10/02/08

Women against foreskins

Reproduced below in full is a commentary about circumcision from the Zambia Post. It is massively sensible, but it misses a trick. Dr Phiri reminds us that some men are worried that they’ll have less fun during sex if they get snipped. He cites studies that show that circumcised men have as much fun (“no loss of sensitivity” is probably how they put it). But why does no-one ask women what they think? I’m not going to give away my sample size, but in my experience circumcised men tend to have more stamina (possibly because of the loss of sensitivity), which makes them better lays, which means they’ll probably have a happier time with more contented partners. Circumcision of HIV-positive men does not protect their wives or girlfriends from infection, we learned this week, but from the satisfaction point of view it seems to me that circumcision is good for both women and men.

What follows is Dr. Mannasseh Phiri’s weekly column, “Reflecting on AIDS with Dr. Mannasseh Phiri,” which appears in the Lifestyle section of the the Zambia Post weekend edition. Dr. Phiri is Senior Medical Advisor with PSI affiliate SFH Zambia. This column appeared in Issue January 13, 2008. Thanks to Michel Carael for bringing it to my attention.

Debunking Fears and Myths Around Male Circumcision

BBC correspondent in Zambia, Kennedy Gondwe, telephoned a member of the Society for Family Health’s (SFH) Male Circumcision (MC) team one Friday evening late last year to say that he wanted to do a “story” for the BBC World Service Radio on circumcision in Zambia. At that time, no one (not Kennedy Gondwe, not anyone at SFH and not anyone else in the world) had the slightest clue that this phone conversation marked the beginning of what would end up being probably the most famous removal of a man’s foreskin of modern times. (If it is not the most famous it is certainly the most widely discussed circumcision in the world).

On the morning of 22nd November 2007, two days after he had had HIV counselling and testing, Kennedy Gondwe drove back to the New Start Centre at the YWCA premises on Nationalist Road in Lusaka. This time he had MC counseling and a clinical assessment by a specially trained Clinical Officer – trained in the nuances and practical detail of providing MC for the prevention of HIV infection.

(As far as is known, this SFH MC Centre at YWCA is the first of its kind in the world. It is the first operating room purpose built and dedicated to providing MC for HIV prevention. Other such rooms in Kisumu, western Kenya and in Uganda were built and equipped for the purposes of providing MC for research).

At midday, Gondwe was lying down on the operating table facing the ceiling with his BBC recorder on his chest and his microphone firmly gripped in his left hand, close to his mouth. The two surgeons checked the time and their equipment, Gondwe checked his to make sure the recorder was on. An observer checked his camera, and the first MC operation in history to be recorded for public airing on the BBC World Service radio began.

The conversations between surgeon, client and observer were recorded at every step, while Kennedy’s facial expression was captured on camera – from the injection of the local anaesthetic, through the snip and the stitching, to the application of a small piece of adhesive plaster dressing at the end of the MC just half an hour later.

As he drove home less than two hours after he had laid down for the surgical removal of his foreskin under local anaesthesia, Kennedy Gondwe continued to record his feelings and his thoughts for posterity.

A week later, the recording of this historic MC operation was broadcast to millions of radio listeners all over the world on BBC World Service’s OUTLOOK programme and on Weekend Network Africa. Simultaneously, photographs and written text of the procedure was webcast on the BBC website. (Read Gondwe’s circumcision diary.)

The broadcasts and webcast triggered discussions on the pros and cons of MC, the bravery or otherwise of Kennedy Gondwe’s going so public with what should be a very private and personal experience.

Public discussion of Gondwe’s circumcision was a little muted at home in Zambia, until Friday 21st December 2007 when fellow columnist Edem Djokotoe’s weekly Soul 2 Soul column in THE POST brought it up in Edem’s usual inimitable light hearted humorous style (“The Foreskin Files” – The Post Friday 21th December 2007). Edem received such a “mixed bag” of responses to this article that the following week’s column – “The Foreskin Files – Part II” – was dedicated to some of these reactions and Edem’s views on them.

Most of the responses were of the view that MC is “un-Zambian”. This is puzzling because the Luvale group of tribes – the Luvale themselves, the Mbunda, Luchazi, Chokwe, Ovimbundu, and the Nkangala -in North Western Province of Zambia have practiced circumcision of boy children as a passport to the Mukanda (the traditional rite of passage of boys to men) for centuries. Traditionalists and custodians of the Mukanda tell us that this ceremony has been, and continues to be, a very important integral part of the development and building of the boy child’s character in terms of shaping “personal discipline, livelihood skills, family life skills, community life and village systems”, It is the foundation of how the former boy (now a man) should live as a respected responsible citizen in his community – a hygienically clean, preferred social and sexual partner.

The Luvale groups of tribes are Zambian, and their traditional practices cannot be deemed “un-Zambian”.

These days, anyone going to any of our hospitals for MC will inevitably be put on a waiting list which in some places is as long as three or four months. Ahead of him on that list are other Zambians of all ages, from all tribes and from all walks of life; wishing to get circumcised for many reasons – one of which is the reduction of chances if HIV infection.

One of the respondents to Edem Djokotoe’s article said that it would be “an infringement of human rights if the government of Zambia, through the Ministry of Health, decided to roll out male circumcision in its quest to reduce HIV infections in Zambia”.

One wonders where it is coming from. Firstly, there is no one who is recommending that when government does roll out MC, as it indeed must, it will be forced upon all men! The intention of the roll out is to make safe and high quality MC widely available, so that it is accessible and affordable to as many men as will wish to have the operation. Safe MC should be made available at all levels of the health system starting at the rural health centre, through the larger clinics and centres, to the hospitals – small and large, rural and urban.

As it is now, and as it will continue to be when MC is rolled out, MC will be availed to men who voluntarily go to centres and hospitals to ask for it. The issue of infringement of human rights with MC does not and will not arise. Men seeking MC will be given all the necessary and available information on the science, the research, the benefits and the risks of getting circumcised.

They will be told that having MC done does not provide 100 per cent protection against HIV infection, and so they will still need to take the other precautions – such as reduction of the number of sexual partners, and the use of condoms with partners whose HIV status they do not know, or they know to be HIV positive. MC is not the magic bullet.

Kennedy Gondwe made the choice, completely of his own volition, to go for VCT and then have MC. He made the choice after weighing the facts based on the evidence and information available to him. He also made the free choice to widely publicize his own MC world wide in order to encourage others to follow his example and have the operation.

Understandably, there will not be many men who will follow Kennedy Gondwe’s example to the letter and make their way to an MC Centre with their tape recorders and cameras to have MC done and recorded for broadcast. But without broadcasting, men are following the example and making the choice to have MC because they are convinced it is the best thing to do, and because they heard Gondwe’s broadcast.

The information about MC is being widely disseminated to help even more men to make the choice to have MC and add to what is already available for them to do, to reduce chances of getting HIV infection. Human rights do not come into it.

Secondly, despite all the arguments, fears and misgivings being put forward by those who would wish for the preservation of all men’s foreskins, there is as yet no known harm – scientific, aesthetic and social – that comes to men who lose their foreskin. The foreskin is one of those parts of the human anatomy for which there is no demonstrable function or practical use.

Those who are opposed to MC say that the foreskin provides protection of the head of the penis to maintain its high sensitivity as a sexual organ. There is no scientific evidence that this is the reason why men have foreskins. Recent evidence shows that there is no change in terms of sexual feelings or satisfaction when men are circumcised.

Just this past week, the BBC Website published results of a Ugandan study that shows that circumcision does not reduce sexual satisfaction. The study says that there should be no reservations about using male circumcision as a way to combat HIV.

The BBC quotes a recent article in the British Journal of Urology (BJU) written about a study which was carried out in Uganda by a team of researchers from the Johns Hopkins University in the United States, led by Professor Ronald Gray.

The report says; “Nearly 5,000 Ugandan men were recruited for the study. Half were circumcised, half had yet to undergo surgery. There was little difference between the two groups when they were asked to rate performance and satisfaction” (- in relation to the presence or absence of the foreskin).

The BBC report proceeds; “It is thought there is some reluctance (by some men) to be circumcised over fears that it may impact upon sexual experience”.

“Previous studies into circumcision and satisfaction have given a mixed picture. But the researchers from the John Hopkins University say the size of their study and demographic profile of their participants made it one of the most reliable to date”.

The researchers concluded, “Our study clearly shows that being circumcised did not have an adverse effect on the men who underwent the procedure when we compared them with the men who had not yet received surgery,” said Professor Ronald Gray.

One of respondents to Edem Djokotoe’s column was concerned that MC is not part of the culture of Central Province, where he comes from. He says MC is something they “do not understand and can not pretend to, so to start doing it because that is what people are advocating could cause some cultural earthquakes in our society”.

He wrote, “From this point of view, I think it is wrong for you and others like Dr Mannasseh Phiri to advocate for male circumcision and to make it an issue for public debate because it is a very private thing……”

I strongly disagree.

Of course circumcision is a very “private thing”. But then so is sexual intercourse through which the majority of the HIV transmissions and infections take place. The public health consequences of what is essentially a very intimate and private matter between two people are gargantuan. The people that could be affected from a private act between the two could be legion.

To begin to deal squarely with sexual transmission of HIV, we have had to bring sex into open and frank public discussion. We have made some progress. Sexual issues are more openly discussed now than ten years ago.

In the realm of HIV and AIDS prevention and control, circumcision therefore ceases to be a “private thing”. The aim of Kennedy Gondwe’s public circumcision was to bring MC out of the closet and make it a public public health issue. It aims to debunk myths, fears and misconceptions that surround MC to make it easier for men to make the courageous decision to get circumcised outside of their culture, tribe or upbringing. After all HIV does not know cultural, tribal or other boundaries.

The very role of advocacy – through Kennedy Gondwe’s now world famous circumcision, through writings like this, through lectures, talks and through the literature – is to help increase understanding of MC in its new incarnation as one the most effective means we have available to mankind to reduce HIV infections. It is ignorance and lack of understanding (or refusal to understand presented information and fact) that causes ‘social earthquakes’ like the HIV and AIDS pandemics.

The evidence that circumcising as many sexually active men as possible in Zambia and other non-circumcising countries, will yield significant reductions in HIV infections is compelling. Compelling enough for WHO and UNAIDS to recommend for countries to make safe MC available to as many men as possible.

Brave young man Kennedy Gondwe led the way publicly. Now let us follow him, privately or publicly.
reflectingaids@yahoo.com

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  1. Comment by David, 16/03/08, 04:24:

    I suppose circumcision is just fine if chosen by the man after a thorough understanding of the costs to himself and his partners. And the costs are frankly under-appreciated by the promoters of circumcision who are all American men circumcised at birth. After all, intercourse isn’t the only sexual act people find pleasure in. Are you saying that a longer lay is worth giving up all the foreplay a foreskin promises for both partners? I doubt that a great deal.

  2. Comment by Joe, 17/03/08, 01:27:

    There is more wrong with the posted article than right. It’s hard to know where to begin.
    The Dr’s assertion that: “Recent evidence shows that there is no change in terms of sexual feelings or satisfaction when men are circumcised.” or that in general there is no evidence of deleterious effects shows that he did not perform a very thorough literature search. In just the last year there were at least two publications that refute this notion:
    “Analysis of the results showed that there were no significant differences in sexual drive, erection, ejaculation and ejaculatory latency time between circumcised and uncircumcised men. Masturbatory pleasure decreased after circumcision in 48% of the respondents, while 8% reported increased pleasure. Masturbatory difficulty increased after circumcision in 63% of the respondents but it was easier in 37%. About 6% answered that their sex lives improved, while 20% reported a worse sex life after circumcision.”
    [http://www.medicalnewstoday.com/articles/69318.php]

    “Circumcision ablates the most sensitive parts of the penis.”

    [http://www.nocirc.org/touch-test/bju_6685.pdf]

    Further, the study the Dr. cites could more appropriately be interpreted as follows: “So what they’re really saying is 20x more circumcised men reported dissatisfaction and more than 2x as many reported problems with respect to penetration.”
    [http://www.circumcisionandhiv.com/2008/01/the-numbers-on.html]

    The notion that the foreskin has no function is absurd on its face. That would imply that nature evolved a essentially unnecessary component to its most necessary tool. There are at least a dozen functions: http://www.circumstitions.com/Functions.html and http://www.cirp.org/library/sex_function/

    Finally, the Dr’s statement that human rights don’t apply is simply chilling. Human rights are at the core of this issue. Routine infant circumcision is entirely unethical and no rational thinker can defend it. Perhaps predicting the possible up selling of circumcision as a prophylactic for HIV, The Royal Australasian College of Physicians (RACP) included the following statement in Section 5.2 of their 2005 statement: “However, how much circumcision could contribute to ameliorate the current epidemic of HIV is uncertain. Whatever the future direction of this debate it can not be seen as an argument in favour of universal neonatal circumcision in countries with a low prevalence of HIV.”

    However, as Dave said, if an adult (male or female) wishes to modify their genitals, for whatever purpose they can imagine, they are free to do so. The biggest problem when considering adult circumcision as an HIV prophylactic is that, as Alexander Sanger said in his recent article: The No-Brainer Syndrome, “It is difficult to imagine an effective public health campaign that urged circumcision and continued condom use – why should a man go through circumcision if he still has to wear a condom’s?”

    [http://www.rhrealitycheck.org/comment/reply/6678]

    Mr. Sanger’s statement not only smacks of common sense but also parallels a subsequent publication of the Australian Federation of AIDS Organizations (AFAO) at the 2007 International AIDS Society Conference which discusses the ethics of utilizing circumcision as an HIV prophylactic and conclude in part:
    “How a man factors the known risk reduction alongside the unknown variables into his sexual decision-making is the important thing. Unless he opts to use condoms with all sexual partners whose HIV status is positive or unknown, he remains at risk of acquiring HIV (and if he does this, there is no need to be circumcised for added protection.)”

    [http://www.circumcisionandhiv.com/files/07_05_24_rapport_circoncisions_eng.pdf]

    That’s good advice. The path they are going down in Africa amounts to a violation of human rights and a slow motion train wreck. There are already stories leaking out about people overestimating the protective effects. In a recent article by David Gusongoirye, Nothing can fight HIV/AIDS better than discipline, speaking of the new campaign a man was quoted as saying: “Mister, these Aids people have spoken for long about fighting the disease, but they had never come up with a practical solution as good as this one. Don’t have sex, don’t do this, don’t do that. Eh, man, how can a young man such as I forfeit sex, eh? And the condoms – where is the sense in putting on a condom when you are having sex? Sex is about feeling, and so no young person likes them!”
    [http://www.newtimes.co.rw/index.php?issue=13438&article=4113]

    I am sure this situation will get progressively worse. The question is then, when will the bureaucrats acknowledge it.

  3. Comment by cosmopolite, 19/07/10, 12:30:

    I broadly agree with Joe above.

    “The evidence that circumcising as many sexually active men as possible in Zambia and other non-circumcising countries, will yield significant reductions in HIV infections is compelling.”

    It is NOT compelling. The African RCTs of circ were improperly designed and improperly carried out. I question how the data were analysed. The African RCT would not pass muster with an American human ethics committee. I am confident that the truth will out one day.

    Even all if this were not the case, data gathered from societies where access to soap, running water, and condoms are problematic, and where bizarre notions about sex and pleasure have taken root, have no relevance to present day USA and Canada.

    “The evidence is compelling enough for WHO and UNAIDS to recommend for countries to make safe MC available to as many men as possible.”

    That WHO and UNAIDS deems the evidence compelling has greatly reduced the credibility of those organisations in my eyes.

    The first priority should be free condoms everywhere in Africa, and the education of sex workers. Once that is out of the way, voluntary circumcision under sterile conditions should be an option for men past their 18th birthday.

    But never lose sight of the fact that the vulgar reductionist understanding of circumcision in Africa is that it obviates any need for condoms. This is not only profoundly false, but could also negate any possible benefit from MC.

    “…from the satisfaction point of view it seems to me that circumcision is good for both women and men.”

    Pisani is deplorably mistaken in a way that is all too common among USA medical researchers who lack sexual sophistication and experience, and who are circumcised men or the spouses of such.

    MC removes the most sensitive parts of the entire male body, especially if the frenulum is removed, as is commonly the case in North America. It is simply implausible that MC has no adverse effect on male pleasure. It certainly makes masturbation and manual foreplay more difficult and less fun.

    Quite a few American, Canadian, and Australian women with varied sex lives before their marriages have posted that intact men are as much or more fun than circed men. Quite a few of these women have shared that their discovery of the intact penis was a defining moment in their sexual history.

    American medicine and sex research has emphatically NOT been honest about the possible adverse complications of routine circumcision for penis functioning, and the sexual pleasure of both genders. And I am confident that when the truth eventually outs, it will be damning. So damning that most non-orthodox Jews will abandon brit milah. For starters, the Australian national medical society uses the rule of thumb that 1% of routinely circumcised infants grow up to have sexually damaged penises. This is simply unacceptable, as sexual pleasure is a human birthright, and is a major reason why routine circ is not recommended in Australia.

    Condoms obstruct HIV. If we take the RCT at face value, circ merely improves the odds in the short run. Given enough irresponsible sex, cut men will eventually contract HIV. It is likely that circ, by reducing sensation, especially as the years go by, increases resistance to condom use, and that in the long run, MC is a useless AIDs prevention tactic.

  4. Comment by Dave, 09/01/11, 08:02:

    Circumcision does not prevent HIV and condoms and having safer sex to a better job of preventing HIV transmission than any sort of pointless genital mutilation does.

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