Tuesday, December 09, 2008

A yellow light for male circumcision

In the past few years, a series of randomized controlled trials indicated that male circumcision reduced the risk of men acquiring HIV from women during hetrosexual intercourse. This finding seemed to confirm two decades of less rigorously controlled studies, and has turned out to be a rare success in the world of HIV prevention research, a world still reeling from failed HIV vaccine, diaphragm and microbicide trials. Male circumcision has always been a contested practice, so findings of the randomized controlled trials on male circumcision predictably sparked a great deal of debate. Some critics have argued that the findings were untrustworthy for a variety of reasons: because the trials were stopped prematurely or because not all possible confounders had been controlled for. Some of these criticisms were motivated by sincere concerns about scientific standards, but many times it seemed that criticisms of the trials were driven by a priori ethical views about the irrationality and harmfulness of male circumcision as such. In the meantime, emerging news items about male circumcision and HIV prevention are invariably accompanied by verbal battles among pro- and anti-circumcisionists in their comments sections.

The world has moved on. Or, at least, the biomedical research establishment in developed countries -- and in some developing ones -- seem to have moved on. The methods and findings from the randomized controlled trials are no longer the main event. The focus now is on how to implement male circumcision as an HIV prevention strategy in high HIV-prevalence countries with low-circumcision rates, mainly in sub-Saharan Africa. And the wallets are starting to open. To use a traffic metaphor, the strategy is getting a 'yellow light': proceed, but with caution. Caution for surgical risks in resource-poor clinics. Caution for diversion of scarce resources from other important health needs to circumcision initiatives. Caution for risky sex behavioral change among the recently circumcised. And a variety of other vexing and challenging hurdles. But there is the overwhelming sense of rolling up one's sleeves, that this is a fight worth fighting.

In the interests of full disclosure, my colleagues and I published a 'proceed with caution' piece about HIV and male circumcision last year in the Journal of Medical Ethics. But that piece does not have the same sort of authority or significance as last week's commentary article in Journal of the American Medical Association or the perspective piece in the New England Journal of Medicine: these are prestigious journals with a large and influential readership, and these are some well-known authors. Initiatives to promote male circumcision seem to have gotten the official yellow light, and join the increasingly crowded and messy world of HIV prevention.

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Blogger priya said...

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10:18 AM  
Blogger WizCo said...

if you can't get people to wear a condom, how are you going to get them to agree to amputate a useful part of their bodies? it may help in the fight against AIDS, but you have to think about the effort required to get a fully grown male on the operating table.

1:53 PM  
Blogger MT said...

Nature Really Likes Male Circumcisions

Way down under in Melbourne, Australia is the story of a tightly done male adult circumcision of the ultimate kind. You’ll never believe the story … or will you?
Around 17 years ago, I became aware that circumcision was of interest to me. How to go about it ? What an embarrassment, how to sneak into a Doctor cost etc. I became more and more frustrated, as I knew I wanted it done. Australia is a hot climate too and I wanted a slick model penis, not a sock, at half mast. I had learnt from school that I was bisexual, I would use the odd opportunity to check out and occasionally talk another classmate into pulling down his pants and letting me give him oral sex. Both circumcised and uncircumcised, although I didn’t know what circumcision was then, I was only ten ! We start pretty early in Australia !
Anyway back to circumcision. I became more and more, frustrated and there didn’t seem to be a way of resolving the issue. Then I had a bereavement in the family. If I couldn’t solve this simple problem… It was a question of honor.
So what I did may surprise many. I am an everyday kind of bloke, a family now, job and the rest of it. So don’t be too shocked. Where there is a will there is a way.
I had been researching on the net at the time and I was reading and seeing pics of tribal and African circumcisions. There are great stories of the Tuli in the Philippines and also teens putting their penis on a log with a piece of twine and the elder slicing off the foreskin, high and tight, leaving a terrific red patched scar.
I decided after much viewing and research that this is what I wanted. I was a bit far from the Philippines and Africa, so this is what happened.
One long weekend when there was a Public holiday, I decided to have a go myself. This is not for the faint hearted.
On the Friday night, I did the usual, a few beers then came home. I opened a bottle of white wine and proceeded to watch an x-rated video. Of course with a long ring barked cock or two. After a while I was ready. A bit of popper amyl and I was more or less ready to have a go. At circumcision.
I knew the skin would be sensitive, so I had purchased from an adult store, delay spray. This I think had lidocaine like when you get Suntan mozzie burns cream from the supermarket only stronger. I applied it to my foreskin until the end of my cock felt number, than usual. Another drink and some poppers, a look at the tightly taut scarred cocks on the TV screen and it was time. Time to join the rest of my male brothers on the planet with a permanently forever nude glans and a stripped pointed helmety penis. Intention purple glans to always lead the way, from that night on or else.
I sized and drew a line working out where to cut and checked this out numerous times. Another drink, more amyl and an inspection of the video playing and I was ready.
I took a very sharp pair a medium size sewing scissors and sat down. Carefully lining them up, I very slowly, and I mean really really slowly, put them through the line on the foreskin I had drawn. I had already pulled the foreskin as hard as I ever could in front of my glans.
Slowly but surely I got the job done. Everything dropped back behind my glans and my foreskin lay on a tissue. A dream come true. I couldn’t believe my absolute relief and satisfaction.
All this time later nearly two decades on, I am still happy. A couple a days later, I consulted a friendly doctor and some stitches were added on the quiet to complete the job.
Result is I have a very tightly circumcised penis, with absolutely no frenulum or foreskin.
The absolute tightest male circumcision possible, for myself and any partner I should choose, whether it be female or male. Amazingly there is no two tone scar and the circumcision join is one color and height. No different levels of skin height or misalignment.

Nature really does like circumcisions.

9:42 AM  
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8:54 PM  

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