Although the World Health Organisation has hailed circumcision as the "great white hope" against AIDS and poured billions into programs of mass circumcision of African men, many Africans, including doctors, are sceptical of the effectiveness, the ethics and the cost of such a strategy. On this page we summarise papers recently published in African medical journals and provide an update on South African efforts to protect boys from circumcision. Oddly enough, despite the advice of the new white witchdoctors, South Africa is one of the very few countries to have passed legislation making it an offence (in certain circumstances) to circumcise a minor.
Clutching at straws to control the African HIV/AIDS epidemic has included strident advocacy for circumcision of males (MC) from some (mainly American) quarters, especially following three trials held in South Africa, Kenya and Uganda in 2006-2007. These seemed to show that circumcision did have a limited protective effect, and they were quickly hailed by the circumcision lobby as justifying an immediate “roll-out” of a massive circumcision campaign. Three contributions in the October 2008 edition of the South African Medical Journal, including an editorial, vigorously contest the usefulness, cost and ethics of circumcision in the prevention of HIV and condemn the indecent haste with which the Word Health Organisation, under pressure from American money, has sought to enforce mass circumcision on African men.
Objective. To investigate the nature of male circumcision and its relationship to HIV infection.
Methods. Analysis of a sub-sample of 3,025 men aged 15 years and older who participated in the first national population based survey on HIV/AIDS in 2002. Chi-square tests and Wilcoxon rank sum tests were used to identify factors associated with circumcision and HIV status, followed by a logistic regression model.
Results. One-third of the men (35.3%) were circumcised. The factors strongly associated with circumcision were age >50, black living in rural areas and speaking SePedi (71.2%) or IsiXhosa (64.3%). The median age was significantly older for blacks (18 years) compared with other racial groups (3.5 years), p <0.001. Among blacks, circumcisions were mainly conducted outside hospital settings. In 40.5% of subjects, circumcision took place after sexual debut; two-thirds of the men circumcised after their 17th birthday were already sexually active. HIV and circumcision were not associated (12.3% HIV positive in the circumcised group v. 12% HIV positive in the uncircumcised group). HIV was, however, significantly lower in men circumcised before 12 years of age (6.8%) than in those circumcised after 12 years of age (13.5%, p=0.02). When restricted to sexually active men, the difference that remained did not reach statistical significance (8.9% v. 13.6%, p=0.08.). There was no effect when adjusted for possible confounding.
Conclusion. Circumcision had no protective effect in the prevention of HIV transmission. This is a concern, and has implications for the possible adoption of the mass male circumcision strategy both as a public health policy and an HIV prevention strategy.
Full article here. PDF available on request.
Catherine Connolly, Leickness C Simbayi, Rebecca Shanmugam, Ayanda Nqeketo, Male circumcision and its relationship to HIV infection in South Africa: Results of a national survey in 2002, South African Medical Journal, Vol. 98, No. 10, October 2008
A second article by Sidler et al argues that there are profound objections on grounds of effectiveness, cost and ethics to the use of circumcision as a a tactic against AIDS. The article opens as follows:
Non-therapeutic, non-religious circumcision is the surgical procedure most commonly published about, but for which substantive indications are lacking. Since its introduction to the USA during the Victorian period, when it was thought that it prevented masturbation, medical justifications for the procedure progressed to prevention of various infective conditions (sexually transmitted diseases, penile and cervical cancer) and controlling of the sexual drive. Recent Joint United Nations Programme on HIV/AIDS/World Health Organization (UNAIDS/WHO) policy proposes male circumcision for the prevention of HIV/AIDS.
HIV/AIDS in Africa is mainly spread by multiple concurrent heterosexual relationships, compounded by female subjugation and poverty. Condoms, although highly protective, are infrequently used, particularly among circumcised males.
The HIV/AIDS crisis demands extraordinary curtailment measures. It is, however, questionable how circumcision, and particularly neonatal circumcision, could achieve such a goal. A rational and critical analysis of the scientific evidence ought to conclude that non-therapeutic infant circumcision is merely the medicalisation of an old ritual that should not, in the 21st century, be advocated as prevention strategy for HIV/AIDS. Repeated publications of matching opinions do not necessarily lead to solid scientific evidence and policies.
They rather suggest that the peer review process of journal publication may be unreliable. Information overload can cause limitations, for example influencing expert and public opinion with ideological and pseudoscientific content. This context and such therapeutic misconceptions contribute to circumcision still being practised as a non-therapeutic infant procedure. This mainly applies to English-speaking countries, where circumcision appears to have become a medicalised ritual. In contrast, in Europe non-therapeutic circumcision is not the norm.
Many reviews question the necessity of non-therapeutic infant circumcision, showing it to have neither short- nor long-term medical benefits. It has been suggested that parents should be granted responsibility and final decision making authority after having thoroughly considered all the relevant facts. The reported increase in demand for preventive circumcision, long before publication of results of the three randomised controlled trials (RCTs) in South Africa, Kenya and Uganda that have shown that circumcision is partially protective against HIV, suggests that informed proxy consent, within the context of the HIV/AIDS epidemic and the prevalence of poverty and ignorance, has to be seriously questioned. The desperate hope and need for action of people ravaged by HIV/AIDS, rather than solid scientific evidence, may be driving the increased demand for preventive circumcision.
A recent Centers for Disease Control (CDC) and WHO report confirms previous reports that circumcision does not prevent sexually transmitted diseases (STDs). Teens 15 years and older in the USA have the highest rate of STDs in any industrialised country and half will contract a sexually transmitted disease by age, despite two-thirds of young males having been circumcised. Such reports suggest that the social experiment of circumcision to prevent STDs, including HIV, has already failed in the USA, which has the highest rate of non-therapeutic infant circumcision in industrialised countries and the highest rate of HIV in the developed world.
Rest of article here with references. PDF available on request
Male non-therapeutic infant circumcision is neither medically nor ethically justified as an HIV prevention tool. Circumcision is not equivalent to successful immunisation, is being practised with decreasing frequency in English-speaking countries, and is becoming illegal in South Africa under the new Children’s Act. There are far more effective prevention tools costing considerably less and offering better HIV reduction outcomes than circumcision.
Finally, the WHO and UNAIDS appear to be basing these multi-million-dollar prevention programmes on limited and in some instances biased information. In order to prevent confusion and parents making misguided decisions on behalf of their infants, and to offer effective help in alleviating the suffering that is being created by HIV/AIDS, a much broader review process would be called for. Such a process would involve more objective scientific opinion, and the involvement of a representative panel of African experts, such as paediatric surgeons and neonatologists.
D Sidler, J Smith, H Rode, Neonatal circumcision does not reduce HIV/AIDS infection rates,
South African Medical Journal, Vol. 98, No. 10, October 2008, 764-766
Two articles [1, 2] published in this issue address male circumcision (MC). Connolly et al.1 show in a national survey that MC, whether pre-pubertal or post-pubertal, has no protective effect on acquisition by males of HIV infection as measured by prevalence.
Sidler et al.  state that neonatal MC continues to be promoted without adequate justification as a medicalised ritual, via an HIV prevention rationale. They caution that for MC to be a therapeutic as opposed to a non-therapeutic procedure, it is necessary to gather more corroborative and consistent evidence of its benefit, consider the potential harms (psychological, sexual, surgical and behavioural/disinhibition), examine the ethical implications, and examine effectiveness and efficiency (costs and benefits) at the population and societal levels. They point out that MC is not just a technical surgical intervention – it takes place in a social context that can radically alter the anticipated outcome. At the 2008 International AIDS Conference  in Mexico cultural, political and educational issues raised by the intervention, such as decreased condom use and marginalisation of women, were hotly debated. Some cultural interpretations may view MC as a licence to have unprotected sex. A case in point is Swaziland, where men are flocking to be circumcised with the understanding that this means they no longer need to use other preventive methods (e.g. wear condoms or limit the number of sexual partners). 
The 2003 Cochrane review5 of observational studies of MC effectiveness concluded that there was insufficient evidence to support it as an anti-HIV intervention. Three randomised controlled trials (RCTs) from South Africa, Kenya and Uganda in 2006-2007 show a protective effect of MC. However, Garenne  has subsequently shown from observational data that there is considerable heterogeneity [inconsistency] of the effect of MC across 14 African countries. Despite the South African RCT showing a protective effect, he reports for the nine South African provinces that ‘there is no evidence that HIV transmission over the period 1994-2004 was slower in those provinces with higher levels of circumcision’. Interestingly, in both Kenya and Uganda, where two of the RCTs were done, a protective effect of MC was observed, but a harmful effect was observed in Cameroon, Lesotho and Malawi. The other eight countries showed no significant effect of MC.
These somewhat discordant findings are difficult to interpret. While RCTs are theoretically strong designs, it is conceivable that their findings are not generalisable beyond their settings. Furthermore, there have been no trials of neonatal MC. Study flaws such as inability to obtain double blinding, and loss to follow-up in RCTs, may effectively degrade their quality to that of observational studies. Meanwhile other disturbing findings referred to by Sidler et al. are emerging, including the reported higher risk for women partners of circumcised HIV positive men, disinhibition, urological complications, relatively small effect sizes of MC at the population level, and relative cost-inefficiency of MC.
Not all objections to MC as an HIV intervention have to do with evidence of effectiveness or cost. Sidler et al. raise ethical objections. Owing to the current climate of desperation with regard to the HIV epidemic, evidence in favour of MC frequently seems overstated. This reduces the scope for informed consent and autonomy for adult men considering the procedure. Further problems arise in the case of neonates whose parents may be considering the procedure. Whereas informed consent is at least possible for adult men, it is clearly not possible for neonates. Parents can only guess what the child’s wishes would be if he were presented with the information they have at their disposal.
If it could be shown that circumcision was necessary in the neonatal period, parental consent on behalf of the neonate would be justified. But since no valid surgical indications for circumcision exist in this period, and the future benefit to the child in respect of HIV avoidance is not relevant before sexual debut, the duty of parents may well be to err on the side of caution, and defer the procedure until the child can make an autonomous decision. In the absence of compelling indications, a procedure such as circumcision could also be seen as a violation of the child’s right to bodily integrity. Furthermore, the ethical principle of non-maleficence cannot be upheld as there are clear harms attached to this practice, to which Sidler et al. refer in their article. Lastly, at a societal level MC may be unjust insofar as it could compete for resources with more effective and less costly interventions  and disadvantage women.
Despite a strong pro-circumcision lobby driven by enthusiasts who have been promoting MC as an (HIV) intervention for many years, and impatience expressed by protagonists about the long delay after the 2006-2007 RCT results and the UNAIDS/WHO policy recommendations8 of March 2007, few mass campaigns have been launched in African countries. Given the epidemiological uncertainties and the economic, cultural, ethical and logistical barriers, it seems neither justified nor practicable to roll out MC as a mass anti-HIV/AIDS intervention.
Humanities student, University of Cape Town
School of Public Health and Family Medicine University of Cape Town
Corresponding author: J Myers (email@example.com)
1. Connolly C, Simbayi LC, Shanmugam R, Nqeketo A. Male circumcision and its relationship to HIV infection in South Africa: Results from a national survey in 2002. S Afr Med J 2008; 98: 789-794.
2. Sidler D, Smith J, Rode H. Neonatal circumcision does not reduce HIV infection rates. S Afr Med J 2008; 98: 764-766.
3. Male Circumcision: To Cut or Not to Cut (dedicated session, 7 August). AIDS 2008 – Mexico City 3-8 August 2008 – XVII International AIDS Conference. http://www.aids2008.org/Pag/ PSession.aspx?s=41 (last accessed 8 August 2008).
4. Swaziland: Circumcision gives men an excuse not to use condoms. http://www.irinnews. org/Report.aspx?ReportId=79557 (last accessed 7 August 2008).
5. Siegfried N, Muller M, Volmink J, et al. Male circumcision for prevention of heterosexual acquisition of HIV in men. Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD003362. DOI: 10.1002/14651858.CD003362.
6. Garenne M. Long-term population effect of male circumcision in generalised HIV epidemics in sub-Saharan Africa. African Journal of AIDS Research 2008; 7(1): 1-8.
7. New study shows condoms 95 times more cost-effective than circumcision in HIV battle. http://www.prweb.com/releases/2008/08/prweb1151894.htm (last accessed 7 August 2008).
8. WHO/UNAIDS Technical Consultation Male Circumcision and HIV Prevention: Research Implications for Policy and Programming. Montreux, 6 - 8 March 2007. Conclusions and Recommendations. http://data.unaids.org/pub/Report/2007/mc_recommendations_en.pdf (accessed 25 August 2008). October 2008, Vol. 98, No. 10 SAMJ
See also A. and J. Myers, Male circumcision: The new hope?, South Africa Medical Journal, Vol. 97 (5), May 2007
The following editorial was published in the Ugandan newspaper Daily Monitor in December 2009.
A few days ago I found it necessary to restate my position, calmly and quietly, that my sons – two so far – should under no circumstances be circumcised. Two very simple and I am persuaded, logical reasons. First, while I respect the standpoint of those who argue for circumcision, I personally do not believe in it. Circumcision is such a personal affair; nobody has the right to decide for anybody else whether or not they should undergo it. And since kids are too young to appreciate the merits (probably lack of them) of a matter as personal and important as losing their foreskin, I argue that it is improper for somebody else (parent though they be) to make that decision for them, unless it is a medical emergency that has implications on their immediate survival or potency. If as adults they decide to submit to the knife, that is their responsibility.
The other reason is that the advocates of circumcision in Uganda today are advancing very lame, wrong and wholly incompetent reasons for it. Their message is two-fold: that circumcision will help protect men from contracting HIV – the virus that causes AIDS.
Secondly we are told that circumcision promotes hygiene among men. As we speak, billions of shillings have been sunk into programmes about circumcision, telling every Ugandan that this is the new miraculous discovery that will keep them safe. This lie needs to be unmasked and exposed, because we are playing with fire. Who in their right mind would believe that a man can have unprotected sexual intercourse with an infected woman and come out intact just because he is circumcised? Any argument about how hardened a circumcised male organ is and how it is able to withstand whatever period of sexual intercourse and emerge without scratches and, therefore, without possibility of infection is purely academic … and deadly.
The truth behind circumcision is that it is just a new excuse invented by unscrupulous and incompetent scientists, plus bureaucrats in the United Nations, African governments and civil society to eat free money. They have not told us who did the research, what methodology they employed or which experimentation humans they used. In the end, therefore, the current campaign for circumcision has nothing to do with your health and safety. It is all about people making money. Our young men will now believe that you can sleep with whoever it is and you’ll be safe just because you are circumcised. And they will die. Our girls will be told, “I am circumcised” and they will presume they are safe. And they will die.
Strangely enough, the protagonists of circumcision argue that it affords only a 60 per cent chance at best of avoiding the virus and that circumcision should be used “in combination” with other safety measures such as condom use. I think the ABC strategy that Uganda had adopted is good enough to help us fight AIDS. Abstain from sex, or Be faithful to your (one) partner or if push comes to shove, use a condom. For hygiene I will encourage my sons to take a bath regularly. I will also take them through another course on how a man ought to keep himself clean. For now I find it important to put the country on notice: we are being duped and as your kids bleed all the way from hospital, a small clique is laughing all the way to the bank.
Unmasking the Lie: Circumcision, Sex and HIV/AIDS
By Gawaya Tegulle
Daily Monitor (Uganda) December 12, 2009
Despite the AIDS crisis about which we hear so much, South Africa is one of the very few countries in the world that has actually passed a law regulating and to some extent prohibiting circumcision of male minors. This is a fact about which we hear very little. The relevant sections of the Children's Act (2005) are as follows.
7. (1) Whenever a provision of this Act requires the best interests of the child standard to be applied, the following factors must be taken into consideration where relevant, namely -
(l) the need to protect the child from any physical or psychological harm that may be caused by ... (i) subjecting the child to maltreatment, abuse, neglect, exploitation or degradation or exposing the child to violence or exploitation or other harmful behaviour
12. (1) Every child has the right not to be subjected to social, cultural and religious practices which are detrimental to his or her well-being
(3) Genital mutilation or the circumcision of female children is prohibited. ...
(8) Circumcision of male children under the age of 16 is prohibited, except when (a) circumcision is performed for religious purposes in
accordance with the practices of the religion concerned and in the manner prescribed; or (b) circumcision is performed for medical reasons on the recommendation of a medical practitioner.
As you can see, there are problems with this. For a start there is gross gender discrimination, in that girls are given blanket protection against any kind of harm, but boys have to make do with qualified protection. The exception for "religious purposes" allows practising Jewish and Muslim parents to circumcise without constraint, but the failure to specify the religions accorded the exemption provides a loophole for anybody who wants to invent his own religion. More seriously, the reference to "medical reasons" fails to define what they are. If they mean a situation where circumcision is necessary to treat an injury, deformity or disease that has failed to respond to conservative treatment after reasonable efforts, that is one thing and will provide a significant level of protection
If, on the other hand, they mean circumcision performed in the belief that it will reduce the risk of contracting diseases to which the child may be exposed at some later date (i.e. prophylactic or precautionary circumcision), that is quite another, and will provide no protection at all against the circumcision promoters. Most non-religious circumcision is prophylactic circumcision, but it should not be confused with therapeutic (i.e. treatment for an existing problem). It is significant that in its paper on the legal status of circumcision of male minors the Tasmanian Law Reform Institute is careful to explain that prophylactic circumcision is not therapeutic.
Still, South Africa is way ahead of Australia and most developed nations in making some attempt to crack this difficult nut.
Interestingly enough, the South African Medical Association does not consider the AIDS crisis a sufficient justification for routine circumcision of male infants or other normal male minors. In response to an inquiry from Nocirc of South Africa, the South African Medical Association stated that there was no justification for routine circumcision of infants or children. In letter to Nocirc SA, dated 4 February 2005, and signed by Professor Ed Coetzee, Chairperson of the SAMA Education, Science and Technology Committee, the Association states:
“After lengthy DISCUSSION on the matter, the Committee RESOLVED that it be conveyed to NOCIRC-SA that, from a medical point of view, there was no medical justification for routine circumcision in males and children.”
In this conclusion, SAMA joins medical authorities in Britain, Canada, the USA, Australia and New Zealand in agreeing that there is no medical case for routine circumcision. In fact, it goes slightly further than the Royal Australian College of Physicians, which states that there is “no medical indication”; SAMA says there is “no medical justification”, an even stronger rejection.
Coming from a country with an extremely high incidence of HIV infection (and also a high incidence of male circumcision), this is a significant declaration.
One of the concerns driving the South African legislation is the sad fact that each year traditional ritual circumcision of Xhosa teenagers leaves a trail of devastation: dozens of boys killed and many more injured. Appalled by the general indifference to this toll, the South African Medical Journal in 2003 called for "action to stop the carnage".
“Circumcision leaves 24 dead, 10 in hospital”, read the headline in The Star of Kuala Lumpur, Malaysia, on 16 July 2002. The report continued: “South Africa’s initiation season ended this weekend with a gruesome toll of 24 deaths reported to police and more than 100 teenagers hospitalised with gangrene and septicaemia after botched circumcisions and severe beatings. One boy’s penis dropped off as a result of gangrene, at least one other had to have his penis amputated, and another will have to have both legs amputated, authorities said”.
Similar horrifying circumcision outcomes have been observed again this year, with reports of the deaths and mutilations being beamed across the world by all the major news services. No one understands why we as a country – or as communities – have seemingly stood by and done little or nothing as these deaths rock the country year after year. Anywhere else in the enlightened world, this kind of mayhem would have evoked community outrage and led to urgent and drastic action to prevent it.
Why are we not sufficiently agitated by the slaughter to find ways to stop it? Perhaps in today’s South Africa, where violence constitutes one of the leading causes of death (including 23,000 officially acknowledged murders per annum), we have become hardened against the horror of needless death. In any event, deaths due to ritual circumcision largely occur in the impoverished and faceless rural and peri-urban communities, and those of us north of he railroad are in denial about this, just as we are about much of the other misery in that quarter. The communities themselves have perhaps come to accept these occurrences as part of their fate, along with unsafe minibus taxis and random street shootings. Middle class families from circumcising backgrounds ensure that their sons are circumcised in safe and nurturing environments. Unless this elite is moved and inspire to do something about the circumcision deaths among the less privileged, nothing will change.
A further reason for playing down the deaths may be a deep-sated fear among the affected communities (largely in the eastern Cape and the Limpopo provinces) that this hallowed ancient tradition is under threat of extinction, and that any move to modernise it may push it over the edge. Certainly, some voices coming through on radio talk shows seem much more concerned with the survival of the ritual itself (often rather broadly if inaccurately labelled “our African culture”) than about the reported deaths and mutilations.
Daniel J. Ncayiyana, Editor
South Africa Medical Journal, Vol. 93, No. 8, August 2003
In 2006 the British Medical Journal reported:
Fourteen boys have died as a result of botched circumcisions in the past month in the Eastern Cape province of South Africa. Hundreds more boys have been maimed and mutilated in the same process which takes place annually at “circumcision schools,” usually conducted in the bush, away from towns and villages. In South Africa, in many groups, boys are circumcised between puberty and adulthood, and it marks the ritualised passing from boyhood to manhood.
In the past few years, however, this “circumcision season” has been marred by untrained and bogus traditional surgeons trying to make money but whose technique lacks expertise and hygiene. The provincial department of health says that 243 deaths and 216 genital amputations from circumcisions were recorded between 1995 and 2004. Last year there were more than 20 deaths. Laws and regulations in the Eastern Cape were passed in the hope of controlling the practice and ensuring hygienic conditions. Traditional surgeons have to be officially recognised and register with the department. Surgeons caught running initiation schools without authority can be sent to prison.
Pat Sidley, Johannesburg
British Medical Journal, Vol. 333, 8 July 2006, p. 62
And the story is much the same this year: see news reports at CIRP and Circumstitions. According to the latter, there have been 53 deaths so far this year in Eastern Cape Province. Not much evidence there that circumcision is improving child health.
In a letter dated 23 June 2011, the South African Medical Association has stated that it does not support the practice of circumcision of infants as a means of preventing HIv transmission and that it considers circumcision of infants to be both unethical and illegal. The letter was signed by Ms Ulundi Behrtel, Chairperson of the Human Rights, Law and Ethics Committee. The full text of the letter follows:
23 June 2011
Mr Dean Ferris, Co-Director
National Organisation of Circumcision Information Resource Centres
Dear Mr Ferris
CIRCUMCISION OF BABIES FOR PROPOSED HIV PREVENTION
We refer to the above matter and your email correspondence of 16 February 2011. The matter was discussed by the members of the Human Rights, Law & Ethics Committee at their previous meeting and they agreed with the content of the letter by NOCIRC SA. The Committee stated that it was unethical and illegal to perform circumcision on infant boys in this instance. In particular, the Committee expressed serious concern that not enough scientifically-based evidence was available to confirm that circumcisions prevented HIV contraction and that the public at large was influenced by incorrect and misrepresented information. The Committee reiterated its view that it did not support circumcision to prevent HIV transmission. We trust that you will find this in order.
Ms Ulundi Behrtel
Head: Human Rights, Law & Ethics unit
Obo Chairperson: Human Rights, Law & Ethics Committee
SA Medical Association
A pdf of the letter is available on request through the contact form.
In 2007 the World Health Organisation recommended circumcision of adult males as an additional measure to control the spread of HIV-AIDS in African countries with high levels of HIV prevalence in the general population. The recommendation was based on limited evidence: no more than three clinical trials (in South Africa, Kenya and Uganda), the results of which appeared to show that circumcision could reduce a male’s risk of acquiring HIV through sexual intercourse with an infected female partner by a significant degree - commonly reported as 60 per cent, but subsequently estimated by the Cochrane Review as somewhere between 38 and 66 per cent.
These trials have already been the target of several critical reviews, all of which have found them flawed in many crucial areas - most importantly that they exaggerate the protective effect of circumcision, while ignoring complications, ethical and human rights issues, and harm to sexual function and body image. A new critique by George Hill and Professor Greg Boyle, in the Journal of Law and Medicine, goes further: after a careful analysis of the data reported in the published reports of the trials, finds that the protective effect of circumcision was nothing like 60 per cent. The impression of significance was achieved by reporting the risk reduction in terms of relative risk, suppressing the fact the the absolute risk reduction was pretty insignificant - probably as low as 1.3 per cent. But even as an estimate of relative risk the 60 per cent figure was an exaggeration; after correcting for lead-time bias it should be lowered to 49 per cent.
This is not the only problem. Boyle and Hill find numerous flaw in the methodology of the three trials, any one of which would be enough to cast doubt on the results:
To measure researcher expectation bias, they analysed the references the researchers used and found significantly more pro-circumcision and fewer anti-circumcision or neutral references than are available in the HIV literature. In an appendix, the authors identify no fewer than 13 studies that found no association between circumcision and HIV status, and three studies that found a greater risk of HIV infection in circumcised men. These compare with only three studies (the famous African trials that supposedly gave us the “gold standard” of proof) finding a higher risk of HIV among the uncircumcised. No prizes for guessing which studies the media have highlighted, and which they have ignored.
The authors point out that the early termination of all three trials would have amplified the protective effect of "lead-time bias" (delay by circumcised men in resuming sex). In at least four cases in the Kenyan trial, men apparently contracted HIV through circumcision. Just as seriously, in a separate trial of the effect of circumcision on male to female transmission of HIV, there appears to have been a 61 per cent relative increase in the incidence of HIV infection among the female partners of HIV-positive circumcised men.
The authors also raise serious concerns about the ethical and human rights aspects of all the trials, and especially the male-to-female trial, in that the women were not informed that their partners were HIV-positive so that they could protect themselves. “Since some men acquired HIV without reporting unprotected sexual exposures, the RCT authors had a duty of care to investigate such non-sexual transmission," they say. "Researchers controlled the information available to men so that provision of fully informed consent may have been compromised.”
Given all these problems, the authors conclude that “Male circumcision is a dangerous distraction and waste of scarce resources that should be used for known preventive measures.” It is obvious that if the circumcision solution is not the right approach for Africa's vast HIV problem, there is no shadow of an argument for the deployment of circumcision as an AIDS control measure in developed countries.
Boyle GJ, Hill G. Sub-Saharan African randomised clinical trials into male circumcision and HIV transmission: Methodological, ethical and legal concerns. Journal of Law Med and Medicine, Vol. 19, December 2011: 316-34.
According to most of the media reports, the African circumcision trials are supposed to have achieved a “60 per cent reduction” in the risk of acquiring HIV. This statement has been repeated so often that it has become a received “truth”, and has been been inflated into the totally false claim that “circumcision prevents AIDS.” Even if the data in the trials were valid, the most that could be claimed is that circumcision reduced the risk. But there are many misrepresentations in the report that the degree of risk reduction is “60 per cent”. The most serious are:
1. It is not stated that this reduction, even if true, occurs only in a highly specific context: unprotected vaginal intercourse with an infected female partner, in a population with a high level of HIV prevalence, widespread sexual promiscuity, a low level of condom use, and numerous infected females.
2. Analysis by the Cochrane review (a research unit that assesses clinical trials and similar studies)* concluded that the risk reduction was not 60 per cent at all, but somewhere between 38 and 66 per cent. On average, this would mean a risk reduction of about 50 per cent. All this means is that in a population such as that described in point 1, circumcised men who have sex with a variety of sexual partners and do not use condoms will take twice as long to get infected.
3. The magical 60 per cent figure is relative risk reduction, not actual risk reduction. What dos this mean? As Boyle and Hill explain, Across all the female to male trials, of the 5,411 men circumcised, 64 (1.18 per cent) became HIV-positive. Of the 5,497 controls (men who were not circumcised), 137 (2.49 per cent) became HIV-positive. As you can see, the actual numbers are very small (a measly 1.3%), but expressed as a percentage, the difference turns into an impressive “60%”.
There were many reasons why the circumcised sample might have presented fewer infections, including less time to get infected (since they could not have sex while the circumcision would was healing), better knowledge of safe sex from the counselling they received, and greater condom use, since they were given condoms in the counselling sessions. There is actually no proof that the observed risk reduction was the effect of circumcision, rather than factors such as these.
This is the entire extent of the evidence for circumcision having a protective effect against HIV, and the basis for billions of dollars being spent on bribing and coercing African men to get themselves and their male children circumcised, largely at the expense of Western taxpayers.
For further analysis and graphic representation of the evidence, see the deconstruction by Hugh Young at Circumstitions.com.
* Siegfried N, Muller M, Deeks JJ, Volmink J. Male circumcision for prevention of heterosexual acquisition of HIV in men (Cochrane Review). In: The Cochrane Database of Systematic Reviews; Issue 2; 2009 Apr 15. Chichester ( UK ): John Wiley; 2009.
Impact of male circumcision on HIV doubted
by Gilbert Nyambabvu
New Zimbabwe News, 22 February 2012
Dangerous distraction ... Circumcision impact questioned
MALE circumcision is a dangerous distraction in the fight against HIV/AIDS, researchers have warned insisting that contrary to widespread claims the procedure only reduces transmission rates by no more than 1.3 percent. Zimbabwe is among several countries in sub-Saharan Africa that have launched mass male circumcision campaigns after the World Health Organisation (WHO) and UNAIDS recommended the procedure in 2007 as an effective HIVAIDS preventive measure. The WHO/UNAIDS recommendation was based on clinical trials carried out in Kenya, South Africa and Uganda which suggested that circumcision could reduce female-to-male HIV transmission by up to 60 percent. Thousands of men have undergone the surgical nip and tuck since Zimbabwe launched the campaign in 2009 with promoters enthusiastically claiming that if at least 80 percent of the adult male population was circumcised about 750 000 cases of HIV infections could be prevented.
But new research has cast doubt on the supposed efficacy of the procedure with an article in the December Australian Journal of Law and Medicine citing numerous flaws in the Kenya, South Africa and Uganda studies. Researchers Gregory J. Boyle and Gregory Hill claimed the 60 percent reduction in transmission was only relative with the absolute reduction rate actually no more than 1.3 percent. Boyle and Hill said: “What does the frequently claimed ‘60 percent relative reduction’ in HIV infections actually mean? “Across all the three female-to-male trials, of the 5,411 men subjected to male circumcision, 64 (1.18 percent) became HIV positive while among the 5,497 controls 137 (2.49 percent) became HIV positive. “So the absolute decrease in HIV infection was only 1.31 percent, which is statistically not significant.” The authors of the article insisted that the WHO/UNAIDS recommendation “uncritically accepted” the findings of the Kenya, South Africa and Uganda trials, in the process ignoring a vast body of contradictory evidence.
“Examination of epidemiological data shows that male circumcision does not provide protection against HIV transmission in several sub-Saharan African countries including Cameroon, Ghana, Lesotho, Malawi, Rwanda and Tanzania all of which have higher prevalence of HIV infection among circumcised men,” they said. “In Malawi, the HIV prevalence rate is 13.2 percent among circumcised men and 9.5 percent among those who are intact. (Again) in Cameroon prevalence among those circumcised is 5.1 percent compare to 1.5 percent for those who are intact. “If male circumcision reduces HIV transmission as the trials claim then why is HIV prevalence much higher in the United States (where most men are circumcised) than in developed countries where most men are intact (such as Europe, the United Kingdom and Scandinavia)?”
The article warns that relying on male circumcision in the fight against HIV/AIDS is especially dangerous for sub-Saharan Africa women because circumcised men could still acquire and transmit the virus to their sexual partners. “Evidence suggests that mass circumcision programs may exacerbate the HIV epidemic among women (and) under these circumstances it would be irresponsible and unethical to advocate mass circumcision programmes in southern Africa,” the article concludes. “Male circumcision is a dangerous distraction and a waste of scarce resources that should be used for known preventive measures (such as condoms which are 80 percent effective.”
In a hard hitting editorial that raises the spectre of neocolonialism, the South African Medical Journal has condemned the push for mass circumcision of African men as the solution to the nation’s HIV-AIDS problem. The editorial, by the journal editor Professor Daniel Ncayiyana, reviews the evidence for the claim that circumcision reduces the risk of female-to-male infection, and finds it less conclusive than assumed (and far less significant than regularly proclaimed in sensationalist newspaper headlines). The weakness of the case arises partly because the three clinical trials on which it is based were terminated prematurely, and partly because surveys show no consistency in the pattern of HIV infection among circumcised and uncircumcised men. (In some places there is little difference, and in some the incidence of HIV is higher in circumcised men.) There is certainly nothing in the results of the trials to justify the wild claim that circumcision provides “lifelong protection” against HIV; the most that could be said is that in areas of high HIV prevalence circumcision reduces the risk of female-to-male transmission in unprotected intercourse. Despite the much-touted “60 per cent” figure, nobody really knows the extent of the risk reduction in real world situations. Circumcision provides no protection to homosexual men or injecting drug users, and may increase the risk of male-to-female transmission.
The editorial warns that an excessive and disproportionate focus on expensive surgical interventions such as circumcision will discourage condom use (known to be 90 per cent effective against HIV transmission) and deplete the resources needed in other critical health areas (such as malaria and tuberculosis). Already there is evidence that many men believe that the chief advantage of circumcision is that they will no longer have to wear condoms. At the same time, promoters of the circumcision solution still insist on condom use even after circumcision. Clearly, as Van Howe and Storms point out, this demand implies lack of faith in their own prescription: “Circumcision is either inadequate (otherwise there would be no need for continued condom use) or redundant (as condoms provide nearly complete protection).” * The editorial urges South Africa to follow the recommendation of the Australian Federation of AIDS Organisations, which has rejected circumcision and reiterated that “correct and consistent condom use … is the most effective means of reducing female-to-male transmission, and vice-versa.” **
Raising the spectre of human rights abuses and colonialism, the editorial is particularly concerned at the push for universal circumcision of infants and children, despite the fact that the South African Children’s Act specifically prohibits circumcision of boys under the age of 16 years. The editorial notes that much of the push for circumcision in Africa comes not from native Africans, but from international aid agencies dominated by United States funders and policy-makers, and that many programs are funded by the vastly wealthy Bill and Melinda Gates Foundation. It comments that it is “curious and even worrisome that the campaign to circumcise African men seems to be driven by donor funding and research from the North.”
Mutilation of African native bodies by white and Arab slave traders and other exploiters was a sad feature of African experience in the dark days of colonialism, before the various nations achieved independence. In more modern times, western pharmaceutical companies have treated African and other “Third World” peoples as convenient guinea pigs on which to test their drugs – often with tragic results. It is strange to see such similar practices being revived and enforced by benevolent white medical missionaries, but their determination to carve their mark on the bodies of African men certainly looks like a new and particularly insidious form of cultural imperialism.
Source: “Editorial: The illusive promise of circumcision to prevent female-to-male HIV infection: Not the way to go for South Africa”. South African Medical Journal, Vol. 101, November 2011, 775-776.
* Van Howe RS, Storms MR. How the circumcision solution in Africa will increase HIV infections. Journal of Public Health in Africa 2011;2:e4. doi:10.4081/jphia.2011.e4
A study of Nigerian prostitutes in 1988 found that, after counselling sessions, condom use increased markedly and that even occasional condom use had a significant protective effect: of 28 women who never used a condom, only eight escaped infection with HIV; but of 50 women who used them in approximately one third of sexual encounters, 27 (54 per cent) avoided infection. It is instructive to compare this with the results of the recent clinical trials of circumcision, which reported a risk reduction of between 50 and 60 per cent: about the same as the risk reduction achieved by condom use 30 per cent of the time. See E.N. Ngugi et al, “Prevention of transmission of human immunodeficiency virus in Africa: Effectiveness of condom promotion and health education among prostitutes”. Lancet, Vol. 332, No. 8616, 15 October 1988, 887-890.
** Australian Federation of AIDS Organizations. Male circumcision has no role in the Australian HIV epidemic. Briefing Paper, 23 July 2007. Available at http://www.afao.org.au/__data/assets/pdf_file/0019/4528/BP0709_Circumcision.pdf
Health officials in Zimbabwe are worried that the massive drive to have 1, 2 million men circumcised by 2015 might backfire following indications that HIV prevalence is higher among men that have undergone the procedure. According to [very limited] research, circumcision reduces the transmission of the HIV virus by 60 percent [actually, by an unknown factor, believed to be somewhere between 38 and 66 per cent] among heterosexual men. But the latest Zimbabwe Health Demographic Survey (ZHDS 2010/2011), indicates that the HIV prevalence rate among circumcised men is 14 percent but only 12 percent among the uncircumcised. The findings are for circumcised males between the ages of 15 and 49. This is blamed on the misconception that circumcision completely shields people from HIV infection.
National Aids Council (NAC) public health officer Blessing Mutede said authorities were concerned about the high rate of infection among the circumcised. Health officials say most men, after circumcision, harbour the false impression that they have been equipped with an invisible condom. “It is a worrying development that at a time when we are promoting male circumcision as a preventive measure to combat HIV, we are recording a high prevalence rate amongst the group that has been circumcised largely due to uninformed risky compensatory behaviours,” Mutede said.
Source: The Africa Report, 22 July 2012
Meanwhile, Mugabe's health advisor, Timothy Stamps, has rubbished claims that male circumcision reduces HIV and Aids prevalence rate at a time the country had embarked on a foreskin cutting crusade, ostensibly to lessen chances of contracting the deadly disease. The former minister of health said circumcision did not make any difference to the adult prevalence rate, noting researches had shown that countries with a higher number of circumcised men, like the US, also had a high HIV prevalence rate. He said instead of channelling funds towards circumcision, the money must be used to save pregnant mothers who die in huge numbers in this country. “When we are losing 960 mothers for every 100 000 pregnancies, should circumcision be a priority?” said Stamps. He said circumcision had led to men being more reckless in sleeping around. “Young men are happier to take risks and chances without the use of condoms or any other preventive measures because they are told circumcision will protect them,” he said.
Source: All Africa News, 22 July 2012
This diagram shows that the incidence of HIV infection is consistently higher among circumcised men in Zimbabwe, and that while there has been s slight reduction in the over all incidence of HIV infection since 2005, the reduction has been just as great among the uncircumcised as among the circumcised.
Recent reports from African countries that have pursued ambitious American-funded circumcision campaigns in the belief that they would solve their HIV-AIDS problem show that circumcision is not reducing the incidence of infection, but (as in parts of Kenya) actually increasing it. At the same time, opposition to the programs is growing, especially in Zimbabwe, where critics have accused the (highly authoritarian) government of misleading propaganda and unethical efforts to circumcise boys and infants rather than consenting adults. (This is contrary to the original recommendations of the World Health Organisation, which stressed that circumcision should be performed only as a free, informed choice, and that programs should be conducted in accordance with human rights principles.)
In Zimbabwe critics of the American-funded circumcision campaign have accused the (authoritarian) government of misleading propaganda and unethical efforts to circumcise boys and infants rather than consenting adults. As in several African countries, the testing and circumcision procedures are being carried out by Population Services International, a US-based global health agency. One of their methods of persuading boys and adolescent to get circumcised is to send actors and entertainers into schools. Dr. Karin Hatzold, deputy head of PSI Zimbabwe said: “We have campaigns that are specifically targeting adolescents, people in schools — so during school holidays we are doing massive mobilisations on mass media. So get smart, get circumcised. Male circumcision is not only HIV prevention intervention, but it is improving hygiene, you are cleaner, you are smarter.” But some Zimbabweans have complained that such tactics were unethical in that the propaganda gave a false sense of security, failed to mention the risks and harms of circumcision and put pressure on schoolboys that amounted to coercion.
Raymond Majongwe, a National Aids Council board member, said the media campaigns on male circumcision were mischievous in that they give a false sense of security to those who would have gone under the knife. “They then think they are macho and can go on bedding girls. It is like a licence to be promiscuous. I also do not believe in those said “celebrities” that are being used to promote the idea. Stunner for example, is another male circumcision ambassador who after being circumcised went on to shoot a sex video that went viral, exposing his circumcised manhood,” Majongwe said. He added that he has always been skeptical of the on-going male circumcision campaigns.
Supporting Majongwe’s views is the Matobo senator Sithembile Mlotshwa who has called on the ministry of Health and Child Care to stop circumcising children under the 2009 medical male circumcision programme. “In our constitution, everyone is born with a right to life and I think it is wrong for a father and mother to sit down and decide to circumcise this young child who is a month old whereas the father was circumcised at the age of 40. This circumcised man's parents gave him all these years to mature and know the uses of all the organs of his body so as to decide how best to remake what is God-given. So then why does this person want to agree with his wife to circumcise an infant who is a third person who has a right to be fully developed as he is so that he makes his own decisions about his body organs?” Mlotshwa believes children should be allowed to make their own choices when they grow up instead of being circumcised under this programme funded by international donors. “I want to take our minister of Health to task because I believe that you don't have to circumcise infants.”
A other member of parliament, Jessie Fungayi Majome said it is a sad or happy (depending on the circumstances) fact of life that children are bundled with the fate and decisions of their parents. “To cut or not to cut must be decided according to which of the two is in the best interests of the child as required in our new Constitution.” Since the authorities insisted that men should still wear a condom even after getting circumcised, it was obvious that the protection given could not be all that great. “I think more research must be done to give objective knowledge of the pros and cons of male circumcision.”
Political activist Tabani Moyo said that “those agitating circumcision should engage in ethical advertising by outlining the dangers that come with the process so that when people decide to do it, they do so with all the critical information at hand. At the moment, there is too much high voltage advertising which borders on deceit that might end up leading to unintended consequences as the adverts seem to give an impression that your chances of getting HIV/Aids for example are reduced, this is irresponsible advertising.”
Child circumcision ignites debate. Bulawayo 24 Hours, 25 May 2014.
Meanwhile in Kenya, following the arrival of large sums of American cash, the authorities set a target of increasing the number of circumcised men from 85 to 94 per cent. Unfortunately, the governments on studies show that circumcision is not reducing the incidence of HIV, but that infections actually increasing in the regions where the circumcision program has been most successful. As a Kenyan newspaper reports: “Most studies on male circumcision, including the Kenya Aids Indicator Survey 2013 (KAIS), have so far concentrated on the quantity of procedures but none has shown it is achieving its primary objective of reducing HIV infections. Started almost seven years ago, on the promise that it could reduce the risk of infection by 60 per cent, the KAIS report showed a spike in prevalence in places like Nyanza where the circumcision programme is most intense.” If Kenya already had a severe HIV epidemic with 85 per cent of the male population circumcised, it is hard to see how circumcising a further 9 per cent is going to make any difference.
Gatonye Gathura. Male cut staff overwhelmed with work. Standard Digital (Kenya), 22 May 2014.
See also Joseph 4GI, Mass circumcision campaigns: The emasculation and harassment of Africa.
In Kenya, circumcision and other forms of sexual violence and genital mutilation are being used to terrorise minority groups and political opponents of the dominant tribal elites. This is the alarming conclusion of a study published in the journal Ethnicity and Health, which also reports that the US-led push for mass circumcision in Africa as a tactic against HIV-AIDS is producing major violations of human rights and doing little for health. In Kenya the majority of the population belong to tribal groups that traditionally practice circumcision as an initiation ritual in late childhood. There are, however, several minority ethnic groups that do not practise circumcision, and these have been subject to various forms of oppression and mistreatment by the majority, including forced circumcision, sometimes by mobs who kidnap men in the street, as Michael Glass reported in the Journal of Medical Ethics last year. These outrages are clearly a form of sexual violence against males and a blatant violation of both civil law and human rights principles, and further evidence that the US-funded campaign for mass circumcision in Africa is leading to shameful abuses and placing vulnerable minorities at the mercy of their traditional enemies: the law of unintended consequences at work. It is disgraceful that international human rights agencies have been silent on these developments. The Abstract of the paper follows.
Background. As a contribution to ongoing research addressing sexual violence in war and conflict situations in the Democratic Republic of Congo, Kenya and Rwanda, this paper argues that the way sexual violence intersects with other markers of identity, including ethnicity and class, is not clearly articulated. Male circumcision has been popularized, as a public health strategy for prevention of HIV transmission, although evidence of its efficacy is disputable and insufficient attention has been given to the social and cultural implications of male circumcision
Methods. This paper draws from media reporting and the material supporting the prosecutor at the International Criminal Court case against four Kenyans accused of crimes against humanity, to explore the postelection violence, especially forcible male circumcision.
Results. During the postelection violence in Kenya, women were, as in other conflict situations, raped. In addition, men largely from the Luo ethnic group were forcibly circumcised. Male circumcision among the Gikuyu people is a rite of passage, but when forced upon the Luo men, it was also associated with cases of castration and other forms of genital mutilation. The aim appears to have been to humiliate and terrorize not just the individual men, but their entire communities. The paper examines male circumcision and questions why a ritual that has marked a life-course transition for inculcating ethical analysis of the self and others, became a tool of violence against men from an ethnic group where male circumcision is not a cultural practice.
Conclusion. The paper then reviews the persistence and change in the ritual and more specifically, how male circumcision has become, not just a sexual health risk, but, contrary to the emerging health discourse and more significantly, a politicized ethnic tool and a status symbol among the Gikuyu elite. In the view of the way male circumcision was perpetrated in Kenya, we argue it should be considered as sexual violence, with far-reaching consequences for men’s physical and mental health.
Source: Beth Maina Ahlberg and Kezia Muthoni Njoroge. ‘Not men enough to rule!’: Politicization of ethnicities and forcible circumcision of Luo men during the post-election violence in Kenya. Ethnicity and Health, Vol 18 (5), 2013. DOI http://dx.doi.org/10.1080/13557858.2013.772326
In a related paper, Robert Darby considers the parallels between responses to syphilis in Victorian Britain and HIV-AIDS in contemporary Africa, and finds that circumcision was recommended in both cases for reasons that had little to do with an objective assessment of the value of the surgery, but had everything to do with cultural prejudice. He points out that many African countries hit hard by AIDS already had high rates of circumcision and that the majorities in these places welcomed the US-sponsored circumcision campaign as an excuse to force their non-circumcision minorities into line.
In this paper, I discuss the parallels between responses to syphilis in nineteenth century Britain and HIV/AIDS in contemporary Africa. In each case, an incurable disease connected with sexual behaviour aroused fear, stigmatisation and moralistic responses, as well as a desperate scramble to find an effective means of control. In both cases, circumcision of adult males, and then of children or infants, was proposed as the key tactic. In the ensuing debates over the effectiveness and propriety of this approach, three questions occupied health authorities in both Victorian Britain and the contemporary world: (1) Were circumcised men at significantly lower risk of these diseases? (2) If there was evidence pointing to an affirmative answer, was it altered anatomy or different behaviour that explained the difference? (3) Given that circumcision was a surgical procedure with attendant risks of infection, was it possible that circumcision spread syphilis or HIV? I show that in both situations the answers to these questions were inconclusive, argue that circumcision played little or no role in the eventual control of syphilis and suggest that attention to nineteenth century debates may assist contemporary policy-makers to avoid the treatment dead-ends and ethical transgressions that marked the war on syphilis.
Source: Robert Darby. Syphilis 1855 and HIV-AIDS 2007: Historical reflections on the tendency to blame human anatomy for the action of micro-organisms. Global Public Health, Advance access, 30 September 2014. http://dx.doi.org/10.1080/17441692.2014.957231
Malawians have questioned the motives of the United States and other Western NGOs that are promoting circumcision despite evidence showing that the questionable initiative does not reduce HIV as claimed. Vetting their anger and frustrations on social media, the people took to task the US for “prioritizing sex” and not real development. The US announced a $6.8 million (K3.8 billion) aid to support male circumcision which the US Ambassador to Malawi, Virginia Palmer, said has “has potential” to curb the spread of HIV.
But all the comments that Malawi24 monitored on a story published by one of the local online publications expressed dismay at the focus of the aid, with many hinting that circumcision is not an effective means to fighting the spread of HIV. Athoko Chisale Mbewe wrote “American government is a joke. Chinese are giving money for development and all this ambassador cares about is sex? Ha ha ha …. if you want my foreskin I will trade it for K500,000.00. FYI My uncle has HIV /aids but he is circumsized”. While approving Athoko’s comment, Emmanuel Samikwa said that evidence from the Eastern region of the country back studies which question the credibility of circumcision to reduce HIV. Circumcision is common in the region, particularly among the Yao people, with people being circumcised during childhood.
Most commentators made comparison between the support that the US and China are providing Malawi. The people called on the US to support initiatives that would savage Malawi’s ailing economy. “$6.8M for what?? Of all problems Malawi is facing, they think Male circumcision is top priority??. Why cant they learn from their Chinese counterparts?? This is laughable” posed Joseph Mutupha. Jonathan Pierre Ng’oma also urged the US to reflect on the priorities of its aid: “Come on, do we need money for such useless exercise? Our economy is in total shamble, will that going to help our economy?” Like others before him, Abram Nkasala commented by questioning the logic of the US to support circumcision which he observed is encouraging more people to engage in sex after circumcision, putting them at higher risk of infection. “Malawi needs food not jando this is encouraging AIDS because people are not caring after circumsion.People in Nsanje, Zomba are dying now”.
Malawi24 previously revealed that there is not conclusive evidence to support claims that male circumcision reduce HIV infection. The Malawi Demographic and Health Survey, a study conducted in 2010 by country’s National Statics Office, also found that circumcised males were more likely to get HIV in Malawi. Another recent report also revealed that the HIV prevalence rate had doubled in Thyolo, one of the areas where medical circumcision was first rolled out in the country.
Kondwani Mkhalipi-Manyungwa, Malawians blasts the US: “We don’t need aid for circumcision”. Malawi24, 25 October 2015
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