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Kebaabetswe et al obviously believe the conventional wisdom that heterosexual sex is the major vector for the transmission/reception of 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 programme of neonatal circumcision in Botswana in the hope of reducing the HIV infection rate 15 years later.1
It has been believed since about 1988 that heterosexual coitus accounts for 90% 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 criticised for their methodological flaws, including their failure to control for numerous confounding factors.4,5
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 strongly argue that unsafe healthcare practices, especially non-sterile injections, not heterosexual intercourse, are the principal vectors by which HIV is transmitted. A programme of mass circumcision would be ineffective against iatrogenic transmission of HIV through unsafe health care.
Circumcision has some little known effects that may 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 lysozyme10—an enzyme that attacks HIV.11 Circumcision destroys this natural protection.
Circumcision removes erogenous tissue,12 desensitises the penis,13 changes sexual behaviour, and makes males more likely to engage in unsafe sex practices.14 Circumcised males, therefore, are less willing to use additionally desensitising 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 programme 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 proved 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%.9 Gissellquist and Potterat now estimate the proportion attributable to heterosexual intercourse at only about 30%8—only a 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 to address the 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.19,20 Circumcision, therefore, must be regarded as degrading treatment. Degrading treatment is an additional violation of human rights.21
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 person18,22 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.
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.
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 HIV1; 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 among children in South Africa as a result of iatrogenic infection from non-sterile injections, etc.2,9 They have not shown that safe, aseptic circumcisions can be delivered in Botswana. A programme of mass circumcision would destroy the natural protections of the foreskin, further expose children to an apparently unsafe healthcare system, and would be more likely to increase 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% of infections that now are attributed to sexual activity. It would have no effect on the other 70%. Its effect, therefore, would be minimal at best and could not have an effect for the first 15 years,1 during which time behavioural 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
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