News > May 4, 2007

Circumcision Promotion Divides AIDS Activists

Should results of African AIDS study be applied in the United States?

By Dana Goldstein

A Swazi patient undergoes circumcision in Mbabane

The last time circumcision made headlines in New York City, the city Department of Health and Mental Hygiene was objecting to an ultra-Orthodox Jewish practice in which mohels—professional circumcisers—sucked blood out of the wounds of newly cut infants. After three babies contracted herpes, the city tried to ban the obscure ritual in 2005, provoking an angry response from the Orthodox community and a media dust-up.

Now circumcision is news again in New York, but this time the city is promoting the practice. The April 5 New York Times reported that the city health department has decided to encourage male circumcision as an HIV-prevention method among at-risk populations, particularly gay and African-American men. The move comes after several clinical studies in Africa showed that circumcision of an adult male can decrease his likelihood of infection by as much as 60 percent.

But New York’s campaign brings up thorny questions for AIDS researchers and activists. Many are concerned about extrapolating prevention methods for American high-risk men, many of whom are bisexual or gay, from the African circumcision studies, which were conducted primarily among heterosexual groups. Meanwhile, others question how a male partner’s circumcision affects a woman’s susceptibility to HIV.

Two decades of research show women are less likely to contract a variety of sexually transmitted infections when their male partners are circumcised. But a recent Johns Hopkins University study examining 997 men in Uganda found that their female partners were more likely to contract HIV following a circumcision if the men ignored doctors’ orders to abstain from sex until their wounds were fully healed, which usually takes about a month. And with the continued lack of a female-controlled HIV-prevention method—microbicide gels have yet to advance out of the trial phase—any HIV education effort must include a heavy emphasis on condom use. Spokespeople for the New York City Department of Health and Mental Hygiene and the Health and Hospital Corporation, which operates public clinics and hospitals in the city, say the city hasn’t established any formal procedures for encouraging HIV-testing prior to circumcision in light of women’s increased risk, but stress that any public circumcision efforts will be just one part of a multi-pronged HIV-prevention program.

Cultural stigma against circumcision also remains, especially among immigrant groups like Caribbean Americans. Though about 60 percent of American men are circumcised, the practice is relatively rare worldwide. And it has become less popular in recent years as parents have come to see circumcision as a painful surgery that removes an integral part of the male sexual anatomy. According to the CDC, in 2003, the American circumcision rate dropped to a postwar low of 55.9 percent.

Marjan Hezareh, scientific director of the Los Angeles-based AIDS Research Alliance, is cheered by New York City’s decision to explore circumcision as what she terms an “additional prevention strategy” to condoms. For Hezareh, the health benefits for women of having a circumcised partner have been sufficiently proven and the medical benefits should outweigh any stigma against both adult and infant circumcision.

“We must disassociate circumcision from a sign of belonging to a specific religion or culture, and show it to people as another medical prevention strategy,” she says. “I bet people will be very open about this.”

But Tokes Osubu, executive director of Gay Men of African Descent in New York, is not so confident. He says he is baffled by the city’s decision to focus on circumcision. “We might be sending the wrong message to people who are already circumcised,” he says. “They might think, ‘Oh, because I’m circumcised, I might be okay!’ We are still dealing with the effects of HIV being misunderstood 25 years ago as a gay disease. Now I’m afraid people will say, ‘I don’t have a problem because Mayor Bloomberg said so.’”

AIDS activists also fear that a circumcision drive will undermine their long-term strategy to emphasize condom use. Indeed, homosexual anal sex is so risky that doctors agree circumcision provides little protection against HIV for gay men.

Ronald Goldman, a psychologist and founder of the Circumcision Resource Center, makes the point that “the U.S. has the highest circumcision rate and the highest HIV-infection rate in the developed world.” A longtime anti-circumcision advocate, Goldman says, “If you’re treating a problem, medical ethics would say use the least invasive method available. And condoms are more effective, plus they’re cheaper.”

But in battling a disease that continues to grow at alarming rates in urban areas (one in 20 Washington, D.C. residents is HIV-positive, and in New York City, African-American and gay men have infection rates as high as 10 to 20 percent), New York City’s proposed circumcision drive is at the vanguard of public health efforts. Whether HIV/AIDS activists will get on board remains to be seen.

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• Reader Comments

  Considering that 80% of the world is intact, it’s remarkable how few people WITH foreskins are talking about cutting them off.  I think I know why. 

  The foreskin is without a doubt the best part of the penis, possessing over half the sensual nerve endings and typically including about 15 square inches of sexual interface. 

  Most of the half-million US men who have died of AIDS were circumcised at birth.  It’s obvious that circumcsion is no AIDS vaccine.  It costs the UN just 3 cents to give away a condom.

  Posted by TLCTugger on May 5, 2007 at 10:22 PM

  “...the city health department has decided to encourage male circumcision as an HIV-prevention method among at-risk populations, particularly gay and African-American men...”

  African-American men are more “at risk”? Why would that be? If this is true (which I’m questioning), what makes it so? This statement just sort of hangs there, as though it’s obvious to anyone when in fact it is far from obvious.

  And as for gay men, I’ve read several times in the last few years that the US gay male population has actually experienced a flattening of HIV infection rates, relative to the past, because of active efforts to inform members of that group about the mechanics of transmission, the wisdom of condom discipline, etc etc. Is that old data? Have infection rates steepened again for gay men?

  Some recent (and unbiased, if I can get it) data would be welcome.

  I wonder if what really should get the focus here is promiscuity, as opposed to sexual preference or racial identity. It seems much more “to the point” when HIV infection is the topic, and is far from exclusive to gay or Af-Am men. Promiscuity also seems more salient as an infection factor than whether a guy is “turtleneck” or “turtlehead”.

  Posted by Kuya on May 7, 2007 at 1:39 AM

  Also, I notice that the little “edit” thingy doesn’t appear on my posts any more…

  ...too many posters “editing” in posts of a million characters, I suppose.

  Posted by Kuya on May 7, 2007 at 1:41 AM

  Kuya - the “edit"t thingy only shows up when there are more than about 5 posts (why, i do not know).  (It shows up when you click “extended discussion, which only shows up when the discussion gets “long enough”.)

  When my boys were born i had a very difficult time deciding whether to circumcise them or not. Ultimately i choose not to (i am circumcised myself and have no complaints). If i were starting again, i would still mull over the options and i *might* choose differently today.

  “African-American men are more “at risk”? Why would that be? “

  Let me take a stab. They are homophobic and thus the gay men tend to stay on the down low, pretending to themselves they are not gay. Denial can lead to risky behaviours. They also probably are not circumcised as widely, another risk factor. Finally they may use condoms less frequently due to social reasons.

  Empowering women could only help with HIV prevention.The ability to say “no” or “not without a condom” is lacking in far too much of our society (and much of Africa is far far worse in this regard).

  Posted by wolf on May 7, 2007 at 8:30 AM

  Thanks wolf, I didn’t catch the fact that the discussion has to go to 6 posts before editing is possible.

  The remark in the article above about Af-Am men and gay men still hits me funny, seems to rest upon a lot of unclarified assumptions. The “studies” cited aren’t really cited at all, just the word “studies”, as though the reader ought to accept that word like it’s actually meaningful.

  We circumcised my boy after long conversations and not a few misgivings. I told him that if he ever wants to get reconstructed I’ll pay for it. He doesn’t seem too bugged by it all.

  Condoms really seem to make more sense refs HIV, even if they’re not perfect. I definitely agree it’s too much lacking that a woman anywhere in the world can stipulate a relatively trivial condition before she accepts a sexual advance. I suppose it’s based on versions of the idea of a man’s sexual rights, which in plenty of places means she doesn’t have refusal rights and better not say “no”, not even “no glove no love”.

  Here in the Phils there’s been a transformation in pop culture about condoms. In the past they were difficult or impossible to get, but in the last few years they’ve become widely available, even in the provinces (that makes some difference here). We even have radio and TV commercials advertising flavored ones, ribbed, dotted, etc. It’s a good step to have made; the population growth rate is almost 3% per year, meaning a rough doubling of the population in about 24 years. Bad scene in an archipelago with only 1/3 of its islands being habitable.

  And, of course, there’s the uncool aspect of the sex trade here. Yet another reason to make sure you take balloons to the party. As for realistic HIV/AIDS rates here, I believe the authorities lie like hell to understate them so I have no idea how prevalent it really is. More than all those overfed caucasian/east asian “tourists” looking for little brown rented girlfriends think, is my guess. May their hydraulics fail on approach.

  Posted by Kuya on May 8, 2007 at 2:47 AM

• extended discussion >>>Continued...

  Discussions with more than 5 comments are continued on our special discussion page to encourage continuity and ease of use. There are currently 8 posts.

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Also by Dana Goldstein

• Genetic Disorder
  Parents with limited incomes are being denied access to genetic tests and the counseling that experts say should accompany them
• Circumcision Promotion Divides AIDS Activists
  Should results of African AIDS study be applied in the United States?