Dear Editor

Despite the long-standing recommendation to vaccinate men who have sex with men (MSM) attending genitourinary medicine (GUM) clinics,[1] coverage of vaccination in this group has been difficult to achieve.[2,3] In a study of GUM attendees, post infection immunity (anti-HBs prevalence) was found to be 31% in homosexual men and vaccine coverage to be 40% in London and only 24% outside London.[4] Yee and Rhodes highlight the need for cheap and available hepatitis B vaccine as one way to increase immunisation rates among homo/bisexual men.[5]

In England, the Department of Health (DH) has introduced specific vaccination standards for MSM as part of their strategy for sexual health.[6] All MSM who are attending GUM clinics for the first time should be offered vaccination against hepatitis B. To help facilitate this, the DH has distributed extra doses of vaccine to all GUM clinics in England.

As Yee and Rhodes point out, vaccination uptake rates need to be monitored to determine whether this strategy will be effective. To help achieve this, a simple surveillance system called HepB3, was introduced to all GUM clinics across England in December 2002. The survey is being coordinated by the Communicable Disease Surveillance Centre (CDSC) on behalf of the DH. In an attempt to avoid adding to the already substantial workload of clinics,[7,8] the breadth of data requested has been kept to a minimum. None-the-less, it will enable first dose and complete courses of vaccine among new MSM attendees to be monitored, along with reasons for non-vaccination. While in essence the study is merely an audit, this is the first step towards enhanced surveillance of hepatitis B vaccination. It is proposed that the HepB3 survey will eventually be assimilated into the Programme of Enhanced Surveillance of Sexually Transmitted Infections, currently operating in GUM clinics in London and parts of South East England and which is planned for roll out nationwide over the next few years. This will enable immunisation data to be linked with anonymised, patient-based, demographic data such as ethnicity, previous infection and some behavioural information. Over the next few years, it will be possible to determine whether the DH’s strategy for increasing hepatitis B vaccination rates in MSM has been effective, and our understanding of factors influencing vaccination coverage in this group should be substantially improved.

References

(1) Department of Health. Immunisation Against Infectious Diseases – The Green Book 1996 http://www.doh.gov.uk/greenbook

(2) MacKellar DA, Valleroy LA, et al. Two decades after vaccine license: hepatitis B immunization and infection among young men who have sex with men. American Journal of Public Health 2001;91(6): 965-971.

(3) Rhodes SD, DiClemente RJ, et al. Correlates of hepatitis B vaccination in a high-risk population: An internet sample. American Journal of Medicine 2001;110: 628-632.

(4) Department of Health. Prevalence of HIV and hepatitis infections in the United Kingdom 2000. Annual report of the UA prevalence monitoring programme 2001: 32-36.

(5) Yee LJ, Rhodes SD. Understanding correlates of hepatitis B virus vaccination in men who have sex with men: what have we learned? Sex Transm Infect 2002;78: 374-377.

(6) Department of Health. The National Strategy for Sexual Health and HIV – Implementation Action Plan, June 2002. http://www.doh.gov.uk/sexualhealthandhiv/index.htm

(7) Djuretic T, Catchpole M, et al. Genitourinary medicine services in the United Kingdom are failing to meet current demands. Int J STD & AIDS 2001;12:571-572.

(8) Foley E, Patel R, et al. Access to Genitourinary medicine clinics in the United Kingdom. Sex Trans Infect 2001;77(1):12-14.

Dear Editor

I am sure it is not pure co-incidence that the editorial 'Sexual Health-Health of the Nation' appears in the same issue as a paper emphasising the missed opportunity of treating sexually transmitted infections in primary care and like Michael Adler, I feel melancholic about the future of the sexual health of our nation. As a GP/Hospital Practitioner in GU Medicine for thirty years, I fail to comprehend the apparent shambolic lack of co-ordination of the various programmes for better STI care.

We are encouraged to develop strategies for universal Chlamydia screening, which has been placed before successive governments and warm political words of encouragement have been received in the same breaths as the apparent hollow promises of strong finance to follow. Do they think us stupid? Actually, we must be, for we believe them every time! Despite the many hundreds of hours put in by hundreds of dedicated HCWs into strategies to improve the health of this nation, based on strong clinical evidence, it would seem that these opinions are for nothing.

The current Sexual Health policy encourages GPs, amongst others, to participate in the control of sexual diseases and the programmes for training are being enthusiastically attended and enjoyed. I may not be the brightest cookie in the tin but I can smell staleness when the 'sale by dates' of policies are passed. Recently, all GPs have received a tome called their new contract. This was defined in conjunction with a review body and, in draft form, seemed encouragingly thorough and well-intentioned and we all thought a bright new sensible future was dawning. Once again, how stupid we are; I can find no written words in the whole document relating to the Sexual Health Strategy. Contraception, maternity care, termination and cervical smears are given a cursory and traditional style mention but nowhere can I find any encouragement for GPs to take the sexual health strategy seriously. However, we are told that we will be rewarded for collecting data on the investigation and treatment of heart disease, diabetes and chest ailments, but sexual health is no longer politically important. Why has no one incorporated the sexual health strategy into the GP contract? What a golden opportunity of timing has been missed. Is the reason for this omission a genuine oversight, poor intelligence (an expression used by American politicians to cover stupidity), or, is it a deliberate fudge in order to disguise the lack of money for any excellent and intelligent new strategy? I suspect it is the latter.

Twelve months ago, I was flattered to be asked to sit as a GP representative on the DoH Sexual Health Services Data Group in order to produce a 'Recommended Minimum data-set for sexual health services providing levels 1-3 elements of care in England'. Many of the esteemed and experienced committee members had already been dealing with this weighty tome for many months before, but the constant hammering in my mind about this essential tool was the threat that there had to date been no mention of finance behind the strategy. Sadly, my nightmares seem to be coming true. It would appear that there has never been any intention to co- ordinate GP time and to offer financial incentive into this paper, or sexual health would be up there with the other major threats in the new contract, and, unless it is mentioned alongside items of service payment, no GP in the land is going to bother to put his or her gloves on for this 'below the belt' topic. Yet again, the politicians have sold us a dummy.

Perhaps it is time that all those altruistic HCWs who spend hundreds of unpaid hours of their lives dedicating time to the services of Whitehall should stop wasting it and return to the three to six week queues of patients clamouring in the waiting rooms of their clinics.

Yours, very disillusioned

Ted Hiscock

Dear Editor

Thank you for your refreshing piece of research into health care in the real world.

In 1980 I worked in a deprived area in Kingston, Jamaica on an USAID funded "Adolescent Fertility Project". I treated only young women, many of whom had cervicitis or PID. I always felt that the more valuable part of my work was education. When the women returned to say that their boyfriends had insisted on seven big red and black capsules (ampicillin 500mg) and two benemid capsules from the pharmacist, rather than "a couple of the red and blacks", I was vindicated. This was of course prior to the introduction of penicillin resistant gonorrhoea to Jamaica, and my contract only covered the treatment of females.

Since then I have been producing a "Radio Doctor" programme for fourteen years. Again, teaching listeners the standard of care that they should expect has been more valuable than any individual patient treatment.

It is necessary that we acknowedge that much care is provided by pharmacists.We do, however, need to take care, that this acnowledgement is not construed as an acceptance of what is still an imperfect state of affairs.

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 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.

(23) HIV/AIDS and Human Rights, Geneva: Office of the United Nations High Commissioner for Human Rights, 2002. Available at: http://www.unhchr.ch/hiv/index1.htm#approach

(24) Committee on Medical Ethics. The law & ethics of male circumcision - guidance for doctors. London: British Medical Association, 2003. Available at: http://www.bma.org.uk/ap.nsf/Content/malecircumcision2003

(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.

(28) Ramos GAS. Circumcision: the uncut version. Healthbeat (Manilla) 2003 Available at: http://www.doh.gov.ph/mmc/issue01/tule.htm