The article by Crucitti et al.[1] evaluated five PCR techniques for
Trichomonas vaginalis including the one published by our group (Mayta et al. [2]). The authors however did not follow the protocol we published
and so got results that we consider to be erroneous.
In our work we used
simple Taq polymerase while Crucitti used Taq gold for this purpose. He
did this without chang...
The article by Crucitti et al.[1] evaluated five PCR techniques for
Trichomonas vaginalis including the one published by our group (Mayta et al. [2]). The authors however did not follow the protocol we published
and so got results that we consider to be erroneous.
In our work we used
simple Taq polymerase while Crucitti used Taq gold for this purpose. He
did this without changing or proving that the same cycle conditions will
provide similar sensitivity. In our studies using the same cycles Taq
gold is rarely positive and frequently gives negative results even when
the culture is positive. In addition, they used a DNA extraction that was
different from the one we used for our Trichomonas study.
In the article by Crucitti et al. the primer set TV1/TV2 was found to
be less sensitive presumably due to the use of an untried new protocol.
We feel strongly that unless the authors follow the original protocol
their results for the PCR sensitivity are not valid. In any comparative
study of methods the published protocol should be followed and not
modified without validation. This appears not to be done by Crucitti et al.
References
(1) T Crucitti, E Van Dyck, A Tehe, S Abdellati, B Vuylsteke, A Buve, and M Laga. Comparison of culture and different PCR assays for detection of Trichomonas vaginalis in self collected vaginal swab specimens. Sex Transm Infect 2003; 79: 393-398.
(2) Mayta H, Gilman RH, Calderon MM, et al. 18S Ribosomal DNA-based PCR for diagnosis of Trichomonas vaginalis. J Clin Microbiol 2000;38:2683–7.
Nicola Low [1] is right to highlight the need to consider the number
of HIV diagnoses made in Britain in each ethnic group in light of the size
of that ethnic group.
For some years we have been told ad infinitum that
the number of diagnoses of heterosexually acquired HIV has ‘out-stripped’
the number of homosexually acquired diagnoses, as if that indicated some
kind of equivalence of impa...
Nicola Low [1] is right to highlight the need to consider the number
of HIV diagnoses made in Britain in each ethnic group in light of the size
of that ethnic group.
For some years we have been told ad infinitum that
the number of diagnoses of heterosexually acquired HIV has ‘out-stripped’
the number of homosexually acquired diagnoses, as if that indicated some
kind of equivalence of impact on heterosexually and homosexually active
adults. Even if all the heterosexually acquired infections being diagnosed
in Britain were acquired in Britain (which they are not), the homosexually
active population is tiny compared to the heterosexually active.
Low herself makes the same oversight among Caribbeans in Britain, not
even alluding to the disproportionate impact of HIV on gay men in the
Caribbean or in the UK. If we estimate that among Caribbeans in Britain:
there are equal numbers of men and women; 75% of the population are adult;
and that the prevalence of male sexual activity is as in the general
population [2] with 91.0% having sex with women and 2.6% having sex with
men, in 2001 [3] the HIV diagnoses rates per 100 000 were 31.1 among all
adult Black Caribbeans, 23.7 among all females and 35.7 among all males.
Further, it was 25.9 among heterosexually active men but 924.4 among
homosexually active men. This latter is 30 times the rate for all
Carribean adults in the UK.
The fact that, among Caribbeans, the majority of heterosexually
acquired infections are migratory and the majority of homosexually
acquired infections occurred in Britain [3] makes this inequality even
more acute. The HIV epidemic among all ethnicities in Britain very
disproportionately effects homosexually active men yet this continue to be
an afterthought for public health and policy. The need to resist this
obscurantism is even greater among Black communities in Britain where
sexism (and the corresponding heterosexism) is even stronger than in the
White majority.
The group most likely to acquire HIV in Britain are Black African gay
men and Black Caribbean gay men. The small size of these groups is no
excuse for ignoring their needs. It is imperative that British HIV prevention programmes for Black people
over-serve gay and bisexual men, and that programmes for gay and bisexual
men over-serve Black men, if these groups are not to continue to be the
least served.
References
1. Low N. HIV infection in black Caribbeans in the United Kingdom.
Sexually Transmitted Infections. 2004; 80, 2-3.
2. Johnson AM, Mercer CH, Erens B et al. Sexual behaviours in Britain:
partnerships, practices and HIV risk behaviours. Lancet. 2001; 358 (9296),
1835-1842.
3. Dougan S, Payne LJC, Brown AE et al. Black Caribbean adults with HIV
in England, Wales and Northern Ireland: an emerging epidemic. Sexually
Transmitted Infections. 2004; 80, 18-23.
I agree with Dr Carne that the requirement to offer 90% (next year
100%) of our new patients an HIV test precludes us from offering everyone
discussion about the HIV test as recommended by the UK Departments of
Health in their Guidelines on HIV Pre-test Discussion.[1] However, the
guidelines still include the statement that for, "individuals actively
seeking an HIV test for the first occasion, here a...
I agree with Dr Carne that the requirement to offer 90% (next year
100%) of our new patients an HIV test precludes us from offering everyone
discussion about the HIV test as recommended by the UK Departments of
Health in their Guidelines on HIV Pre-test Discussion.[1] However, the
guidelines still include the statement that for, "individuals actively
seeking an HIV test for the first occasion, here a pre-test discussion
session involving all 5 stages is desirable, supplemented by written
information." Is it desirable that we feel we can only ignore guidelines
from the Departments of Health?
Of course the guidelines are nearly eight-years-old now and much has
changed in that time. The involvement of the BASHH HIV Special Interest
Group seems a good suggestion; perhaps it would like to collect some
examples of written HIV pre-test information, produce a version that would
be valuable to both Genito-Urinary Medicine and Primary Care and meet with
the Departments of Health to agree 21st century guidelines.
I agree that presenting an appropriate amount of written information
to substitute for an HIV pre-test discussion is problematical. We
introduced such a system with some misgivings but felt that it was the
only way that we could comply with the Royal College of Physicians second
Speciality Specific Standard without seriously disrupting the se...
I agree that presenting an appropriate amount of written information
to substitute for an HIV pre-test discussion is problematical. We
introduced such a system with some misgivings but felt that it was the
only way that we could comply with the Royal College of Physicians second
Speciality Specific Standard without seriously disrupting the service.[1]
In writing our handout I bore in mind the statement in the Department
of Health guideline he refers to that "the extent of provision of pre-test
discussion reflects the varying needs of different clinical situations".[2] I have interpreted this to mean that for low-risk, non-anxious
patients not all five aspects of the pre-test discussion are mandatory.
After reading our handout patients are asked to indicate at the
bottom whether or not they wish to take a test, or whether they would like
further discussion. A sexual history is taken from all patients and all
are asked if they have injected drugs. The health care worker may cover
certain points of the pre-test discussion if they feel it is appropriate
even if the patient has not indicated a wish for this. Having used the
system for over one year my informal assessment is that it works well.
I am happy to provide a copy of our handout on request for what it is
worth. It may be that the HIV Special Interest Group might consider
producing a more definitive version.
It appears as if the lesion is present on the dorsal aspect of the
penis since the fingers at the root of the penis rotating it are not seen.
Actually the lesion was present on the ventral aspect of the penis only.
Since the penis was rotated by 90 degree at its root for easy photography,
in the photograph it looks different. So the legend put for the figure is
correct.
In this otherwise excellent description the site of the lesion is
referred to as ventral, when it should be dorsal. In the anatomical
position, the penis is erect.
This article, and that by Bradbeer and Mears, are to be applauded.
Their value will be all the greater if specific examples of the
recommendations are shared and adopted by the specialty. In particular I
would be interested to see a brief information sheet that can replace
verbal discussion about HIV testing and still deliver the recommended five
main components of pre-test discussion.[1] I have tried...
This article, and that by Bradbeer and Mears, are to be applauded.
Their value will be all the greater if specific examples of the
recommendations are shared and adopted by the specialty. In particular I
would be interested to see a brief information sheet that can replace
verbal discussion about HIV testing and still deliver the recommended five
main components of pre-test discussion.[1] I have tried to produce such
a document. It has been called many things but never, “brief”!
References
(1) Carne CA. STI services in the United Kingdom: a way forward. Sex Transm Infect 2003; 79: 439-441.
(2) Bradbeer C, Mears A. STI services in the United Kingdom: how shall we cope? Sex Transm Infect 2003 79: 435-438.
Kebaabetswe et al0. obviously believe the conventional wisdom that heterosexual sex is the major vector for the transmission/reception of human immunodeficiency virus (HIV), and that male circumcision is an effective deterrent to infection.[1]> Based on that belief, they have constructed an elaborate and impressive study of the acceptability of circumcision as a prophylactic measure in Botswana. Fu...
Kebaabetswe et al0. obviously believe the conventional wisdom that heterosexual sex is the major vector for the transmission/reception of human immunodeficiency virus (HIV), and that male circumcision is an effective deterrent to infection.[1]> Based on that belief, they have constructed an elaborate and impressive study of the acceptability of circumcision as a prophylactic measure in Botswana. Furthermore, they argue for a program of neonatal circumcision in Botswana in hope of reducing the HIV infection rate fifteen years later.[1]
Discussion
It has been believed since about 1988 that heterosexual coitus accounts for 90 percent of the HIV infection in Africa.[2,3] Many studies do argue that circumcision can reduce the transmission of HIV through heterosexual coitus. The quality of these studies has been criticized for their methodological flaws, including their failure to control for numerous confounding factors.[4]
Gray et al. found that transmission by coitus “is unlikely to account for the explosive HIV-1 epidemic in sub-Saharan Africa.[6] It now appears that these studies have not accounted for the largest confounding factor of all—iatrogenic transmission of HIV. Earlier this year the International Journal of STD & AIDS published a trilogy of articles.[3,7,8] These articles, which strongly argue that unsafe health care practices, especially non-sterile injections—not heterosexual intercourse—are the principal vectors by which HIV is transmitted. A program of mass circumcision would be ineffective against iatrogenic transmission of HIV through unsafe health care.
Heterosexual transmission of HIV that one sees in Africa also cannot explain the incidence of HIV in children.[3,9]
Circumcision has some little known effects that may to promote rather than deter HIV infection
The human foreskin has physiological functions designed to protect the human body from infection. The sub-preputial moisture contains lysozyme,[10] an enzyme that attacks HIV.[11] Circumcision destroys this natural protection.
Circumcision removes erogenous tissue,[12] desensitizes the penis,[13] changes sexual behavior and makes males more likely to engage in unsafe sex practices.[14] Circumcised males, therefore, are less willing to use additionally desensitizing condoms.[5]
Male circumcision produces hardened scar tissue that encircles the shaft of the penis. The scar scrapes the inside of the partner’s vagina during coitus and, therefore, may enhance the transmission/reception of HIV.
A program of mass circumcision would expose African males to unsafe genital cutting,[4] would destroy the natural protection of the foreskin,[10] would not be effective against iatrogenic unsafe health care,[4] would divert scarce medical and social resources from measures of proven effectiveness,[5] and, therefore, is likely to increase the transmission of HIV.[5]
The proportion of HIV infection attributable to heterosexual intercourse has been placed at 90 percent.[9] Gissellquist & Potterat now estimate the proportion attributable to heterosexual intercourse at only about 30 percent.[8] —only one-third of the previous estimate.
Circumcision has not yet been shown to be an effective deterrent against HIV infection.[5] The Council on Scientific Affairs of the American Medical Association says that “circumcision cannot be responsibly viewed as ‘protecting’ against such infections.”[15] The Task Force on Circumcision of the American Academy of Pediatrics identifies behavioural factors, not lack of circumcision, as the major cause of HIV infection.[16]
The article by Kebaabetswe et al. seems to show a strong cultural bias on the part of the authors in favour of circumcision. This may be due to their desire to preserve their culture of origin.[17]
Bioethics and Human Rights
Finally, we would like address on legal and ethical issues. As noted above, male circumcision excises a large amount of functional healthy erogenous tissue from the penis.[12] It is a clear violation of the basic human right to security of the person.[18]
Several authorities report that circumcision degrades the erectile function of the penis.<_1920 circumcision="circumcision" therefore="therefore" must="must" be="be" regarded="regarded" as="as" degrading="degrading" treatment.="treatment." treatment="treatment" is="is" an="an" additional="additional" violation="violation" of="of" human="human" rights.21="rights.21" p="p"/>The leading international statement of medical ethics is the European Convention on Human Rights and Bioethics.[21] Article 20(1) prohibits non-therapeutic tissue removal from those who do not have the capacity to consent. Children have a right to the protection of the security of their person[18,22] and to protection from degrading treatment.[21,23] Circumcision would violate those human rights. Doctors must respect patient human rights.[24] Prophylactic circumcisions ethically may not be carried out on minors. Circumcisions, therefore, would have to be limited to adult males who legally may give informed consent.
Political Factors
Ntozi warns:
It is important that, while circumcision interventions are being planned, several points must be considered carefully. If the experiment fails, Africans are likely to feel abused and exploited by scientists who recommended the circumcision policy. In a region highly sensitive to previous colonial exploitation and suspicious of the biological warfare origin of the virus, failure of circumcision is likely to be a big issue. Those recommending it should know how to handle the political implications.[25]
Approval of circumcision by the surveyed Botswana people apparently is based on their belief that circumcision is efficacious in preventing the spread of HIV. If circumcision fails to control HIV, there would be disillusionment and anger. African males would have sacrificed their erogenous tissue for a false hope of preventing HIV infection. There is no evidence that Kebaabetswe et al. have considered the political issues that would arise if a circumcision experiment should fail.
Conclusion
Kebaabetswe et al. propose the universal circumcision of male children in Botswana. They accept without question that HIV is primarily sexually transmitted in Africa by heterosexual coitus and that circumcision reduces or prevents the transmission of HIV,[1] however, medical authorities do not accept the evidence of this.[4,5,15]
Kebaabetswe et al. propose to provide in-hospital circumcision of male children in Botswana.[1] However, there is already a substantial incidence of infection amongst children in South Africa due to iatrogenic infection from non-sterile injections, etc.[2,9] They have not shown that safe, aseptic circumcisions can be delivered in Botswana. A program of mass circumcision, would destroy the natural protections of the foreskin, further expose children to an apparently unsafe health care system, and would be more likely to increase infection than decrease infection.
Even if circumcision eventually should be shown to provide some protection against HIV infection, that protection could only work to reduce the 30 percent of infections that now are attributed to sexual activity. It would have no effect on the other 70 percent. Its effect, therefore, would be minimal at best and could not have an effect for the first fifteen years,[1] during which time behavioral changes could be introduced into society through education, and a HIV vaccine could be developed to provide immunity.
Circumcision of male children with the intent of reducing an epidemic not of their making is unacceptable from medical, ethical, and legal perspectives. As a public health measure, male neonatal circumcision fails all tests.[26]
(1) Kebaabetswe, Lockman S, Mogwe S, et al. Male circumcision: an acceptable strategy for HIV prevention in Botswana. Sex Transm Inf
2003;79:214-9.
(2) Gisselquist D, Rothenberg R, Potterat J, Drucker E. Non-sexual transmission of HIV has been overlooked in developing countries. BMJ
2002;324:235.
(3) Gisselquist D, Potterat JJ, Brody S. Let it be sexual: how health care transmission of HIV was ignored.. Int J STD AIDS
2003;14:148-61. URL: http://www.rsm.ac.uk/new/std148main.pdf
(4) de Vincenzi I, Mertens T. Male circumcision: a role in HIV prevention? AIDS
1994;8(2): 153-16.
(5) Van Howe RS. Circumcision and HIV infection: review of the literature and meta-analysis. Int J STD AIDS
1999;10:8-16.
(6) Gray RH, Wawer MJ, Brookmeyer R, et al. Probability of HIV-1 transmission per coital act in monogamous, heterosexual, HIV-1-discordant couples in Rakai, Uganda. Lancet 2001;
357: 1149-53.
(7) Brewer DD, Brody S, Drucker E, et al. Mounting anomalies in the epidemiology of HIV in Africa: cry the beloved paradigm. Int J STD AIDS 2003;14:144-7. URL:
http://www.rsm.ac.uk/new/std144intro.pdf
(8) Gisselquist D, Potterat JJ. Heterosexual transmission of HIV in Africa: an empiric estimate. Int J STD AIDS
2003;14:162-73. URL:
http://www.rsm.ac.uk/new/std162stats.pdf
(9) Brody S, Gisselquist D, Potterat JJ, Drucker E. Evidence of iatrogenic HIV transmission in children in South Africa. Br J Obstet Gynaecol
2003;110:450-2. URL:
http://www.cirp.org/library/disease/HIV/brody1/
(10) Fleiss P, Hodges F, Van Howe RS. Immunological functions of the human prepuce. Sex Trans Inf
1998;74:364-367.
(11) Lee-Huang S, Huang PL, Sun Y, et al. Lysozyme and RNases as anti-HIV components in beta-core preparations of human chorionic gonadotropin. Proc Natl Acad Sci USA
1999;96(6):2678-2681.
(12) Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol
1996;77:291-29
(16) Task Force on Circumcision, American Academy of Pediatrics . Circumcision Policy Statement. Pediatrics
1999;103(3):686-93. URL:
http://www.aap.org/policy/re9850.html
(17) Goldman R. The psychological impact of circumcision. BJU Int 1999;83 Suppl. 1:93-103.
(18) Article 3, Universal Declaration of Human Rights, G.A. res. 217A (III), U.N. Doc A/810 at 71 (1948).
(19) Coursey JW, Morey AF, McAninch JW, et al. Erectile function after anterior urethroplasty. J Urol
2001;166(6):2273-6.
(20) Fink KS, Carson CC, DeVellis RF. Adult Circumcision Outcomes Study: Effect on Erectile Function, Penile Sensitivity, Sexual Activity and Satisfaction. J Urol
2002;167(5):2113-2116.
(21) Article 5, Universal Declaration of Human Rights, G.A. res. 217A (III), U.N. Doc A/810 at 71 (1948).
(22) Council of Europe. Convention for the Protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine. Adopted at Oviedo, 4 April 1997.
(23) Article 37, U.N. Convention on the Rights of the Child (1989). UN General Assembly Document A/RES/44/25.
(25) Ntozi JPM. Using circumcision to prevent HIV infection in sub-Saharan Africa: the view of an African. In: Health Transition Review (Australia) 1997: 7 Supplement: URL:
http://www.cirp.org/library/disease/HIV/ntozi1/
A team lead by Kebaabetswe propose the introduction of infant circumcision in Botwana, based on:
1. a survey of its acceptability to Batswana, 2. its practice in certain Western nations, and 3. its alleged value in preventing HIV infection.[1]
There are several medical, psychological, sexual, social, ethical, and legal problems with this proposal.
Medical effects
Male neonatal circumcision is not an innocuous procedure. There are many complications ranging from trivial to life-threatening. Complications generally include bleeding, infection, and surgical accident, including penile necrosis and penile amputations.[2] Bleeding or infection can progress to death.[3,4] It is difficult to control complications with mass circumcisions.[5]
Circumcision excises significant amounts of nerve bearing penile skin and mucosa, especially the ridged band structure near the muco-cutaneous boundary.[6] The protective effects of circumcision against HIV remain controversial.[7] UNAIDS has not accepted circumcision as a useful public health measure.
In neighbouring South Africa, many children are infected with HIV.[8] This is attributed to unsafe health care. Circumcision creates an open wound through which infection may proceed.[9] It is not clear that safe aseptic circumcisions can be delivered in Botswana. It is possible that mass circumcision may worsen the epidemic.
Psychological effects
Psychological manifestations of circumcision have been an area of study at Bond University.
Neonatal circumcision is an intensely painful, traumatic, and stressful operation.[10] General anaesthesia is unsafe in the newborn. Available methods of anaesthesia are only partially effective.[10] Circumcised infants show hypersensitivity to pain suggestive of posttraumatic stress disorder (PTSD).[11] Our study of the incidence of PTSD in the Philippines found extensive PTSD in circumcised boys.[12]
PTSD secondary to neonatal circumcision has been documented in adult males.[13] Victims of trauma tend to reenact their trauma either on themselves or others in a cycle of violence.[14]
Circumcised males may rely on psychological defence mechanisms such as rationalisation and denial, and strongly avoid thoughts, feelings, or conversations about circumcision.[15]
There are additional concerns. The state of the phallus is closely related to a man’s sense of well-being.[16] Men who were neonatally circumcised may feel unhappy about being circumcised, experience significant anger, sadness, feeling incomplete, cheated, hurt, concerned, frustrated, abnormal, and violated. In addition, circumcised men may suffer from resultant low self-esteem,[16] which frequently can result in a host of disordered behaviours.
Circumcision may be difficult to eradicate from a society once it is introduced. In addition, to the reenactment described above,[16] Goldman reports that circumcised men tend to defend the practice.[16] Circumcised doctors tend to develop intellectual arguments to support genital cutting.[17] Fathers who are circumcised may adamantly insist on a son’s circumcision in an emotional defence against their own painful feelings of grief for a lost body part and reduced sexual function.[18] Kebaabetswe et al. (p. 217) reported that, “ Being circumcised was the only significant predictor for a man who would definitely or probably circumcise a male child.”
Sexual effects
As noted above, circumcision excises large amounts of skin and mucosa from the penis. The removal of the prepuce tightens the remaining skin and makes it relatively immobile. Since stimulation of the sex nerves normally occurs by movement of the mobile skin, this further desensitises the penis,[17] perhaps even more than the removal of the ridged band of erogenous nerves noted by Taylor.[6] Excision of sexual nerve endings necessarily reduces sensory input. A decrease in sensation may therefore decrease the sexual response.[19,20]
Male circumcision also may adversely affect female sexual response. A survey of women found that they were markedly less likely to orgasm with a circumcised partner.[21]
Social effects
There has been little study of social problems that may occur when entire cohorts of males are circumcised and consequently most of the men in a society bear physical and psychological wounds associated with circumcision. We might expect more dependence on alcohol to relieve the symptoms of PTSD. Low self-esteem may generate a feeling of shame. Shame may generate problems with relationship dissatisfaction, poorer health, depression, drug use, and loneliness. Increased sexual incompatibility and marital problems in circumcised societies might be expected due to reduced penile sensory input, increased sexual dysfunction, PTSD, and low self-esteem among circumcised men.[22]
Increased anti-social behaviour may also be expected. Thus, we might expect to see higher levels of domestic violence, rape, child sexual abuse, suicide, and theft.[22]
Human Rights
The fight against HIV-AIDS requires the careful protection of human rights.[23] Amongst these human rights one finds the rights to security of the person and protection from degrading treatment. The unnecessary excision of normal human tissue[6] from unconsenting minor children is an obvious violation of the security of the person. Through amputation of erogenous tissue, circumcision necessarily diminishes sexual sensation and function as described above and may constitute degrading treatment.
Ethics
Doctors have a duty of care to behave in an ethical fashion. Amongst other requirements, they are expected to respect the human rights of their child-patients.[24] Circumcision has been shown to be a violation of the child’s human rights, and clearly, many ethical doctors are unwilling to carry out destructive circumcisions on normal, healthy boys. The British Medical Association recognises the right to conscientious objection to the performance of circumcision.[24]
Law
Male circumcision is not unlawful, but valid consent must be obtained. This may be a problem in the case of circumcision performed on unconsenting minors, in the absence of any medical indication.
Cases involving the right of parents to consent to the non-therapeutic surgical sterilization of a child have been heard in several nations.[25,26] The cases agree that, in the absence of any medical indication, parents are not empowered to consent to the non-therapeutic, irreversible, surgical alteration of their child’s genitals.
In the absence of a valid consent, a circumcision may constitute an assault.[27]
Conclusion
The value of male circumcision in preventing HIV infection remains unclear. Non-sterile circumcisions may increase the risk.
The proposal by Kebaabetswe and colleagues for the introduction of circumcision into Botswana is seriously flawed, and is irresponsible in failing to place the emphasis on safe sex practices. As described herein, there are many medical, sexual, psychological, social, human rights, ethical, and legal aspects that must be considered. Reliance on circumcision to prevent HIV transmission is wishful fantasy, and can only result in a calamitous worsening of the HIV-AIDS epidemic.
Once started, circumcision tends to persist even when the need is over. Circumcision was introduced more than 100 years ago in Western nations on the grounds than it would prevent masturbation, which would prevent mental and emotional illness. That, of course, is no longer believed, but the practice of circumcision persists and has proven difficult to eradicate although progress is being made. The incidence of circumcision is declining in Western nations. The Department of Health of the Philippines is trying to discourage circumcision (called “tule”) in that nation where it has persisted.[28] The practice of neonatal circumcision in certain Western countries such as the United States does not constitute a valid reason for introducing neonatal circumcision in Botswana.
Extreme care must be taken in a decision to introduce circumcision into a society.
References
(1) Kebaabetswe P, Lockman S, Mogwe S, et al. Male circumcision: an acceptable strategy for HIV prevention in Botwana.
Sex Transm Inf 2003; 79: 214-219.
(2) Williams N, Kapila L. Complications of Circumcision. Brit J Surg 1993;
80: 1231-1236.
(3) Scurlock JM, Pemberton PJ. Neonatal meningitis and circumcision. Med J Aust
1977;1(10):332-4.
(4) Proctor P. Totally unexpected death of baby probed. The Province, Vancouver, British Columbia, Thursday, 29 August 2002.
(5) Ozdemir E. Significantly increased complication risks with mass circumcisions.
Br J Urol 1997;80:136-139.
(6) Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol
1996;77:291-295.
(7) Van Howe, RS , Cold C, Storms MR. Some science would not have gone amiss BMJ
2000;321:1467.
(8) Brody S, Gisselquist D, Potterat JJ, Drucker E. Evidence of iatrogenic HIV transmission in children in South Africa.
Br J Obstet Gynaecol 2003;110:450–2.
(9) Committee on Fetus and Newborn: Standards and Recommendations for Hospital Care of Newborn Infants. Sixth Edition. American Academy of Pediatrics; Evanston, IL, 1977: 121.
(10) Lander J, Brady-Freyer B, Metcalfe JB, et al. Comparison of ring block, dorsal penile nerve block, and topical anesthesia for neonatal circumcision. JAMA
1997; 278:2158-2162.
(11) Taddio A, Katz J, Ilersich AL, Koren G. Effect of neonatal circumcision on pain response during subsequent routine vaccination.
Lancet 1997;349(9052):599-603
(12) Ramos, S., & Boyle, G. J. Ritual and medical circumcision among Filipino boys: Evidence of post-traumatic stress disorder. In G. C. Denniston, F. M. Hodges, & M. F. Milos (Eds.),
Understanding circumcision: A multi-disciplinary approach to a multi-dimensional
problem. New York: Kluwer/Plenum, 2001.
(13) Rhinehart J. Neonatal circumcision reconsidered. Transactional Analysis J
1999;29(3):215-221.
(14) van der Kolk BA. The compulsion to repeat the trauma: re-enactment, revictimization, and masochism.
Psychiatric Clinics of North America 1989;12(2):389-411.
(15) 309.81 Posttraumatic Stress Disorder. In: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. American Psychiatric Association, Washington 1994:424-429.
(16) Goldman R. The psychological impact of circumcision. BJU Int 1999;83 Suppl. 1:93-103.
(17) Gemmell T, Boyle GJ. Neonatal circumcision its long-term sexual effects. In:
Understanding Circumcision: A Multi-Disciplinary Approach to a Multi-Dimensional
Problem. Eds. GC Denniston, FM Hodges, and MF Milos. New York: Kluwer Academic/Plenum Publishers, 2001.
(18) Boyle GJ, Goldman R, Svoboda JS, Fernandez E. Male circumcision: pain, trauma and psychosexual sequelae.
J Health Psychol 2002;7(3):329-43.
(19) Winkelmann RK. The erogenous zones: their nerve supply and significance. Proceedings of the Staff Meetings of the Mayo Clinic
1959;34(2):39-47.
(20) Halata Z, Spaethe A. Sensory innervation of the human penis. Adv Exp Med Biol
1997;424:265-6.
(21) O'Hara K, O'Hara J. The effect of male circumcision on the sexual enjoyment of the female partner.
BJU Int 1999;83 Suppl 1, 79-84.
(22) Goldman R. Circumcision: The Hidden Trauma. Boston: Vanguard Publications, 1997:139-75.
(25) E. (Mrs.) v. Eve, 2 S.C.R 388 (1986), Supreme Court of Canada.
(26) Secretary, Department of Health and Community Services v. J.W.B. and S.M.B. (Marion's Case.) (1992) 175 CLR 218 F.C. 92/010, High Court of Australia.
(27) Boyle GJ, Svoboda JS, Price CP, Turner JN. Circumcision of healthy boys: criminal assault?
J Law Med 2000;301-10.
As a strategy for preventing sexually transmitted infections, surgical reduction of genital tissue has its drawbacks. Taylor et al. found that circumcision removes "an important component of the overall sensory mechanism of the human penis" [1] Winkelmann described the prepuce as a "specific erogenous zone".[2] Fink et al. found a statistically significant decrease in penile sensation following...
As a strategy for preventing sexually transmitted infections, surgical reduction of genital tissue has its drawbacks. Taylor et al. found that circumcision removes "an important component of the overall sensory mechanism of the human penis" [1] Winkelmann described the prepuce as a "specific erogenous zone".[2] Fink et al. found a statistically significant decrease in penile sensation following circumcision.[3]
In any case, the evidence regarding the medical benefits of circumcision is conflicting. In a national probability sample of 1410 American men, Laumann et al. found that "circumcision provides no discernible prophylactic benefit and may in fact increase the likelihood of STD contraction."[4]
Thus the depiction of male circumcision as an innocuous intervention with significant prophylactic benefits is open to question. Even if such benefits exist, controlling sexually transmitted infections by amputating erogenous zones is ethically problematic, especially when the recipients of such treatment are too young to give informed consent.
References
(1) Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996;77:291-295.
(2) Winkelmann RK. The erogenous zones: their nerve supply and its significance. Mayo Clin Proc 1959;34:39-47.
(3) Fink KS, Carson CC, DeVellis RF. Adult Circumcision Outcomes Study: Effect on Erectile Function, Penile Sensitivity, Sexual Activity and Satisfaction. J Urol 2002;167(5):2113-2116.
Dear Editor
The article by Crucitti et al.[1] evaluated five PCR techniques for Trichomonas vaginalis including the one published by our group (Mayta et al. [2]). The authors however did not follow the protocol we published and so got results that we consider to be erroneous.
In our work we used simple Taq polymerase while Crucitti used Taq gold for this purpose. He did this without chang...
Dear Editor
Nicola Low [1] is right to highlight the need to consider the number of HIV diagnoses made in Britain in each ethnic group in light of the size of that ethnic group.
For some years we have been told ad infinitum that the number of diagnoses of heterosexually acquired HIV has ‘out-stripped’ the number of homosexually acquired diagnoses, as if that indicated some kind of equivalence of impa...
Dear Editor
I agree with Dr Carne that the requirement to offer 90% (next year 100%) of our new patients an HIV test precludes us from offering everyone discussion about the HIV test as recommended by the UK Departments of Health in their Guidelines on HIV Pre-test Discussion.[1] However, the guidelines still include the statement that for, "individuals actively seeking an HIV test for the first occasion, here a...
Dear Editor
I am grateful for Dr Watson's generous comments.
I agree that presenting an appropriate amount of written information to substitute for an HIV pre-test discussion is problematical. We introduced such a system with some misgivings but felt that it was the only way that we could comply with the Royal College of Physicians second Speciality Specific Standard without seriously disrupting the se...
Dear Editor
It appears as if the lesion is present on the dorsal aspect of the penis since the fingers at the root of the penis rotating it are not seen. Actually the lesion was present on the ventral aspect of the penis only. Since the penis was rotated by 90 degree at its root for easy photography, in the photograph it looks different. So the legend put for the figure is correct.
Dear Editor
In this otherwise excellent description the site of the lesion is referred to as ventral, when it should be dorsal. In the anatomical position, the penis is erect.
Dear Editor
This article, and that by Bradbeer and Mears, are to be applauded. Their value will be all the greater if specific examples of the recommendations are shared and adopted by the specialty. In particular I would be interested to see a brief information sheet that can replace verbal discussion about HIV testing and still deliver the recommended five main components of pre-test discussion.[1] I have tried...
Dear Editor
Kebaabetswe et al0. obviously believe the conventional wisdom that heterosexual sex is the major vector for the transmission/reception of human immunodeficiency virus (HIV), and that male circumcision is an effective deterrent to infection.[1]> Based on that belief, they have constructed an elaborate and impressive study of the acceptability of circumcision as a prophylactic measure in Botswana. Fu...
Dear Editor
A team lead by Kebaabetswe propose the introduction of infant circumcision in Botwana, based on:
1. a survey of its acceptability to Batswana,
2. its practice in certain Western nations, and
3. its alleged value in preventing HIV infection.[1]
There are several medical, psychological, sexual, social, ethical, and legal problems with this pro...
Dear Editor
As a strategy for preventing sexually transmitted infections, surgical reduction of genital tissue has its drawbacks. Taylor et al. found that circumcision removes "an important component of the overall sensory mechanism of the human penis" [1] Winkelmann described the prepuce as a "specific erogenous zone".[2] Fink et al. found a statistically significant decrease in penile sensation following...
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