The circumcision solution: Is it a poisoned chalice?

I am a huge fan of debates and I have a cut-and-dry opinion on a whole gamut of issues. Aside from the fact that debates give me that sizzling rush of hormones in my blood,  for the most part, they help me clarify my own values and worldview in a way that reading a book, listening to my favorite music or watching a historical documentary (my other three hobbies) would scarcely do.  I feel it is also one way of exercising my intellectual muscles, just as we exercise our body muscles when we jog or have push-ups every morning or muscles of our spiritual self when we regularly kneel down to worship a supreme deity.

Seldom do I find myself sitting on the fence on a topical issue as I am now on the issue of mass male circumcision in the public health discourse. Recently, the Ministry of Health in Malawi and other organizations in the health sector embarked on a 60 day campaign targeting some 60, 000 men in selected districts across the country. The campaign fared remarkably well, but it also brought to surface the skepticism still simmering over the effectiveness of mass male circumcision as an HIV preventive strategy and public health policy. My news feed on Facebook was awash with cynical posts and shared links regarding the issue. Until that time, I had not thought seriously about the circumcision issue, beyond my small concern over loss of sensitivity if I would get that “extra skin” on my manhood chopped off. But the buzz generated by the social media over the issue prodded me to delve further into the topic, starting with readings on the three randomized clinical trials (RCT’s) that were carried out in South Africa, Kenya and Uganda to study the protective effect of circumcision against female to male HIV transmission.

From the literature that I perused, I learned there is a great deal of controversy on the RCT’s mentioned in the foregoing paragraph. For one thing, some critics have found fault with lack of placebo control in the studies. In a placebo control, an experimental group is administered an actual intervention while a control group is administered a dummy intervention and both the researchers and participants (double-blinding) do not know who has received a “placebo” (the dummy intervention) or not until the results are in. Although this basic principle of clinical trials was violated in this instance, critics do agree that it was inherently tricky to set up a placebo control in this kind of trial. They nonetheless advise caution in interpretation of results of such uncontrolled studies.

Critics have also identified the role of researcher expectation bias, overestimated size of the protective effect of circumcision against female to male HIV transmission due to massive drop-out/attrition of participants over the course of the study, the influence of additional counseling given to participants on their sexual behavior (which reduced risk of HIV infection among the circumcised relative to other men that were uncircumcised and hence not given this additional counseling) as well as the fact that these adult volunteers are already more likely to have a greater propensity to protect themselves than the adult volunteers who did not volunteer to participate in the studies (needless perhaps to point out that enrolling adult volunteers in the studies would also barely pass for random sampling, another important statistical criterion for an ideal clinical trial). All these issues point toward the need to exercise caution when “extrapolating” the results of these observational studies for the population.

Beyond the flaws in the studies, critics of the circumcision agenda also highlight the dangerous possibility of sexual behavior disinhibition (some call it “risk compensation”) among circumcised men. It has been observed that men who circumcise in order to reduce the risk of HIV infection may actually develop a sense of false security and get involved in more unprotected sex, thus offsetting the widely touted benefits of getting circumcised.

In their spirited defense of the circumcision solution, some circumcision advocates have likened the surgical procedure to “a vaccine of high efficacy” and even dubbed it “a surgical AIDS vaccine,” a view that has been found wanting by critics who firmly believe circumcision could never be as highly efficacious as an HIV vaccine. Already, rumors abound that circumcision acts as a “natural condom”.  In many of the conversations I have had with a lot of fellow young people within my social network regarding male circumcision, I have been dumbstruck by their express attitudes towards male circumcision. What I grasp from these conversations is that many of these young people who are opting for circumcision are doing so as a way of doing away with rubber (who really enjoys using latex anyway?).  And should we ever be surprised when a lot of circumcised young people stop using condoms because they believe they already have a “natural condom” in circumcision? What incentive would there be for a young man to wear a condom (which many would rather live happily without, if there were no STI’s) on top of already having gone through the trouble of losing a foreskin (which basic science tells us has so many receptors and enhances sensitivity during coitus) to prevent HIV transmission?

I remain convinced that circumcision indeed has a significant protective effect against vaginal-to-penile HIV transmission but my thoughts are still evolving on whether mass male circumcision will be an effective tool in stemming the spread of the HIV/AIDS pandemic. Meanwhile, I opine that for mass male circumcision to have its intended outcomes in Africa, we must be careful the way we package our messages regarding medical circumcision so that people do not take it as a license for unprotected sex. We should have robust monitoring and evaluation systems for follow-up of clients in clinics administering medical circumcision (something very likely to be compromised in a mass campaign). Besides, the mass campaign for circumcision seems to be diverting attention (and soon, it will be resources) from other proven and more effective instruments for HIV prevention such as condoms. Above all, nobody has a monopoly over intelligence, let alone facts. I believe we must continue to have an honest and sober evidence-based conversation about this invasive procedure. Otherwise, not many generations from now, Africa may one day realize it was handed a poisoned chalice on circumcision.