 8th, 2009 @ 12:04 pm
I just checked and the link is working again. I will however paste the entire abstract here, in case it goes anywhere again. And I’ll dig into it to find more studies when I get to the UCLA library again.
October 9th, 2009 @ 11:05 am
Adrian, thank you so much for talking about this. I hope you can mention in your sex-ed classes what circumcision is, the problems with it, the ethical dilemmas around it, and tell the American boys in your classes the truth about it.
I didn’t find out what had happened to me until I was 24! Every porn I’ve ever seen, and every diagram of the human body I saw in school, always had a circumcised man. That would be worth talking about: American anatomy or sex-ed textbooks, and the prevalence of circumcised-only male diagrams.
October 9th, 2009 @ 11:20 pm
The Planned Parenthood curriculum that I teach from does show two drawings, one of an intact and one of a circumcised penis. So that’s a good start. I state that the origin of routine circumcision was a way to stop masturbation and talk about how it’s performed nowhere outside the US as a routine medical procedure. After that it gets tricky because I don’t want to tell boys that their equipment is defective, or lesser than. I read a study about circumcised women that reported that orgasm rates for circumcised women in supportive communities as significantly higher than in communities where circumcision is seen as a mutilation or violation. Sex is so very much in the head that it just becomes tricky to talk frankly, even to the general community, about how male circumcision is a sensation-reducing genital modification/mutilation. I end the one-minute I spend on circumcision by saying, “Whatever penis you have, it’s fine, it works, but you probably won’t be circumcising your boys when you have kids.”
You and I are in the same boat, by the way. I’m circumcised as well and without my parent’s consent. It just happened. A too-common story.
October 12th, 2009 @ 12:56 pm
Your approach to teaching American boys about it sounds very well-considered and respectful. I think one of the barriers to ending this practice in the US is that American men don’t want to admit that their penis is lacking its most sensitive parts or in any way sub-optimal.
I heard that prior to the late 1980s circumcision was mandatory, in that the baby was mutilated before the parents even got to take him home, and without being told what was going to happen or what had happened already. Is that what you mean by “without my parent’s consent?”
I have a number of friends who are nurse midwives, and they’ve told me stories about the origins of “birth plans” where a woman can make a strict plan about what is allowed to be done to her, and what is not. Apparently it came out of the women’s rights movement when they rebelled against having many painful or unnecessary procedures performed on them when they were unable to protest during pregnancy. It sounds like doctors got a little bit carried away when it comes to controlling other people’s bodies.
Amazing to think that was in the latter half of the twentieth century…we’ve got a long, long way to go yet!
October 12th, 2009 @ 6:35 pm
Precisely and that was also one of the biggest barriers encountered by people fighting against female genital modification. How do you approach a grandmother, when you’re trying to convince her she shouldn’t cut her granddaughter, without flat out telling her that she’s a defective human being. No one likes to accept that they are sub-optimal. I’m conscious of not freaking my own self out by thinking about it too much. Where I’ve landed is that the sexual system is over-engineered, like every other part of the body. Just like we could burn off a huge part of our skin surface before it damped our immune response or made too little vitamin D, we can trim off all the all the best parts of someone’s genitals and still have the carved up result transmit sexual pleasure. The response of sexual pleasure developed through evolution is just that rugged. And the orgasmic response is rugged right along with it. Circumcised women have orgasms at high rates. (Journal of Sexual Medicine 2007, 4:1666-1678). Circumcised men regularly have orgasms.
But just because it still works doesn’t mean you should keep cutting stuff off, obviously.
To answer your question, I was brought into the room, where my mom and dad were waiting, already cut. Neither was asked permission.
Interesting analogy between a pregnant woman’s right to choose procedures and her baby’s rights. I hope that can become a ride-along. We do have a long long way to go on this one. I don’t know if you know the organization Intact America. It’s headed by Georganne Chapin, who is also a health care reformer in general and a great woman. I think you’d really love their website.
October 13th, 2009 @ 2:01 pm
Readers might be interested to hear about St. Vincent Hospital in Santa Fe, which in 1995 came up with a Conscientious Objectors agreement for nurses and doctors who object to circumcision. It allows them to choose not to have anything to do with circumcision, and to be protected in that choice. You can read the text here:
http://www.consciencelaws.org/Conscience-Policies-Papers/PPPSettlements04.htm
Interestingly it has strong stipulations that they can’t publicly disagree with the hospital’s policy, they must always present the hospital in a positive light, they must always support parents’ choice to have their infant forcibly circumcised (I say forcibly because the child isn’t choosing it), and it puts strict limits on what kinds of literature can be presented to parents on the topic of circumcision.
December 5th, 2009 @ 10:55 am
I was considering becoming a doula a year ago. Yes, a birth plan is something a pregnant woman or pregnant couple write and give to their doctor, NP, doula, midwife and staff of wherever they plan to –intend to at least- give birth. It covers issues of anesthesia and epidurals, episiotomies, who cuts the cord, circumcision, etc. It’s a good script with things like Dad or Other Mommy will cut the cord, who has the baby when it is finally born, does it go straight to Mom’s chest, who else is in the room, will the baby stay in Mom’s room, what to do in emergencies and contingency plans… all kinds of good stuff that you don’t have to decide on the spot. I like the responsibility it makes parents and medical staff take on to think about all of this ahead of time and consider emergencies, and lifetime decisions.
The fact that you were circumcised without your parents’ permission is truly saddening and maddening.
Can’t we just make a salve for these Langerhans?
Sorry… humor is the only thing that can make me stomach all these illogical “studies” about circumcision and HIV transmission.
I’m glad you brought up Bush’s Global Gag rule in a previous blog.
Yes, America Giveth, and then America Taketh with Great Conditions and Stipulations.