Now, researchers in neighbouring Australia are suggesting that slathering penises in oestrogen cream might do just as well. The study, published in the (wonderful, open access) Public Library of Science, showed that creaming the underside of the foreskin gold-plates (well, keratinises) the sensitive Langerhans cells, that can act as a conduit for HIV into the body. They suggest this might have the same effect as lopping off the foreskin, but would be cheaper and less likely to enrage the Whole Organ lobby.
They only tried it on two men, it’s true, and they haven’t actually shown that it has any effect on the acquisition of HIV. But they did measure a “highly significant increase in the number of desquamated, keratinised epithelian cells”.

Any volunteers, lads?

According to a report in The Nation Kenya’s Ministry of Health has published a new policy on male circumcision (the policy hasn’t made it on to the MoH website yet.) The country aims to provide circumcision for any man who wants it. It’s not a radical decision in terms of public health. Although the anti-circumcision ring-masters continue to rail against the data, most public health professionals are convinced by studies suggesting that a man without a foreskin is 60% less likely to contract HIV than a man with a foreskin. Uganda and Rwanda have already decided to try and circumcise as many men as are willing. The controversy comes, rather, from people who are worried about two things: behaviour and culture.

The behavioural worry is this: if men think they can’t get infected if they are circumcised, they won’t bother with condoms. Possibly. But the reason a third of adults are infected with HIV in some parts of Kenya is that men aren’t bothering with condoms in any case. If you can reduce the likelihood that those men will contract the disease, how is that a bad thing?

The cultural worry comes from the “in some parts of Kenya” thing. HIV is much higher among some of Kenya’s tribes than among others. It is notably higher among the non-circumcising Luo, for example (22%), than among the circumcising Kikuyu (5%). Nationwide, HIV among non-circumcised men is 13%, compared with 3% among men who have had the snip. Current president Mwai Kibaki is Kikuyu. Raila Odinga, who believes he should be president following December’s disputed election, is Luo. There’s an uneasy truce between the two at the moment, but just a couple of months ago being a member of one group or the other was enough to get you burned out of your house or slaughtered. In these circumstances, markers of tribal identity such as a foreskin take on a significance that goes way beyond a concentration of HIV-susceptible cells. Circumcising everyone would remove that badge of identity. In my mind, that another reason for circumcision, not against it.

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

For more information:
• Zambia

Archives

Condoms, when they get used in the real world (with bursts, slips and whatnot) reduce the risk of acquiring heterosexual HIV by upwards of 90%. But of course lots of people don’t use them, and lots more only use them some of the time. For an individual, using condoms 73% of the time still offers more protection than circumcision (and obviously the benefit is greater still if people use them with those partners most likely to be infected with HIV). But most people are realistic about their own behaviour. Yes, I’ll try and use condoms, but it’s quite nice to know that when I drift into second bottle territory and perhaps slip up, my chances of getting HIV will only be a third of what they were before I got snipped.

Public health types worry about the “when I perhaps slip up” part of it. They fear that if people start to regard circumcision as a “natural condom”, the latex will go out the window. Where rates of condom use are currently high, the widespread promotion of circumcision could undermine condom use and potentially lead to more risk of infection rather than less. There’s also some concern about how well circumcision protects in anal sex. It’s hard to disentangle, because so many gay men like to be tops and bottoms in anal sex. But a new study among gay men in the US, by Greg Millet of CDC (reported by Reuters) suggests that circumcision does not protect even those men who always take the insertive role.

My own suspicion is that the trauma (by which I mean tears and microlesions) associated with anal sex is greater than the protection associated with lopping off the foreskin, and with it the Langerhans’ cells that are particularly susceptible to HIV infection. Conclusion: If you’ve got a penis and you like to sleep around, by all means get the snip. But use your latex too, (even in second bottle territory).