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ABC, not circumcision
Posted by ml66uk on 12 Jan 2010 at 16:50 GMT
Vaginal bacterial communities probably change significantly after *female* circumcision, but we don't have armies of researchers trying to justify female circumcision.
There is also strong evidence (Stallings) that female circumcision protects against HIV btw.
Male circumcision is a dangerous distraction in the fight against AIDS. There are six African countries where men are *more* likely to be HIV+ if they've been circumcised: Cameroon, Ghana, Lesotho, Malawi, Rwanda, and Swaziland. Eg in Malawi, the HIV rate is 13.2% among circumcised men, but only 9.5% among intact men. In Rwanda, the HIV rate is 3.5% among circumcised men, but only 2.1% among intact men (figures from www.measuredhs.com). If circumcision really worked against AIDS in the real world, this just wouldn't happen. We now have people calling circumcision a "vaccine" or "invisible condom", and viewing circumcision as an alternative to condoms.
The one randomized controlled trial (Wawer) into male-to-female transmission showed a 54% higher rate in the group where the men had been circumcised btw.
ABC (Abstinence, Being faithful, Condoms) is the way forward. Promoting genital surgery will cost African lives, not save them.
This is a study about the microbial changes associated with male circumcision. I would prefer to restrict these chats to that subject; however, I will say a few things in response to ml66uk:
Male and female circumcisions are not equivalent. To say so, one would have to be disingenuous or ignorant to the details of these procedures.
Just comparing infection rates is highly susceptible to bias. Randomized control trials are the most robust tools for evaluating a clinical intervention. All three randomized control trials conducted so far indicate that male circumcision reduces the risk for HIV acquisition in men.
The study that you mention showing increased male-to-female transmission rates involved HIV positive men. Circumcising adult HIV negative men does NOT increase male-to-female transmission, but does reduce risk for female-to-male transmission.
Your paper starts off with the premise that circumcision protects against HIV, so I believe it's fair to question that assumption.
I consider it disingenuous to suggest that there is something fundamentally different between cutting parts off male genitalia or cutting parts off female genitalia. The people who cut girls certainly don't think so, and neither did the western doctors who used to perform the procedure in the middle of the 20th century. Some forms of female circumcision do a lot less damage than the standard form of male circumcision. I don't believe any RCT involving removal of any part of the female genitalia would ever be considered though. I doubt there is any paper considering the effects of any of the various forms of female circumcision on the vulval microbiome, though it seems likely that similar changes would be observed.
RCT's can provide very useful information, but there have been several criticisms of the three to which you refer. Van Howe makes a good summary here:
It is not possible for you or anyone else to say with any certainty that "circumcising adult HIV negative men does NOT increase male-to-female transmission". Firstly, Brewer 2007 found that "Circumcised male and female virgins were substantially more likely to be HIV infected than uncircumcised virgins". Even if we were to assume that no-one was infected by circumcision itself, and also that it takes them longer to become infected, there are no real figures to show how much more infective they might become once they did. The best estimate we currently have, based on very little data, is that they become 54% more infective.
Infection rates show the effects of male circumcision in the real world, and there is no dramatic reduction of HIV in communities which circumcise males:
"Conclusions: We find a protective effect of circumcision in only one of the eight countries for which there are nationally-representative HIV seroprevalence data. The results are important in considering the development of circumcision-focused interventions within AIDS prevention programs."
"Results: … No consistent relationship between male circumcision and HIV risk was observed in most countries."
Meanwhile, the South African National Communication Survey on HIV/AIDS (NCS), 2009 found that "12-22% of men and 12-17% of women across age groups (15% in total) also believe that circumcised men do not need to use condoms."
It seems clear to me that promoting male circumcision to prevent HIV will cost lives rather than save them.