Medical Journal of Australia publishes replies to Cooper et al

"An article in the 20 September issue of the Journal that suggested circumcision of infant boys could be considered a “surgical vaccine” against future heterosexually transmitted HIV has attracted strong criticism from many of our readers."

[Contrary to policy of responsible medical authorities]

In a recent editorial, Cooper and colleagues recommend increasing infant circumcision to combat increasing rates of heterosexual transmission of HIV infection, and contend that the major obstacle to increasing male circumcision in Australia is a Royal Australasian College of Physicians (RACP) policy. [1]

In September, after a literature review and analysis, the RACP released a revised policy on infant male circumcision, concluding that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand. [2] While evidence of HIV prevention by circumcision is strong in high-prevalence settings with predominantly heterosexual transmission, [3] this is not so in low-prevalence environments where homosexual transmission is more important. [4] Evidence of the protective effect of circumcision against other sexually transmitted infections in Australia is limited. [5]

Cooper et al’s comparison of circumcision with vaccines is misleading. Protection against HIV by circumcision is predominantly for males, and the risk for females may increase. [6] There is minimal protection against homosexual acquisition of HIV. [4]

The RACP acknowledges the strong and differing opinions on this topic, ranging from the strong pro-circumcision views of Cooper et al to the equally strong diametrically opposed views of the Royal Dutch Medical Association, which believes that (for reasons of ethics and medical risks) legal prohibition of infant circumcision is warranted. [7]

The RACP recognises the important role of parents in decision making, and recommends that parents contemplating circumcision of their newborn sons be carefully apprised of the risks and benefits. If they elect to proceed with circumcision, the procedure should be undertaken in a safe child-friendly environment, with appropriate analgesia, and by an appropriately trained, competent practitioner who is capable of dealing with complications. We believe that this approach safeguards the social and community interests of children, and offers protection from unnecessary surgical risks. [2]

The RACP does not accept that its policy on circumcision of infant males represents an obstacle to effective public health policy — it believes that, at present, the evidence does not allow a recommendation for widespread infant male circumcision and that Cooper et al have misrepresented this evidence. In the interests of children, and of public health more generally, it is important that this evidence be kept under review and decisions that could lead to increased morbidity and mortality of children only be made when it is clear that the benefits very clearly outweigh any risks.

David A Forbes, Chair, Policy and Advocacy Committee Paediatrics and Child Health Division, Royal Australasian College of Physicians, Sydney.

1. Cooper DA, Wodak AD, Morris BJ. The case for boosting infant male circumcision in the face of rising heterosexual transmission of HIV [editorial]. Med J Aust 2010; 193: 318-319.

2. Royal Australasian College of Physicians. Circumcision of infant males. Sydney: RACP, 2010.

3. Siegfried N, Muller M, Deeks JJ, Volmink J. Male circumcision for prevention of heterosexual acquisition of HIV in men. Cochrane Database Syst Rev 2009; (2): CD003362.

4. Templeton DJ, Jin F, Mao L, et al. Circumcision and risk of HIV infection in Australian homosexual men. AIDS 2009; 23: 2347-2351.

5. Templeton DJ, Jin F, Prestage GP, et al. Circumcision and risk of sexually transmissible infections in a community-based cohort of HIV-negative homosexual men in Sydney, Australia. J Infect Dis 2009; 200: 1813-1819.

6. Wawer MJ, Makumbi F, Kigozi G, et al. Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial. Lancet 2009; 374: 229-237.

7. Royal Dutch Medical Association. Non-therapeutic circumcision of male minors. Utrecht: KNMG, 2010.

[Circumcision ineffective, risky and cruel]

In their recent editorial, Cooper and colleagues propose newborn circumcision as primary prevention for heterosexual HIV transmission in Australia. [1] However, they cite no evidence for its effectiveness as a primary prevention measure, and their editorial references few high-quality studies, offering instead opinions from like-minded individuals.

Experience in the United States suggests that circumcision is unlikely to be effective in preventing heterosexual HIV transmission. While having a high infant circumcision rate for the past 60 years, the US has had one of the highest rates of heterosexually transmitted HIV infection among developed nations. African Americans have the highest rates of both circumcision [2] and heterosexually transmitted HIV infection. [3] Circumcision removes the most sensitive tissue of the penis [4] and serious complications include death (about 0.9 deaths per 10 000 circumcisions). [5] If two-thirds of Australian newborn boys were circumcised at birth, around nine would die every year from complications.

Cooper et al sidestep the ethical issues raised by non-therapeutic circumcision. Infants and children lack the legal capacity to grant consent but have human rights. The High Court of Australia holds that parents may grant consent only when surgery to the genital organs is therapeutic, [6] which does not include neonatal circumcision. Without valid consent, circumcision constitutes legal battery. It is far preferable legally and ethically for circumcision decisions to be deferred until the child is competent to make a fully informed decision for himself. Cooper et al state that infant circumcision is cost-effective, but the cost analysis that they reference does not directly assess cost effectiveness. [7] In fact, the data suggest that infant circumcision costs more than it saves. Another cost analysis showed that a circumcision program would be five times more costly in preventing HIV than providing free condoms, and that condoms are 95 times more effective than circumcision. [8]

In summary, newborn circumcision for primary prevention of HIV remains unsupported by evidence of efficacy or cost-effectiveness, introduces potentially serious risks, and raises complex ethical and medico-legal issues. New 2010 Royal Australasian College of Physicians guidelines [9] continue to not recommend circumcision, despite pressure from a well funded, international, pro-circumcision lobby group. [10] Instead of adopting a circumcision experiment that has failed in the US, Australia should take its lead from the Royal Dutch Medical Association and condemn non-therapeutic circumcision in boys. [11]

John W Travis, Adjunct Professor, School of Health Sciences, RMIT, Melbourne; Sarah J Buckley, General Practitioner, Brisbane; Paul Mason, Former Commissioner for Children, Tasmania; Ken McGrath, Senior Lecturer in Pathology, Auckland University of Technology; Robert S Van Howe, Clinical Professor, Department of Pediatrics and Human Development, Michigan State University; George Williams, Former Director, Newborn Intensive Care Unit, Sydney Children’s Hospital.

1. Cooper DA, Wodak AD, Morris BJ. The case for boosting infant male circumcision in the face of rising heterosexual transmission of HIV [editorial]. Med J Aust 2010; 193: 318-319.

2. Mor Z, Kent CK, Kohn RP, Klausner JD. Declining rates in male circumcision amidst increasing evidence of its public health benefit. PLoS ONE 2007; 2: e861.

3. Centers for Disease Control and Prevention. Racial/ ethnic disparities in diagnoses of HIV/AIDS — 33 states, 2001–2005. MMWR Morb Mortal Wkly Rep 2007; 56: 189-193.

4. Sorrells ML, Snyder JL, Reiss MD, et al. Fine-touch pressure thresholds in the adult penis. BJU Int 2007; 99: 864-869.

5. Bollinger D. Lost boys: an estimate of US circumcision-related infant deaths. Thymos 2010; 4: 78-90.

6. Secretary, Department of Health and Community Services v JWB and SMB (Marion’s case) (1992) 175 CLR 218, FC 92/010.

7. Schoen EJ, Colby CJ, To TT. Cost analysis of neonatal circumcision in a large health maintenance organization. J Urol 2006; 175: 1111-1115.

8. McAllister RG, Travis JW, Bollinger D, et al. The cost to circumcise Africa. Int J Men’s Health 2008; 7: 307- 316.

9. Royal Australasian College of Physicians. Circumcision of infant males. Sydney: RACP, 2010.

10. Llewellyn DJ. The circumcision lobby. The 11th International Symposium on Circumcision, Genital Integrity, and Human Rights. Genital Autonomy. Program and Syllabus of Abstracts; 2010 Jul 29–31; University of California, Berkeley.

11. Royal Dutch Medical Association. Non-therapeutic circumcision of male minors. Utrecht: KNMG, 2010.

[Circumcision irrelevant to Australian conditions]

We refer to a recent editorial in which Cooper and colleagues made a case for boosting infant male circumcision in Australia to reduce female-to-male HIV transmission. [1] The case is strong for hyperendemic countries, such as those in sub-Saharan Africa, given the evidence for circumcision reducing the prevalence of HIV when infections are primarily from heterosexual contact. [2] However, the epidemiology of the HIV epidemic in Australia paints a radically different picture from these countries. Most striking is that men who have sex with men (MSM) still comprise the largest group — around 83% — of people living with HIV. [3] Prevalence of HIV among men and women who report a history of heterosexual contact only remains at less than 0.5%4 while MSM continue to have the majority of new infections. [4] In short, efforts to reduce Australia’s HIV epidemic still require a primary focus on MSM.

With this in mind, a recent meta-analysis of 18 international studies and a combined pool of 53 567 MSM5 showed only a small, statistically non-significant trend toward a protective benefit from circumcision with regard to HIV and other sexually transmitted infections. Hypothesised benefits are limited to the insertive partner; however, circumcised MSM who engaged primarily in insertive anal intercourse (IAI) were not significantly less likely to be HIV-positive than other MSM.

The sexual repertoire of many MSM suggests that interventions designed specifically to protect those who engage in IAI are unlikely to be successful at a population level. Data from a national survey of 856 homosexual men, conducted recently by the Australian Research Centre in Sex, Health and Society, show that only 9% of those who had anal intercourse in the past 12 months reported taking an exclusively insertive role. Of the remainder, 8% were exclusively receptive and 83% were versatile, adopting each role at least once over the preceding 12 months. Uncircumcised men who engaged exclusively in IAI were just as likely to be HIV-negative as their circumcised counterparts (P=0.90).

As infant male circumcision programs are rolled out in some hyperendemic countries, we encourage policymakers to tread carefully when considering such a move in Australia. Boosting education campaigns that promote HIV awareness and safer sex may prove to be more cost-effective and successful than largescale infant male circumcision programs which seem likely to offer, at most, a marginal benefit to the extremely small proportion of the Australian male population who are exclusively insertive partners in homosexual anal intercourse.

Anthony N Lyons, Research Fellow; Marian Pitts, Director; Anthony Smith; Professor Jeffrey Grierson, Senior Research Fellow, Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne.

1. Cooper DA, Wodak AD, Morris BJ. The case for boosting infant male circumcision in the face of rising heterosexual transmission of HIV. Med J Aust 2010; 193: 318-319.

2. Doyle SM, Kahn JG, Hosang N, et al. The impact of male circumcision on HIV transmission. J Urol 2010; 183: 21-26.

3. Grierson J, Power J, Croy S, et al. HIV futures six: making positive lives count. Melbourne: La Trobe University, 2009.

4. National Centre in HIV Epidemiology and Clinical Research. HIV/AIDS, viral hepatitis and sexually transmissible infections in Australia: annual surveillance report 2009.

5. Millett GA, Flores SA, Marks G, et al. Circumcision status and risk of HIV and sexually transmitted infections among men who have sex with men: a meta-analysis. J Am Med Assoc 2008; 300: 1674- 1684.

[Circumcision: Not enough evidence of efficacy]

In their recent editorial, Cooper and colleagues argue for a shift in Australian policy to boost neonatal male circumcision levels, in an effort to prevent future heterosexual acquisition of HIV. [1] There is very strong evidence for a protective effect of male circumcision against HIV acquisition in high-prevalence settings, where heterosexual intercourse is the most common mode of transmission and access to antiretroviral therapy is poor. However, Australia is a low-prevalence setting with an HIV epidemic that largely affects the homosexual population and excellent access to condoms and antiretroviral therapy.

There have been very few studies on the protective effect of male circumcision in settings similar to Australia, and those that have been reported have produced variable results. [2] The publications cited by Cooper et al do not strongly support the notion that male circumcision confers similar protection in both high- and low-prevalence settings — the conclusions are based on expert opinion or other inconclusive, low-quality evidence. [2-4] There are also other issues to consider when discussing a population-based intervention strategy for a low-prevalence disease. Given that rates of male circumcision in Australia are currently low,1 compliance could be an issue, as parents may be unwilling to accept a surgical procedure for their newborns on the basis of predictions about future HIV protection.

Is circumcision cost-effective compared with other modalities used to prevent or treat heterosexually transmitted HIV? Cost effectiveness studies have been carried out in the United States, where health care costs are likely to be significantly different to those in Australia. The Centers for Disease Control and Prevention consultation report cited by the authors acknowledges that the available cost and cost-effectiveness research on male circumcision is subject to a variety of “methodological limitations and data insufficiencies”. [3] Further, the case needs to be made that neonatal male circumcision is a more cost-effective option in preventing heterosexual HIV transmission than the current response — targeted education campaigns, antiretroviral therapy, and medical advice regarding safe sex practices.

In conclusion, the jury is still out with regard to the role of male circumcision in HIV prevention in Australia on two counts: efficacy and cost-effectiveness. To justify a shift in policy towards actively encouraging routine neonatal circumcision at a national level, we should have access to high-quality, relevant data. Until such information is available, the environment doesn’t exist for parents or policymakers to make a truly informed decision about this issue.

Niall Conroy, Public Health Registrar, Sir Albert Sakzewski Virus Research Centre, Queensland Paediatric Infectious Diseases Laboratory, Brisbane.

1. Cooper DA, Wodak AD, Morris BJ. The case for boosting infant male circumcision in the face of rising heterosexual transmission of HIV [editorial]. Med J Aust 2010; 193: 318-319.

2. Smith DK, Taylor A, Kilmarx PH, et al. Male circumcision in the United States for the prevention of HIV infection and other adverse health outcomes: a report from a CDC consultation. Public Health Rep 2010; 125 Suppl 1: 72-82.

3. Centers for Disease Control and Prevention. Male circumcision and risk for HIV transmission and other health conditions: implications for the United States [CDC HIV/AIDS science facts]. Atlanta: CDC, 2008.

4. Morris BJ. Why circumcision is a biomedical imperative for the 21st century. Bioessays 2007; 29: 1147- 1158.

[Circumcision violates principles of medical ethics and human rights]

In a recent editorial, Cooper and colleagues asserted that infant male circumcision reduces heterosexual (female-to-male) transmission of HIV. [1] However, they failed to acknowledge the serious methodological flaws of the three African randomised controlled trials (RCTs) on which the claim is based, including early termination and loss of participants to follow-up. These RCTs reported on circumcision of adults in Africa and, therefore, are not relevant to children in Australia. In a major oversight, the editorial did not cite contradictory RCT evidence that male circumcision increases heterosexual (male-to-female) HIV transmission by 61.4%. [2] Therefore increased male-to-female transmission of HIV would negate any reduction in female-to-male HIV transmission.

Common law recognises the right of bodily integrity. International human rights law enshrines the right to security of the person. The High Court of Australia opines that parents may grant surrogate consent only when a surgical intervention is therapeutic. As male circumcision amputates healthy, functional, protective, erogenous tissue, imposing male circumcision on unconsenting minors violates these rights. It has been strongly argued that non-therapeutic infant circumcision is tantamount to criminal assault. [3]

Unlike America, which has a high incidence of male circumcision and a high prevalence of HIV infection (0.6%),4 in the Australian context there is a low incidence of male circumcision among men aged under 35 years combined with a very low prevalence of HIV (0.1%). [4, 5] HIV infection in Australia occurs mostly among homosexual men. [6] It has been reported that any prophylactic value of male circumcision in preventing homosexual transmission of HIV is not statistically significant, [7] so male circumcision would be of little value in reducing future Australian HIV infection rates.

Despite calling for increased non-therapeutic infant male circumcision, Cooper et al unequivocally stated “Condom use remains essential”. Since this is the case, what is the purpose of inflicting lifelong bodily and psychosexual harm [8] on defenceless children, contrary to ethical or moral principles? Furthermore, circumcision of unconsenting minors may amount to criminal assault.

Gregory J Boyle, Professor of Psychology, Bond University, Queensland; George Hill, Independent Consultant, Port Allen, La, USA.

1. Cooper DA, Wodak AD, Morris BJ. The case for boosting infant male circumcision in the face of rising heterosexual transmission of HIV. Med J Aust 2010; 193: 318-319.

2. Wawer MJ, Makumbi F, Kigozi G, et al. Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial. Lancet 2009; 374: 229-237.

3. Boyle GJ, Svoboda JS, Price CP, Turner JN. Circumcision of healthy boys: criminal assault? J Law Med 2000; 7: 301-310.

4. UNAIDS. Country factsheets. Geneva: UNAIDS, 2010. http://cfs.unaids.org/ (accessed Dec 2010).

5. National Centre in HIV Epidemiology and Clinical Research. HIV/AIDS, viral hepatitis and sexually transmissible infections in Australia: annual surveillance report 2009. Sydney: NCHECR, 2009.

6. Richters J, Smith AMA, de Visser RO, et al. Circumcision in Australia: prevalence and effects on sexual health. Int J STD AIDS 2006; 17: 547-554.

7. Millett GA, Flores SA, Marks G, et al. Circumcision status and risk of HIV and sexually transmitted infections among men who have sex with men: a meta-analysis. JAMA 2008; 300: 1674-1684.

8. Boyle GJ, Goldman R, Svoboda JS, Fernandez E. Male circumcision: pain, trauma and psychosexual sequelae. J Health Psych 2002; 7: 329-343.

[Violates principles of evidence-based medicine]

Cooper and colleagues propose circumcision of male infants in Australia as a strategy for reducing the incidence of heterosexually transmitted HIV infection. [1] They base this suggestion on evidence, from three clinical trials in Africa, that circumcision of adult men can reduce the risk of men acquiring HIV during unprotected sexual intercourse with an infected female partner. The proposal must be rejected because it is irrelevant to the Australian situation and departs from the principles of evidence-based medicine.

The proposal is irrelevant because it targets infants, who are not at risk of infection by sexual contact and will not be at risk until they become sexually active in 16–20 years time, by which time treatment and prevention options, and the virus itself, may have altered beyond recognition. Evidence-based medicine requires that recommendations for treatment or prophylaxis follow logically and directly from the evidence. In this case, there is a radical disconnect between the evidence and the recommendation. Even assuming the African evidence is reliable and applicable (and ignoring the many critiques), [2, 3] the logical prescription arising from these data is that sexually active adult men who have regular intercourse with numerous different female partners and who do not always use condoms should consider circumcision for themselves as a means of lowering their risk of infection.

This is not what Cooper et al propose. What they prescribe is that parents be advised to circumcise their boys in infancy as a precaution against a risk they will not face until they are adults, and against a disease that is very rare among heterosexually active adult men in Australia. Even if circumcised, they would still have to use a condom to be sure of avoiding infection, as the risk reduction promised by the African data is only partial — between 38 and 66 per cent. [4] We have no data at all on what the risk reduction in Australia might be. If it is still necessary to wear a condom there seems little point in getting circumcised.

As others point out, [5] moreover, the African trials on which Cooper et al rely involved sexually active adult men, not infants, and there is no hard evidence that neonatal circumcision has any protective effect against acquiring HIV. Arguments concerning other possible, non-HIV-related benefits of circumcision (all contested in the literature and rejected in the policy statement on circumcision recently issued by the Royal Australasian College of Physicians [6]) are irrelevant to HIV infection itself. In sum, the prescription offered has so little connection with the evidence on which it relies that it cannot be taken seriously.

Robert J L Darby, Independent Researcher, Canberra, ACT.

1. Cooper DA, Wodak AD, Morris BJ. The case for boosting infant male circumcision in the face of rising heterosexual transmission of HIV [editorial]. Med J Aust 2010; 193: 318-319.

2. Green LW, McAlister RG, Peterson KW, Travis JW. Male circumcision is not the surgical vaccine we have been waiting for. Futur HIV Ther 2008; 2: 193- 199.

3. Myers A, Myers JE. Rolling out male circumcision as a mass HIV/AIDS intervention seems neither justified nor practicable [editorial]. S Afr Med J 2008; 98: 781-782.

4. Siegfried N, Muller M, Deeks JJ, Volmink J. Male circumcision for prevention of heterosexual acquisition of HIV in men. Cochrane Database Syst Rev 2009; (2): CD003362.

5. Perera CL, Bridgewater FHG, Thavaneswaran P, Maddern GJ. Safety and efficacy of nontherapeutic male circumcision: a systematic review. Ann Fam Med 2010; 8: 64-72.

6. Royal Australasian College of Physicians. Circumcision of infant males. Sydney: RACP, 2010.

[Proposed cure worse than the disease]

I write in response to the editorial by Cooper and colleagues, which advocates an increase in male infant circumcision as an anti-HIV strategy. [1] The authors claim that male circumcision is effectively a surgical vaccine for preventing female-to-male HIV transmission and, while the authors do present evidence in favour of this, they fail to canvass the serious and inevitable long-term adverse effects of the procedure. Far from being an inconsequential snip, male circumcision is a highly mutilating operation which seriously impairs penile function.

Glibly quoting four articles which “prove” that circumcised and uncircumcised males are equally satisfied sexually, the authors totally ignore a large and expanding body of evidence to the contrary, [2-4] and indeed growing popular movements against circumcision and for restoration of the foreskin. Circumcision typically removes nearly half the skin of the penis [3] — including its most sensitive areas — and, by exposing the glans to the elements, induces keratinisation of its formerly moist mucosal surface — making it rougher, dryer and less sensitive. It also destroys the “sliding” or “rolling” action of the shaft in the skin tube and most certainly impairs both male and female sexual satisfaction. [4,5]

It is totally inappropriate to suggest that circumcision is akin to vaccination: needle vaccination generally confers high-level immunity to the majority of its recipients with few, if any, long-term sequelae. In contrast, circumcision confers moderate immunity at best, and does so at the cost of mutilating and de-functioning every penis so treated. I strongly urge my colleagues who still believe that male circumcision is a trivial operation to type “foreskin restoration” into a search engine and see what they find. Finally, I implore us all to refrain from removing body parts from our unconsenting children without immediate and direct surgical need.

Bruce R Paix, Anaesthetist, Department of Anaesthesia, Flinders Medical Centre, Adelaide.

1. Cooper DA, Wodak AD, Morris BJ. The case for boosting infant male circumcision in the face of rising heterosexual transmission of HIV [editorial]. Med J Aust 2010; 193: 318-319.

2. Zoossmann-Diskin A, Blustein R. Challenges to circumcision in Israel. In: Denniston GC, Mansfield Hodges F, Milos MF, editors. Male and female circumcision: medical, legal and ethical considerations in pediatric practice. New York: Kluwer Academic/ Plenum Publishers, 1999: 343-350.

3. Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996; 77: 291-295.

4. Fleiss PM, Hodges FM, Van Howe RS. Immunological functions of the human prepuce. Sex Transm Infect 1998; 74: 364-367.

5. Cold CJ, Taylor JR. The prepuce. Br J Urol 1999; 83 Suppl 1: 41.

[Circumcision for HIV prevention not relevant to children]

I read with interest the editorial by Cooper and colleagues in which the authors argue for infant male circumcision as a population-wide strategy to reduce HIV transmission. Circumcision is an irreversible body-altering procedure and, therefore, as far as possible, individuals should participate in the decision of whether or not to be circumcised. Male circumcision in infancy removes an individual’s ability to participate in the decision-making process. Further, the protective benefits of infant circumcision with regard to reduction of HIV transmission are not conferred until an individual becomes sexually active and is capable of understanding the risks and benefits. Deferment of circumcision to a later age would allow individuals to fully appreciate the magnitude of the procedure and participate in the decision-making process, and it would not necessarily negate the protective benefits. This should be considered by anyone who advocates infant male circumcision as a strategy to reduce HIV transmission.

Jeremy J Chin, Intern, Northern Health, Melbourne.

Source: Medical Journal of Australia, Vol. 194 (2), 17 January 2011, 97-101. Headings to the letters have been added by Circumcision Information Australia.

 

Circumcision and HIV: Cooper, Wodak and Morris reply to their critics

... and get themselves into even deeper water

 

They write: In our editorial we, just as other academic experts in various countries, [1-4] likened infant male circumcision to a “surgical vaccine”. Both vaccination and male circumcision effectively, safely and inexpensively afford lifelong protection against a wide array of adverse, sometimes fatal, medical conditions. Both are most effective if provided early in life. Both are criticised vigorously and relentlessly by opponents.

There is now an impressive and growing number of high-quality research publications attesting to the wide-ranging benefits of male circumcision. [2, 4] The letters to the Journal in response to our editorial rely largely on opinions, and often cite superseded and spurious references. Forbes ignores the high prevalence in Australia of sexually transmitted infections (STIs), which male circumcision protects against, including oncogenic human papillomaviruses. Moreover, male circumcision provides similar protection against heterosexual HIV infections in men in low-prevalence settings as those in high-prevalence settings. [1-5] In the United States, infant male circumcision is cost-saving for HIV prevention. [6] In claiming that male circumcision increases HIV risk to women, Forbes, Boyle and Hill cite an outlier study, ignoring a meta-analysis and new data which show that male circumcision reduces the risk of male-to-female transmission. [7, 8] There is no reason to expect that male circumcision would protect a man who engages in receptive anal intercourse, the primary mode of HIV transmission in Australia and the US. Australian data show, however, greater than 90% protection protection against HIV and syphilis in the smaller proportion of homosexual men who are insertive only. [9] While there are few Australian studies of other STIs and male circumcision in heterosexual people, research in the US and elsewhere, including randomised controlled trials (RCTs), shows strong protection. [2,4]

Paix argues that circumcision is a “highly mutilating operation which seriously impairs penile function”, while Travis and colleagues assert that circumcision “removes the most sensitive part of the penis”. However, there is now strong research evidence, including RCTs, showing not only no loss of function, satisfaction, sensitivity or sensation, [2] but, in one large RCT, that sexual experience is enhanced by male circumcision. [10]

In rejecting male circumcision for HIV prevention, Travis et al and Boyle and Hill present arguments against circumcision repudiated previously by 48 international academic experts. [11] Moreover, in response to Darby, it is well established that condoms are often not in place during sex, whereas male circumcision always is. Also, population- level condom use does not correlate with reduced HIV transmission. [12] Parents have a duty to help prevent renal damage, physical, inflammatory and hygiene problems, STIs and cancers in their sons and their sons’ future sexual partners. They can do this by arranging for their son to be circumcised. The level of risk and severity of such adverse medical conditions in Australia is sufficiently high to support infant male circumcision. Not to do so may have legal ramifications. [13]

Chin argues that male circumcision should be delayed until the boy can make up his own mind. He fails to recognise that, as for vaccination, infancy is by far the safest, quickest, cheapest and most convenient time for male circumcision; when performed in infancy, circumcision confers immediate benefits with very limited short and long-term risks. [1-4] While our warning of a future HIV epidemic in Australia unless infant male circumcision is increased is based on a rise in the proportion of new infections attributable to heterosexual sex (from 841 in 2000–2004 [20% of total diagnoses] to 1185 [23%] in 2005–2008), [14] there are currently epidemics of other STIs, many of which could have been prevented by male circumcision. The very low risk and considerable benefits of male circumcision attest to the wisdom of performing the procedure in infancy to maximise individual and public health gains.

David A Cooper, Director, National Centre in HIV Epidemiology and Clinical Research, Sydney; Alex D Wodak, Director, Alcohol and Drug Service, St Vincent’s Hospital, Sydney; Brian J Morris, Professor of Molecular Medical Sciences, University of Sydney.

1. Schoen EJ. Circumcision as a lifetime vaccination with many benefits. J Men’s Hlth Gender 2007; 4: 306-311.

2. Morris BJ. Why circumcision is a biomedical imperative for the 21st century. Bioessays 2007; 29: 1147- 1158.

3. Ben KL, Xu JC, Lu L, et al. [Male circumcision is an effective “surgical vaccine” for HIV prevention and reproductive health] [Chinese]. Zhonghua Nan Ke Xue 2009; 15: 395-402.

4. Tobian AA, Gray RH, Quinn TC. Male circumcision for the prevention of acquisition and transmission of sexually transmitted infections: the case for neonatal circumcision. Arch Pediatr Adolesc Med 2010; 164: 78-84.

5. Warner L, Ghanem KG, Newman DR, et al. Male circumcision and risk of HIV infection among heterosexual African American men attending Baltimore sexually transmitted disease clinics. J Infect Dis 2009; 199: 59-65.

6. Sansom SL, Prabhu VS, Hutchinson AB, et al. Cost effectiveness of newborn circumcision in reducing lifetime HIV risk among US males PLoS One 2010; 5: e8723.

7. Weiss HA, Hankins CA, Dickson K. Male circumcision and risk of HIV infection in women: a systematic review and meta-analysis. Lancet Infect Dis 2009; 9: 669-677.

8. Hallett TB, Alsallaq RA, Baeten JM, et al. Will circumcision provide even more protection from HIV to women and men? New estimates of the population impact of circumcision interventions. Sex Transm Infect 2010; Oct 21 [Epub ahead of print].

9. Templeton DJ, Jin F, Mao L, et al. Circumcision and risk of HIV infection in Australian homosexual men. AIDS 2009; 23: 2347-2351.

10. Krieger JN, Mehta SD, Bailey RC, et al. Adult male circumcision: effects on sexual function and sexual satisfaction in Kisumu, Kenya. J Sex Med 2008; 5: 2610-2622.

11. Wamai RG, Weiss HA, Hankins C, et al. Male circumcision is an efficacious, lasting and cost-effective strategy for combating HIV in high-prevalence AIDS epidemics. Future HIV Ther 2008; 2: 399-405.

12. Slaymaker E. A critique of international indicators of sexual risk behaviour. Sex Transm Infect 2004; 80 Suppl 2: ii13-ii21.

13. Russell T. Non-circumcision a legal risk. Aust Doctor 1996; Sep 20: 57.

14. National Centre in HIV Epidemiology and Clinical Research. HIV/AIDS, viral hepatitis and sexually transmissible infections in Australia: annual surveillance report 2009.

Criticism of the reply

A feeble argument is not strengthened by adding more weak links to the chain

Cooper, Wodak and Morris were given generous space for their reply (twice as many words as any of their critics), but instead of strengthening their case they have succeeded in weakening it even further. What is most remarkable about their reply is the speed with which they fell into the trap identified in the letter from Dr Robert Darby: evidently fearing that the case for neonatal circumcision as a preventive of heterosexually acquired HIV was not strong enough to stand alone, they have sought to shore it up with numerous other alleged (and far from proven) benefits. Not only will widespread (ideally universal) circumcision save the world from AIDS, it will also protect us from all other sexually transmitted diseases, herpes and cancers caused by wart viruses, not to mention “renal damage”, and all those terrible “inflammatory and hygiene problems” in boys. On top of all that, circumcision will preserve the health of any future sexual partners they may be able to attract and vastly improve their experience of sex.

Methinks the lady doth protest too much. It’s the old litany of the “benefits of circumcision” first trotted out by the anti-masturbation crusaders of late Victorian England, brought to perfection by Dr Peter Charles Remondino in his History of Circumcision: Moral and Physical Reasons for its Performance (1891), the very chap who invented the illogical and anti-scientific notion of circumcision as a surgical vaccine. The only benefits of circumcision missing from the list are such old favourites of Professor Morris as infallible protection from zipper injury, avoidance of those nasty splashes on the bathroom floor, banishing that terrible foreskin smell, and vastly improved aesthetic appeal (at least to Prof. Morris).

Cooper, Wodak and Morris seem determined to make life difficult for themselves. In their original article they only had to prove that:

• the incidence of heterosexually transmitted HIV in Australia is rising to a dangerous level, comparable to the epidemics in sub-Saharan Africa;
• circumcision is the only effective way of countering this challenge;
• widespread circumcision of infants is the only way of achieving a sufficient circumcision incidence to stave off an HIV epidemic on the African scale.

But after their reply, in addition to this rather tall order, they now also have to prove that circumcision is necessary:

• to prevent epidemics of other sexually transmitted diseases;
• to protect males and females from genital cancers;
• to prevent renal damage and inflammatory problems (whatever they are);
• to ensure “hygiene”;
• to improve everybody’s sex life.

A very tall order indeed, particularly as the most recent comprehensive survey of the benefits of infant circumcision (Perera et al 2010) found the benefits to be minimal or non-existent.

It is perfectly obvious that if Cooper, Wodak and Morris have to adduce all these additional benefits, however dubious, they are all too conscious that their original case for boosting neonatal circumcision as the only possible response to an alleged rising incidence of heterosexual transmission of HIV in Australia is too feeble to stand alone. Their original article was limited to asserting that neonatal circumcision was needed to prevent an AIDS epidemic among the heterosexual population, and that the evidence for the protective effect of circumcision was to be found in the three much-vaunted clinical trials in Africa. The proposal stands or falls on the robustness of the African data; whether its is applicable to Australia; whether there is “rising heterosexual transmission of HIV” in Australia, and if so whether the rise is sufficient to justify and demand such a radical, costly and controversial response; whether the African evidence can be extrapolated to a developed country such as Australia, where AIDS is very rarely found among heterosexuals and is a problem almost entirely confined to homosexual sub-cultures; and whether the African evidence justifies circumcision of infants, as opposed to (sexually active) adult men.

Cooper, Wodak and Morris make no attempt to address these crucial issues. On top of this failure they make any number of unsubstantiated claims, the most serious of which are (1) their assertion that circumcision must be performed in infancy to provide the necessary protection; (2) their blatant misrepresentation of the statistics on heterosexual HIV infection in Australia; and (3) their snide insinuation that opponents of circumcision are also against vaccination.

Why circumcision in infancy?

There is no evidence that circumcision must be performed in infancy to provide a protective effect against HIV. All the evidence for circumcision having a protective effect comes from circumcision of sexually active adult men in the African clinical trials. If the aim is to forestall a heterosexual AIDS epidemic in Australia, it will be sufficient to ensure that sexually active adult men who plan to enjoy a wide variety of partners and are careless about condoms can choose to get themselves circumcised. And in truth, any adult male in Australia who wishes to get himself circumcised, for this or any other reason, can do so without difficulty or trouble, and get the operation subsidised by Medicare. No further action is needed.

Why, then, do our gang of three insist on neonatal circumcision? Quite simply because it is obvious that the vast majority of adult men prefer to hang on to their foreskins and will not be persuaded to submit to circumcision. To force them to do so would be impractical, to bribe them (as in Africa) would be too expensive; and to coerce them (e.g. at gunpoint) would be illegal. But if it is immoral, unethical or illegal to forcibly circumcise an adult male, why is it any less immoral, unethical or illegal to forcibly circumcise an adult-to-be (that is, a child)? Sexual intercourse without consent is rape, and society regards the crime as all the more wicked if the victim is a child; yet it could be argued that circumcision – an irreversible physical disfigurement, as Paix and Chin point out – is a more serious assault than rape. Even if that argument is not accepted, it is clear that if adult men do not wish to get themselves circumcised as a precaution against HIV, it is morally unacceptable to force the operation on children.

Fundamentally, Cooper, Wodak and Morris lack faith in their own prescription. If the argument for circumcision as a precaution against heterosexually transmitted HIV was as cogent as they claim, men would be lining up to get it done. That they do not suggests both that the argument is weak and that men are not convinced. Recognising this reluctance, the gang of three fail to propose what is logically suggested by the evidence (circumcision to be available for men at high risk of heterosexually transmitted HIV ), and instead turn their sights on those too young to defend their own interests – children, who are at zero risk of sexually transmitted infections, and who will not be at risk for the foreseeable future, by which time treatment and prevention options, and the virus itself, may well have changed beyond recognition.

Misrepresentation of statistics on HIV infection

For all Cooper et al's assumption of a looming epidemic of heterosexual HIV infection in Australia, the fact is that HIV contracted through unprotected intercourse with an infected female partner (the only avenue of infection of which there is any evidence of circumcision having a protective effect) remains extremely rare here. As the 2010 surveillance report, issued by the very organisation of which Professor Cooper is director, states:

• “the annual number of new HIV diagnoses has remained relatively stable at around 1000 over the past four years”;
• “HIV continues to be transmitted primarily through sexual contact between men”;
• “of 1185 cases of HIV infection newly diagnosed in 2005-2009, 58% were in people from high prevalence countries or their partners” - i.e. were not contracted in Australia unless from a partner.

From 1995 to 2005 fewer than 1000 people a year were diagnosed with HIV in Australia [1] and in no year since the beginning of the HIV epidemic has the number of diagnoses of Australian-born men acquired by heterosexual contact ever approached 100. Of the 1001 people diagnosed in total in 2008, 271 were infected by heterosexual contact, of whom 144 were men, of whom in the vicinity of 60 were Australian-born, of whom only a fraction were intact. It is only to this tiny sub-sub-sub-subgroup that circumcision could have afforded some reduction in risk. Had all 5 million Australian-born males in the susceptible age range been circumcised instead of only two thirds [2, 3] (an additional 1.7 million circumcisions) then, based on the hypothetical assumption that circumcision would have reduced infection in that group by 60%, the total number of diagnoses in Australia would have been cut by a measly 2%.

Life tables for intact men and circumcised men based on age-specific prevalences of circumcision among Australian-born men [2, 3] current age specific incidence rates of HIV infection by heterosexual contact [4], and the hypothetical assumption that circumcision reduces female-to-male transmission of HIV by 60% show that the estimated lifetime risk for an intact Australian-born man of acquiring HIV by heterosexual contact is less than 1 in 1,000 and that the number of circumcisions required to prevent one infection during a lifetime is greater than 1,800.

Contrary to the authors’ contention, circumcising 1,800 babies in 2010, in the hope that it may prevent one HIV infection sometime from 2030 onwards (but only if no progress has been made in reducing the incidence of HIV in the next 20 years, assuming the characteristics of the virus do not change, that it remains as lethal as now, and that treatment methods do not improve), does not make sense.

1. AIDS & HIV statistics by transmission route and gender

2. Smith, A. et al. Australian Study of Health and Relationships Australian and New Zealand Journal of Public Health, Volume 27, Number 2, April 2003

3. Ferris JA, Richters J, Pitts MK, Shelley JM, Simpson JM. Ryall R, Smith AMA. Circumcision in Australia: further evidence on its effects on sexual health and wellbeing, Australian and New Zealand Journal of Public Health, 34:2, pp160-4

4. Australian Public Access Datasets on newly diagnosed HIV infection and AIDS

This is not the only area where Coooper, Wodak and Morris have misrepresented or misunderstood the data. In their original article they also made misleading claims as to the recommendations made by the World Health Organisation on circumcision as a tactic for AIDS control in Africa, and also about the incidence of circumcision in Australia.

Misrepresentation of WHO recommendations on circumcision

In their original paper Cooper et al state: “The protection conferred to heterosexual males by circumcision is similar in hyperendemic and low-prevalence settings (refs. 3-5).” This is untrue, and shown to be untrue by their own references.

Reference 3 states: “Male circumcision, together with other prevention interventions, could play an important role in HIV prevention in settings similar to those of the clinical trials.” (http://www.cdc.gov/hiv/resources/factsheets/circumcision.htm) That is, it is not recommended in countries with low HIV prevalence such as Australia.

Reference 4 states: “Together, these three trials provided strong evidence that MC can significantly reduce men’s risk of acquiring HIV infection in the contexts in which the trials were conducted.”  (Public Health Rep 2010; 125 Suppl 1: 72-82)

Reference 5 is to Morris BJ. Why circumcision is a biomedical imperative for the 21st century. Bioessays 2007; 29: 1147-1158. This is simply an opinion piece by one of the authors of the article under consideration. The one reference in this that might bear on the issue proves to be to yet another opinion piece by the same author.

No researchers have published any results of clinical trials of male circumcision outside Africa, and very limited observational data exist on the association between circumcision status and HIV infection among men – but much of what does exist shows that circumcision is of no benefit at all. Mor et al.’s study of nearly 58,000 men attending San Francisco's STD clinics found “no significant differences between circumcision status and the risk of HIV or syphilis infection” in either men who have sex with men or heterosexual men. [5]

The claim that circumcision prevents heterosexual HIV transmission from women to men is based on three non-double-blinded, non-placebo-controlled Randomised Controlled Trials in Africa [6,7,8] in which a total of 5,400 men were circumcised, all called off after less than two years, at which time a total of 64 of the men in the circumcised experimental groups had HIV, compared to 137 in the non-circumcised control groups. 673 men in total were lost from those trials, their HIV status unknown. But even granting that those trials proved that circumcision grants “60% reduction” in female-to-male heterosexual HIV transmission (the most widely quoted figure, even though the Cochrane Review estimates it as between 38 and 64 per cent, and we have no idea as to that the risk reduction in Australia, if any, might be), a case for widespread neonatal circumcision does not follow.

5. Mor Z, Kent CK, Kohn RP, Klausner JD (2007) Declining Rates in Male Circumcision amidst Increasing Evidence of its Public Health Benefit. PLoS ONE 2(9): e861. doi:10.1371/journal.pone.0000861

6. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, et al. 2005. Randomized, controlled intervention trial of male Circumcision for reduction of HIV infection risk: The ANRS 1265 Trial. PLoS Med 2:e298.

7. Bailey RC, Moses S, Parker CB, Agot K, Maclean I, et al. 2007. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet 369:643-656.

8. Gray RH, Kigozi G, Serwadda D, Makumbi F, Watya S, et al. 2007. Male ircumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet 369:657-666.

Misrepresentation of statistics on the incidence of circumcision in Australia

Cooper, Wodak and Morris claim: “Despite official discouragement, Medicare statistics show a rise in the rate of infant male circumcision in Australia from 13% in 1998 to 19% in 2009.”

In fact, the national rate of infant male circumcision, based on Medicare claims statistics [9] and births data published by the Australian Bureau of Statistics [10], has not exceeded 13% at any time during the period for which Medicare statistics are available on-line (July 1993 to the present). Since public hospitals in most states do not provide non-therapeutic circumcisions, the total number of infant circumcisions has probably gone down, but this would not have been reflected in Medicare statistics (except perhaps by a rise in the number of claims on Medicare). It is therefore likely that the decline in the real rate of infant circumcision that began some 40 years ago has continued in recent years. Certainly, the rate fell sharply in Tasmania and Northern Territory several years ago, has recently fallen substantially in Queensland, and is well below 10% in the majority of states and territories. A charitable explanation is not that Cooper et al are statistically illiterate, but that they have confused figures for New South Wales with figures for the nation as a whole. It is apparent that there is a gaggle of circumcision promoters centred around Professor Morris in Sydney, and that they are having an effect on the incidence of circumcision in that state. Elsewhere, however, respect for the principles of evidence-based medicine and medical ethics take precedence over their emotion-driven hatred of normal human anatomy.

9. https://www.medicareaustralia.gov.au/statistics/mbs_item.shtml

10. Australian Bureau of Statistics

Circumcision and vaccination

Perhaps the most scandalous gambit in the Cooper et al reply to critics is their insinuation that opponents of circumcision as a tactic against HIV control in Australia are also against vaccination. This allegation is unfounded and untrue: no prominent critic of circumcision has ever attacked vaccination, nor did any of the letters to which Cooper et al were responding. There may be some individuals among the general public who are opposed to both circumcision and vaccination, but most critics of circumcision, both within the medical profession (such as the Royal Australasian College of Physicians in its recent policy statement) and among the informed public (such as this website) are not merely not opposed to vaccination, but fully support it as a valid instance of preventive, evidence-based medicine.

Circumcision promoters seem unable to grasp the fundamental difference between amputating body parts to provide limited protection against a rare disease to which the individual is unlikely to be exposed, and giving a person a needle that confers a high level of immunity to common or contagious diseases. The justification for vaccination of non-consenting children is that the diseases to which it confers immunity are common and/or highly contagious. Airborne diseases, such as smallpox, diphtheria, measles and scarlet fever were all major killers before vaccines were developed. Edward Jenner’s vaccine against smallpox was one of the few preventive health success stories of the nineteenth century. Because such diseases are spread by breathing, one person can quickly infect many others: a single child can infect a class or a whole school, just by being there. Vaccination thus protects both the individual who receives the treatment and the people with whom he comes into contact.

Unlike these diseases, HIV is a low-virulence disease. It is very difficult to pass on a disease that is spread by bodily fluids such as blood and sperm, which must enter the bloodstream of the other person before they can do any harm. No matter how much close social interaction with other people there is, there is no risk that an HIV-positive person can pass on the virus to anybody else – unless he or she has unprotected sexual intercourse or otherwise transfers bodily fluids into the other person’s system. Even in cases of unprotected intercourse, the risk of infection is quite low – estimated at rather less than 10 per cent. Quite apart from the vital matter of disfigurement, the justification for vaccination against highly contagious diseases simply does not apply to HIV-AIDS.

It is actually quite hypocritical for Cooper, Wodak and Morris to attack critics of circumcision by suggesting that they are anti-vaccination. Morris himself is on record as disparaging the vaccine (Gardasil) recently developed to protect women against varieties of human papilloma virus that cause cervical cancer.

So let’s have no more of this anti-scientific nonsense. Circumcision is amputation of a prominent, functional body part that causes injury, loss and harm for a merely speculative gain. Vaccination is a harmless pinprick that strengthens the body’s natural defence mechanisms and confers a high level of immunity against contagious diseases.