defective yeti: Research Day: Circumsicison and HIV

The following post was inspired by the seventy-first suggestion in No One Cares What You Had for Lunch: 100 Ideas for Your Blog, which was randomly selected by Alison Headley of bluishorange.

I used to work in the field of HIV and AIDS research. So when a friend of mine recently discovered that he was to be the father of a baby boy, he sent me the following email:

What do you know about connection between circumcision and reduced chance of acquiring HIV? We hadn't even considered circumcision until we heard about the study, but now we're wondering about it

To which I responded:

I don't want to discount the HIV transmission thing, but, in your case, I don't know that I'd put a lot of stock in it either. There was a lot of talk about this study back when I was working at the lab, and I don't dispute the findings. But bear in mind that these trials were conducted in areas where HIV was prevalent, and where the participants were engaging in "high risk" behavior (multiple partners, unprotected sex, etc).
If you educate your kid to take precautions against HIV, and he lives in an area where HIV isn't rampant, and he's monogamous (or just-a-fewgamous), his being circumcised might only decrease his overall chance of infection from "pretty low" to "pretty low minus a smidge" (as opposed to, say, a Kenyan trucker who has lots of sex with multiple, concurrent partners, and whose circumcision is his only form of "protection.").

But, before hitting send, it occurred to me that I might not know what I was talking about. I mean, yes, I used to work in the field of HIV and AIDS research, but only as a programmer -- not as one of the genius who actually design the clinical trials or analyze the results.

So I sent my friend's question, and my reply, to M, a statistician I know who still works there. Here's what she had to say:

Hey Matthew, To assess individual risk, one would need to account for many characteristics and behaviors on the individual level. In most clinical studies, such as those conducted regarding male circumcision, data is collected on risk factors associated with the outcome (HIV infection in this case) and the exposure (circumcision, say). In stat. analyses, we adjust for these factors so that we can come up with a reasonable estimate for the risk of the exposure accounting for all the other potential "confounding" characteristics/behaviors on a population level. For the individual, however, his/her risk is highly dependent on his/her individual profile of risk. Circumcision, for example, is only one characteristic of a man that might put him at risk for HIV infection. There exist a plethora of others such as HIV status of his sex partners, numbers of sex partners, alcohol/ drug use, injection drug use, condom use, etc. Your points are well made regarding the differences between heterosexual risk in the US and that in high HIV prevalent areas such as sub-Saharan Africa in that in the US, among heterosexual males, the risk of transmission is much lower since the prevalence of HIV among all people is lower. For example, "In 2004, men who have sex with men (MSM) (47%) and persons exposed through heterosexual contact (33%) accounted for an estimated 80% of all HIV/AIDS cases diagnosed in areas in the U.S. with confidential name-based reporting. Blacks accounted for 49% of cases and Hispanics for 18%. Infection rates in both groups were several-fold higher than that in whites. An overall prevalence of about less than 0.5% was estimated for the general population [15]." See http://www.cdc.gov/hiv/resources/factsheets/circumcision.htm for more details. In observational studies in the US, however, the relative risk of HIV infection among non-circumcised men was typically two-fold that of circumcised men. So, whether you are a man in Africa driving a truck and having sex with many women, or you are a man in the US having sex with one woman, if you are having sex with an HIV+ woman and you are not circumcised, you are pretty much at the same level of risk for HIV, with all other characteristics being equal. One issue that has not been determined, though, is whether or not the different clades of HIV strains could have an impact on the susceptibility of acquisition. If there were a difference, the geographic location (i.e. who you were having sex with and thus, what strain of virus they have), could have an impact on acquisition. In other words, your risk is highly dependent on your own personal behaviors, rather than the population's behaviors. We use the population stats to help us understand, in general, what behaviors on the individual level will put us at higher risk than other behaviors. But, we cannot quantify an individual's risk based on population numbers unless we design a study in such a way to make these calculations possible. There is, of course, many other considerations regarding male circumcision for babies, such as risk of infection, pain, etc. to go through the operation. This should be weighed with the benefit (as you pointed out to your friend) of other harms (such as HIV, as well as other sexually transmitted diseases such as Human Papillomavirus, Gonorrhea, Herpes, etc.). Also safe sex practices (using a condom!), in general, will most likely outweigh any risk of not being circumcised if this baby boy grows up to be a real swinger (either with men or women)!! Hope that helps. Also see http://www3.niaid.nih.gov/news/QA/AMC12_QA.htm for another website to consult, and the press release on the trial in Kenya and Uganda.
Cheers!

M also asked that I add the following disclaimer: "This was written by an anonymous, somewhat crazy biostatistician-woman who happens to have some extended experience researching HIV/AIDS, among mostly & ironically, Men who have Sex with Men (MSM). Please take her words regarding the male genitalia, and what should be done with it, with a grain of salt!"

Me, I wouldn't think that circumcision and salt would go together but, like I said, I'm just a code-jockey.

making a rash assumption that the parents of this new little boy are a heterosexual couple, I think that it is great that his parents are aware that this little guy, regardless of his sexual orientation, could possibly contract HIV down the road, and are educating themselves to see what steps they can take to help him prevent it.

We've come a long way, baby.

Posted by: chzplz on February 2, 2007 4:00 PM

I used to work for the HIV/AIDS education and testing department of the Thurston County Health Department in Washington, and most of the statistics we saw were parallel with what both you and your anonymous tipster are concluding.

I think the issue regarding HIV is not one where circumcision matters, to bluntly reduce everything to a one-sentence opinion. There are far more issues as stake than HIV, though it's nice these new parents are concerned about it. I'd be far more concerned as to the issue I have encountered as a heterosexual woman with some just-a-fewgamous partners both circumcised and not: UNcircumcised partners have more difficult experiences with condoms, in my experience. It is entirely possible that I had a random and coincidental sampling of men, but each of the men with intact foreskins had trouble putting the condom on, and complained of occasional discomfort. If this fact ALONE were presented I would say get the kid circumcised.

Also, it's easier to give a blowjob to an uncircumcised penis. Just my two cents.

Posted by: Subspace on February 2, 2007 6:04 PM

Thank you. I'm not sure I should explain in detail but this information could come in handy in the next few years! (OK, it's not the complicated. I want to have another baby, child might be male, Jewish spouse has strong feelings on the matter, need to rationalize my own qualms at anything that might make my baby cry, etc.)

Circumcision cuts down on STD rates. That should also matter since that is more likely perhaps than HIV even if less scary.

Posted by: ozma on February 2, 2007 10:14 PM

A small reduction in the odds of getting HIV (and it's a very small reduction) is not worth mutilating your baby. It hurts the child for little to no benefit - and as the foreskin is chock-full of nerve endings, it makes the penis less sensitive, and thus may well decrease your child's eventual enjoyment of sex.

I think that people should only lop off parts of babies for serious medical issues, not so that the penis will be lower maintenance or something. If your son really doesn't like being uncircumcised, let him make that decision for himself. After all, it's a lot harder to get a new foreskin than it is to have the old one removed.

Posted by: Jake Boone on February 3, 2007 12:37 AM

What circumcised man recalls the pain of his circumcision?! Please, that's not a consideration. That's an indication you're about to raise a momma's boy.

Posted by: jack haas on February 3, 2007 12:40 AM

Jake is 100% correct. Circumcision is a barbaric custom rooted in religious superstition. The penis is in exactly the form as nature intended, no modification is needed. I implore you to do some research online and I am sure the preponderance of information out there weighs against this horrible custom. Tell your son how to use condoms and he'll be fine.

By Jack's logic we should be allowed to torture people if we could just have them forget about it. A baby can suffer just as much as an adult while the experience is happening, and maybe even more so since the baby has no understanding of what is going on. Try to find the episode of Penn & Teller's show "Bullshit" which showed a circumcision taking place. After seeing that you will never want to inflict such a painful and unnatural procedure on your baby.

Please let your baby live intact. "If it ain't broke...!"

Posted by: Karl on February 3, 2007 9:34 AM

Rory Parle I bet they could reduce the risk even further if they just cut his penis off altogether!

Yeah, but studies show that men that have their penis cut off are higher risk for I.V. drugs. Giving them an greater risk of HIV.

Ok. there was no study, but I'd use a lot of drugs if I had no penis.

Posted by: Martin on February 3, 2007 12:00 PM

There are a lot of nerves in the foreskin. Why would you ever consider performing genital mutilation on your child? What a horrible thing to do to someone--to take away a significant part of their future sexual pleasure just because of your own neurosis about germs.

Posted by: on February 3, 2007 6:15 PM

It is simply the most repulsive aspect of US Culture; the mutilation of male genitalia for no good reason. The practice among Gentiles dates to Dr. Kellogg asserting it would diminish the sex drive, cutting down on masturbation and other sinful practices. As a victim of the practice, I refute that stupid idea several times a week.

I've yet to hear one good reason it's medically beneficial. And certainly cannot imagine hearing one that explains why its Ethical.

My dick hurts just thinking about it.

Posted by: Dan Isaacs on February 3, 2007 9:55 PM

ozma, if you are not Jewish, your son wouldn't be either. Ergo, no reason to mutilate his flesh for the sake of some ancient religious ceremony. Hell, even if he were, still no reason.

Posted by: Dan Isaacs on February 3, 2007 10:00 PM

On the other end of the spectrum, here, I'm circumsized and I don't think I have any emotional scars as a result. I've got uncircumsized friends who complain about certain aspects of it. They're more likely to experience pain during sex. For example, one complains that he's too sensitive and that oral sex hurts as a result.

For the record, my vote on my future child is uncirc, and my wife wants to circumsize. I certainly don't think it's "barbaric", and it can't be compared to female circumcision, which is truly barbaric.

Posted by: James on February 5, 2007 7:15 AM

As an uncircumsized man, I'd like to refute a couple of the assertions above.
1. Using a condom is no problem, as an erect penis' foreskin is rolled back and the penis looks/acts no different than a circumsized one.

2. I've never experienced pain during sex, and none of the uncirc'd guys I know have either. If it hurts, I have serious doubts about it being caused by the foreskin, and wonder what the hell those guys are doing.

Posted by: mike on February 5, 2007 8:20 AM

Mike, again, as I said previously, having more experience with penises than you, every sexual encounter I've had with a man with a foreskin has included the troublesome task of trying to comfortably fit the condom over the foreskin. I guess you should consider yourself lucky. I've literally sat and watched as a partner went through three condoms in an attempt to get it put on to a degree that he could then have sex (why so many? kept getting pre-ejaculate onto the exterior of the condom).

Those here that call it "mutilateion" or horrible" "barbaric" and "torture" are in fact being abusive toward the caring adult parents of perfectly happy children. And anyone who trusts Penn and Teller for their moral and ethical decision-making needs to wash their eyes out with carbolic acid.

People mutilate babies all the time, folks. What about kids with tails? Extra thumbs? Broken heart valves? Sure, it may not kill him, but we're talking about cracking his damn chest open! Anyone who has been in a room with a fresh baby and a room full of doctors (as I have) cringes as they slap, shake, stab and poke that babies while it screams. Being alive is rough business.

Posted by: Subspace on February 5, 2007 8:48 AM

Just because the medical practice currently treats babies as if they aren't sensitive (slapping, shaking, poking and ignoring of screams) doesn't mean it doesn't have an effect on that child.

There is also a difference between cutting off a perfectly healthy piece of flesh that isn't causing any harm and open heart surgery to correct a deadly defect.

If male genital mutilation is still alive and well in this country, I'm surprised more female genital mutilation isn't being done. After all... it is just a clit and can be a little too sensitive when some women have sex. Let's just cut 'em all off.

Posted by: Tracy on February 6, 2007 11:19 PM

Subspace,

If your partner was having such a hard time with his foreskin he has the free choice to have it removed any time. This is a choice a baby does not have. There is nothing wrong with an adult making such a decision about his own body.

Equating a naturally occurring foreskin to a malformed heart valve is a bad analogy.

Just because a practice is common does not make it right. Caring adult parents of perfectly happy children need to be educated and fully informed before they make decisions for their baby that are irreversible. If you do the research I think you will find words like "barbaric" to be quite fitting.

Obviously there may be benefits to being circumcised, but there are also drawbacks. The decision to go through with the procedure should be made by the individual himself when he is old enough to understand all the pros and cons.

Posted by: Karl on February 7, 2007 7:24 PM