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Another ill-contrived circumcision study

Timothy Kincaid

December 8th, 2010

Should there be any researchers reading, let me give you a bit of advice: gay sex and straight sex are not identical. While most heterosexual men do not have penises inserted into their anuses with regularity, this is not an uncommon part of the sexual practices of many gay men.

And further, the easiest way that a gay guy can become infected with HIV is through anally receptive unprotected sex. That isn’t new, surprising, or even contested.

Yep, HIV transmission among gay men in the US is primarily due to taking it bare up the butt. And any research which seeks to understand factors contributing to HIV transmission which does not consider that simple fact is a complete waste of money and time.

And today we get word of yet another Wasted Money Study on whether circumcision impacts HIV transmission between gay men. Reuters:

In a study of more than 1,800 men from the U.S. and Peru, researchers found that overall, the risk of contracting HIV over 18 months did not significantly differ between circumcised and uncircumcised men.

Over the study period, 5 percent of the 1,365 uncircumcised men became HIV-positive, as did 4 percent of the 457 circumcised men, according to findings published in the journal AIDS.

Well, gee, that information would be useful to know… if the study wasn’t conducted in a mind-numbingly stupid way.

Because, you see, that study doesn’t take into consideration whether the men were engaging in receptive or penetrative anal sex. I just assumes that gay men pass HIV to other gay men in some unknown and mysterious manner. Maybe by osmosis.

Well guess what? It really doesn’t matter one iota whether a bottom’s penis is circumcised, pierced, tattooed, or wearing a funny hat if he has semen up his butt. And any study that focuses only on whether a penis is circumcised – but not what you’re doing with it – is going to provide useless information.

I will give this study partial credit for even wondering, as a side note, whether circumcision impacts the transmission of guys who are using their penises in penetrative anal sex. And while they couldn’t bother to craft a study that looked at that issue, they did at least ask. Kinda.

And guess what?

The researchers did find some hints that circumcision could be protective among men who primarily had insertive sex with other men. Among men who said they’d had insertive sex with their last three male partners at least 60 percent of the time, circumcision was linked to a 69 percent lower HIV risk.

That difference, however, was not statistically significant, which means the finding could be due to chance.

But the truly stupid aspects of this Wasted Money Study isn’t limited to having no concept whatsoever about how HIV is transmitted. It also made these glaring errors:

Male circumcision is far more common in the U.S. than in most other countries, and 82 percent of the 462 American men in the study were circumcised, compared with just 6 percent of the 1,360 Peruvian men.

D’ya think that this may be a material difference in populations? That perhaps there are differences between the cultures, practices, or even extent of HIV exposure between the two countries?

All of the men in the study reported having sex with other men and were considered to be at increased risk of HIV infection because they were already infected with the genital herpes virus (herpes simplex type 2), which can make people more susceptible to HIV.

So we’re talking about men who potentially have open sores… which are known to be ways in which HIV enters the body… but all that can be ignored to discuss the results of circumcision.

None of which discouraged declarations based on the results of the “study”

Taken together, the results “indicate no overall protective benefit from male circumcision” when it comes to male-to-male HIV transmission, write the researchers, led by Dr. Jorge Sanchez of the research organization Impacta Peru, in Lima.

No, Dr. Sanchez, taken together the results indicate an incredibly stupid study which tells us absolutely nothing whatsoever about circumcision and HIV transmission and was a complete waste of time and money. I really hope that my tax dollars did not fund your folly.

We don’t really need studies that inform us that anally receptive men don’t reduce their HIV risk by becoming circumcised. They also aren’t benefited by having flocked wall-paper or a charming haircut.

But I, for one, would be interested in a study that looked at whether HIV transmission could be reduced by means of circumcision among anally penetrative men. That question has not been answered (this Wasted Money Study, notwithstanding) and it would be beneficial to know whether circumcision is a risk mitigator among this subset of gay men, and to what extent.

And, I guess they did add that recommendation to their nonsensical reporting of their results.

They add that studies should continue to look at whether circumcision affects HIV risk from insertive sex and do so in larger, more diverse study groups.

Yeah. Ya think?

Comments

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TampaZeke
December 8th, 2010 | LINK

Regardless of whether circumcision decreases the rate, doesn’t decrease the rate or increases the rate of HIV infection, the decision as to whether a male is circumcised or not should be made by the male HIMSELF, when he’s an adult and able to make an informed decision, and not by ANY other person.

I’m all for circumcision for anyone who wants it for him/herself. Hell, I don’t care if a person want to cut the whole thing off but such a personal and permanent and painful decision should be for the individual alone to make.

tim
December 8th, 2010 | LINK

@TampaZeke

Your parents make all sorts of decisions for you throughout the course of your childhood that have a greater impact to your life than getting cut or not. What makes this decision any different?

(cut here)

Bryan
December 8th, 2010 | LINK

So wait, a 69% difference in HIV risk between circumcised and uncircumcised penetrative men isn’t statistically significant? That’s seems to be a pretty huge margin of error.

Pender
December 8th, 2010 | LINK

If a parent is considering whether to circumcise a baby, the relevant question with respect to HIV is how this will affect the child’s likelihood of contracting HIV. This study answers that question, at least in the event that the child is gay. The parent probably is NOT asking him/herself how this will affect the child’s likelihood of contracting HIV given that the child grows into a gay adult who tops without protection but does not bottom without protection.

Anyway, to answer Tim, parents aren’t permitted to cut off any other part of their baby’s body except to rectify a deformity, and that’s a good rule that should be used for any cosmetic/elective procedure that can be postponed without harm until the child is old enough to make an informed decision.

Timothy Kincaid
December 8th, 2010 | LINK

Pender,

This study answers that question, at least in the event that the child is gay.

I believe that I demonstrated exactly the opposite. This study answers nothing whatsoever about circumcision and HIV transmission, whether heterosexual or gay.

However, several other studies have concluded that HIV transmission in heterosexual men can be reduced up to 60%.

I hope that those who oppose circumcision will refrain from spinning this completely bogus “study” to support their own purposes. This is a behavior that anti-gay activists like Peter LaBarbera excel at, but it is not an admirable effort by anyone.

TampaZeke
December 8th, 2010 | LINK

Timothy, it’s pro involuntary circumcision supporters who run with every flawed study that comes down the pike. The one from Africa was shameful in its methodology but virtually no one who repeated it as basis for circumcision took a moment to review it.

Tim, what do you have against allowing a person to make such a personal and permanent decision for himself? And I’m unaware of all of these lifelong, irreversible, voluntary, invasive surgical procedures that parents decide for their children that your talking about. I’m a parent and I certainly haven’t.

Timothy Kincaid
December 8th, 2010 | LINK

Zeke,

At this point there is no credible question as to whether circumcision significantly reduces HIV transmission in Africa. The study has now been replicated repeatedly.

The only folks dismissing it are anti-circumcision activists. And at some point they begin to sound like HIV denialists.

I’m not personally pro-circumcision or anti-circumcision. But I am pro-honesty and anti-spin.

As for whether this should be a decision held off for adults or whether it should be a parent’s choice is a debate for another time. I don’t have a dog in that fight (I know men who have had adult circumcisions and those who have chosen to keep their foreskin).

But I believe the anti-circumcision activists only are convincing and credible to the extent that they are willing to be honest. I’d prefer hearing the merits debated by those who I think are not engaging in spin.

Pender
December 8th, 2010 | LINK

I guess I just don’t see the anti-gay angle here. It’s TRUE that circumcision is not an effective way to protect a gay person against HIV, and it’s true precisely because gay men tend to have anally receptive sex. You seem to acknowledge each of these points in isolation, so I’m not sure what your overall objection is — that the conclusion is too obvious to need a study? That it’s trying to push the message that gay people are dirtier or more infectious because circumcision isn’t an effective HIV prophylactic for us? It seems so labored that I wonder if I’m misunderstanding you.

There’s also just not enough detail in the Reuters summary to know whether the American/Peruvian samples actually messed with the data or whether the researchers compared the results within and not between the two countries.

truthteller
December 8th, 2010 | LINK

@ Timothy,

You write:
“But I believe the anti-circumcision activists…”

How is someone who doesn’t believe in circumcision an activist? You seem to be using right wing tactics to discourage the opposition, like calling a gay person who believes in equality a gay-activist.

You do make good points about the stupidity of this study, but overall, I agree with Zeke. I think that the decision should be made by the adult owner of the penis.

Ashton
December 8th, 2010 | LINK

“They also aren’t benefited by having flocked wall-paper or a charming haircut.”

I would think that they may actually be at a higher HIV risk if they have a charming haircut due to all of the potential partners they would attract with it. However, one could consider attracting many people as a benefit in general.

Emily K
December 9th, 2010 | LINK

I think timothy was referring specifically to people like the “intactivists.” You can see them marching in parades wearing phallus suits.

TampaZeke
December 9th, 2010 | LINK

People who are against involuntary circumcision, NOT against circumcision per se, are “anti-circumcision activists” and those who promote INVOLUNTARY circumcision aren’t called activists. You may claim to not care one way or the other but your choice of words and the way you write these articles makes it very clear that you do.

My issue is not, and never has been, with circumcision itself. It’s always been with the denial of one’s right to make such a critical decision for himself. How can a person say “my body my choice” when speaking of a woman’s right to an abortion and not believe that “my body my choice” applies equally as much to a male’s right to decide for himself whether he wants part of his genitalia surgically removed?

If circumcision reduces HIV then why is there not a SINGLE European country with a higher, or even EQUAL, rate of HIV to America? Why does every single European country, where circumcision is very rare, have considerably lower rates of HIV infection among gay AND straight populations?

Timothy, have you bothered to look for critical reviews of the African study? You are usually a stickler for methodology. That’s something I admire about you. You can’t possibly have read the methodology of the African study without having alarm bells go off. My suspicion is that you didn’t read the methodology or any critical reviews.

TampaZeke
December 9th, 2010 | LINK

Here’s a very simple critical review of the study that should be enough to make the average person question the African study:

http://www.huffingtonpost.com/ali-a-rizvi/male-circumcision-and-the_b_249728.html

Of course I’m sure this physician will be dismissed as an “activist”. After all, he’s Canadian and Indian. What would non-Americans, without a deeply embedded circumcision culture, have credible to offer to a discussion on circumcision?

TampaZeke
December 9th, 2010 | LINK

Emily K, when Timothy refers to other people who promote choice, dismissively as “activists”, then I will agree with you.

AJD
December 9th, 2010 | LINK

I read the piece by Ali Rizvi that TampaZeke linked to, and while it doesn’t carry the same weight as an academic study, there are indeed some serious red flags that call into question the validity of the Africa study.

Most of all, the fact that the circumcised men were told to abstain from sex for six weeks and cautioned to use condoms if they didn’t, while the uncircumcised men were told no such thing, while neither group was followed afterward to see if they continued using condoms. In other words, you had a six-week window in which one group of men continued to engage in high-risk activity, while the other did not — so of course the circumcised men’s risk of getting HIV was lower.

Meanwhile, I’ll reiterate what Zeke and Rizvi said because it’s important: The U.S. has the highest rate of circumcised men of any developed country (routine circumcision has been on the wane in Canada, Australia and New Zealand for years), yet it also has the highest rate of HIV infection.

And this is only conjecture, but I think it’s reasonable to be concerned that promoting circumcision as a means of combating HIV could lead to an increase in unprotected sex, particularly among young people, who may be emboldened to go without jimmy hats. Hell, from my own experience in a predominantly circumcised country and a predominantly uncircumcised one, cut guys here tend to be a little less attentive to cleanliness in that area because they think being cut makes them clean.

At the end of the day, an uncut guy with a condom is still at much lower risk of transmitting or contracting HIV and other STIs than a cut guy without one.

Timothy Kincaid
December 9th, 2010 | LINK

Zeke,
There are also those who hold ideological objections to circumcision in general but are not activists, those who think the decision should be with the adult individual, some who think that circumcision is a good thing, and a whole bunch of folk who just don’t care that much one way or the other. Generally, our readers fall somewhere in here.

But there are also anti-circumcision activists. And generally they are the ones denouncing any science that doesn’t fit their paradigm.

I’ve perused the objections to the Africa study – though I’ve not done deep analysis. They seemed less than credible to me. And my impression of the Africa study’s possible limitations in methodology do not seem capable of resulting in the dramatic results of 50% and 60%. If we were seeing 10%, perhaps.

As for northern europe, that is a good question. I read that there are current increases in transmission, but that isn’t what you are asking.

The answer is a difficult one to ponder because one can sound insensitive. And, of course, I may not be correct as to the reason.

But I think that part of the reasons for the distribution of HIV in the world is genetic. It has long been known that some persons with Scandinavian heritage are virtually immune to the virus. And as I discussed here earlier this year, those with African heritage may have as high as 40% more susceptibility to the virus.

When we speak of the HIV rate in the US, we tend to conflate populations. We say that about 12% of gay men have the virus. That’s really only part of the truth, because that 12% is not a homogeneous representation of “gay men”.

Gay blacks have an HIV incidence rate of something like 30%. Some of that can be attributed to culture, economics, religion, institutionalized racism, and other factors, but some of it is genetics.

I’m not making the case for some strange racial supremacy or trying to give some racists “its the blacks” rant. I hope no one take this that way.

But if you ask for why Europe’s HIV is not significantly higher, I think this is a part of the equation.

HIV transmission is a very complex subject. And unfortunately everything that impacts transmission (or may impact transmission) is touchy and troublesome: race, gender, orientation, circumcision, sexual stimulation and fantasy, and religion.

AJD
December 9th, 2010 | LINK

“I’ve perused the objections to the Africa study – though I’ve not done deep analysis. They seemed less than credible to me. And my impression of the Africa study’s possible limitations in methodology do not seem capable of resulting in the dramatic results of 50% and 60%. If we were seeing 10%, perhaps.”

In my job, I often write about vaccine trials (which are very similar to this), and one thing I’ve learned is that they’re difficult to do well compared with trials of drugs to treat existing disease states because you can’t effectively determine whether a patient contracts or doesn’t contract a disease because of the vaccine, a change in behavior or simple luck.

That six-week disparity between the circumcised and uncircumcised men and the advice the former received to use condoms (which the uncircumcised men didn’t, apparently) represent major methodological flaws, because it basically means the researchers allowed the placebo group to be open to exposure to the virus for six weeks while actively trying to protect the treatment group from exposure.

If the researchers had also taken steps to prevent the uncircumcised men from having sex or had them use condoms when they did during those same six weeks and instructed both groups to have only unprotected sex after the six weeks and then gotten similar results, then we could say they were onto something.

Timothy Kincaid
December 9th, 2010 | LINK

AJD,

When reading Rizvi’s article, it was clear that he had a bias. It was only after his first eight paragraphs stating his opinions on why circumcision is wrong, that he got around to seeking to debunk the studies.

We all have bias, but Rizvi appears to be one of those elusive anti-circumcision advocates we discussed above. Which doesn’t make him wrong, just gives us a clue that he may be slanting his “facts”.

For example, Rizvi implies that uncircumcized participants were denied safe-sex information and condoms. But if I recall correctly (and I did read about the original studies carefully), ALL participants were given condoms and safe-sex information. Indeed, it would be abhorent if they had not.

And I very much doubt that there was any extra effort to “protect the treatment group from exposure”. That suggests some sort of bizarre conspiracy. Actually, what Rizvi is talking about is that those who had been circumcized during the study were instructed not to have sex at all so that they could heal.

The no-sex-for-six-weeks lectures could play some part in the variance between the results. But, at present, I very much doubt that it could account for 50-60%.

I also note that those who are most dedicated to battling HIV/AIDS were satisfied with the findings and that the objections are coming not from HIV/AIDS sources but from those whose interest in the study is motivated solely by their interest in circumcision. Which, again, does not make the studies right, but should give us some hint as to motivations.

We may find that there was some major flaw in the studies some day. But so far, I’m just not seeing the objectors are claiming.

And we may discover that HIV actually does discriminate based on orientation and that circumcision impacts HIV transmission rates for heterosexual insertive men but not homosexual insertive men, for some as yet unknow reason.

But this very poor study didn’t show that at all. What we need is a good study that can answer the question, or at least no more studies that waste time and money to make wacky pronouncements.

Hugh7
December 9th, 2010 | LINK

“studies should continue to look at whether circumcision affects HIV risk from insertive sex” Why? There is no such thing as “insertive sex” without an exactly equal amount of receptive sex, and when one is unprotected, so it the other. The only rational use of circumcision in this context would be for an insertive-only man (a minority) who gets tested between every act of unprotected sex with men of unknown HIV status, in order to (slighly, perhaps) reduce his calculated risk.

The main objection to the three RCTs is that the absolute difference in transmission, less than two years after circumcising 5,400 men was 73 (64 HIV+ circumcised, 137 HIV+ non-circumcised) a Number Needed to Treat of 39. If you told a roomful of 39 men “By circumcising all of you, one will be protected from HIV for two years,” How many would volunteer? Instead they hammer away at “60% reduction”. As someone else put it, if a shipload of condoms was found to be 40% full of holes, US embassies would be burnt down.

But also, 673 men dropped out, their HIV status unknown – a black hole big enough to drive a truck through. The trials were neither double-blinded nor placebo-controlled, opening the way for all sorts of experimenter and experimentee effects, when everyone involved desperately wanted circumcision to be effective, the subjects were paid and many of the experimenters have a history of promoting circumcision. There was no contact-tracing so we have no idea how many of the transmissions were even (hetero)sexual.

These trials are just another sordid epiode in the long history of circumcision’s search for a disease to be the “cure” for.

Craig
December 9th, 2010 | LINK

Timothy ,

I’ve sat on this for 24 hours because there are currently so many more-time-critical issues about which to worry, but I believe this issue is important to address.

You (correctly, in my opinion) criticize a study that compares Peruvian men to American men, but you then assert that

“At this point there is no credible question as to whether circumcision significantly reduces HIV transmission in Africa. The study has now been replicated repeatedly”

I see no logical reason to conclude that HIV transmission occurs the same on the continent of Africa as it does anywhere else on the planet based upon studies in *some* subsets of Africa men. You haven’t cited the studies to which you’re referring, so I can’t address them specifically, but many of the African studies I’ve read have compared non-random samplings of men (e.g., Muslims, circumcised, halal, with many hygienic and societal sexual restrictions, in some parts of southern Africa, compared to not-circumcised non-Muslim, truck drivers in other parts of Africa who frequent prostitutes/brothels along the major road routes they travel), while others have compared “like” African men who have little in common with, for example, North American men who live in first-world nations, with access to clean, running water, soap, other hygienic benefits, health care, and who may have the luxury to choose not to be sexually irresponsible and promiscuous with a population of women who have a different rate of sexually transmitted diseases, due in part to different societal expectations placed on women’s sexual lives.

I also see no logical reason to conclude that a study comparing Peruvian men to American men is “ill-contrived” while a study of subsets of African men can be reasonably assumed to reach a conclusion about the effects on men in general around the planet (or perhaps elsewhere :-)

If I were a sexually irresponsible, promiscuous man who lived in an area where the women with whom I had sex had a relatively high rate of STDs, and I had limited access to condoms, clean, running water, cleansing options, health care and other means of caring for myself, then given the African studies I *would* assert, as you do, that “there is no credible question” that I should consider getting myself circumcised.

But I’m not such a person.

I see no scientific evidence to conclude that I have been protected in ANY way whatsoever from HIV transmission because I was circumcised 18 YEARS before I ever became sexually active — passively or otherwise. (and yes — I’ve just now admitted that I didn’t get laid until my 18th birthday :-(

And if I were raising a son with the expectation that he would become a sexually irresponsible, promiscuous man who lived in an area where the women with whom he was likely to have sex had a relatively high rate of STDs, and he had limited access to (and was unlikely to use) condoms, clean, running water, cleansing options, health care and other means of caring for himself, then given the African studies I would assert that “there is no credible question” that I would recommend to him that he consider getting himself circumcised ONCE HE BECAME SEXUALLY ACTIVE. But in my judgment, my obligation to him would be to convince him to make wise life choices, rather than to take away some of his life options.

But I raised my son with higher expectations than that. And while he might ultimately disappoint me, the choice is HIS, not mine (and yes, it has been a struggle to accept that I can’t control my children’s life choices). And studies from Peru or Africa have NOTHING to do with HIS life choices. “There is no credible question” that it is HIS life, and not mine.

In short: I agree with you that the study you cite is flawed and meaningless, but I also assert that the studies upon which you rely to assert that “there is no credible question as to whether circumcision significantly reduces HIV transmission” (although the sentence from which I’m quoting specifies “in Africa”) are also flawed and meaningless as far as MY life and the life of my friends and children are concerned.

My advice to any young man is:

given the studies I’ve seen:

if you’re sexually irresponsible and promiscuous, and

if the women with whom you’re having sex are sexually irresponsible and promiscuous, and

especially if you have limited access to running water and other hygienic options, then

INVEST IN CONDOMS (and use them), and

if you cannot do that, and you cannot control yourselves, consider getting yourself circumcised.

But otherwise, it’s not an issue for you.

Hugh7
December 10th, 2010 | LINK

@Timothy Kincaid: “those who had been circumcized during the study were instructed not to have sex at all so that they could heal.

“The no-sex-for-six-weeks lectures could play some part in the variance between the results. But, at present, I very much doubt that it could account for 50-60%.”

I’m sure a study has shown somewhere that if you administer a sharp pain, especially in an impressive medical setting, it will reinforce any other message you give. (If it hasn’t, it should be done.) That is what happened to the experimental group, but not the control group.

They were also told that if they did have sex within six weeks, they must use condoms. Presumably after six weeks they were not told “OK, you don’t have to use condoms now.” So they were now in the habit of using them, knew how to use them, and were altogether condom-sensitised in ways the control group was not.

And the difference doesn’t have to amount to “50-60%”, only enough to make the results not statistically significant.

Timothy Kincaid
December 10th, 2010 | LINK

Craig,

The Africa studies were pretty well reported. Wikipedia has a fairly good synopsis both of those studies as well as the views of those who disagree.

Hugh7
December 10th, 2010 | LINK

Or rather, the studies were widely and uncritically reported. Wikipedia circumcision entries are ruthlessly edited by someone who knows the rules backward and has a strong interest in the pro-circumcision position.

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