Monday, May 21, 2007

The Unkindest Cut

In the spirit of the holiday, the post today is decidedly non-political. Instead, for your viewing pleasure, I present this interesting picture.

This is an actual billboard in Mbabane, Swaziland. I don't know who the three guys are, but they are clearly pleased about being circumcised. The photograph was snapped by my good friend Stephen Mostad on a recent trip to the region. Stephen is a journalist and communications consultant who has been doing contract work for the United Nations. In this capacity he has been fortunate to travel to some pretty exotic places, including Angola, Iran, Gambia and the aforementioned Swaziland. Oh, and he's also been to Vancouver.

If you're interested in seeing some truly amazing pictures of his adventures, surf on over to his website.

Finally, as a physician, I would be remiss not to give at least passing mention to the practice of male circumcision. Although it's not within my area of specialty, the procedure itself remains somewhat controversial. There is data to suggest that neonatal circumcision reduces the risk of transmission of ulcerative STD's such as herpes anywhere from 2 - 7 fold. Additionally, there may be a reduced rate of HIV transmissability amongst circumcised males, but the quality and methods of these studies have been questioned. Circumcision may also reduce the rate of urinary tract infections during the first year of life. Having said all of that, there is evidence that many of the potential risks may be mitigated by good hygeine, and that transmission of STD's has substantially more to do with sexual habits than with circumcision. As a result, there is little in the way of compelling evidence either way. The Canadian Pediatric Society echoes this in its position statement: "The overall evidence of the benefits and harms of circumcision is so evenly balanced that it does not support recommending circumcision as a routine procedure for newborns". If you are an expectant mother (or just a curious guy) and have further questions, you should consult your local family physician or pediatrician.


knb said...

I'm sure I read an article that suggested that circumcision did play a role in reducing HIV. It was specific to Africa.

I have no doubt that it is an unkind cut, but nothing like the female circumcision that goes on.

Sorry red canuck, I'm not being adversarial. I just always look to find something that will help what is going on. If this is having a small impact, good. Does more study have to happen, of course. But the damn condom discussion has been shut down too many times and I want this to be explored.

You comment on good hygiene. Perhaps that could be a campaign too, but if you don't have water...

You know I love ya though.

Red Canuck said...

an article that suggested that circumcision did play a role in reducing HIV

Yes, there have been a few population studies which have suggested this. Unfortunately because of study design issues (i.e. correlational studies), the results have been questioned by some. Also, there is data to suggest that HIV transmissability may actually be higher in recently circumcised men.

but nothing like the female circumcision that goes on

You're absolutely right. The apalling practice of female circumcision is another whole issue, which I didn't feel like tackling on Victoria Day. :)

You know I love ya though

Right back at ya!

Anonymous said...

You sound like a Doctor in the '60's who questioned the methodology of studies conducted that demonstrated a link between smoking and cancer.

Deny, deny, deny to support your own bias and prejudice.

More than one study shows some benefit in the fight against AIDS by promoting circumsision.

Let it be Red Canuck.

Let's save some lives!

Red Canuck said...

Deny, deny, deny to support your own bias and prejudice

Deny what? Examining the design of a study is a necessary part of analysing the validity of the results. Personally, I am in favour of doing anything that helps to reduce the burden of HIV/AIDS, especially in Africa. All I'm saying is that we need to be clear about the actual risks and benefits of any medical procedure, and this requires rigorous data collection.
If you bothered to read my post, you would see that I presented a plethora of putative benefits of circumcision, so I'm not sure where you get your ridiculous assumptions about my "bias and prejudice" (which in any case are completely incorrect).

knb said...

anon, had you read the post, you would see that it's not red canuck that is supporting a prejudice.

You seem to be though.

I don't understand why this is so difficult. Why, within reason, can't we just look at all sensible alternatives, options.

I agree that studies should be done, gawd knows we have ton's of legal drugs here that are proving to be bad.

I see nothing in red canuck's post that suggests he is in denial.

I do think it's an important discussion to have though.

Red Canuck said...

knb - I've been doing some more reading on this subject, and I feel I need to correct something I implied earlier. While there have been several correlational studies on the subject, randomized controlled trial data exists to corroborate the efficacy of circumcision in lowering the transmission of HIV.
Here is the UN AIDS circumcision fact sheet, which summarizes other randomized controlled trials, and provides the UN position, which is oddly noncommittal, given the preponderance of data.

Red Tory said...

It sounds like things have gotten a lot more complicated than since when we had to make this decision regarding our son. At that time we were told it made no difference one way or the other. Basically, that it was personal preference or a cultural thing, if applicable. Accordingly, we decided not to have it done.

Dumb question… why is the picture so dark?

Anonymous said...

The only other thing I can add, Red Canuck: foreskinless is freedom.

That's why I always recommend one circumnavigates circumcised - it's the only way to travel.

Anonymous said...

Doctors is the '60's also pointed out that studies linking smoking to cancer were "inconclusive".

knb said...

Thanks for the heads up re' your update.

I suppose the best we can hope for are more studies that bring this issue to a conclusion, one way or another.

It certainly makes you think about the magnitude of the disease and just how many areas of research must be explored to get answers.

Paul Rapopso said...

The difference in those studies between infected and not infected is literally about a dozen men, out of hundreds and thousands.

In one study, 24 intact males became HIV+, while 11 cut males became HIV+. The idea of issuing cosmetic surgery as a cure-all-fix for HIV based on a baker's dozen difference is absurd.

What about the uncircumcised males who are not infected? What of all the circumscribed males who are infected? HIV transmission, as RT correctly points out, is about activity and hygiene, not foreskins.

Lastly, Sub Saharan Africa is notoriously anti-gay, and none of those studies accounted for male to male transmission. All the researchers assumed all the males are strictly heterosexual.

This is going to be a disaster. In the sixties researchers looking for a cheap polio vaccine used infected ape kidneys to make their serum and essentially caused the HIV crisis in Africa. Now, researchers are looking to use a band-aid solution to cure HIV.

Circumcision has always a cure looking for a disease.

Red Canuck said...

RT - Yes, the issue has become a bit more complicated. But circumcision for HIV prevention is a whole different ballgame than routine neonatal circumcision in the West. The latter remains essentially a personal/cultural choice, as the CPS statement reflects.
Re: the dark picture. I just posted it as is. I guess I could have played around with it in Photoshop or Picasa, but laziness was the order of the day. :)

Red Canuck said...

Paul Rapopso - Thank you for your illuminating comment. My own sense was that mass education and widespread condom use (as well as affordable treatment for the affected) would go much farther in helping to reduce the burden of HIV in Africa than circumcision alone. But as I said, I'm no expert in this area. If future studies confirm a real and meaningful benefit to circumcision, then it may need to considered as part of a multi-pronged approach to the problem.

Beanie's Appa said...

It shouldn't be this complicated. If you cut a body part off, then you'll avoid diseases on that body part. Duh! My question is why cut it off, when the diseases are all treatable or avoidable?

Do we remove toenails to avoid fungus and ingrown nails? do we remove all appendices, tonsils, gallbladders from newborns because they could cause trouble later?

What I'm mad about most, is that nobody asked me whether or not I wanted half my penile skin and nerves cut off as a baby. I'd rather grow up with my whole body, so I can make the choice to wear condoms and take antibiotics when I get infected, instead of cutting off half of my penile skin and nerves. The foreskin has value: sexual pleasure, and protecting the head from the environment.

Our son is intact, and has had no health or hygeine problems with it.

TLC Tugger said...

The Kenya and Uganda human amputation trials are in no sense conclusive. The subjects self-selected for the procedure, the trials were cut shorter than the agreed protocol (magnifying the effect of HIV not being detectable often until months after infection), and researcher bias is evident in the prior writings of Halperin and Bailey.

The mere fact that most of the half-million US men who have died of AIDS were circumcised at birth is slam-dunk proof that circumcision does not prevent AIDS. Even in the Africa studies, the cut Africans CONTRACTED HIV at rate SIX TIMES HIGHER than the rate of new infection for African-American men.

It costs the UN just 3 cents to give away a condom. Why are we trying to convince men to amputate the best part of their penis?

WiseWoman said...
This comment has been removed by the author.
WiseWoman said...

There is a much stronger message against circumcision on the B.C. College of Phys & Surgeons website.
Why? Because a healthy, 6 wk old baby boy died in 2002 after being circumcised in a Penticton, BC hospital. Ryleigh McWillis, may he rest in peace. Now that there are whistle blowers in the hospitals reporting these abuses, the doctors of BC have finally taken responsibility to speak out against this barbaric practise.

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