COMMON MISCONCEPTIONS ABOUT MMC

The aim of this section is to critically evaluate arguments made by male circumcision opponents who question the now widely accepted evidence of several large randomised controlled trails (RCTs) in sub-Saharan Africa that have shown MMC protects against heterosexual acquisition of HIV.

Most of the claims offered by this fraternity are not new. Importantly, experts have found all such claims to be seriously flawed.

Most of the criticisms of the studies lack novelty and do not acknowledge the detailed critiques of previous articles by research experts in the field. It is essential to put science at the core of the debate on MMC for HIV prevention and to reassure the HIV policy and implementation community that the evidence in support of MMC for HIV prevention is solid, consistent and beyond reasonable doubt.

  • 1. “The science supporting MMC is flawed”.

    There is no shortage of scientific evidence on the protection against HIV conferred by male circumcision. Many circumcision denialists question the science behind the claims of MMC benefits:

    a. “There is not enough evidence to show that MMC has a protective effect in the prevention of HIV transmission.”

    This is simply not true. Extensive analyses have been produced over the years. There have been 4 ecological studies; 35 cross sectional studies; 14 prospective studies; 3 randomised controlled trails and hundreds of reviews, systematic reviews and met-analyses. These studies involve different methodologies. They provide useful data and direction for translating results into policy and to guide clinical practice. Of the numerous systematic reviews, the well-respected Cochrane Reviews and meta-analyses has endorsed the role of MMC in the reduction of female to male HIV transmission.
    The World Health Organisation (WHO) and the President’s Emergency Plan for AIDS Relief (PEPFAR) have identified MMC as a priority HIV-prevention intervention based on strong scientific evidence.
    Initially, anecdotal evidence from observations suggested that HIV prevalence was often higher in countries where male circumcision is uncommon (and lower in countries or areas where male circumcision is common).

    References:

    • Bongaarts J et al. 1989. The relationship between male circumcision and HIV infection in African populations. AIDS 3: 373–377.
    • Moses S et al. 1990. Geographical patterns of male circumcision practices in Africa: Association with HIV seroprevalence. Int J Epidemiol 19: 693–697.
    • Halperin DT and Bailey RC. 1999. Male circumcision and HIV infection: Ten years and counting. Lancet 354: 1813–1815

    This prompted further investigation which included:

    Observational studies:

    • Cameron DW et al. 1989. Female to male transmission of human immunodeficiency virus type 1: Risk factors for seroconversion in men. Lancet 2: 403–407.
    • Gray RM, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: A randomised trial. Lancet 2007;369(9562):651-666. [http://dx.doi.org/10.1016/S0140-6736(07)60313-4]
    • Weiss HA, Quigley MA and Hayes RJ. 2000. Male circumcision and risk of HIV infection in sub-Saharan Africa: A systematic review and meta-analysis. AIDS 14: 2361–2370.

    As well as several large randomised controlled (not clinical) trials:

    • Quinn TC et al. 2000. Viral load and heterosexual transmission of human immunodeficiency virus type 1. Rakai Project Study Group. N Eng J Med 342: 921–929
    • Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med. 2005 Nov;2(11):e298. Erratum in: PLoS Med. 2006 May;3(5):e298.
    • Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisuma, Kenya: A randomised controlled trial. Lancet 2007;369(9562):643-656. [http://dx.doi.org/10.1016/S0140-6736(07)60312-2]

    And the following abstracts:

    • Kong G et al. 2012. Longer-Term Effects of Male Circumcision on HIV Incidence and Risk Behaviors during Post-Trial Surveillance in Rakai, Uganda. Paper #36. 18th Conference on Retroviruses and Opportunistic Infections, February 27–March 2, Boston, Mass.
    • Auvert BH et al. 2012. Decrease of HIV Prevalence over Time among the Male Population of Orange Farm, South Africa, following a Circumcision Roll-out (ANRS-12126). Presentation at the 2012 International AIDS Conference, July 22–27. Washington, DC. Abstract TUAC0403.
    • Taljaard D, Rech D, Doyle S, et al. Estimating the uptake of safe and free male circumcision in a South African community. XVII International AIDS Conference, Mexico City, 3 – 8 August 2008. Abstract TUAC0306.

    And three seminal publications which are associated with validating the science behind the MMC randomised control trials:

    • Siegfried N, Muller M, Deeks JJ, Volmink J. Male circumcision for prevention of heterosexual acquisition of HIV in men. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: D003362. DOI: 10.1002/14651858.CD003362.pub2.
    • Review: a critical evaluation of arguments opposing male circumcision for HIV prevention in developed countries. Morris BJ, Bailey RC, Klausner JD, Leibowitz A, Wamai RG, Waskett JH, Banerjee J, Halperin DT, Zoloth L, Weiss HA, Hankins CA. AIDS Care. 2012;24(12):1565-75. doi: 10.1080/09540121.2012.661836. Epub 2012 Mar 28. Review.
    • Siegfried N, Muller M, Deeks J, Volmink J 2009. Male circumcision for prevention of heterosexual acquisition of HIV in men. Cochrane Database of Systematic Reviews 2009 John Wiley & Sons, Ltd

    A critical evaluation of the Morris study is provided by Dr Gareth Lowndes and is provided below.

    b. “The validity of the randomised controlled trials was questionable”

    The RCTs results were supported by international funding organisations; the review editors of journals that published the results and the policy community (including WHO and UNAIDS) who endorsed the findings. The trials in Kenya and Uganda were funded and ethically approved in part by the US National Institutes of Health (NIH); the South African trial by the French National Agency for AIDS research. In all three countries approval was also granted by national institutional review bodies.

    c. “The trials were stopped early, therefore we cannot trust their findings.”

    The trials were stopped early due to overwhelming evidence – which is considered the best outcome for randomised clinical trials. The early termination of the trials was based on interim analyses that showed a significantly lower rate of newly-acquired HIV infection for the circumcised versus the uncircumcised men. It was considered unethical to delay offering the control group the opportunity for circumcision any longer. As overwhelming evidence emerged, former UNAIDS director Peter Piot noted that, had male circumcision been adopted without delay, “it could have saved lives.”
    These three studies (Auvert, Bailey and Kong) later formed the basis of a Cochrane review, which confirmed the value of surgical circumcision as a method for preventing heterosexual HIV transmission. The combined results showed that MMC reduced incident HIV infection rates by 60%.

    Reference:

    • Siegfried N, Muller M, Deeks J, Volmink J 2009. Male circumcision for prevention of heterosexual acquisition of HIV in men. Cochrane Database of Systematic Reviews 2009 John Wiley & Sons, Ltd

    d. “There are scientific studies that prove circumcision had no protective effect in the prevention of HIV transmission.”

    Randomised Controlled Trials are the established “gold standard” of evidence and epidemiology.
    There is overwhelming support for MMC. In contrast there are no strong, credible references opposing male circumcision. There are only specious arguments made in the absence of support by experts in the scientific community. Anti- MMC protagonists often cite outlier studies.

    Reference:

    • Connolly C, Leickness S, Shanmugam R, Nqeketo A. Male circumcision and its relationship to HIV infection in South Africa: Results from a national survey in 2002. S Afr Med J 2008; 98: 789-794.

    We need to be cognisant of the overall support for MMC provided by systematic reviews and meta-analyses. The current data on male circumcision satisfy six of the nine criteria on causality; namely strength of association, consistency, temporality, coherence, biological plausibility and experiment.
    In cases where anti-MMC data has been published in peer reviewed journals it has generally been exposed as fallacious in published critiques that have followed.

    The majority of observational studies support MMC. There are a few articles that reflect an anti-MMC conclusion. Of the numerous systematic reviews, Cochrane reviews and meta-analyses conducted, a single study found a positive correlation between MMC and HIV infection. Critical evaluations of the article, by several different experts found erroneous methodology and discrepancies that concluded it lacked credibility. Its conclusions have been rejected. All other reviews and meta-analysis have found that male circumcision protects men against acquisition of HIV infection during heterosexual intercourse.

    e. “Circumcision is not a beneficial preventative intervention as it encourages men to participate in unprotected sexual activity.”

    The truth is that despite counselling and increased knowledge, the use of condoms remains sporadic among men. The differences between the control and circumcised groups would not have become apparent so quickly if the men had been using condoms as advised. South Africa’s latest HIV survey finds boys having sex earlier as well as plummeting condom use.
    Source: http://www.health-e.org.za/2014/04/02/hiv-goes-condom-use-goes/

    Reference:

    In all male circumcision randomised controlled trials, sexual behaviour was naturally taken into account as a factor associated with HIV acquisition. Evidence has shown that in the context of a randomised controlled trial, circumcision does not result in increased HIV risk behaviour, also called risk compensation. However, its continued monitoring, together with evaluation and intensification of HIV prevention messaging on an individual and population level, is necessary to support the efficacy of male circumcision.

    Reference:

    • Mattson CL, Campbell RT, Bailey RC, Agot K, Ndinya-Achola JO, Moses S. Risk compensation is not associated with male circumcision in Kisumu, Kenya: a multi-faceted assessment of men enrolled in a randomized controlled trial. PLoS ONE 2008; 3: e2443

    A recent trial in Uganda found that although risky sexual behaviours were more common among circumcised men, HIV prevalence was still lower among the circumcised men relative to the uncircumcised. These observations suggest a need to promote the already known HIV intervention strategies, especially among the circumcised men, rather than disprove the efficacy of MMC.

    Reference:

    • Kibira et al.: Differences in risky sexual behaviors and HIV prevalence of circumcised and uncircumcised men in Uganda: evidence from a 2011 cross-sectional national survey. Reproductive Health 2014 11:25.

    f. “Circumcision increases the spread of HIV as resuming sexual activity before wound healing increases the risk of HIV acquisition.”

    Resuming sexual activity after MMC but before wound healing may increase the risk of HIV acquisition for both the men and their partners. Fortunately this risk applies only for a limited period of time (about three weeks), and imprudent behaviour may still be prevented by counselling. The risk also does not outweigh the far greater benefits of male circumcision (please refer to the three randomised trials for more information).

  • 2. “MMC is an attack on cultural practices, i.e. traditional circumcision”.

    The right to participate in cultural practices should be protected. However, it is a limited right and does not entail a right to activities that cause serious and avoidable harm. This does not imply that the practice should be abolished. Rather, the practice should be regulated to prevent harm. Traditional leaders bear much responsibility and they need to be aware that their right to perform traditional surgeries is a privilege granted by society to show respect for culture. The right to keep that privilege may require that some of the customary aspects of the practice need to change, to prevent harm.
    Ethically, because male circumcision is effective and its cost reasonable, it has to be offered and made available to the general population in heterosexual HIV epidemic settings.
    Some elders have expressed the belief that for cultures to survive, they must evolve (Malan M: 2012). Many elders understand that cutting the foreskin of all initiates with the same blade is not a safe practice, especially with the increased risk of transmitting HIV. It has been reported that the Congress of Traditional Leaders of South Africa has called for co-operation between the National Department of Health and itself. This is very welcome news. However, the need for action is urgent. It is surely possible to find a way to protect culture and ensure the health and well-being of initiates.

    Reference:

    • K Behrens: Traditional male circumcision: Balancing cultural rights and the prevention of serious, avoidable harm. S Afr Med J 2014;104(1):15-16. DOI:10.7196/SAMJ.7493

    Source: Malan M. 2012. The chief who lit a cultural fire in Zambia. Mail & Guardian, July 20. Accessed September 18, 2012 mg.co.za/article/2012-07-19-the-chief-who-lit-a-cultural-fire-in-zambia

  • 3. “Male circumcision is the same as female genital mutilation”.

    There is a difference between circumcision and genital mutilation. Male circumcision removes only the foreskin covering the glans penis. The comparable physiology in the female would involve the removal of the clitoral hood.

    Male circumcision has been shown to have several prophylactic (protective) benefits. No benefits, however, have been shown in the female case. There is, therefore, no medical reason for the removal of the clitoral hood or any other parts of the female genitalia. The practice can only be described as female genital mutilation, and wholly unrelated to medical male circumcision which protects health without impairing sexual function.

    Reference:

    4. WHO FGM fact sheet 2014

  • 4. “MMC encourages risky behaviour as circumcised men feel they no longer need to use condoms”.

    Despite the benefits of MMC outlined in the literature there is concern about how men perceive the protective effect of circumcision. If circumcised men believe that circumcision confers substantial or complete protection against HIV infection, they may engage in increased risk behaviour, commonly referred to as risk compensation or behavioural disinhibition. Significant risk compensation could reduce the protective effect of circumcision and possibly result in increased rather than decreased incidence of HIV.

    Reference:

    • World Health Organization (2005) UNAIDS statement on South African trial findings regarding male circumcision and HIV Statement developed by the World Health Organization (WHO), the United Nations Population Fund (UNFPA,) the United Nations Children’s Fund (UNICEF) and the UNAIDS Secretariat, 26 July 2005. www.who.int/mediacentre/news/releases/2005/pr32/en/

    There are consistent findings from five studies that risk compensation is essentially absent after circumcision, however, it will be necessary to further evaluate the possibility that men increase their HIV risk behaviour after circumcision is offered.

    References:

    5. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med. 2005 Nov;2(11):e298. Erratum in: PLoS Med. 2006 May;3(5):e298.
    6. Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisuma, Kenya: A randomised controlled trial. Lancet 2007;369(9562):643-656. dx.doi.org/10.1016/S0140-6736(07)60312-2
    7. Kong G et al. 2012. Longer-Term Effects of Male Circumcision on HIV Incidence and Risk Behaviors during Post-Trial Surveillance in Rakai, Uganda. Paper #36. 18th Conference on Retroviruses and Opportunistic Infections, February 27–March 2, Boston, Mass.
    8. Auvert BH et al. 2012. Decrease of HIV Prevalence over Time among the Male Population of Orange Farm, South Africa, following a Circumcision Roll-out (ANRS-12126). Presentation at the 2012 International AIDS Conference, July 22–27. Washington, DC. Abstract TUAC0403.
    9. Taljaard D, Rech D, Doyle S, et al. Estimating the uptake of safe and free male circumcision in a South African community. XVII International AIDS Conference, Mexico City, 3 – 8 August 2008. Abstract TUAC0306.

    Alternatively and preferably, until further evidence becomes available, as MMC services are introduced and promoted, the HIV prevention community should ensure that MMC services are integrated with a full package of HIV prevention measures including delay in the onset of sexual relations and reduction in the number of sexual partners; providing and promoting correct and consistent use of male and female condoms; providing HIV testing and counselling services; and providing services for the treatment of STIs. Studies suggest that under such conditions, HIV risk behaviours after circumcision are unlikely to increase and on the contrary are likely to decline.
    Risk-taking levels remain relatively fixed over time among circumcised and uncircumcised men, even among recently circumcised men, although some studies suggest possible small increases in risk compensation.

    References:

    10. Quinn TC et al. 2000. Viral load and heterosexual transmission of human immunodeficiency virus type 1. Rakai Project Study Group. N Eng J Med 342: 921–929
    11. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med. 2005 Nov;2(11):e298. Erratum in: PLoS Med. 2006 May;3(5):e298.
    12. Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisuma, Kenya: A randomised controlled trial. Lancet 2007;369(9562):643-656. dx.doi.org/10.1016/S0140-6736(07)60312-2
    13. World Health Organization. 2007. Male Circumcision and HIV Prevention: Research Implications for Policy and Programming. Montreux, 6- 8 March 2007

    Three research studies suggest that circumcision does not significantly change the way a condom is used (Grey 2007). In fact, some men have suggested that putting on a condom is easier after circumcision (Bailey).

    References:

    14. Quinn TC et al. 2000. Viral load and heterosexual transmission of human immunodeficiency virus type 1. Rakai Project Study Group. N Eng J Med 342: 921–929
    15. Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisuma, Kenya: A randomised controlled trial. Lancet 2007;369(9562):643-656. dx.doi.org/10.1016/S0140-6736(07)60312-2

    A new study, published online on 21 July 2014 in the journal AIDS and Behavior, is the first population-level longitudinal assessment of risk compensation associated with adult male circumcision. It concluded that men do not engage in riskier behaviours after they are circumcised.

    Reference:

    • Nelli Westercamp, Kawango Agot, Walter Jaoko, Robert C. Bailey. Risk Compensation Following Male Circumcision: Results from a Two-Year Prospective Cohort Study of Recently Circumcised and Uncircumcised Men in Nyanza Province, Kenya. AIDS and Behavior, 2014; DOI: 10.1007/s10461-014-0846-4

  • 5. “MMC only has health benefits for men – what about women?”

    a. MMC reduces HIV acquisition in women

    More incidence studies are needed to investigate the association of MMC rollout with HIV among women. However, the findings of Bertran Auvert (24) that MMC reduces the risk of women acquiring HIV are probably due to the lower HIV prevalence rate among circumcised men.
    A 2011 study goes further to state that “nearly half of projected infections averted by 2025 are expected to be among women.”

    Reference:

    • Hankins C, Forsythe S, Njeuhmeli E. Voluntary medical male circumcision: an introduction to the cost, impact, and challenges of accelerated scaling up. PLoS Med 2011; 8: e1001127.

    b. MMC reduces HPV and genital herpes acquisition in women

    A randomised controlled trial in Orange Farm has shown that male circumcision markedly reduced human papillomavirus (HPV) acquisition by men, thus also reducing their female partners’ exposure to HPV. HPV is the main cause of cervical cancer among women. This means that male circumcision is also indirectly beneficial to women in reducing their exposure to sexually transmitted diseases other than HIV.

    References:

    • Association of Low-Risk Human Papillomavirus Infection with Male Circumcision in Young Men: Results from a Longitudinal Study Conducted in Orange Farm (South Africa) Chloe Tarnaud,Pascale Lissouba, Ewalde Cutler, Adrian Puren, Dirk Taljaard, and Bertran Auvert Infectious Diseases in Obstetrics and Gynecology, Volume 2011, Article ID 567408, 7 pages doi:10.1155/2011/567408
    • Castellsagué X et al. X et al. 2002. Male circumcision, penile human papillomavirus infection, and cervical cancer in female partners. N Engl J Med 346: 1105–1112
    • Hernandez BY et al. 2008. Circumcision and human papillomavirus infection in men: A site-specific comparison. J Infect Dis 197(6): 787–794.
    • Wheeler CM1, Kjaer SK, Sigurdsson K, et al. The impact of quadrivalent human papillomavirus (HPV; types 6, 11, 16, and 18) L1 virus-like particle vaccine on infection and disease due to oncogenic nonvaccine HPV types in sexually active women aged 16-26 years. J Infect Dis. 2009 Apr 1;199(7):936-44. doi: 10.1086/597309.

    A 2009 meta-analysis (Weiss) of the benefits to women of circumcising men found no evidence that having sex with a circumcised, rather than an uncircumcised, man reduced the risk of HIV infection to women, though there have been studies that show that male circumcision reduces the risk of human papillomavirus (HPV) and genital herpes (HSV2) in women.

    Reference:

    • HA Weiss, CA Hankins, and K Dickson. Male circumcision and risk of HIV infection in women: a systematic review and meta-analysis. Lancet Infectious Diseases 9(11):669-677 November 2009.

  • 6. “Adverse events related to circumcision far outweigh the benefits”.

    MMC is a low risk procedure. However, there are some risks associated with MMC both during and following the procedure. These are termed an adverse event (AE). Most of the reported adverse events (99%) are not severe and can be easily treated. The current overall AE rate is typically 1%- 2% in South Africa.

    Despite the endorsement of MMC, safety became a concern once mass programmes were implemented in resource-limited settings. In developed countries, adverse events following neonatal circumcision are well documented and their incidence is very low (0.2 to 0.6%). The randomised control trials, which provided services in a clinical trial setting, reported the following adverse event rates: 3.8% in Orange Farm, South Africa; 1.5% in Kisumu, Kenya; and 3.6% in Rakai, Uganda. Most recently, at the former Orange Farm RCT site, 1.8% of medical male circumcisions offered in one high-volume facility resulted in an adverse event.”

    Reference:

    WHO: Factors associated with the safety of voluntary medical male circumcision in Nyanza province, Kenya. Bulletin of the World Health Organization Past issues Volume 90: 2012 Volume 90, Number 10, October 2012, 713-792

    Adverse events are mostly caused by early resumption of sex/masturbation (abstinence period of six weeks is recommended) or poor wound care (keeping penis upright, washing regularly with salt water and changing of dressings).

  • 7. “MMC negatively affects penile sensation and sexual function”.

    Well-designed studies of sexual sensation and function in relation to male circumcision are few, and the results present a mixed picture. Kigozi in 2008 stated 98% of men reported sexual satisfaction and normal sexual function after circumcision in a rural population in Uganda and concluded that adult male circumcision does not have clinically significant deleterious effects on sexual pleasure or function amongst circumcised men.
    There is also no evidence to indicate a negative impact on female sexual satisfaction due to circumcision of their male sexual partners. In Kenya, Krieger published data that showed adult male circumcision was not associated with sexual dysfunction. Circumcised men reported increased penile sensitivity and enhanced ease of reaching orgasm and integration of male circumcision into programmes to reduce HIV risk is unlikely to adversely affect male sexual function. There is also no evidence suggesting that male circumcision can have any negative impact on fertility. The three African trials found high levels of satisfaction among the men after circumcision.

    References:

    • Quinn TC et al. 2000. Viral load and heterosexual transmission of human immunodeficiency virus type 1. Rakai Project Study Group. N Eng J Med 342: 921–929
    • Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med. 2005 Nov;2(11):e298. Erratum in: PLoS Med. 2006 May;3(5):e298.
    • Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisuma, Kenya: A randomised controlled trial. Lancet 2007;369(9562):643-656. [http://dx.doi.org/10.1016/S0140-6736(07)60312-2]
    • Kigozi G et al. 2008. The effect of male circumcision on sexual satisfaction and function: Results from a randomized trial of male circumcision for human immunodeficiency virus prevention, Rakai, Uganda. BJU International 101(1): 65–70.
    • Krieger JJN. 2008. Adult male circumcision: Effects on sexual function and sexual satisfaction in Kisumu, Kenya. Journal of Sexual Medicine 5(11): 2610–2622
    • Sorrells ML, Snyder JL, Reiss MD, et al. Fine-touch pressure thresholds in the adult penis. BJU Int. 2007 Apr;99(4):864-9. Erratum in: BJU Int. 2007 Aug;100(2):481.
    • Krieger JN, Bailey RC, Opeya JC, et al. Adult male circumcision outcomes: experience in a developing country setting. Urol Int. 2007;78(3):235-40.
    • Collins S, Upshaw J, Rutchik S, et al. Effects of circumcision on male sexual function: debunking a myth? J Urol. 2002;167:2111-2.
    • Senkul T, Iseri C, Sen B, et al. Circumcision in adults: effect on sexual function. Urology. 2004;63:155-8.
    • Masood S, Patel HRH, Himpson RC, et al. Penile sensitivity and sexual satisfaction after circumcision: are we informing men correctly? Urol Int. 2004;75:62-6

  • A critical evaluation of arguments opposing Medical Male Circumcision (MMC)

    Reference:

    Review: A critical evaluation of arguments opposing male circumcision for HIV prevention in developed countries, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, DOI:10.1080/09540121.2012.661836. Brian J. Morris, Robert C. Bailey, Jeffrey D. Klausner, Arleen Leibowitz, Richard G. Wamai, Jake H.Waskett, Joya Banerjee, Daniel T. Halperin, Laurie Zoloth, Helen A. Weiss & Catherine A. Hankins (2012)

    Summary of Content

    • A potential impediment to evidence-based policy development on medical male circumcision (MMC) exists where opponents of this procedure are vocal.
    • This paper evaluates 13 recent opinion-pieces opposed to MMC.
    • Often these statements misrepresent valid studies, selectively cite flawed references, use discredited references or fallacious information, and draw erroneous conclusions.
    • Unscientific arguments have been used to drive ballot measures aimed at banning MMC of minors, eliminate insurance coverage for medical MMC for low-income families, and threaten large fines and incarceration for health care providers.
    • The publication explores and endorses scientific studies around:
      - Sexual function, sensation and satisfaction
      - Deaths from infant MMC
      - HIV infection in men
      - Other sexually transmitted infections (STIs)
      - HIV risk to women
      - Condoms
      - Delaying circumcision
      - Cost and risk – versus benefit
      - A surgical vaccine
      - Distortions of evidence by MMC opponents

    Summary of the publication

    A reasoned policy debate on MMC must separate ‘‘values’’ discussions from factual discussions. Scientists are trained to properly evaluate information and make evidence-based conclusions. Misinformation, distortions and specious arguments by MMC opponents could subvert evidence-based policies, leading to suffering and deaths.

    Topic Opposed – MMC Pro-MMC
    Sexual function, sensation and satisfaction
    • Mutilating
    • Impairs penile function
    • Amputates healthy, functional, protective
    • The foreskin is an erogenous zone
    • Sexual dysfunction is either more common or no different in uncircumcised versus circumcised men
    • Data show no difference in penile sensitivity, sexual satisfaction, premature ejaculation or intravaginal ejaculatory latency time
    • Sexual satisfaction may increase. RCT confirm similar or enhanced sexual function, sensitivity and satisfaction
    • Foreskin: The ventral surface of the penis is highest for ‘‘sexual pleasure’’ and ‘‘orgasm intensity’’, followed by the upper surface and sides. The foreskin being less important