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NEWS EXTRA: Janice Hopkins Tanne US group lobbies UN to outlaw male circumcision BMJ 2005; 331: 422-b [Full text]

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Predictable American Response from King Holmes

David Wilton   (19 August 2005)

Flawed Study on Male Genital Mutilation

Brian A. Waldman   (19 August 2005)

Human Rights, HIV, and Circumcision

George Hill, John V. Geisheker, J.D., LL.M   (22 August 2005)

Re: Flawed critique of "Male Genital Mutilation"

James S. Smeltzer, MD, FACOG   (22 August 2005)

Predictable American Response from King Holmes 19 August 2005
David Wilton, Attorney Law Office, 15 Boardman Pl, San Francisco, CA 94103 Send response to journal: Re: Predictable American Response from King Holmes	I cannot imagine a more evangelistic and irresponsible statement than the one you quote from King Holmes. Did he not hear the results of the study? Eighteen circumcised men contracted HIV. So, how is this practice "essentially an anatomic vaccine for life"? Eighteen men may be forgiven for disagreeing with him. And given enough time and unsafe sexual encounters, many more will undoubtedly take issue with the doctor's conclusions. Only long term follow up with the study participants will provide a clear picture of the meaning of this unpublished study. Moreover, a prophylactic effect does not invalidate Matthew Hess's point concerning consent. Please note another study presented at the same conference, this one published, found female circumcision seemed to have a prophylactic effect vis-a-vis HIV as well. Where are the calls to make this practice a public health measure? It is not surprising that no one has made such a ridiculous call. Perhaps this is because the West does not have a lobby for female circumcision unlike that for male circumcision. Competing interests: None declared
Flawed Study on Male Genital Mutilation 19 August 2005
Brian A. Waldman, Professional Toronto M3J 2V6 Send response to journal: Re: Flawed Study on Male Genital Mutilation	I find it interesting that, inter alia, a number of women have so eagerly jumped on this study that advances the notion of male circumcision. They totally ignore the fundamental flaws in the study - and in its conclusion - for reasons I can only speculate. First, in spite of the fact that the relatively uneducated men in the study were informed of condom use and given condoms to use, there was no follow-up or measure as to whether or not the subjects actually used them, if they used them properly, and to what extent they were employed by each group. For example, if 90% of the men who had been circumcised use the condoms but only 30% of the intact men had done so, the conclusion would have been drastically different. If condoms are the mode of "safe sex" and prevent the spread of HIV, how is it that 69 men contracted HIV using them? And if they did use them, then the study is irrelevant on its surface. Had NONE of the men used condoms, that would tend to validate the study to some extent. But had condoms been employed, the study is valueless. One can also, just as validly, conclude that men who have been circumcised need not use condoms. As the comment in the article notes, "this is a preventative for HIV!" I trust the commentator is only joking here. The study does NOT prove that MGM reduces the transmission of female to male HIV by 65%. This is an example of "figures don't lie but liars figure." It extrapolates the INCIDENCE of ACTUAL transmission rather than dealing with the raw scores. Of the 1,500 men in each group, 3.4% of the intact group contracted HIV, while 1.2% of the "mutilated" group were infected. The REAL "rate of reduction" is only 2.2% - not 65%! Any credible statistician will tell you that. Moreover, every statistic involves "standard variation." There is no such variation provided in this so-called "study." Next is the question of the ethics of a group of scientists that would engage in a study in which they actually hoped that the subjects would contract a deadly disease to effect their "research", but I'll leave that to the reader to ponder. Even if true - even if MGM was to reduce the incidence of HIV by 65% - so what? Does this validate the genital mutialation of an unconsenting infant against the small chance (2.2%) that he MIGHT contract HIV in the future? I'd suggest that using condoms and staying away from infected women (e.g. prostitutes) is far more effective and far less invasive both medically and physically. What about circumcision of women who transmit the disease to the men? Should a similar study be done, or is this considered "sexist", "abuse of women", or somehow party to an illegal, unacceptable review? Since we have cultures to engage in female genital mutilation, why not a study comparing the incidence of HIV in those societies against women in other cultures where this is not done? And what if the results of that "study" showed that circumcised women contract HIV 65% less than uncircumcised women? Would proponents of MGM get on the bandwagon for FGM as quickly as seems to be the case here? The questions here are, of course, rhetorical. Are we really to conclude from this numerical gyration by clearly biased "researchers" that EVERY male should have part of his sex cut off so that 2 in 100 might not get HIV? What do you propose to tell a man to whom this has been done and gets HIV in any case? "Whoops. Sorry about that!"?? On a similar note, radical mastectomy or the surgical removal of breast buds in infant girls would reduce the incidence of breast cancer (the #2 killer of women) by almost 100%. Again rhetorically, should this prophylaxis be done universally? HIV in men and women is a "spit in the ocean" compared to breast cancer in women alone. Outside the Arab world, the USA has the highest rate of MGM in the world - and the highest incidence of HIV. THAT is a far more valid piece of information than what has come from this flawed study whose only interest seems to be supporting the views of special interest groups, certain women (who insist on it because they like "the look") and misandryists. Competing interests: None declared
Human Rights, HIV, and Circumcision 22 August 2005
George Hill, Executive Secretary Doctors Opposing Circumcision, Suite 42, 2442 NW Market Street, Seattle, Washington 98107-4137, USA, John V. Geisheker, J.D., LL.M Send response to journal: Re: Human Rights, HIV, and Circumcision	To the editor: Tanne1 has conflated two unrelated stories into one, with confusing results. Human Rights and Circumcision. The first story is about Matthew Hess’s call for UN action to declare male circumcision a human rights violation. It is indisputably true that male circumcision violates numerous human rights. The Norwegian Council for Medical Ethics has already said as much.2 So does Jacqueline Smith, writing for the Netherlands Institute of Human Rights.3 Hellsten argues, with regard to circumcision of children, that we have to focus on child rights protection.4 Fox and Thomson have declared circumcision to be unethical and find no reason to believe that circumcision is lawful.5 Moreover, the inherent mutilation of circumcision brings it into conflict with existing child protection laws. One man already is in gaol for having performed a circumcision.6 Hess’s well-intentioned call for UN action is on solid ground. Unfortunately, given the current state of gridlock at the UN, no action can be expected. HIV and Circumcision. The second story is about Auvert’s so-called randomized controlled trial (RCT) of circumcision to prevent female-to-male HIV transmission. The Wall Street Journal reports that Lancet refused to print Auvert’s report and it apparently has not been published elsewhere, so only the scant information from the abstract7 is available. There has been no public peer review. The private peer review at Lancet that resulted in a refusal to print the article is not encouraging. In the absence of publication, public comment and criticism is speculative. Several observations, however, are possible from the abstract. The study purports to be a RCT, yet the men were not selected at random. Auvert et al. eliminated those men who were not willing to be circumcised so an element of selection has entered into the picture.7 The Auvert study found that circumcision reduces but does not eliminate infection with HIV.7 The authors then terminated the study early. Had the study continued its planned length, it is probable that it would have shown that circumcision merely delays infection and does not stop it. In the end the infection rate likely would have been the same had the study continued for long enough. The protective effect of male circumcision, to the extent it exists, is limited to female-to-male heterosexual transmission. It would not affect male-to-female transmission, homosexual transmission, or transmission by unsafe health care, which is a problem in Africa.8 Its overall value in fighting the epidemic remains unclear. In the Auvert study, black males were observed while they became infected with HIV. Apparently, they were not given or allowed to use condoms or this would have disturbed the experiment. Sadly, this is all too reminiscent of the infamous Tuskegee syphilis experiment in which newly discovered penicillin was withheld so that the study could continue.9 Auvert and colleagues have not said if they would subject children to circumcision in an effort to prevent HIV infection. This would be unacceptable from a human rights and ethical perpective.2-5 Fox and Thomson observe that bioethics requires the most conservative treatment. Since condoms and sex education are less invasive they must be preferred to circumcision.5 In addition, they point out that “circumcision has long existed as a procedure in need of a justification” and that the current focus on HIV “needs to be assessed in light of this.”5 Even if male circumcision ultimately is found to protect against HIV, there are numerous factors, which have been discussed elsewhere, that must be weighed before such a programme should be instituted.10 11 George Hill, Bioethicist Executive Secretary   John V. Geisheker, J.D, LL.M. General Counsel Doctors Opposing Circumcision Suite 42 2442 NW Market Street Seattle, Washington 98107-4137 USA Web: http://www.doctorsopposingcircumcision.org References Tanne JH. US group lobbies UN to outlaw male circumcision. BMJ 2005;331:422. [Full Text] Gulbrandsen P. Rituell omskjæring av gutter. [Ritual circumcision of boys.] Tidsskr Nor Lægeforen [Journal of the Norwegian Medical Association] 2001;121(25):2994. [Full Text] (In Norwegian) Smith J. Male Circumcision and the Rights of the Child. In: Mielle Bulterman, Aart Hendriks and Jacqueline Smith (Eds.), To Baehr in Our Minds: Essays in Human Rights from the Heart of the Netherlands (SIM Special No. 21). Netherlands Institute of Human Rights (SIM), University of Utrecht, Utrecht, Netherlands, 1998: pp. 465-498. [Full Text] Hellsten SK. Rationalising circumcision: from tradition to fashion, from public health to individual freedom-critical notes on cultural persistence of the practice of genital mutilation. J Med Ethics 2004;30:248-53. [Full Text] Fox M, Thomson M. A covenant with the status quo? Male circumcision and the new BMA guidance to doctors. J Med Ethics 2005;31(8):463-9. [Full Text] Hill G, Geisheker JV. Circumcision bioethics: a proposal for reform. J Med Ethics 2005 Rapid response, 9 August. [Full Text] Auvert B. Puren A, Taliaard D, et al. Impact of male circumcision on the female-to-male transmission of HIV. Presented at the 3rd IAS conference on HIV Pathogenesis and Treatment. Rio de Janeiro, 24-27 July 2005. [Abstract] Gisselquist D, Rothenberg R, Potterat J, Drucker E. Non-sexual transmission of HIV has been overlooked in developing countries. BMJ 2002;324:235. [Full Text] Bhopal R. Spectre of racism in health and health care: lessons from history and the United States. BMJ 1998;316:1970-3. [Full Text] Boyle GJ. Issues associated with the introduction of circumcision into a non-circumcising society. Sex Trans Inf 2003;79:427-8. [Full Text] Hill G, Denniston GC. HIV and circumcision: new factors to consider. Sex Trans Inf 2003;79:495-6. [Full Text] Competing interests: None declared
Re: Flawed critique of "Male Genital Mutilation" 22 August 2005
James S. Smeltzer, MD, FACOG, Consultant, Maternal Fetal Medicine 787 Campbell Hill St, Marietta GA, USA 30060 Send response to journal: Re: Re: Flawed critique of "Male Genital Mutilation"	The term genital mutilation is intrinsically inflammatory and pejorative to those who have been circumcised. This was a randomized controlled trial of consenting adults. No-one hoped they would contract HIV. Certainly no-one would argue that any prevention is as effective as restricting intercourse to marriage. The issue is not one of child abuse but of public health. The same arguments raised against "consent" could be raised for any of the childhood immunizations, which each carry a risk which is small compared to the general benefit to the recipient and his society. Currently a parent, with a full appreciation of current medical knowledge of reduced infectious risk during childhood and adulthood, could rationally, based on those data, either give or withhold medical consent for male circumcision. The critics would better refrain from polemic and assess the source of their vehemence on this issue. Competing interests: The author cares for women with and without HIV.