Why Cooper, Wodak and Morris are wrong about circumcision and AIDS control


Australia is not Africa: Neonatal circumcision plan unscientific,

irrelevant and unethical

In their celebrated opinion piece ("Editorial") published in the Medical Journal of Australia on 19 September 2010, Cooper, Wodak and Morris propose near universal circumcision of male infants in Australia as a strategy for reducing the incidence of heterosexually transmitted HIV infection. [1] They base this suggestion on evidence from three clinical trials in Africa that circumcision of adult men can significantly reduce the risk of a male’s acquiring HIV during unprotected sexual intercourse with an infected female partner.

There are many objections to such a proposal. The most important are that it is marred by unscientific thinking; is irrelevant to the Australian situation; departs from the tenets of evidence-based medicine; and is contrary to established principles of bioethics and human rights.

Lacks scientific rigour

The proposal lacks scientific rigour because it uses hyperbolic language in describing circumcision as a “surgical vaccine”, when it is nothing of the sort; [2] misrepresents the risk of a person acquiring HIV in Australia; ignores African and other critiques of the clinical trials and the manner in which WHO recommendations arising from them have been implemented; [3, 4] and slides over the fact that it will be many years before we can know whether the current African circumcision programs have reduced HIV population prevalence, and consequently incidence, as hoped.

Irrelevant to Australia's AIDS problem

The proposal is irrelevant because Australia is not sub-Saharan Africa, where HIV is a generalised epidemic spread throughout the population and transmitted largely by heterosexual intercourse. [5] In Australia, AIDS is a relatively low prevalence disease, largely contained within the specific sub-cultures where it has always been found: mostly homosexual men (80 per cent), plus a very small population of injecting drug users (4 per cent). [6]

The proposal is not so misguided as to suggest that these categories would receive any protection from circumcision, but relies instead on the small incidence of heterosexual transmission - currently running at a very low level. Indeed, the incidence of female to male heterosexual transmission of HIV (the only situation where here is evidence of circumcision having any protective effect) is so low in Australia that the idea of introducing universal circumcision is hardly worth even debating: to call it a case of using a steam hammer to crack a nut is putting it mildly. According to figures released for 2008, [6] only 13.5 per cent of newly diagnosed infections were due to heterosexual transmission, and 59 per cent of these were attributed to people from and/or those who had sex with people from a high prevalence country. Of the actual incident infections (people provably infected within the previous twelve months) only 10.7 per cent were attributable to heterosexual contact. Indeed, 83 per cent of incident infections occur where they have traditionally been found – among gay men. [6]

Cooper, Wodak and Morris suggest that the incidence of female-to-male transmission is increasing, but the numbers are still very small (e.g. 18 men newly heterosexually infected in 2008), and the rate of increase is very slow when the 28-year stretch of the Australian epidemic is taken into account (16 men newly heterosexually infected in 2006, 16 in 2004, 12 in 2000). There is no evidence that uncircumcised men are over-represented in this group. Is it really a constructive health initiative to circumcise 128,000 boys each year merely to halve these tiny numbers?

The proposal is also irrelevant because it targets infants, who are not at risk of infection by sexual contact and will not be at risk until they become sexually active in 16-20 years time, by which time treatment and prevention options, and the virus itself, may have altered beyond recognition.

Violates principles of evidence-based medicine

Evidence-based medicine requires that recommendations for treatment or prophylaxis follow logically and directly from the evidence. In this case there is a radical disconnect between the evidence and the recommendation. Even assuming the African evidence is reliable and applicable, the logical prescription arising from these data is that sexually active adult men, who have regular intercourse with numerous different female partners and who do not always use condoms, should consider circumcision for themselves as a means of lowering their risk of infection. One possible expression of the policy might be that sexual health advice targeted at this category of men would include circumcision as a prophylactic option among a comprehensive range of sexual health offerings, as the WHO policy has recommended.

But this is not what Cooper, Wodak and Morris propose. What they prescribe is that parents be advised to circumcise their boys as neonates as a precaution against a risk they will not face until they are adults, and against a disease that is very rare among heterosexually active adult men in Australia. Even if circumcised they would still have to use a condom to be sure of avoiding infection, since the risk reduction promised by the African data is only partial: somewhere between 38 and 66 per cent. [7] We have no data at all on what the risk reduction in Australia might be. If it is still necessary to wear a condom there seems little point in getting circumcised.

As Perera et al. point out, [8] moreover, the African trials on which Cooper, Wodak and Morris rely involved sexually active adult men, not infants, and there is actually no hard evidence that neonatal circumcision has any protective effect against HIV. Arguments concerning other possible, non HIV-related benefits of circumcision (all contested in the literature and rejected by paediatric authorities) are irrelevant in relation to HIV infection itself. In sum, the prescription offered has very little connection with the evidence cited.

Violates principles of medical ethics and human rights

But even if the proposal were relevant to the Australian situation, to be ethically acceptable a medical intervention must pass the five tests proposed by Beauchamp and Childress:

Beneficence — Does the proposed procedure provide a net therapeutic benefit to the patient, considering the risk, pain, and loss of normal function?

Non-maleficence — Does the procedure avoid permanently diminishing the patient in any way that could be avoided?

Proportionality — Will the final result provide a significant net benefit to the patient in proportion to the risk undertaken and the losses sustained?

Justice — Will the patient be treated as fairly as we would all wish to be treated?

Autonomy — Lacking life-threatening urgency, will the procedure honour the patient’s right to his or her own likely choice? Could it wait for the patient’s assent? [9]

Cooper, Wodak and Morris ignore ethical and human rights issues, but their proposal would not be acceptable in a country such as Australia unless it were established that non-therapeutic circumcision of non-consenting minors were permissible within the above guidelines. It has been persuasively argued that in the absence of a life-threatening disorder, surrogate consent for non-therapeutic surgery of this type is not ethically permissible and may not even be legally valid. [10, 11]


1. Cooper DA, Wodak AD, Morris BJ. The case for boosting infant male circumcision in the face of rising heterosexual transmission of HIV. Med J Aust 2010; 193 (6): 318-319

2. Green LW, McAlister RG, Peterson KW, Travis JW. Male circumcision is not the surgical vaccine we have been waiting for, Future HIV Therapy 2008; 2 (3): 193-199

3. Myers A, Myers JE. Editorial: Rolling out male circumcision as a mass HIV/AIDS intervention seems neither justified nor practicable, South African Med J 2008; 98 (10): 781-782

4. Van Howe RS, Svoboda JS. Neonatal circumcision is neither medically necessary nor ethically permissible: A response to Clark et al. Medical Science Monitor 2008; 14 (8) LE7-13

5. James Chin, The AIDS Pandemic: The Collision of Epidemiology with Political Correctness. Oxford: Radcliffe Publishing, 2007

6. National Centre in HIV Epidemiology and Clinical Research. HIV/AIDS, viral hepatitis and sexually transmissible infections in Australia, Annual Surveillance Report 2009. National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, NSW: Tables 1.1.1 and 1.2.1.

7. Siegfried N, Muller M, Deeks JJ, Volmink J. Male circumcision for prevention of heterosexual acquisition of HIV in men. Cochrane Database of Systematic Reviews 2009; Apr 15; (2): CD003362

8. Perera CL, Bridgewater FHG, Thavaneswaran P, Maddern GJ, Safety and efficacy of nontherapeutic male circumcision: A systematic review. Ann Fam Med 2010; 8 (1): 64-72

9. Beauchamp TL and Childress JF. Principles of Biomedical Ethics 1977; 6th edn, Oxford University Press, 2009, Part II

10. Svoboda JS, Van Howe RS, Dwyer JG. Informed consent for neonatal circumcision: An ethical and legal conundrum. J Contemp Health Law Policy 2000; 17: 61-133

11. Tasmania Law Reform Institute. Non-therapeutic male circumcision. Issues Paper No. 14. Hobart: June 2009

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