Why the “circumcision solution” to the AIDS epidemic in Africa may increase it | Hacker News Reader

Why the “circumcision solution” to the AIDS epidemic in Africa may increase it

blog.practicalethics.ox.ac.uk

53 pointsisomorph53 comments

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Bill Gates doesn't seem to care that that science behind the project is terrible. It must have been pointed out to him, yet he was still promoting the project in 2015: https://www.youtube.com/watch?v=_ovf8GYfNbw&t=40s

https://www.youtube.com/watch?v=HFtSt862sKY - how much informed consent do you think was involved here?

A lawsuit against PSI Zimbabwe, also supported[1] by the Bill & Melinda Gates Foundation http://nehandaradio.com/2018/09/02/400-000-circumcision-laws...

15,269,720 "voluntary medical male circumcisions" based on this bogus science http://www.aidsmap.com/PEPFAR-funded-15-million-medical-male...

[1] https://www.psi.org/2016/11/using-market-research-for-long-t...

Didn't realise how into it Bill Gates was - thanks for pointing that out.

Hearing that boy's sadness in that video is very upsetting.

I've heard from people inside WHO that Gates' mentality is that he wants solutions NOW and doesn't concern himself much with potential issues around the solutions. I've heard that they would rather not have his money than be forced to put out vaccines that have questionable manufacturing practices.

Well yeah he probably wants to see results before he dies

Do gooders tend to cause harm Thu do not intend. That Gates has good intentions means little if he makes things worse by pushing non solutions that happen to harmonize with his dick chopping ideology.

A million people die from HIV every year -- a sense of urgency is warranted.

The true science in this is:- Circumcision removes the skin that covers the tip as well as the glands that lubricate these surfaces and it dries out. The HIV virus can not penetrate intact dry skin, but it can penetrate the moist and thinner skin of intact males. This reduces infection, but not all. The opening at the top where you pee is still moist and the virus can enter there. It is well know the Jewish men have far fewer infections of assorted viruses, like HPV that causes cancer in women and that is why cervical cancer is rare in Jewish women.

Basically I agree with this sentiment "So what should we conclude? Green et al. get it right: “Before circumcising millions of men in regions with high prevalences of HIV infection, it is important to consider alternatives. A comparison of male circumcision to condom use concluded that supplying free condoms is 95 times more cost effective.”"

Says it all, really. Interestingly the same applies back home...

That's as silly as focusing on teaching abstinence. Sure, it'd work... in theory. In practice, people don't like condoms and HIV rates would be largely unchanged.

The best hope we have is to work on many fronts at the same time: education, condoms, voluntary circumcision, etc.

People don't like condoms in western countries too but they don't seem to have the same sky-high HIV rates. I don't see how making condoms available for free would hurt.

You're indicting the entire premise of modern safe sex. Either condoms are rarely used and people cannot be taught to use them reliably, or you're wrong. The low infection rate in industrialized countries with good sex education and readily available condoms suggests you're wrong. Contrarily, abstinence hasn't been demonstrated to work anywhere.

The page currently times out loading, but from what I gather from the title, it seems that my distrust in the circumcicion against AIDS stories was on track.

It always felt a bit like puritans trying to find empiric evidence for their moral and cultural traditions.

Cached version: http://webcache.googleusercontent.com/search?q=cache:blog.pr...

There is a definite neo-colonial shadow hanging over it

This is why we need to integrate more africans into modern science fields.

There are many African students at the London School of Hygiene and Tropical Medicine (an alumnus of which runs the World Health Organization).

The discourse at that institution around circumcision, and the taboo of mentioning it alongside FGM/C without saying "circumcision is NOTHING compared to FGM" are difficult

The fallacy that MGM and FGM need to compete rhetorically is a significant hurdle in the discourse. Too many people see it as an unnecessary game of one-upmanship for some reason.

It’s unbelievable how far people will twist themselves in knots trying to find utilitarian justifications for what is, at the end of the day, non-consensual mutilation done for no reason other than “because tradition.”

People downvoting the above - see the cached version of the article to see why the utilitarian / public health justifications are incorrect.

I agree - it's on the wrong side of history. When we look back will be shocked at what we did to ourselves and our children, simply because we could not evaluate a study correctly.

In the case of infants it's certainly non-consensual

In the case of adults there is an issue with the "informed" part of informed consent

There is massive historical momentum behind it https://en.wikipedia.org/wiki/History_of_male_circumcision#R...

If someone sliced off the tip of his kid’s pinky finger because he claimed God told him to do it, we’d lock him in a padded room. But the tip of the kid’s penis is not only totally fine, we’ll try to convince more people to do it!

My kid was born in a US hospital and the woman who did the circumcisions was very pushy that we should get it done ASAP. We said we'd let him decide when he became an adult and she said "but if you let him decide he'll decide not to do it" which seemed like a pretty good argument to me!

I did hear from the staff that she got peed on pretty much every time.

It's seams like a very bad argument for me. What about tonsil removal ASAP? He may decide not to do that. What about a lobotomy ASAP?

I think you're agreeing with gumby -- they meant 'good argument' either sarcastically, or as in 'a good argument not to do it now'.

Her argument was very convincing against her position.

However now you mention lobotomy...that might have made child rearing much simpler. A bit late for me, but you might consider proselytizing this issue for the good of parents everywhere...

Bonus that a child who had a premptive lobotomy would never regret the decision or wonder what life would have been like without it. There is literally no downside...

When it's done on a woman, we call it "genital mutilation", but when done on a man it's "status-quo"

I don't think most people do it "because tradition" unless you believe for some reason that most people are Jewish. They do it variously for religious reasons, health reasons, aesthetic reasons, or maybe just because some guy wants his son's dick to look the same as his. At the end of the day, the kid doesn't even remember. Should people get circumcised as a matter of policy? No. But if you do it to your kid that's your call and if the kid later has a problem with it that's on you. As a general matter it seems that a lot of men with severe psychological hang-ups over circumcision have issues that I have a very difficult time attributing to their lack of foreskin.

I mean, I'm sure FGM reduces AIDS rates too, since women who were subjected to it are going to be less interested in sexual activity...

These is personal experience and views;

Male circumcision is prevalent in Africa mostly as as the norm. It is painless at childhood but gruesome when done to older kids. In some cultures around the world male circumcision is akin to piercing the ears of a baby girl for earrings.

In places where circumcision is a ritual, it gets done to older kids (early teens) as a rite of passage into adulthood. To me that will be more agonizing considering the awareness of the pain eg. when your dick gets caught in a zipper.

I personally dont find male circumcision at birth repugnant because I literally have no memory of it and I but I appreciate it was done to me appropriately.

According to https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5422680/

"The timing and reason for circumcision in boys or men vary across the continent. Circumcision is prevalent in as much as 93% of the countries in Northern Africa compared to 62% of countries in sub-Saharan Africa. Whereas the procedure is done for religious purposes in Western and Northern parts of Africa, it is seldom performed in neonates in Eastern and Southern regions of the continent where circumcision is, often, a rite of passage into adulthood"

What I'll love to see if the comparative AIDS footprint between countries with varying degrees of circumcision.

Mutilating baby penis is a tragedy.

Circumcision of children should be banned entirely. If adults want to do it, fine.

There is also the aspect of who has a dog in the fight and skin in the game.

When you have Americans telling Africans to get themselves circumcised you do have to wonder what is really going on, particularly when there is this dubious level of 'science'.

In the U.S. there is always the profit motive. Hence male circumcision is sold to parents as hygienic and beneficial, they go along with it and the hospital makes some money, everyone getting bonuses except for the baby boy.

To contrast with this profit-motive-situation you have places like the UK where healthcare is provided by the government - e.g. the NHS. The hospital has no financial incentive to circumcise as many boys as possible, doing so would be a cost, not a profitable thing, so it doesn't happen. Therefore the population ends up being un-circumcised as a general rule.

By adulthood men have had long enough to rationalise with what happened to their foreskin. If it has been removed then they tend to want this for others including their own boys. Meanwhile, those with intact foreskin don't talk about such matters in public as they know that open discussion will deeply hurt someone in the room who has been circumcised.

I think that this experiment to circumcise millions of African men for their own good would have been easier to get to the bottom of if everyone involved had to explain their viewpoint in just their 'birthday suit'.

True, regarding the UK.

There are some complex dynamics at work

1. a conflict of interest when there is a financial incentive to do a surgery

2. a pattern of doctors / father who are circumcised feeling the need to promote it to others

3. an issue where men circumcised as infants are never approached for follow-up consent by healthcare professionals, so never know what happened

4. an issue where men circumcised as infants know what happened but rationalise it

You can add to that a large part of why circumcision was promoted in the US originally was to control men's sexuality (see: Dr. Kellogg[1] - incidentally he also promoted using acid to circumcise girls). You can bet that the idea of desexualizing African men appeals to a certain subset of fearful white Americans.

That may be an inflammatory statement but if one looks at some of the more extreme corners of internet opinion it's not hard to believe. That said I wouldn't expect most people who the idea appeals to to admit it, but given that science is obviously not on the side of those promoting circumcision one has to look for possible motivation elsewhere.

[1] https://www.psychologytoday.com/us/blog/moral-landscapes/201...

You are attributing to malice what could easily be attributed to stupidity.

It's entirely fair to consider the possibility of malice as a subconscious motivation among some people. The very frequent blind application of Hanlon's razor seems to me to be almost worse than ignoring it entirely.

Yes, but what motivates those people isn't relevant unless they're the ones making the decisions.

For what it's worth, circumcision is slowly declining in the US[1]. We did not circumcise our son when he was born. The hospital asked us, we said no. No questions asked. We came fully prepared to justify our decision, worried that doctors would perform it by default or try to guilt us into it to avoid the spread of STDs.

[1] https://www.usatoday.com/story/news/nation/2013/08/22/circum...

Well that is terrifying, the fact you have to think ahead like that, fearing what you might have to say, assuming a default.

Since it is a binary option with moral overtones and since your boy will eventually compare notes with his contemporaries you could gift him a story that sidesteps the matter.

The story might not be grounded in truth any more than Santa Claus is. The mythical backstory could be that it was decided on a coin toss, heads it stayed on, tails it came off. Maybe embellish it so that the doctor, his mum and yourself all had coins, it being a 'best of three' with the doctor calling 'tails', you calling 'heads' and his mum having the deciding coin.

Such a white lie can be useful for him when he needs to dig himself out of a conversational hole when he gets older so as to not have that awkward moment with a religious workmate/sister's boyfriend etc., even if by then he knows the story is a myth.

Site has been overwhelmed by traffic - cached version: http://webcache.googleusercontent.com/search?q=cache:blog.pr...

circumcision is just mutilation

This piece from 2012 (posted now why?) loses all credibility in the section called "2. Misleading results":

It is tempting to think that the 60% figure that’s being thrown around in media reports is just too large a percentage to ignore–even if the studies had some flaws. But do you know what the “60%” statistic is actually referring to? Boyle and Hill explain: What does the frequently cited “60% relative reduction” in HIV infections actually mean? Across all three female-to-male trials, of the 5,411 men subjected to male circumcision, 64 (1.18%) became HIV-positive. Among the 5,497 controls, 137 (2.49%) became HIV-positive, so the absolute decrease in HIV infection was only 1.31%.

That’s right: 60% is the relative reduction in infection rates, comparing two very small percentages

I don't even know where to begin. What does he think people will interpret it to mean? His entire point here is made in bad faith. What he's saying basically comes down to "the infection rate in this trial was low to begin with, therefore there's no point trying to make it lower," which is preposterous. The authors claim a reduction, which any speaker of the English language should know how to interpret.

I think it's entirely valid to argue the validity of the study and the blowback issue, but his sloppy argumentation throughout the article is underscored here.

Not sure why you are being downvoted. That part of the article is indeed disingenuous (I'm not sure whether it's sloppy or purposely misleading). Of course the 60% reduction is a relative reduction in infection rates.

In fact, the "absolute decrease [of] only 1.31%" claimed by the article, if anything, is misleading, because that number (representing 60% of the 2.49%) is over a certain small amount of time, and therefore will only grow larger as time passes.

I am a 59 y/o male and an "Intactivist." Tomorrow morning, I'll be flying from my home in Kirkland, Washington, to Orlando, Florida, to join my colleagues in protesting non-therapeutic circumcision at the site where the AAP is hosting its convention. I routinely join the Bloodstained Men and their Friends in their various protests / education events. I also carry my various signs in front of a local hospital (Evergreen Hospital, Kirkland, WA) which performs NTC on healthy male infants and neonates when their parents request it. I also routinely speak against NTC in the public meetings of the Board of Commissioners for EGH.

I'm currently contemplating what kind of legal action I could take against the Board of Commissioners of the Public Hospital District that oversees the EvergreenHealth organization.

Over the last year, I have been sharing information with them. The management team of EGH has been relying on the AAP 2012 Circumcision Policy Statement as their justification for offering the harm they offer to parents. I have informed them that the Policy Statement expired in 2017, but they continue to defend the offering of this harm. I also submitted copies of a statement-by-statement refutation of the Policy Statement written by Dr. Robert S. Van Howe, who was (may still be) the Interim Chairman of the Department of Pediatrics at the Central Michigan College of Medicine.

If anyone has any suggestions for me as regards what kind of legal action might be considered, to compel / encourage the Board of Commissioners to do the work necessary to decide for themselves whether they are harming healthy infants and neonates by continuing to offer this harm, I would appreciate it.

The legal system cannot help at this stage. I have met this guy http://www.oldsquare.co.uk/our-people/profile/james-chegwidd... who successfully defended two boys’ right to choose in the UK (this was only made possible because their mother DIDN’T want them circumcised and their dad did).

There is no legal basis for circumcision but unfortunately the law cannot help in this case as it reflects public opinion.

Check this out written by the author of this article https://youtu.be/sQQTIpBWqvY

I am considering retraining from software engineering into health policy to combat non-therapeutic infant circumcision in the UK

This article is FUD. If the article raised some questions about the (multiple) studies that show the effect, I would just shrug and let it go. But then to go on and say it "may increase it" is irresponsible. There is zero evidence for this -- and in fact a lot of evidence to the contrary. [1]

Yes, every study has limitations. The fact that you can't do a blind study or a placebo control with circumcision is just a fact of life -- people tend to know if they're circumcised or not. This does not refute the many studies' findings.

Can you imagine the outrage if the author published a paper questioning the effect of smoking on lung cancer, and then wondered if smoking actually reduces your chances for lung cancer? That's what this article is doing.

I'm glad that Gates is standing on the side of science here.

1. http://www.croiconference.org/sessions/impact-male-circumcis...

> Can you imagine the outrage if the author published a paper questioning the effect of smoking on lung cancer, and then wondered if smoking actually reduces your chances for lung cancer? That's what this article is doing.

I don't think the evidence bases are exactly comparable (even acknowledging that the study you've linked to doesn't sound quite as appallingly constructed as the one described by the blog). And people argue about whether recommendations with thin justifications around stuff like diets have counterproductive side effects all the time, especially when the recommendations are pretty drastic.

The article is very old now, so that was a fair point... when it was published.

But in 2018 we have a lot of evidence that show the effect on transmission is real -- and we also have evidence that circumcised people do not engage in more risky behavior. [1]

So that's why I think this is similar to denying climate change or claiming vaccines cause autism. It could have a real impact on public health.

I suspect I'm getting downvoted because some people are passionately anti-circumcision. And that's fine! Nobody is going to make you get circumcised. But the science doesn't care about one's personal views regarding circumcision.

1. https://www.fhi360.org/sites/default/files/media/documents/M...

> I suspect I'm getting downvoted because some people are passionately anti-circumcision. And that's fine! Nobody is going to make you get circumcised.

Yeah, the problem is that this "science" is inevitably used to justify performing an invasive, unnecessary procedure on babies because in 15+ years it will reduce his risk of acquiring HIV during unprotected sex with an HIV-positive woman from 4/10,000 to 2.4/10,000.

Maybe that's worthwhile in certain cultures experiencing pandemic levels of HIV, but in the USA it's borderline medical malpractice. There are only about 250,000 women in the entire country with HIV.

Actually - someone did make me get circumcised. I was forcibly circumcised as an infant

> But then to go on and say it "may increase it" is irresponsible.

I would say it's actually common sense when you consider how HIV is actually transmitted and account for the fact that conditions, where the procedures are happening, are very likely far from ideal.

The whole thing represents a pretty pointless complication and infection risk, not just from HIV but all kinds of other nasty things.

If there's nothing wrong, there's no reason to cut off pieces from people.

> After all, if someone knows (or thinks) that they’re getting a great big helping of medicine, they might act in various ways—whether consciously or unconsciously—that have the effect of generating positive health outcomes but which have nothing to do with the intervention itself.

That sounds strangely like the Hawthorne Effect[∆].

[∆]https://en.m.wikipedia.org/wiki/Hawthorne_effect

Mods: maybe add (2012)

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