The ethics of foreskin

One of the highlights of last week’s International AIDS Society conference in Brazil was the presentation of new data suggesting that circumcision significantly reduces a man’s chance of becoming infected by HIV through hetrosexual intercourse. A study sponsored by the French National Agency for AIDS research (ANRS) and conducted with over three thousand HIV-negative young (18-24 yrs.) South African men found that circumcision reduced female-to-male HIV transmission by approximately 65%. The ANRS 1265 study is the first randomized controlled trial demonstrating a strong protective effect of male circumcision on HIV transmission. Data from two similarly designed studies in Uganda and Kenya will be available in 2007. (And no, none of these trials are double-blinded.)

The suspicion that circumcision could reduce the risk of men acquiring HIV through heterosexual intercourse has been around since 1986. Since then, around thirty studies have indicated a positive association between circumcision and lowered HIV transmission, but these studies (and their policy implications) have long been controversial. Skeptics have questioned their scientific validity, while others have deep reservations about the ethics of circumcision as a public health intervention, even if the causal relationship between circumcision and transmission is confirmed.

According to skeptics, previous studies have proven incapable of demonstrating that lower transmission rates among circumcised men are due to the removal of foreskin itself rather than confounding variables. For example, much has been made of the lowered HIV acquisition rates among circumcised Muslim males, but this could be due to differences in sexual ethics and other cultural factors, such as prohibitions against alcohol. Especially in Africa, the rite of circumcision is closely tied to ethnicity, making it difficult to disentangle the effects of circumcision from behaviors rooted in local tradition. If a website passionately devoted to the virtues of males remaining ‘intact’ is anything to go by, the new ANRS study may leave skeptics cold. It is worth pointing out that during medical history circumcision has also been said to prevent insanity, paralysis, bedwetting, excessive masturbation, impotence, tuberculosis, prostate cancer, syphilis, cervical and penile cancer. Foreskins have long been unpopular in medical circles.

But there are ethical worries about implementation even if the conclusions of the study seem solid. The ‘good news’ may cause a sharp demand for circumcisions in sub-Saharan Africa, but at present they are most likely to be performed by traditional healers in less-than-hygienic circumstances. Circumcision may also increase unsafe sex practices in so far as men and women come to regard it as a ‘natural condom’: a tragic outcome, since a policy of circumcision does nothing to reduce the risks of male-to-female transmission of HIV. And if circumcision is encouraged but the long-term protectiveness of circumcision turns out to be much less than supposed, the damage to public confidence in the medical establishment and the impact on the fight against HIV/AIDS could be enormous.