Should all boys be circumcised?
New evidence suggests removal of the foreskin can protect not just against HIV, but other diseases that kill millions. Now some doctors are reconsidering their views on an ancient and controversial procedure
If you were the parent of a baby boy and were told a minor operation could provide him with protection against three diseases (at least) that kill millions worldwide, would you be interested? It is safe to assume that you would. When, however, you discovered that the operation in question was circumcision, would your enthusiasm dwindle?
Circumcision is the world’s most common surgical procedure. But it is also among the most sensitive – politically, culturally and ethically. Even within the scientific community it is difficult to have a reasoned debate about the pros and cons, examining the evidence, without people taking sides. For several decades, the medical community has kept quiet about circumcision, mindful of the sensitivities around it. Doctors are broadly agreed that the operation is “not medically necessary” – except in a tiny minority of cases, for example where the foreskin will not retract. They say it is for parents and the public to decide about the ethics of circumcision for religious or other non-medical reasons.
Now that cosy consensus has been challenged by the emergence of evidence showing that the removal of the foreskin can prevent a number of sexually transmitted diseases. Three landmark randomised controlled trials conducted in South Africa, Kenya and Uganda between 2005 and 2007 demonstrated that adult male circumcision reduced the risk of contracting HIV by 50 to 60 per cent. This is well known and has led to the development of programmes offering circumcision in a number of African countries, backed by the World Health Organisation, with predictions that in the long term it could save millions of lives.
But the act seems to be having little effect. In July last year, 15 boys died and 90 were taken to hospital after botched circumcisions. The main causes of death and hospitalisation are blood loss and dehydration.
Circumcisions kill S African boys
South African officials say 15 boys have died and 90 have been taken to hospital in the Eastern Cape after botched circumcisions.
The deaths were reported as authorities announced a campaign to prevent badly-performed initiation rites.
Police have arrested six people in connection with the casualties, health official Sizwe Kupelo said.
Mr Kupelo said the authorities were not interfering with the custom of circumcision, but wanted to save lives.
Circumcision is practiced in rural areas of South Africa during winter.
It is a traditional rite of passage for many South African boys. In 2001 the government passed an act requiring a licence from a medical officer for each circumcision, but traditional leaders have said the act infringes community rights.
Most deaths occur after circumcisions in illegal centres.
Health officials linked the recent cases to what they say is parental negligence, the BBC’s Mpho Lakaje reports from South Africa.
They say most initiates are sent home after being improperly circumcised, only to die there.
Dehydration has also been cited as one of the reasons for the deaths.
news.bbc.co.uk
Previous research has suggested circumcision doesn’t make a difference when anal sex is involved. The latest study, by CDC researchers, looked at nearly 4,900 men who had anal sex with an HIV-infected partner and found the infection rate, about 3.5 percent, was approximately the same whether the men were circumcised or not. Presumably the same applies to men having anal sex with women.
KwaZulu Natal Province has one of the highest HIV infection rates of any South African province. If circumcision does not reduce transmission rates then thousands of young men’s lives and well-being will have been put at risk for nothing. Women’s lives will also be at risk as these men become their sexual partners. There is still no conclusive evidence that circumcision works any better than good hygiene.
The trial in The Lancet reported above concluded that ‘Condom use after male circumcision is essential for HIV prevention.’
By Jeremy Laurance
UK Royal College of Paediatrics