Soaring incidence of AIDS among circumcised populations …

… shows that foreskin not the problem and circumcision not the answer

Reports from the United States and several African countries show that, despite the WHO push for circumcision as the key strategy against AIDS in underdeveloped countries, HIV infection rates are increasing rapidly among circumcised populations. The most recent evidence to undermine the hypothesis that circumcision is the most effective preventive intervention against AIDS is a report in the New England Journal of Medicine, which reveals an HIV epidemic in the (largely circumcised) USA that rivals the problem in (largely circumcised) regions of Africa.

The NEJM reports that more than 1 in 30 adults in Washington, D.C., are HIV-positive — a prevalence higher than that found in Ethiopia, Nigeria, or Rwanda. Among men who have sex with men, the study reveals that in some parts of the USA as many as 30 per cent of active men are infected. With the overwhelming majority of adult males in the USA circumcised in infancy, these figures cast serious doubt the case that circumcision is a useful strategy against AIDS.

In other news, we find that 6 out of 10 new HIV cases in British Africans are among Muslims (almost all circumcised), and that in Uganda “confused” young Muslim men are having to be reminded that circumcision is not an adequate protection against sexual diseases. In Kenya, where mass circumcision of young men has been funded by the WHO and touted as the solution to the AIDS problem, it has been revealed that in two areas of almost universal male circumcision, HIV infections are rising rapidly – reaching 8.3 percent in Kenya’s coastal province. On top of that, women are complaining that circumcision is giving promiscuous men a false sense of security, and discouraging condom use.

The authors of the NEJM report suggest that ideology is hampering America’s approach to HIV prevention and point out that “Preventive interventions must be rooted in science, not driven by ideological concerns.” They mention homophobia as one of these ideologies, but we would suggest that posthephobia (irrational hatred of the foreskin) should also be listed among the ideological obsessions that hamper the fight against AIDS.

Most recently, a study of 4,889 men published in the journal AIDS has shown that circumcised gay men are not less likely to become infected with HIV. Headlined in the press as “Circumcision may not cut HIV spread among gay men”, the study in fact showed that HIV infection was higher among circumcised men than among the uncut After controlling for sexual behaviours and demographic factors the report concluded there was no difference between the two groups.

On this page

1. Rising incidence of HIV-AIDS in the United States

2. 60 per cent of new AIDS cases among British Africans affect Muslims

3. Kenya: Rapid rise in AIDS cases in areas of universal circumcision

4. Uganda: Muslim youth reminded that circumcision does not stop AIDS

5. Circumcised gay men at greater risk of AIDS

6. British researchers attack foreskin fetishism

7. Malawi bucks the WHO witchdoctors

8.  Malaysia: AIDS more prevalent among (circumcised) Muslims

9.  Swaziland: AIDS more common among circumcised men

10. Kenya: Circumcised men just as likely to be HIV-positive

11. Uganda: Circumcision campaign increases HIV infections

12.  Zambia: Another study fails to find that foreskins increase risk of HIV

13. Zimbabwe: Despite circumcision propaganda, circumcised men still get AIDS

1. HIV and circumcision in United States

Social disadvantage and sexual networks to blame for AIDS spread, not foreskins

Despite Americans’ faith in circumcision as the most reliable form of health insurance known to man, and the high incidence of circumcision among American males, the prevalence of AIDS in some part of the United States now exceeds the infection rate in several hard-hit African countries. An article in the New England Journal of Medicine reports (18 March 2010) that the incidence of HIV infection in New York is 1 in 40 among Blacks, 1 in 10 among men who have sex with men, and 1 in 8 among injection drug users. In Washington DC the prevalence is 1 in 30 adults. In some urban areas the HIV prevalence among men who have sex with men is as high as 30 per cent – many times higher than the over all incidence of 7.8 per cent in Kenya and 16.9 per cent in South Africa.

The authors of the report attribute the high incidence of AIDS to promiscuity within specific communities, associated with interlocking sexual networks; social disadvantage, meaning poor education, less access to safe sex information, and greater probability of spending time in prison (where unsafe sex is the rule); and various health or moral ideologies that generate inappropriate control strategies.

The following extracts from the article make clear that the authors do not consider that “lack of circumcision” (i.e. normal male anatomy) is part of the problem, and hence do not believe that yet more circumcision is part of the solution.

1. Promiscuity and sexual networks

“Unlike the generalized HIV epidemics in sub-Saharan Africa, the U.S. epidemic primarily affects certain discrete geographic areas — especially urban areas of the Northeast and West Coast and cities and small towns in the South (see U.S. map). Within these areas, specific neighborhoods are often disproportionately affected (see New York City map), in part because of residents’ engagement in unprotected sex within relatively insular social– sexual networks. Many of the populations most affected tend to have limited social mobility; thus, partner selection tends to concentrate transmission patterns and amplify spread within defined geographic areas. …

“The extent of the risk of acquiring HIV in the United States today is largely defined by a person’s sexual network rather than his or her individual behaviors. Understanding the context and settings in which risk is increased may lead to more robust and effective preventive interventions. For example, black men who have sex with men are at increased risk for HIV infection in part because of its high prevalence in their sexual networks and their likelihood of choosing racially similar partners; they have also been shown to be less likely than their white counterparts to be aware of their HIV status and thus are more likely to unknowingly transmit HIV.”

2. Social disadvantage

“Most glaringly, HIV disproportionately affects poor black Americans who have substandard education, unstable housing, and limited social mobility. This confluence of factors may result in high rates of incarceration, which threaten a community’s social fabric. Such vulnerable populations must be engaged in research, program development, and interventions that are culturally relevant and address the socioeconomic milieu in which HIV transmission occurs. …

The situation is similar for black and Hispanic women, whose increased risk of HIV acquisition is attributable in greater part to their vulnerable social and economic situations and their sexual networks than to their own risky behaviors. Socioeconomic disadvantage and instability of partnerships due to high rates of incarceration among men in their communities may lead women to engage in concurrent relationships or serial monogamy. In addition, they may be unaware of their partners’ HIV status or may be involved in abusive or economically dependent relationships and thus be unable to negotiate safer sex with their partners.”

Prison = unsafe sex

As the authors of the report acknowledge, the large number of Blacks and Hispanics in American prisons is a significant factor in the high and increasing incidence of AIDS among the Black and Hispanic population. A recent article in the New York Review of Books on the problem of rape and other sexual abuse in American gaols and juvenile detention centres points out that sexual contact, both forced and otherwise, is rife in such institutions, and that authorities, in their anxiety not to “condone” such practices, refuse to make condoms available. They thus ensure that most of the sexual contact that occurs is of the unsafe variety. The authors of the review quote the Report of the National Prison Rape Elimination Commission as suggesting that the increasing incidence of HIV among American Blacks is the result of rape and other unsafe sex in prisons:

“In 2005–2006, 21,980 State and Federal prisoners were HIV positive or living with AIDS. Researchers believe the prevalence of hepatitis C in correctional facilities is dramatically higher, based on [the] number of prisoners with a history of injecting illegal drugs prior to incarceration. … The incidence of HIV in certain populations outside correctional systems is likely attributable in part to [sexual] activity within correctional systems. Because of the disproportionate representation of minority men and women in correctional settings it is likely that the spread of these diseases in confinement will have an even greater impact on minority men, women, and children and their communities.” (National Prison Rape Elimination Commission Report, pp. 129–130).

The commissioners seem to be saying here, as delicately as they can, that they suspect prisoner rape has contributed to the way HIV infection in this country has shifted demographically: i.e., to the way in which AIDS has changed from being a predominantly gay disease to a predominantly black one.

David Kaiser and Lovisa Stannow, The rape of American prisoners, New York Review of Books, 11 March 2010.

3. Ideology

"Preventive interventions must be rooted in science, not driven by ideological concerns. Homophobia may have impeded the development of sexually appropriate prevention studies among men who have sex with men. Reluctance to fund studies of needle exchange or conditional cash transfer (providing financial incentives for healthy behavior) or to support work in high-risk venues, such as bathhouses, has hampered progress."

The authors of the article discuss homophobia (hostility to men who have sex with men) and moralistic objections to people who take injecting drugs as obstacles to the development of effective strategies to control the spread of AIDS. They might also have mentioned the moralistic objections to sex education that have hindered instruction in safe sex and distribution of condoms, and the diversion of funds to laughably ineffective “abstinence education"; and the posthephobia (irrational hatred of the foreskin) that has caused medical bureaucrats to focus on lack of circumcision as the most important factor in susceptibility to HIV infection, and thus on yet more circumcision as the most promising intervention.

But as officials in Africa have finally admitted (see below), circumcision is not sufficient to give immunity to AIDS. Only consistent use of condoms and practice of other forms of safe sex and the avoidance of promiscuity can guarantee that a person will remain uninfected; and if he is doing all that, there is no need for circumcision at all. He might as well hang on to his foreskin and exploit its vast potential for safe sex.

Source: Wafaa M. El-Sadr, Kenneth H. Meyer and Sally L. Hodder, AIDS in America: Forgotten but not gone, New England Journal of Medicine, Vol. 362, 18 March 2010, 967-970

2. Britain: 60 per cent of new AIDS cases among Africans are among African Muslims

Meanwhile in Britain, the British Broadcasting Corporation reports that six out of ten new AIDS cases among British African men are among Muslims. Since the vast majority of these men were circumcised as infants or children in accordance with Islamic custom, it is evident that circumcision has done nothing to protect them from the disease.

The BBC reports: According to Dr Shima Tariq, who has studied the transmission of HIV, more than half of newly diagnosed patients caught HIV through heterosexual sex, and two-thirds of them are of black African origin or descent. But most of this group are not Christian: six out of 10 are Muslim.  Ibrahim, a Muslim who came to Britain from the Ivory Coast, is HIV positive. “It’s quite difficult for me because the thing is I can’t tell anybody. Because my family...nobody knows. None of my friends know. Nobody. Because if I tell them they will leave me alone and I will have to live alone and it will be a hard life for me.”

Along with a conservative African culture, religion has played a significant role in creating this taboo. Ismael is 40 and originally from Sudan. “The imams don’t talk too much about it, but they start off by saying ‘this is a taboo, this is a sin, a punishment from Allah’. When you disclose it, straight away they think you are gay, or maybe you got it from a prostitute or you did something bad and Allah is punishing you. That is why it has to be kept secret.”

The African HIV Policy Network has asked imams to break the taboo by talking openly about HIV. One of them, Mohamed Bashir of the North Brixton mosque in London, says imams need to acknowledge “that not everyone practises their religion to the letter”. There are Muslims who go to the mosque, who pray. They do everything similarly nicely and they suffer moments of lapse in judgement. They have extra-marital relations that they will not speak about, and engage in risky behaviour. Some imams might not want to admit that.”

Mohamed Bashir has agreed to train other imams on how to tackle the taboo. He accepts that in the face of HIV, condoms may be the lesser of two evils, but says communicating that to a congregation is a sensitive issue. “It won’t be considered responsible for an imam to say ‘when you’re making a mistake make sure you use a condom’, because that could be misunderstood as condoning that particular activity. In our awareness programme, literature is presented to members of the Muslim community. They can go to GM clinics, they can anonymously stock up on condoms. But to actively share them out, that wouldn’t be proper for an Islamic centre or an imam probably to do that.”

BBC World News, 1 December 2009

3. Kenya: Rapid rise in AIDS cases in areas of universal circumcision

And in Kenya, where circumcision is already practised on most boys as a matter of tribal custom or adherence to Islam, and uncircumcised men have been assaulted in the streets and forcibly circumcised by angry mobs, the incidence of AIDS is rising rapidly in regions where circumcision is near universal.

All Africa News reports

Nairobi: As thousands of young men in Nyanza Province troop to health centres to be circumcised in hopes of fending off HIV, new studies show it might be too early to claim victory. Although circumcision has been touted as one of the ways to prevent HIV infection, recent findings show an increase in HIV infection in regions where most males are circumcised. According to findings of the Kenya Aids Indicator Survey (Kais) released last week, North Eastern and Coast provinces, where 97 per cent of males are circumcised, registered an increase in HIV prevalence.

Within a span of five years, HIV prevalence in North Eastern and Coast provinces increased from 0 to 1.0 per cent and from 5.8 per cent to 8.3 per cent respectively. In the same period, HIV prevalence in Nyanza Province, where about 48 per cent of males are circumcised, stood at 15 per cent, the highest in the country.

These are sobering statistics for young men who have rushed to get circumcised in he belief that doing so would provide complete protection from HIV infection. The new findings of growing HIV prevalence among circumcised males indicates the practice cannot completely protect an individual from HIV infection unless it is combined with other practices including using condoms, being faithful to one partner, or abstaining from sex.

[In fact, using condoms, being faithful to one’s partner or consistently practising safe sex would provide near total protection from AIDS without the need for circumcision and all the risks, cost and loss that this surgery entails. The versatility, sensitivity and mobility of the foreskin provide greatly enlarged scope for safe sex practices.]

Health officials acknowledge that getting people to look at circumcision in the larger context of other factors and strategies can be challenging. “The figures from these two provinces are sending a warning that circumcision alone is not the magic bullet to controlling the disease. Other methods have to be used in combination,” said Dr Ibrahim Mohammed, Head of National Aids and STD Control Programmes in the Ministry of Medical Services.

The increase in prevalence in communities that circumcise indicates there are other factors that contribute to the spread of the disease among males in addition to being uncircumcised. Multiple sexual partners, low condom use and alcohol and drug abuse are some of the factors. “Unless we address all the reasons predisposing people to HIV infection, we might not make much headway,” said Judy Adero, who has lived with the virus for nine years. But scientists still believe circumcision will result in the lowering of HIV prevalence in provinces such as Nyanza.

[No real scientist would continue to believe something if the evidence against it started to pile up, or if a hypothesis was not consistently confirmed by subsequent experience. Belief in the superior effectiveness of circumcision against AIDS is actually concentrated more among public health and medical bureaucrats who are under pressure to produce quick fixes. Their continuing faith in circumcision is a typical prejudice, driven more by religious belief, tribal custom and American cultural commitment to circumcision than by genuine scientific open-mindedness.]

Women complain that circumcised men believe they are immune to AIDS and do not need to use condoms

Following the World Health Organisation’s policy decision to pour billions of medical aid money into circumcision, clinics offering free operations have been opened in many African countries. Vigorous propaganda campaigns urge uncircumcised men to get themselves done at these centres.

In Kenya, more than 30,000 men have been circumcised since the call first went out; the target of 100,000 circumcised men is expected to be reached by year’s end. Female activists, however, have criticised the way the whole operation is being carried out, arguing that it is making women more vulnerable as men engage in more frequent sex with multiple partners in the belief that their recent circumcision has made them immune to infection with HIV.

Circumcision not enough to stop AIDS, experts warn, All Africa News, 26 September 2009

4. Uganda: Muslim youth reminded that circumcision does not stop AIDS

In Uganda, to, circumcised Muslim men are having to be reminded that circumcision does not give them immunity to HIV infection. As East Africa News and Entertainment reports:

The Muslim Youth League has launched a campaign to fight against the spread of HIV among Muslims in the country. The Chairperson of the Youth League, Abdalla Karim Musitwa says the campaign will mainly target preventing HIV infection amongst the Muslim youths. Musitwa says recent researches showing circumcision helps to protect men from HIV infection has confused some Muslims to go on rampage having multiple sexual relationships without any protection hoping that they are safe because of being circumcised.

He says the campaign will among others convince Muslims that circumcision is not a guaranteed protection against HIV infection. Musitwa says the Muslim Youth League will be promoting abstinence and being faithful as the major means of protection against HIV infection. He says without a HIV cure in place, prevention of infections remains the key intervention against the spread of HIV/AIDS.

Uganda Health News: Muslim youth launch campaign against HIV/AIDS

Ugpulse: East Africa News and Entertainment, 7 June 2009

5. Circumcised gay men at greater risk of AIDS

A study of 4,889 men published in the journal AIDS has shown that circumcised gay men are not less likely to become infected with HIV. Headlined in the press as “Circumcision may not cut HIV spread among gay men”, the study in fact showed that HIV infection was higher among circumcised men than among the uncut After controlling for sexual behaviours and demographic factors the report concluded there was no difference between the two groups.

See abstract of article below.

This result is similar to a British study of 12,433 gay men published in 2001 by Sigma Research, which indicated a significantly higher risk of HIV among circumcised men. After controlling for factors likely to influence circumcision status – such as age and living in London – the authors found no association between circumcision status and HIV.

David Reid, Peter Weatherburn, Ford Hickson, Michael Stephens, Know the score: Findings from the National Gay Men’s Sex Survey 2001 (Sigma Research: University of Portsmouth, 2002)  Full text available here.

Later report here:  Hickson F, Weatherburn P, Reid D, et al, Consuming passions: Findings from the United Kingdom Gay Men’s Sex Survey 2005. London: Sigma Research, 2007. PDF available from Sigma research

See below for letter from Sigma researchers to Sexually Transmitted Infections criticising the current foreskin obsession.

Circumcised men may be at greater risk of AIDS

Gust, Deborah A; Wiegand, Ryan E; Kretsinger, Katrina; Sansom, Stephanie; Kilmarx, Peter H; Bartholow, Brad N; Chen, Robert T

Circumcision status and HIV infection among MSM: Reanalysis of a Phase III HIV vaccine clinical trial

AIDS (Official Journal of the International AIDS Society), On-line publication, 17 February 2010


OBJECTIVE: Determine whether male circumcision would be effective in reducing HIV transmission among men who have sex with men (MSM).

DESIGN: Retrospective analysis of the VAXGen VAX004 HIV vaccine clinical trial data.

METHODS: Survival analysis was used to associate time to HIV infection with multiple predictors. Unprotected insertive and receptive anal sex predictors were highly correlated, thus separate models were run.

RESULTS: Four thousand eight hundred and eighty-nine participants were included in this reanalysis; 86.1% were circumcised. Three hundred and forty-two (7.0%) men became infected during the study; 87.4% were circumcised. Controlling for demographic characteristics and risk behaviors, in the model that included unprotected insertive anal sex, being uncircumcised was not associated with incident HIV infection [adjusted hazards ratio (AHR) = 0.97, confidence interval (CI) = 0.56-1.68]. Furthermore, while having unprotected insertive (AHR = 2.25, CI = 1.72-2.93) or receptive (AHR = 3.45, CI = 2.58-4.61) anal sex with an HIV-positive partner were associated with HIV infection, the associations between HIV incidence and the interaction between being uncircumcised and reporting unprotected insertive (AHR = 1.78, CI = 0.90-3.53) or receptive (AHR = 1.26, CI = 0.62-2.57) anal sex with an HIV-positive partner were not statistically significant. Of the study visits when a participant reported unprotected insertive anal sex with an HIV-positive partner, HIV infection among circumcised men was reported in 3.16% of the visits (80/2532) and among uncircumcised men in 3.93% of the visits (14/356) [relative risk (RR) = 0.80, CI = 0.46-1.39].

CONCLUSIONS: Among men who reported unprotected insertive anal sex with HIV-positive partners, being uncircumcised did not confer a statistically significant increase in HIV infection risk. Additional studies with more incident HIV infections or that include a larger proportion of uncircumcised men may provide a more definitive result.

Real conclusion

The real conclusion is that circumcision probably makes no difference to the risk of contracting HIV during male/male sex, but may increase the risk. Being Americans, these researchers are determined to go on wasting public money until they have manufactured enough verbiage to get the foreskin convicted.

6. Sigma researchers attack obsession with foreskin

The authors of the Sigma Research study are critical of the current obsession with circumcision as the magic bullet against AIDS. In 2008 they pointed out he flaws in an editorial in the British journal Sexually Transmitted Infections that called for circumcision of men who have sex with men as a means of reducing their risk of infection with HIV. The editorial was just the sort of opinion piece – long on rhetoric and short on evidence – that newspapers love to headline, and blithely oblivious to the fact that most men who have sex with men find the presence of their foreskin an important component of their sexual experience. The Sigma researchers expressed concern at the medical researchers’ focus on the innocent foreskin at the expense of “much more promising interventions than circumcision”.

Their letter was not published in the print edition of the journal, but only in the on-line edition, accessible only to subscribers. It is reproduced in full here in order to make it more readily available.

The editorial to which Hickson et al replied was Abigail MacDonald, Joanna Humphreys, Harold W. Jaffe, Prevention of HIV transmission in the UK: What is the role of male circumcision?, Sexually Transmitted Infections, Vol. 84 (3), 2008, 158-160.

Dear editor, If MacDonald, Humphreys and Jaffe (2008, STI, 84) are correct in their contention that circumcising men who have sex with men will result in a reduction in HIV incidence among this population, then we would expect circumcised MSM in the UK have a lower incidence of HIV than uncircumcised MSM. This should be reflected in HIV prevalence and since there is no reason to think that circumcision promotes diagnoses of HIV, this difference should be reflected in the prevalence of diagnosed HIV.

In 2001 we carried out a short, community-based, self-completion survey among 12,433 White British men aged 16 and over, living in the UK, who had sex with another man in the last year and/or identify as gay or bisexual. Fieldwork was conducted over the summer at Gay Pride events (52.1% of respondents), on-line through commercial gay web sites (31.6%) and through community based HIV prevention organisations (16.3%). Self report is a valid measure of circumcision in MSM (Termpleton et al., 2008, STI, 84).

Overall, 0.5% (n=64) indicated they did not know whether they had been circumcised or not. Excluding these men, 18.6% (2438/13,127) of respondents said they had been circumcised.

Circumcised men were as a group, older than un-circumcised men (mean age 36.5 years, sd 12.0, median 35, range 16-82 compared with mean 32.3, sd 10.2, median 31, range 16-79). The proportion of men who were circumcised increased step-wise with increasing age (11.9% of teens, 14.7% among those in their 20s, 16.8% in the 30s, 21.7% in the 40s and 38.1% among those 50 and older). More of the circumcised men lived in London (24.8% compare with 19.6% of un-circumcised men ).

Overall, 4.6% of respondents indicated they were living with diagnosed HIV infection. Circumcised men were not more or less likely to be living with diagnosed HIV (5.2% compared with 4.5% in un-circumcised men: chi squared = 1.84, p=0.175). In a multiple logistic regression controlling for age and living in London, the odds ratio of a circumcised man living with diagnosed HIV to an un-circumcised man doing so was 1.01 (95% confidence interval 0.81-1.25).

This suggests that circumcising MSM will make no difference to HIV incidence in this population. Since HIV acquisition in the UK is highly concentrated in MSM (HPA, 2008) and since identification of future MSM pre -puberty is not feasible, this suggest circumcision has little part to play in the UK HIV epidemic. Those concerned with the UK epidemic should be looking elsewhere for solutions. We have no doubt that a multi-pronged approach to minimising HIV infections is required. We also have little doubt that maximising circumcision is not one of them among MSM in the UK. Minimising nitrite inhalant use during unsafe sex might, on the other hand, have a very real effect (McDonald et al. 2008, STI, 84). We support MacDonald, Humphreys and Jaffe's call for more experimental research about HIV among MSM in the UK but stress that these have yet to be done for much more promising interventions than circumcision.

Source:  Ford C.I. Hickson, David Reid, Peter Weatherburn, Michael Stephens, Circumcised MSM in the UK no less likely to be living with HIV, e-letter, Sexually Transmitted Infections, 5 August 2008.

Sexually Transmitted Infections can be searched here. Articles published pre-2006 are freely available; after that, a subscription is required.

7. Malawi bucks the WHO witchdoctors

Malawi is a small country in east central Africa, sandwiched between Mozambique, Zambia and Tanzania. The Secretary to the Office of the President, responsible for HIV/AIDS and Nutrition, Dr. Mary Shaba, has said Malawi cannot follow World Health Organisations recommendations to adopt widespread circumcision of men as a weapon to reduce the spread of HIV through heterosexual contact.

Although the WHO claims that circumcised males are 60 percent less likely to contract HIV through sexual intercourse, Shaba points out that Malawi is not a circumcised country and that those cutting off their children’s foreskin are doing it for religious and cultural reasons. “So it is mainly the Moslems and the Yaos who are doing circumcisions and some of the Lhomwe group,” she said in Capital Radio interview. “Malawi the way it is when you look at the statistics, you find that the majority would already be asking “Are we all becoming Moslems?” if you go that line.”

Shaba said Malawi has no policy and guidelines on circumcision. She said she has been asking for a report to study what condition circumcisions are done in countries doing it and what practices were followed after circumcision. “I have been asking for a report from all those people who have claimed that people are being protected, nobody has been able to give me the report. I want the report. I need to look at the methodology. I need to look at the cultural practices surrounding circumcision," said the free-speaking Shaba.

She pointed out that in Malawi HIV is most prevalent in areas where circumcision is practiced, and that many have died of AIDS in those particular districts.

“We are not a circumcised country as a nation. Circumcision is mainly practiced on a religious basis, and very few of the tribes practice circumcision. You can’t take what is done elsewhere and say we are going to do in Malawi.” She also pointed out that male circumcision will not be effective to fight HIV/AIDS because the new infection rate is highest among women.

Shaba also noted that circumcision can cause some problems for the penis.

Shaba says Malawi cannot follow Rwanda on circumcision to fight Aids, Nyasa Times, 26 January 2010

Officials annoyed by local reluctance, as private clinics try to take advantage of foreign health aid money

LILONGWE, 13 April 2010 (PlusNews): Circumcision is controversial in Malawi and the government has yet to implement a program. But a chain of private clinics run by Banja La Mtsogolo (BLM) – Future Family in the local Chichewa language – has rolled out the procedure at its network of 30 national clinics in 2009. It is the only organization offering circumcision as part of an HIV prevention package.

Following WHO directives, Malawi’s National HIV Prevention Strategy 2009-2013 acknowledges the role of circumcision, but it falls short of outlining a clear policy, and Brendan Hayes, the head of BLM, has admitted that circumcision has been a hard sell. “In Malawi, you’ve got very big differences in the HIV epidemic from north to south, and those differences don’t correlate to differences in circumcision prevalence. High HIV prevalence rates are in the southern part of the country, which is also where we have the most circumcision,” he told IRIN/PlusNews. “These differences aren’t totally inexplicable but I think it’s made people more cautious about moving forward with male circumcision.”

Confusion and controversy

Southern Malawi has a large migrant labour population and an HIV prevalence of about 18 percent, accounting for almost 70 percent of the country’s HIV infections, according to government figures. Circumcision is culturally less prominent in northern Malawi, where the prevalence of HIV is also lower.

The mismatch between HIV prevalence and circumcision incidence has raised doubts among some high-level health officials, particularly Principal Secretary for HIV and AIDS within the Presidency, Dr Mary Shawa [or Shaba]. Earlier this year, Shawa argued that she had not yet been presented with enough clinical evidence on circumcision, and that its efficacy was questionable given the high HIV prevalence among traditionally circumcising populations in the south. Shawa also questioned the acceptability of the practice among ethnic groups that did not traditionally perform the procedure.

Source: PlusNews

8. Malaysia: AIDS most prevalent among (circumcised) Muslims

In Malaysia, the local AIDS Council reports that 72 per cent cent of AIDS/HIV Sufferers in Malaysia are Muslims. In view of the facts that only 60 per cent of the Malaysian population is Muslim, and that nearly all Muslim malls are circumcised when young boys, this figure must mean that the majority of AIDS cases there are found in circumcised men.

KUALA TERENGGANU, June 9 (Bernama) -- More than 70 per cent of the 87,710 HIV/AIDS sufferers in the country are Muslims, Malaysian AIDS Council vice-president Datuk Zaman Khan said on Wednesday. Therefore, he said, the celebration for this year's World AIDS Day would emphasise efforts to enhance the participation of and awareness on AIDS among Muslims. He said what was more worrying a report by the United Nations General Assembly Special Session (UNGASS)on AIDS which stated that nine Malaysians were infected with the disease everyday. Also of concern was the spread of the disease among women, from 9.5 per cent in 2000 to 20 per cent last year, he said when speaking at a function to commemorate World AIDS Day here Tuesday night.

He said that in 2000 the main cause of women being infected with HIV/AIDS was drug addiction, but lately, it had been attributed to heterosexual sex (30 per cent). This happened because of lack of concern and cooperation from the society to protect women from the disease, he added. On HIV/AIDS sufferers in Terengganu, he said, a total of 315 new cases were reported last year. Kelantan recorded the highest number of HIV/AIDS cases at 596, followed by Pahang (431) and Selangor (378), he added.

Bernama: Malaysian National News Agency, 9 June 2010

Further information

Studies casting doubts on wild claims of African "circumcision to stop AIDS" experiments

9. Swaziland: Circumcised men more likely to have AIDS

Despite the hype about circumcision as the magic bullet against HIV infection, new figures from Africa show that AIDS is more common among circumcised men.

Australian circumcision promoters are hitting the headlines with demands for mass circumcision of baby boys in Australia as a precaution against HIV acquired from unprotected heterosexual intercourse. In support of this proposal they refer to old evidence from Africa as to the protective effect of circumcision against heterosexually acquired HIV infection, as shown in three clinical trials. While the World Health Organisation rolled out circumcision programs with funds provided by Bill Gates and President Bush, sceptics warned that the trials were riddled with scientific flaws and that it was far too early to tell whether circumcision would have a significant protective effect in the real world - quite part from the vast cost and serious ethnical doubts. Recent news from Africa is proving the sceptics correct, as the incidence of AIDS in many Africa countries continues to rise among circumcised populations.

In Swaziland, a small nation in south central Africa, where the government is planning particularly ambitious programs, it was recently revealed that the incidence of HIV infection was significantly higher among circumcised men. According to government figures, the incidence of HIV among circumcised men is currently at 22 per cent, but among uncircumcised men at only 20 percent. These are both astronomical figures (nothing like the situation in Australia), but they do not show any evidence of circumcision having a protective effect against HIV; on the contrary, looking at these figures, you would have to conclude that circumcision increased the risk of infection with AIDS.

What is even more scandalous is that the Swaziland government was perfectly aware of these figures when it decided to roll out the circumcision programs. Makes you wonder how some of the Gates/Bush billions have been spent.

Swaziland: Incidence of AIDS higher among circumcised men

Times of Swaziland, 19 September 2010

MBABANE – Even though male circumcision is considered to have a protective effect for HIV infection, circumcised men have a slightly higher HIV infection than those who are not. The Times SUNDAY can today reveal that government has known this for close to three years. It is contained in the Swaziland Demographic and Health Survey (SDHS) of 2007 which still prevails. This report summarises findings of the 2006 survey carried out by the Swaziland Central Statistical Office (SCO). The report places the infection rate for circumcised males at 22 per cent while for those uncircumcised stands at 20 per cent.

The report states that the protective aspect of male circumcision is based in part because of the physiological differences that increase the susceptibility to HIV infection among uncircumcised men. However, the relationship between HIV prevalence and circumcision is not in the expected direction. "It is worth noting that the relationship between male circumcision and HIV infection may be confounded by the fact that the circumcision may not involve the full removal of the foreskin, which provides partial protection," stated the report.

But additional analysis is needed to determine if this lack of a relationship between male circumcision and HIV infection is a result of confounding factors or represents the true situation. In 2007 government introduced a policy on male circumcision, which has a goal of halting the spread of HIV infection to achieve an HIV-free generation. Cited in the report is that to meet this objective, male circumcision services, as part of the national comprehensive HIV prevention package, would have to be availed to men of all ages. To maximise the health benefit for HIV prevention, the primary targets of the services are men who are HIV-negative, in the age bracket of 15-24 and also newborn babies.

Value of circumcision questioned

Meanwhile, the belief that circumcision can provide a considerable measure of protection against HIV infection has been questioned by academicians and medical professionals of repute. Last week Occupational Health Specialist Dr Cleopas Sibanda questioned the rationale of circumcision to justify it being adopted as part of the national HIV and AIDS prevention strategy.

"What exactly happened in Uganda as far as HIV and AIDS and population demographics are concerned to correctly attribute the observed previous decline in their national HIV and AIDS statistics to wholesale male circumcision?" Sibanda was quoted as having asked. But he noted that circumcision for the wrong reasons can be very dangerous, in fact it has increased episodes of diminished consistent use of condoms and increased incidences of HIV and AIDS affected populations. [As shown in an earlier report, printed below.]

More circumcised men are HIV positive

Times of Swaziland, 19 September 2010

After circumcision, men stop using condoms

Times of Swaziland, 8 September 2010

MBELEBELENI – A traditional healer has related how he treats many men who have STIs due to their belief that after circumcision they will not contract HIV. The healer, who wished to be identified only as Nkambule, said he had been receiving an influx of male clients who wanted to be treated for sexually transmitted infections. He said when he questioned them on why they do not use condoms, the response was that they were of the view that since they were circumcised, they did not need to use one. "Most of them then require me to treat them with my traditional medicine," he said.

Nkambule explained that in one instance his client asked him to prepare a concoction that would enhance his manhood as he would not be required to use a condom since he had undergone circumcision. "I always advise them to follow the laid-down procedures a person is expected to undergo after circumcision, but most of them insist that they be given traditional medicine. As a traditional healer, I support circumcision but it is now clear that people have different understandings of it," he said.

Nkambule disclosed that he always advised his clients to test for HIV before opting for traditional treatment. "After observing the condition of my clients, I always advise them to check their status so that the necessary treatment can be administered," he explained.Judging from the number of people who came to him after circumcision, it was clear that people have this strong belief that circumcision prevented one from getting a sexually transmitted disease. "I treat people for different ailments, but the number of those who come with problems of sexually related diseases is increasing," he said.

Inyanga's warning about circumcision

Times of Swaziland, 8 September 2010

Kenya: Circumcised men just as likely to be HIV-positive

A recent study (yet another one) in Kenya has found no association between being uncircumcised and being at greater risk of infection with HIV. To put it another way, the study found that circumcision had no protective effect against HIV-AIDS.

The study, by Matthew Westercamp et al and published by PlosOne, examined “the behaviors, beliefs, and HIV/HSV-2 serostatus of men and women in the traditionally non-circumcising community of Kisumu, Kenya prior to establishment of voluntary medical male circumcision services. A total of 749 men and 906 women participated. Circumcision status was not associated with HIV/HSV-2 infection nor increased high risk sexual behaviors. In males, preference for being or becoming circumcised was associated with inconsistent condom use and increased lifetime number of sexual partners. Preference for circumcision was increased with understanding that circumcised men are less likely to become infected with HIV.”

That is, although there was no difference in HIV incidence between the circumcised and uncircumcised, the people in the survey believed the intensive American propaganda that circumcision gave significant protection against HIV infection.

It is thus not surprising that there was a high level of acceptance of and interest in circumcision among the sample, many of whom stated their intention to get circumcised. The study found that those planning to get circumcised were more likely to have a history of high risk behaviour, involving numerous casual partners and inconsistent condom use.

Matthew Westercamp et al, Male circumcision in the general population of Kisumu, Kenya: Beliefs about protection, risk behaviors, HIV, and STIs, PlosOne, December 2010; Full text of study at PlosOne

Belief in witchcraft and burning of witches also common in Kenya

Before we marvel at the readiness with which Kenyans accept the latest in proven scientific wisdom, we should bear in mind that Kenya is also a country in which there is a strong (and apparently rising) belief in witchcraft, and that burnings of suspected witches are becoming more common. Only last year a Kenyan correspondent for the BBC reported:

I was witnessing a horrific practice which appears to be on the increase in Kenya - the lynching of people accused of being witches. I personally saw the burning alive of five elderly men and women in Itii village. I had been visiting relatives in a nearby town, when I heard what was happening. I dashed to the scene, accompanied by a village elder. He reacted as if what we were watching was quite normal, which was shocking for me. As a stranger I felt I had no choice but to stand by and watch. My fear was that if I showed any sign of disapproval, or made any false move, the angry mob could turn on me. Not one person was protesting or trying to stop the killing. Hours later, the police came and removed the charred bodies. Village youths who took part in the killings told me that the five victims had to die because they had bewitched a young boy. “Of course some people have been burned. But there is proof of witchcraft,” said one youth.

Odhiambo Joseph, Horror of Kenya’s witch lynchings, BBC News, Kenya, 26 June 2009

Other reports at James Randi's skeptic site

Persecution of witches also in Nigeria, Angola and the Congo

In Nigeria, Angola and the Congo anti-witch hysteria targets children rather than old men or women. Hundreds of boys and girls are reported to have been blinded, injected with battery acid, and otherwise tortured in an effort to purge them of the demons thought to be possessing them. Many more have been cast out by their families and left to roam the streets. Especially in Nigeria, the campaign against witches is led by the Evangelical churches, as reported in the Daily Telegraph (Sydney):

In Nigeria as many as 1000 children may have been accused of witchcraft by pastors of evangelical Christian churches, many of whom have subsequently been tortured and burnt.

The idea of witchcraft is hardly new, but it has taken on new life recently partly because of a rapid growth in evangelical Christianity. Campaigners against the practice say around 15,000 children have been accused in two of Nigeria's 36 states over the past decade and around 1,000 have been murdered. In the past month alone, three Nigerian children accused of witchcraft were killed and another three were set on fire. Some of the churches involved are renegade local branches of international franchises. Their parishioners take literally the Biblical exhortation, “Thou shalt not suffer a witch to live” [Exodus, 22:18].

Katharine Houreld, Church burns witchcraft children
Daily Telegraph (Sydney), 20 October 2009

Twin superstitions: Burn the witches; destroy the foreskins

The justification traditionally given for burning witches is remarkably similar to the reasons commonly given for circumcising boys. A passing remark in the Old Testament is not the real reason or cause, but a post-hoc rationalisation: poor and ignorant people want to burn witches for their own traditional reasons, and the biblical text provides no more than a justification after the event, to be brought out when they are required to explain themselves. It is rather similar with circumcision: the circumcision promoters just want to do it for their own superstitious reasons (usually no more than habit), and when challenged to produce reasons they reach into the vast grab-bag of the medical literature and pull out a few choice quotes or stats.

Just like the witch-burners leant on the Book of Exodus to justify the murder of innocent people, circumcision promoters deploy questionable or irrelevant statistics from medical journals to justify the genital mutilation of innocent and unwilling children. And for much the same reasons: because their own or their community’s health, in the opinion of the circumcision promoters, demands and requires such a measure. Like the witch-burners, they are convinced that a crisis situation, with disease (or the devil) rampaging through society is no time for sentimentality (or mercy) if society is not to be engulfed in epidemics, plagues and assorted other disastrous evils. As in ancient times, the best way to appease the angry gods is by sacrificing something precious.

Uganda: Circumcision campaign increases HIV infections

Recent news reports from Africa reveal that circumcision as a tactic for stopping the spread of HIV is having the opposite effect, as men who have consented to be circumcised believe that they are now completely immune to infection and can have as much unsafe sex as they like, with as many partners as they can find, and don’t need to use condoms. In Uganda a report has found that “new HIV/AIDS messages meant to reduce the prevalence of the disease are instead facilitating its spread”, while in Swaziland a poster campaign is generally interpreted by men as meaning “that after circumcision, they would be safe from sexually transmitted illnesses”. This is exactly the result that critics of the circumcision solution have consistently predicted and warned against from the start. Suggesting that circumcision is a “surgical vaccine” against HIV, as many irresponsible researchers, circumcision promoters and journalists have done, gives people a false sense of security and encourages them to engage in unsafe sex - with inevitably tragic results.

Uganda: New HIV/AIDS Messages Worsening HIV Situation

A new report by PANOS Eastern Africa has shown that new HIV/AIDS messages meant to reduce the prevalence of the disease are instead facilitating its spread as they have created false impressions, especially with regard to multiple concurrent partnerships and male circumcision. The report, "Communication challenges in HIV Prevention: Multiple Concurrent Partnerships and Medical Male Circumcision", shows that majority of rural population believed that circumcision gives a complete protection to HIV/AIDS, while more than 88 per cent did not know what the sexual network was.

The report also notes that most of these messages are urban-based with little or no translation for the rural people, while younger people are no longer scared of the HIV pandemic because it is no longer as scary as it used to be. These communications include the "Be a man" campaign, "Go together Know together", "Go Red" campaign and the "Fidelity" campaign. "Current Multiple Concurrent Partnership (MCP) policies, programmes and communication initiatives in Uganda are not addressing the social, cultural and economic issues that underline why people engage in MCP. Future attempts should incorporate an analysis of the social drivers of HIV," the report released last month reads in part.

Speaking at the launch of the report in Kampala, the Director PANOS Eastern Africa, Peter Okubal, said the report was prompted by the increasing number of infections every year. Last year alone, 120,000 new infections were recorded. One of the lead researchers, Daudi Ochieng, from the Uganda Health Marketing Group, said that the messages have lost authority and have become cliché. "People are tired of the same old messages, campaigns are vague and boring, there is nothing shocking about them and they lack coherence as everyone gives a different message," Mr Ochieng said.

Flavia Lanyero, New HIV/Aids Messages Worsening HIV Situation, All Africa News, 5 May 2011

Swaziland: Circumcision campaign targets women

A similar report from Swaziland reveals that a government campaign to encourage women to pressure their partners into getting circumcised has been interpreted as advice that circumcision gives complete protection agains HIV and means that a man can then give up condoms and have more partners. Although the Swazi government has launched a ferocious circumcision campaign, figures show that there is higher incidence of HIV among the circumcised than among: cut men - 21.8%, uncut men - 19.5%.

The report in a Swazi newspaper reads:  THE ministry of health has engaged on a campaign to encourage women to support their partners to circumcise. In an effort to publicise the campaign, billboards and public transport have been branded with posters of women who are supporting the campaign. The campaign is about the involvement of women in the male circumcision programme.

However, this campaign has been misinterpreted by some people who thought that the message being sent out was that they were safe from contracting sexually transmitted infections when they were circumcised and therefore, could have more than one sexual partner. The posters on the public transport display pictures of a man and four women accompanied by the word; “ngingumancoba” (I am a conqueror). To some, this has implied that after circumcision, they would be safe from sexually transmitted illnesses, hence the decision to have multiple concurrent partners.

Winile Masinga , New male circumcision campaign targets women, Observer (Swaziland) 21 April 2011

Zambia: Another study fails to find that foreskins increase risk of HIV …

… but still recommends circumcision

A study of the possible link between genital herpes and increased risk of HIV in Zambia did find that men with herpes were more likely to be HIV-positive, but also found that lack of circumcision did not increase the risk of HIV infection. Quite the contrary, the study found that uncircumcised men were less likely to contract HIV. In their discussion of the results, however, the authors of the study failed to mention this vital fact, and concluded by recommending that circumcision be promoted as an AIDS control strategy – thus violating the most basic principles of evidence-based medicine.

The Zambian study was conducted by researchers from the United States Centers for Disease Control – well known for its pro-circumcision agenda. They recruited 1062 male farm workers at a sugar estate in Zambia to participate in an experiment known as a prospective cohort study.** The researchers were looking for a link between genital herpes (herpes simplex type-2 or HSV-2) infections and developing an infection with HIV-1. The study had two outcomes of interest.

First, they looked at factors that affect the prevalence of HIV-1 infection (whether the men were infected at the time of recruitment). Second, they measured the incidence of HIV-1 infection (new infections detected during the follow-up period). At the time of recruitment 20.7% of the men were HIV-positive. Men with a positive blood test for past herpes were five times more likely to be HIV-positive at the time recruitment. Other factors significantly associated with being HIV-positive were self-reported genital ulcers in the past year, and being widowers (i.e. their wife had died). Rates of HIV-1 infection at the time of recruitment were the same in circumcised men and uncircumcised men (20.71% versus 20.76%). When adjusted for other factors, there was no significant association between circumcision status and HIV-1 prevalence.

The second half of the study involved following 731 participants who started off as HIV-negative and who made at least one follow-up visit. Becoming HIV-positive during the follow-up period was independently associated with a positive blood test for herpes at the beginning of the study, and 18 times more likely in men who developed a first-time HSV-2 (herpes) infection during the follow-up period. During the follow-up period uncircumcised men developed 23 infections in 5686 months of patient follow-up (4.04 per 1000 months), while circumcised men developed four infections in 817 months of follow-up (4.89 per 1000 months). This means that uncircumcised men had a slightly lower (but probably not statistically significant) risk of HIV infection. When adjusted for other factors, circumcision status made no difference to the risk of infection with HIV.

A significant weakness of the study is its reliance on self-reported circumcision status – something about which men are surprisingly uncertain. While the investigators assumed that all the HIV infections were transmitted sexually, it is also possible (even likely) that men with genital herpes would seek medical care, and in doing so placed themselves at greater risk of HIV infection through non-sterile medical treatment (iatrogenic infection) – notoriously common in the over-stretched health services of underdeveloped countries.

This is yet another study that fails to confirm the “60% reduction in risk of HIV infection” claimed for circumcision in the three famous randomized clinical trials. Such a reduction is outside the 95% confidence intervals of this and several other studies, indicating serious doubts about the clinical trials. Despite this, the researchers in the Zambia study recommend that company health centres should “promote and provide medical male circumcisions” as a part of the effort to decrease infection rates: yet their own data that shows that circumcision would either have no impact, or might even increase the risk of HIV infection. It would appear that the authors, even in light of their own negative findings, are unwilling to stray from the CDC’s pro-circumcision agenda, and thus fail to observe the basic principles of evidence-based medicine: that recommendations for treatment must follow logically and directly from the evidence. According to the data in this study, to recommend circumcision as a preventive strategy in Zambia is ideological and plainly anti-scientific.

Source: The article is: Heffron R, Chao A, Mwinga A, Sylvester Sinyangwe S, Sinyama A, Ginwalla R, Shields M, Kafwembe M Kaetano L, Mulenga C, Kasongo W, Mukonka V, Bulterys M. High prevalent and incident HIV-1 and herpes simplex virus 2 infection among male migrant and non-migrant sugar farm workers in Zambia. Sex Transm Infect 2011; 87: 283-8.

** A prospective cohort study is a cohort study that follows over time a group of similar individuals (cohorts) who differ with respect to certain factors under study, to determine how these factors affect rates of a certain outcome.

Zimbabwe: Despite circumcision propaganda, circumcised men still get AIDS

Reports from Africa show that despite all the propaganda about circumcision providing protection against HIV infection, and strong pressure (including physical coercion) to get “snipped”, circumcised men are still getting infected with HIV. A report in the Zimbabwe newspaper The Standard states:

Circumcised men are contracting HIV and Aids after ditching the use of condoms, under a misguided belief that male circumcision (MC) would prevent them from getting infected, The Standard has heard. This revelation comes at a time when the national programme is battling for recognition and relevance as an effective preventive tool for HIV and Aids in the country. Sex workers who spoke to The Standard last week said some circumcised men were no longer using preventive methods, including condoms, because they believed that their chances of getting infected were limited after getting circumcised.

One of the sex workers, who only identified herself as Memory told a United Nations Populations Fund (UNFPA) media training workshop in Bulawayo last week, that most of her circumcised clients were not willing to use condoms. “I have problems with circumcised men because they do not want to use condoms. They always argue that because they have been circumcised they did not need to use condoms,” said the heavily pregnant Memory, who is also HIV-positive. Memory said even after disclosing her HIV status, they still insisted on sleeping with her without any form of protection. “I even take my antiretroviral drugs in their presence but they do not care and because I have a family to feed, I give in to their demands,” said Memory.

But Ministry of Health and Child Care national male circumcision coordinator, Sinokuthemba Xaba maintained that the procedure reduced chances of getting infected by at least 60%, but urged men not to stop using condoms. He defended the programme saying it was a pity that some people were under the misguided opinion that by being circumcised they would not be infected.

Source: Circumcised men indulge in risky sexual behaviour, The Standard, 10 November 2013.

Obviously, if it is still necessary to use a condom, circumcision does not provide any meaningful protection against HIV infection. In fact, demographic reports show that the incidence of HIV in Zimbabwe has been consistently higher among circumcised men by about 2 percentage points.

Circumcision does not lower risk of HIV in MM sex


A study by Crosby et al of Black men in a southern United States city with an “extremely high” HIV prevalence, found that there was no difference in the incidence of HIV and other sexually transmitted infections between circumcised and uncircumcised partners. Curiously, the study also found that circumcised men were twice as likely not to wear a condom when taking the active role in intercourse. This is an interesting result, confirming earlier research that circumcised men are less likely to wear condoms, thus raising the possibility that they may be at greater risk of HIV infection. These points are discussed in a response letter by Morten Frisch, who notes that the study provided no evidence of circumcision having any protective effect against HIV in MM sex, and who draws attention to its side-finding - that circumcised men are far less likely to use condoms. As he points out, this is consistent with other evidence that circumcision dulls the sensitivity of the penis, leading to the frequent complaint from circumcised men that they can’t feel anything through the latex and often lose their erection. The key point is that since condoms (even if worn inconsistently) are the most effective means of HIV prevention, anything that discourages condom use raises the risk of HIV infection.

The full text of Dr Frisch’s letter follows

I read with great interest the recent paper by Crosby et al., in which the authors failed to find any significant difference in the prevalence of HIV (or other sexually transmitted infections) between circumcised and intact young black men who have sex with men (MSM) in the United States [1]. Their findings are in line with those of a 2011 Cochrane review showing no significant association overall between circumcision/foreskin status and HIV infection in MSM, although a subanalysis suggested a possible reduction in HIV risk among circumcised MSM who predominantly take the insertive role during anal sex [2]. However, a subsequent British study found no evidence that circumcision is protective against HIV among MSM who predominantly engage in anal sex as the insertive partner [3].


Crosby et al. highlight an additional, potentially noteworthy finding in their article’s abstract [1]. They report that ‘‘The mean frequency of unprotected insertive anal sex for circumcised men was about twice as high compared to those intact (P = .04).’’ This finding is consistent with evidence from another recent study by Feldblum et al. [4], which pointed to reduced condom use following adult circumcision among a large sample of Kenyan men. Unfortunately, Crosby et al. make no mention anywhere in the main text about this statistically significant finding. Perhaps the authors considered it to be a chance finding because, apparently, it was the only statistically significant result in their study. However, there are reasons why this finding may actually deserve some attention.

First, such a result is plausible on anatomical and behavioral grounds. Since circumcision removes the adult equivalent of approximately 50 cm2 of touch-sensitive tissue (see below), one might expect an overall reduction in penile sensitivity as a function of the surgery. Since condoms tend to decrease penile sensitivity [5], circumcised men may have conscious or unconscious motivations to avoid any further desensitization during sex, which could explain their reduced condom use.

Laboratory investigations have sought to determine whether the foreskin is a particularly sensitive penile structure, and have produced conflicting results. Some researchers have provided evidence that the foreskin is the most sensitive part of the penis [6], while others fail to confirm such findings [7]. However, regardless of whether sensitivity per square centimeter is actually higher in the foreskin compared to other parts of the penis, or the foreskin is merely as sensitive as other parts of the sexual organ, the overall sensory input from a circumcised penis during sex will be reduced in a manner that plausibly depends—at least to some extent—on the amount of foreskin removed. The obvious reason for this is that any sensation that would be experienced in the foreskin itself is necessarily eliminated by circumcision [8].

The adult foreskin—with its rich supply of nerve endings and specialized sensory structures [9]—may comprise up to 100 cm2, with reported average values between 30 and 50 cm2 [10, 11]. The contribution of this motile sleeve of erogenous tissue to overall penile sensitivity is not known with certainty. However, any specific qualitative sensation elicited by the mechanical rolling and gliding movements of the foreskin during sexual activity will in fact be absent or reduced in circumcised men [8].

Consequently, Crosby et al.’s finding that circumcised MSM are significantly less likely than intact MSM to use condoms consistently during insertive anal sex [1] may plausibly reflect that individuals with already reduced penile sensitivity are less likely to adhere to HIV prevention recommendations that will make them feel even less during sex. I agree with Crosby et al. that their findings add to the evidence suggesting that circumcision is unlikely to be an effective strategy for HIV prevention among MSM. For future reference, I kindly ask the authors to provide the actual frequencies of unprotected insertive anal sex for circumcised and intact males, which they found to be around 100 per cent increased among circumcised men in their study.


1. Crosby RA, Graham CA, Mena L, Yarber WL, Sanders SA, Milhausen RR, Geter A. Circumcision status is not associated with condom use and prevalence of sexually transmitted infections among young black MSM. AIDS Behav. 2015. doi:10. 1007/s10461-015-1212-x.  Full text (behind paywall)

2. Wiysonge CS, Kongnyuy EJ, Shey M, Muula AS, Navti OB, Akl EA, Lo YR. Male circumcision for prevention of homosexual acquisition of HIV in men. Cochrane Database Syst Rev. 2011;6:CD007496.

3. Doerner R, McKeown E, Nelson S, Anderson J, Low N, Elford J. Circumcision and HIV infection among men who have sex with men in Britain: the insertive sexual role. Arch Sex Behav. 2013;42(7):1319–26.

4. Feldblum PJ, Okech J, Ochieng R, Hart C, Kiyuka G, Lai JJ, Veena V. Longer-term follow-up of Kenyan men circumcised using the ShangRing device. PLoS One. 2015;10(9):e0137510.

5. Hill BJ, Janssen E, Kvam P, Amick EE, Sanders SA. The effect of condoms on penile vibrotactile sensitivity thresholds in young, heterosexual men. J Sex Med. 2014;11(1):102–6.

6. Sorrells ML, Snyder JL, Reiss MD, Eden C, Milos MF, Wilcox N, Van Howe RS. Fine-touch pressure thresholds in the adult penis. BJU Int. 2007;99(4):864–9.

7. Bossio JA. Examining sexual correlates of neonatal circumcision in adult men. PhD Thesis, Queen’s University, Kingston, Ontario, Canada; 2015.

8. Earp BD. Sex and circumcision. Am J Bioeth. 2015;15(2):43–5.

9. Cold CJ, Taylor JR. The prepuce. BJU Int. 1999;83(Suppl 1):34–44.

10. Werker PM, Terng AS, Kon M. The prepuce free flap: dissection feasibility study and clinical application of a super-thin new flap. Plast Reconstr Surg. 1998;102(4):1075–82.

11. Kigozi G, Wawer M, Ssettuba A, Kagaayi J, Nalugoda F, Watya S, Mangen FW, Kiwanuka N, Bacon MC, Lutalo T, Serwadda D, Gray RH. Foreskin surface area and HIV acquisition in Rakai, Uganda (size matters). AIDS. 2009;23(16):2209–13.

Source: Morten Frisch. Higher Frequency of Unprotected Insertive Anal Sex Among Young Black MSM Who are Circumcised. AIDS Behavior, on-line first, 25 November 2015  Full text (behind paywall)

Also on this site

More evidence that circumcision leads to lower condom use

HIV-AIDS control: Growing doubts on the circumcision solution


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