I read Ison and Hay’s paper concerning validation of grading of
vaginal smears with great interest but am concerned there was no mention
of earlier work which closely resembles their new grading system.[1]
The
examination of stained specimens of vaginal secretions for diagnosis,
research and classification of vaginal pathology has a long and sometimes
confusing history. Medline searches date from...
I read Ison and Hay’s paper concerning validation of grading of
vaginal smears with great interest but am concerned there was no mention
of earlier work which closely resembles their new grading system.[1]
The
examination of stained specimens of vaginal secretions for diagnosis,
research and classification of vaginal pathology has a long and sometimes
confusing history. Medline searches date from 1966 and authors can easily
overlook archived papers, many of which may remain relevant today. In 1914
Curtis described the vaginal flora in health and disease publishing
photomicrographs of stained vaginal specimens from healthy women and from
those with leucorrhoea. He noted that “the more patients deviate from the
absolute normal, with only Döderlein bacilli, i.e, the greater the
tendency to discharge formation and the more purulent its nature , the
more nearly do the bacteriological findings resemble in character the
picture presented by pathological cases.” [2,3] Curtis also cited even
earlier work by Döderlein (1882), Menge & Krönig (1897) and Wegelius
(1909) all of whom contributed to our understanding of the vaginal
bacterial flora.[2] In 1921 Schröder classified the vaginal flora into
three grades of cleanliness, (Reinheitsgrade).
Grade 1: Döderleins bacillionly,
Grade II Döderleins bacilli and other organisms, Grade III organisms
other than Döderleins bacilli, cited by Rakoff, Feo and Goldstein, 1944.[4,5]
In 1939 Liston and Liston, though not referencing Schröder’s earlier
work, introduced a modification of his classification as follows. “Type I,
a pure Döderlein flora’, Type II, Döderlein bacilli with an admixture of
Gram positive bacilli of diptheroid type,with perhaps one or two Gram-negative organisms only. Type III, many different kinds of organisms,
chiefly Gram-negative , generally small cocco-bacilli but including a few
Gram positive bacilli and cocci, comma bacilli (probably an early
reference to Mobiluncus species) leptothrix and spirochaetes.” [6]
Several
later publications concerning vaginal bacteriology also either adopt
and/or refer to Schröder’s original classification. These include Hite,
Hesseltine and Goldstein (1947), Weaver , Scott and Williams( 1950) , Lang
(1955) , Hunter and Long (1958), Burch ,Rees and Kayhoe (1958) and
Davidson and Layton (1968).[7-12] It is interesting that several early publications
note the relationship between increasing vaginal pH and increasing grade
of vaginal flora leading the way to Amsel’s diagnostic criteria for non-
specific vaginitis in 1983.[5,9,13,14]
It is of particular interest that in 1942 Hesseltine, Wolters and
Campbell classified the bacterial flora of the vagina as follows: “type I
reveals only vaginal bacilli present; type II, a mixture of vaginal
bacilli and other bacteria; type III, other bacteria without vaginal
bacilli; and type IV, a single type of some abnormal bacteria.” 15 This
is very similar to Hay and Ison’s new criteria “grade 0 epithelial cells
with no bacteria seen; grade I(normal flora), lactobacillus morphotype
only; grade II (intermediate flora), reduced lactobacillus morphotype with
mixed bacterial morphotypes; gradeIII (BV), mixed bacterial morphotypes
with few or absent lactobacillus morphotypes; grade IV epithelial cells
covered with Gram positive cocci only”.[1] The absence of any bacteria (Hay/Ison grade 0) can be considered normal if a woman has recently used
oral or topical (vaginal) antibacterial agents whilst the presence of
epithelial cells covered with Gram positive cocci (Hay/Ison grade IV)
begs the question of how one should classify a Gram stain in which
planktonic Gram positive bacteria only are observed.
How also should we grade the microscopic findings of gonococcal vaginitis, which, although
more common in prepubertal females, may also occur in adult women? [16]
Hesseltine and colleagues’ grading system (which was in practice a
modification of Schröder’s ) may therefore have distinct advantages. My
personal preference for describing the microbiology of the vagina by Gram
stain is to use Schröder’s original grading for bacteria with a fourth
category, “Other-specify” or, better still, “None of the above-specify”.
The fourth category should describe simply what is seen e.g. “no
bacteria”, “scanty/un-evaluable slide”, “Gram negative diplococci with
polymorphonuclear leucocytes”, “spores/mycelia” etc, etc. The majority of
specimens will reveal a vaginal flora that can be readily ascribed to one
of Schröder’s grades but the fourth category permits a pragmatic solution
for describing smears which cannot be so designated.
Finally, having read many old papers on vaginal infection gleaned by
laboriously hand searching the archival section of the library at St
Thomas’s hospital, London, in the 1970s and 80s, I find it difficult to
admit to having ever had a truly original thought on the subject. I feel
therefore that we should give due credit to Schröder’s work when naming
any “new” classification system of vaginal bacteriology, I wish also to
apologise to any now long dead researcher whose work I have overlooked.
References
(1) Ison CA, Hay PE. Validation of a simplified grading of Gram
stained vaginal smears for use in genitourinary medicine clinics. Sex
Transm Infect 2002; 78,6:413-16
(2) Curtis AH. Etiology and Bacteriology of Leucorrhoea. Surg Gynecol
Obstet 1914;18:299-306.
(3) Döderlein A. Uber Scheidensekrete und Scheidenkeime.
Verhandl.deutsch. Gesellsch. Gynak 1892 ;4:35
(4) Schröder R. Zur Pathogenese und Klinik des vaginalen Fluors .
Zentralbl. Gynak 1921;45:1350
(5) Rakoff AE, Feo LG, Goldstein L. The biological characteristics of
the normal vagina. Am J Obstet Gynecol 1944; 47:467-94.
(6) Liston WG, Liston WA. A study of Trichomonas Vaginitis in
Hospital Practice in Edinburgh. J Obstet Gynecol 1939; 22:474-94.
(7) Hite KE, Hesseltine HC, Goldstein L. A study of the bacterial
flora of the normal and pathologic vagina and uterus. Am J Obstet Gynecol
1947;53:233-40
(8) Weaver JD, Scott S, Williams OB. The bacterial flora found in non-
specific vaginal discharge. Am J Obstet & Gynecol 1950;60:880-84.
(9) Lang WR. Vaginal Acidity and pH. A Review. Obstet and Gynecol
Surv 1955;10:546-60.
(10) Hunter A, Long KR. A study of the microbiological flora of the
vagina. Am J Obstet Gynecol 1958; 75:865-71.
(11) Burch TA, Rees CW, Kayhoe DE. Laboratory and clinical studies on
vaginal trichomoniasis. Am J Obstet Gynecol 1958;76: 658-65.
(12) Davidson AJL, Layton KB. Vaginitis and Haemophilus vaginalis .
Med J Aust 1968;1:757-60.
(13) Cruickshank R,Sharman H. The biology of the vagina in the human
subject. Part II The Bacterial flora and secretion of the vagina in
relation to glycogen in the vaginal epithelium. J Obstet & Gynaec Brit
Emp 1934;41:208-226.
(14) Amsel R, Totten PA, Spiegel CA, et al. Non-specific Vaginitis.
Diagnostic Criteria and Microbial and Epidemiologic Associations. Am J Med
1983;74: 14-22.
(15) Hesseltine HC, Wolters SL,Campbell A. Experimental Human Vaginal
Trichomoniasis. J Infect Dis 1942;71:127-30 .
(16) Blackwell A L . Penicillinase producing Neisseria gonorrhoeae
associated with severe vulvo-vaginitis in a post menopausal woman. Genito-
Urin Med 1993; 69:482-83.
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...
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.
(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.
(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.
Michael Adler’s editorial on sexual health - health of the nation - makes pessimistic reading. While it is apparent that the rate of STIs and unwanted pregnancy has increased in the UK over the last 10 years, he fails to mention what has happened to sexual dysfunction (SD) over that period of time. The National Strategy for Sexual Health and HIV document mentions SD a number of times [1]. SD is indeed part of sex...
Michael Adler’s editorial on sexual health - health of the nation - makes pessimistic reading. While it is apparent that the rate of STIs and unwanted pregnancy has increased in the UK over the last 10 years, he fails to mention what has happened to sexual dysfunction (SD) over that period of time. The National Strategy for Sexual Health and HIV document mentions SD a number of times [1]. SD is indeed part of sexual health.
Problems in sexual functioning such as erectile dysfunction (ED),premature ejaculation, low sexual desire in women and vulvadynia affect a third of men and well over a third of women in the UK [2]. Fifty per cent of patients so effected would want treatment for their problem [2]. Management of ED significantly improves both the quality of life and its
concomitant mental illness [3][4]. Although the absolute cost of ED treatments has risen three fold between 1997 and 2000 in the UK, the cost per patient fell significantly [5]. Much of the cost effectiveness in the treatment of ED is related to very effective pharmaceutical agents such as
sildenafil [4]. However, female sexual dysfunction (FSD), which is largely managed at present by sex therapy and cognitive behaviour therapy, appears to be similarly cost effective [6].
It is my impression that a decade ago most GU medicine clinics did not offer treatment for SD. A study in 1997 [7] and again in 2000 [8] suggested that over 80% of GU clinics supported the notion of treatment of SD and that over 40% actually carried out SD management.
Treating SD, apart from its direct effects on restoring sexual functioning, quality of life and reversing depression, may indeed have positive spin offs in decreasing STI acquisition in men ( e.g. condom use
is only effective on an erect penis) and women with low sexual desire [9].
SD management in GU medicine clinics in the UK, I believe, is still treated as a Cinderella subject by central government and local purchasers, in spite of the surrogate and indirect evidence of its success over the past 10 years. Furthermore, there is no specific funding for it.
Its mention in the National Strategy for Sexual Health document might be perceived as mere lip service to placate the few champions who voice their opinions on behalf of the literally vast numbers of patients with SD
who suffer in embarrassed silence.
I believe central government should look carefully at this neglected success story and encourage it to continue by means of adequate education of medical students and junior doctors in the SD field as well as proper financial support.
References
(1) Department of Health. The National Strategy for Sexual Health and HIV. DoH, London, 2001.
(2) Dunn KM, Croft PR, Hackett GI. Sexual problems: a study of the
prevalence and need for health care in the general population. Fam Pract
1998;15:519-524
(3) Guest JF, Das Gupta R. Health related quality of life in a UK based poulation of men with erectile dysfunction. Pharmacoeconomics2002;20): 109-117
(4) Guiliano F, Pena BM, Mishra A, Smith MD.
Efficacy results and quality of life measures in men receiving sildenafil citrate for the treatment of erectile dysfunction. Qual Life Res2002;(11)359-369
(5) Wilson EC, McKeen ES, Scuffham PA et al. The cost to the United Kingdom Health Service of managing erectile dysfunction: the impact of sildenafil and prescribing restrictions. Pharmacoeconomics, 2002;(20):879-889
(6) Goldmeier D, Malik F, Green J, Phillips R. Cost effectiveness of sexual dysfunction – the female picture, Int J Impotence Res,in press.
(7) Keane FE, Carter P, Goldmeier D, Harris JR The provision of psychosexual services by genitourinary medicine physicians in the United Kingdom, Int J STD AIDS, 1997;(8):402-404
(8) Kell P, The provision of sexual dysfunction services by
genitourinary medicine physicians in the UK 1999, Int J STD AIDS, 2001;(12):395-397
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 comprehe...
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.
In 1997, Professor Adler’s stark assessment of the deterioration of
sexual health of the UK [1] laid the blame for it on presumably highly
influential (though unnamed) groups attempting "to withhold information on
the basis of a particular agenda of family values and morality.[2] At least
his 2003 editorial,[2] charting more recent decline on every parameter
examined, does not repeat this former unre...
In 1997, Professor Adler’s stark assessment of the deterioration of
sexual health of the UK [1] laid the blame for it on presumably highly
influential (though unnamed) groups attempting "to withhold information on
the basis of a particular agenda of family values and morality.[2] At least
his 2003 editorial,[2] charting more recent decline on every parameter
examined, does not repeat this former unreferenced and, in my view
unsupportable, scape-goating. This time, he appears to blame the
government for not making sexual health "an NHS or political priority".
Whilst I agree they have not and the currently allocated financial
resources are totally inadequate, it is the political correctness of
sexual-health policy-makers that is the main barrier to improving the
sexual health of the nation. It is widely accepted that up to 80% of
unplanned pregnancies are due to contraceptive (mainly condom) failure,[3] yet condoms still continue to be promoted as a "the solution" the
very problem they contribute so heavily towards.[4,5]
Condoms, when used consistently and correctly, do provide reasonable
protection against HIV and gonorrhoea.[6] However, they are rarely
consistently and correctly used [7] and even when they are, there is no
evidence that any protection they may provide against the majority of
sexually transmissible agents is anywhere near as good at that for HIV;[6,8] in the case of HPV it is possibly none at all. [6,9]
Adler indicates that reversing adverse trends in sexual behaviour is
a key priority in controlling STI escalation. Increased condom use alone
is "not enough to offset the increase in sexual partners". He also
suggests the increase in sexual intercourse among under-17s as a major
contributor to poor sexual health. If delaying the age of first coitus is
therefore so important, why is there seemingly complete denial in the
Department of Health about the effectiveness of abstinence education?[10]
Both unplanned pregnancy and STI rates have been reduced in appropriate
abstinence-based programmes, not only in the USA [11,12] but also in
Zambia [13] and Uganda.[14]
In spite of such evidence for their effectiveness, abstinence
programmes are labelled in the UK as being unworkable.[15] Instead we
continue to base our programmes for reducing unplanned pregnancy on
condoms, the failure of which is implicated in 80% of them. More recently
the emphasis has switched to the emergency pill, but the unrestricted use
of this from pharmacies will only further the increase in STIs.[16] Until
such short-sighted policies change, we will indeed sadly "witness failure
upon further failure" in sexual health in the UK. However, Professor Adler has not told us the real reasons why.
References
(1) Adler M. Sexual health- a Health of the Nation failure. BMJ 1997;314:1743-1747.
(2) Adler M Sexual health – health of the nation. Sex Trans Infec 2003;79:85-7.
(3) Pearson VAH, Owen MR, Phillips DR, Pereira Gray DJ, Marshall MN.
Pregnant teenagers’ knowledge and use of emergency contraception. BMJ
1995; 310:1644
(4) Richens J, Imrie J, Copas A Condoms and seat belts: the parallels
and the lessons Lancet 2000 355 400-3
(5) Doughty S Charity to hand out free condoms to 11-yr olds Daily
Mail 28.3.2003 http://www.likeitis.org.uk/welcome_to_like_it_is.html
(7) de Visser RO Smith AM When always isn’t enough; implications of
the late application of condoms for the validity and reliability of self-
reported condom use. AIDS Care 200012:221-4.
(8) Mann J, Stine C, Vessey J The role of disease-specific
infectivity and number of disease exposures on long-term effectiveness of
the latex condom. Sex Trans Dis 2002;29:344-9.
(9) Manhart LE, Koutsky LA. Do condoms prevent genital HPV infection,
external genital warts or cervical neoplasia? A meta-analysis. Sex Trans
Dis 2002;29:725-35.
(11) Doniger AS, Adams E, Riley JS, Utter CA, Impact evaluation of the
"Not Me, Not Now”' abstinence-oriented, adolescent pregnancy prevention
communications program, Monroe County, New York. J Health Communication 2001;6:45-60. http:// www.notmenotnow.org/research/NMNNimpactevaluation.pdf
(12) Mohn JK, Tingle LR, Finger R An analysis of the causes of the
decline in non-marital birth and pregnancy rates for teens from 1991 to
1995. Adolesc and Fam Health 2003;3:39-47.
(13) Martin K Zambia’s HEART programme evaluation shows youth respond
positively to AIDS prevention plan promoting abstinence. John Hopkins
University Centre for Communications Programmes 2002. http://www.jhuccp.org/pressroom/2002/07-11.shtml
(14) Hogle J, Green EC, Nantulya R, Stoneburner J et al. Whatever
Happened in Uganda? Declining HIV prevalence, behaviours change and the
national response USAID-Washington and The Synergy Project TvT Associates
Washington D.C. 2002 http://www.usaid.gov/pop_health/aids/Countries/africa/uganda_report.pd
(15) Swann C, Bowe K, McCormick G, Kosmin M Teenage pregnancy and
parenthood; a review of reviews. Health Development Agency 2003.
(16) Stammers T. Emergency contraception from pharmacists misses
opportunity. BMJ 2001;322:1245.
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 seve...
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.
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.
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.
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/
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
I read Ison and Hay’s paper concerning validation of grading of vaginal smears with great interest but am concerned there was no mention of earlier work which closely resembles their new grading system.[1]
The examination of stained specimens of vaginal secretions for diagnosis, research and classification of vaginal pathology has a long and sometimes confusing history. Medline searches date from...
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...
Michael Adler’s editorial on sexual health - health of the nation - makes pessimistic reading. While it is apparent that the rate of STIs and unwanted pregnancy has increased in the UK over the last 10 years, he fails to mention what has happened to sexual dysfunction (SD) over that period of time. The National Strategy for Sexual Health and HIV document mentions SD a number of times [1]. SD is indeed part of sex...
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 comprehe...
Dear Editor
In 1997, Professor Adler’s stark assessment of the deterioration of sexual health of the UK [1] laid the blame for it on presumably highly influential (though unnamed) groups attempting "to withhold information on the basis of a particular agenda of family values and morality.[2] At least his 2003 editorial,[2] charting more recent decline on every parameter examined, does not repeat this former unre...
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 seve...
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...
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
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
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.
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