Daily Archives: April 5, 2007

NYC recommends circumcision to prevent HIV, and distributes free condoms…

If I were a man, I know which I’d choose!

There was a great positioning of stories in today’s Metro section of the New York Times. On the cover of that section was an article about New York City’s Department of Health and Mental Hygiene (can you believe it’s still called that?) moving to recommend that men who are at risk for HIV infection get circumcised as a preventative measure. Their move is in response to the World Health Organization’s recommendation that circumcision be used to help stop the spread of HIV in Africa.

The story was continued on the inside of the paper, and the continuation was right below a story exclaiming the enormous number of NYC-branded condoms given out for free during the month of their release. Five million were distributed between Valentine’s day and mid-march. There are 8 million New York City residents, so this is a pretty amazing number!

I don’t know if the placement of the stories that way was intentional or not, but reliable, regular condom use would seem a much less problematic preventative measure than circumcision.

I’ve been troubled by the recent stories reporting on studies that circumcision reduces male’s risk of contracting HIV for a few reasons. First, circumcision of boy babies is a troubling phenomenon in its own right. The foreskin is an important part of the male sex organ and to remove it is a serious act. A Canadian doctor and medical columnist writes:

The skin removed by circumcision measures from three to five inches in length. That’s about half of the total skin of the penis. Besides, inside the foreskin, there’s a band of tissue that moves in and out like an accordion. This gliding motion triggers sexual reflexes and contributes to sexual pleasure….A detailed microscopic examination of the foreskin revealed it’s not merely a piece of skin. Rather, it’s loaded with blood vessels and nerves. Remove it and you also amputate a large part of the sexual portion of the penis.

I often ask my students to think about it light of female genital mutilation, which generates outrage in most places where it is discussed by westerners. Why is it acceptable to remove the foreskin of a boy’s penis but would be an outrage if we began recommending the surgical removal at birth of the hood of girls’ clitorises? (Note: I oppose female genital mutilation just as I oppose male genital mutilation. In general, I believe genitals should be left intact and that is part of why I’m troubled by these recent studies.)

I know that the research studies that shaped the recent WHO decision indicate that for men having sex with women, circumcision appears to reduce the risk of HIV infection up to 60%. But condom use reduces the risk at least that much, and if condom use is regular and correct it reduces the risk even more. And then, heterosexual intercourse is only one way of catching the virus. Same-sex sex and drug use with infected needles are others, and circumcision clearly has no effect on the latter and has not been studied in relation to same-sex transmission. In addition, circumcision does not appear to have any effect on an infected man’s likelihood of passing on the virus. So the case for circumcision seems tenuous (and there seems to be no reason to think it’s a good idea for NYC, where men’s infections are more likely to come from other men or from contaminated needles, and where women’s infections are more likely to come from infected men or contaminated needles.

The condom seems such an attractive solution. I know that in Africa condoms are a more difficult matter. But here in New York they seem a nobrainer. And today’s article about free condom distribution being so immediately successful makes the circumcision story seem over the top. I know that those condoms don’t all get used properly, and some don’t get used at all, but they’ve got to be a better solution that circumcision. Advocates for Youth reports that

In a two-year study of sero-discordant couples (in which one partner was HIV-positive and one was HIV-negative), no uninfected partner became infected among couples using condoms correctly and consistently at every act of vaginal or anal sex versus 10 percent of those using condoms inconsistently.[1,6]

In a similar two-year study, two percent of uninfected partners who used condoms consistently became HIV-infected versus 12 percent among those who used condoms inconsistently or not at all.[1]

The footnotes are

(1)CDC. Condoms and Their Use in Preventing HIV Infection and Other STDs. PDF file Atlanta, GA: CDC, 1999.

(6) de Vincenzi I. A longitudinal study of human immunodeficiency virus transmission by heterosexual partners. New England Journal of Medicine 1994; 331:341-346.

In the US many groups take circumcision for granted. It’s amazing to think about how many women have never seen an intact penis, and how rarely they are depicted in pornography. It’s amazing that we accept the procedure as a “good hygiene” measure. Again, can you imagine trying to convince American parents that it would be good to remove the hoods of their daughters clits because, you know, really it’s so hard to clean them? And besides, they might some day harbor disease? (This is not a stretch — women in the US have routinely undegone unnecessary hysterectomies because they had fibroids that could, possibly, turn cancerous but wouldn’t necessarily do so, and in the 19th century clitoridectomies for girls were recommended to stop masturbation — just as circumcision was recommended for boys — because masturbation was a “mental hygiene” issue!).

I take HIV/AIDS very seriously. If circumcision is really a better solution than condom use, I’d like to see a lot more evidence before we all jump on the bandwagon. Because even though we in the US assume circumcision to be the norm, it isn’t the norm worldwide, and it isn’t the norm in most developed countries, and it is a serious step to suggest that it become a preventative measure.

I don’t know what the answer is, globally. But here in New York, let’s have more of the free NYC condoms, and lets have them everywhere — bars, clubs, hotels, restaurants, schools, prisons, everywhere — so we can have fewer penises missing important parts.

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