Male circumcision for HIV - conclusions sensitive to assumptions

John D Dalton, Researcher and Archiver,
April 10, 2007
Re: Rennie S, Muula AS, Westreich D. Male circumcision and HIV Prevention: Ethical, Medical and Public Health Tradeoffs in low-income countries.

Rennie and colleagues are to be welcomed for using the age of circumcision as an ethical vantage point rather than looking at the science behind circumcision as prophylaxis for the HIV infection. While recognising that the authors have merely set up points for discussion rather than dogmatic conclusions, the outcome of their approach is strongly dependent on the input data. I would like to reexamine their work from the perspective of a charity set up to represent the interests of patients who feel harmed by circumcision.

Consent

Rennie and colleagues find assent “vexing”. They state that “the older the child is, the more appropriate it seems to seek his agreement. This is embodied in current BMA Guidance on male circumcision which states “The BMA cannot envisage a situation in which it is ethically acceptable to circumcise a competent, informed young person who consistently refuses the procedure”.[1]Perhaps circumcision is so often performed on normal unconsenting infants is because adults fear that older children or adults would not agree to it. In the absence of immediate therapeutic need, such procedures would normally be limited to cases in which the individual affected is able to give informed personal consent.

Feasibility

The question of feasibility is, I suggest, a red-herring in the context of this ethical discussion. It may be highly feasible to circumcise infants as part their mothers’ confinement but that would not make it ethical. Conversely the introduction of cheap highly available condoms and anti-viral drugs to poor countries would be highly ethical but its feasibility is low in the current international climate.

Risk compensation

It is naive in the extreme to assume that risk compensation would not affect populations circumcised in infancy. Those who are brought up to believe that they had to be circumcised to prevent them acquiring HIV will share the same feelings of invulnerability to infection likely to occur in those circumcised as adults or adolescents. As such, risk compensation cannot be discounted for a population circumcised in infancy and cannot be an argument in favour of circumcision of normal unconsenting infants.

Burden on health services

The burden to health services of circumcision does not end with a simple procedure integrated seamlessly into “reproductive care”. Bailey reported a 1.5% complication rate including anaesthetic morbidity, pubic abscess and impotence.[2]Gray reported complications in 3.6%[3]. Complications of circumcision generally include tetanus, loss of the glans, loss of the entire penis and death.[4]These complications are potentially devastating for the individual and may present an intolerable future burden on health services in low income countries. Equipoise may not be possible in the light of reported complication rates and a reduction in absolute risk [Gray] of only 0.67 cases of HIV per 100 man years. This is particularly so when taking account of the likelihood that the complication rate will be much higher when circumcisions are performed in realistic African settings.

Harms intrinsic to circumcision

Most authors on the subject of male circumcision disregard any possibility that the circumcision could, in the absence of complications, be in any way harmful. The minute that the surgeon cuts the skin, harm is done and the benefits of treatment have to exceed the harm before the doctor is doing any good.[5]Male circumcision permanently removes normal, functional, specialised tissue. It removes specialised sensory tissue[6]half the penile skin[6] and removes the normal gliding function of facilitating intromission.[7]The penis has its appearance permanently altered by circumcision. These changes are not welcomed by all. While some consider circumcision to be a beautification others consider it a disfigurement.

Discussion

Rennie and colleagues’ statement that neonatal male circumcision has significant cost and public health advantages must not go unchallenged. The evidence for the effectiveness of male circumcision in preventing diseases is weak. Only four randomised controlled trials have been published and all but one of these all relate to HIV. All of the HIV trials have been terminated early based on criteria set by the authors. Trials terminated early tend to overestimate the size of the effect.[8] The one RCT of circumcision to prevent UTIs concluded that circumcision did not reduce the number of recurrences of UTIs.[9]Evidence in respect of all other health benefits from circumcision is either contradictory or non-existent. There is a further contradiction inherent in the hypothesis that specialised immunological tissue in the foreskin facilitates HIV uptake while not helping to prevent other STIs or UTIs.

It is important to consider whether infant circumcisions performed with a view to preventing HIV should be deemed therapeutic. The term therapeutic normally implies the treatment of existing disease or deformity. The term prophylactic is perhaps more appropriate for interventions intended to prevent disease in future. Prophylactic surgery on normal unconsenting children normally raises serious ethical concerns.[10]Therapeutic surgery is normally justified on the basis of disease being present, non-invasive treatment being impossible, surgery being effective and valid informed consent being present. Non-therapeutic surgery is normally only acceptable when it is requested by an informed consenting adult. In the case of circumcision it seems odd that the one procedure should fit into both categories.

Rennie and colleagues seek to deny male children autonomy in respect of circumcision on the grounds that granting children autonomy would prevent childhood immunisations. While immunisations are invasive, they are minimally so. They remove no tissue and, for the greater part, leave no scar. As such they can be justified on an equipoise of the risks to the child from the immunisation against the benefits to the individual and society from the control of communicable disease. Such a line in the case of circumcision would be unjustifiable since circumcision causes a life-long burden in the loss of the normal specialised tissue, loss of the foreskin’s functions and a permanent change to penile appearance. Not all men are happy to have been reassigned as “round-heads” to meet the wishes or needs of someone else. A discussion of the ethical issues surrounding immunisation and infant circumcision has been presented by Hodges and colleagues.[11]

With regard to children and consent/assent, it would appear symbolic of the status of children in our society that we seek to inflict markings on their bodies that they may not agree to later. The change in appearance to the body and the loss of function remain with the individual as a life-long mark of their position in society. Why should any individual suffer the lifelong burden of something which - however desirable to society - was not actuallynecessary for the child? Dickenson has stated that the right for children to give consent is meaningless without the right to withhold consent.[12]

It is troubling that Rennie and colleagues further seek to erode children’s autonomy on the grounds of “the vagaries of adolescent decision making”. In societies where male circumcision is practised as a pubertal right these “vagaries” manifest in boys running away to circumcision “schools” against their parents’ wishes. This parallels our society in which rebellious teenagers seek invasive procedures and come home with unsightly tattoos and piercings which they may later regret. Parents here seek to limit their children’s autonomy for this reason. Moreover a concern that irreversible procedures might later be regretted by the young person drove the UK Parliament to pass the Tattooing of Minors Act 1969 which forbids tattooing of under-18s with no provision for parental consent.[13]

A parent’s power of proxy decision making in respect of their child stems from their duty to protect and nurture the child. As such it is right for parents to give consent to medical procedures which are in their child’s best interests; but it is also their duty to withhold consent on behalf of the child where the procedure would not be in the child’s interests. Here it is appropriate for the parents to exercise substituted judgement in respect of whether a child should have an intervention or not. In view of the fact that the vast majority of men reaching adulthood with their foreskin intact choose to retain it, it is difficult to see that parents have any legitimate right to consent to circumcision of their child except where there is unavoidable therapeutic need for the procedure. HIV prevention - even where the virus is endemic cannot reasonably override this principle in view of the harm inherent in circumcision and the lack of any certain epidemiogical benefit as noted above.

Rennie and colleagues appeal to a study in Botswana which finds that 55% of parents believe that if male circumcision is to be performed for HIV prevention then it should be performed on young children in a hospital setting. They state that it cannot be ethically sound without “community based research” into its acceptability. Should not sound medical evidence and ethical justification take preference to parental beliefs? Moreover community consent should never be allowed to trump individual autonomy.

Introducing circumcision into societies that do not presently have it in their culture should raise ethical concerns. Is it culturally appropriate to introduce circumcision into cultures that do not perform it? Is it acceptable to provide a therapeutic context - albeit without therapeutic need - to circumcisions in cultures which presently practice circumcision as a tribal rite? Is it right to reintroduce circumcision to cultures which have moved beyond child circumcision? Is it right to change local circumcision practices to introduce the American style of circumcision?

A further concern is that of the “circumcision apartheid” that may be introduced if circumcision is deemed the right thing. Will boys be cast out for “lack of circumcision”? Already there are reports of boys being bullied at school because their peers are circumcised and they are not. Sadly the boys who are victims of the bullying have been sent home until they get circumcised.[14]Thus the school colludes with the bullies to bring about the circumcision of these children rather than protecting them from the bullying and allowing them to retain their physical integrity.

It would of course be wrong to deny the introduction of circumcision on the basis that it is genital mutilation. Many medical procedures are mutilating and yet are still entirely appropriate in treatment practice provided they form part of a treatment hierarchy in which least invasive procedures are used in preference to more invasive ones and the mutilating treatment options kept as a treatment of last resort. As such, non-invasive measures such as ensuring that condoms, anti-viral drugs and vaccines (when developed) are available to those in poor countries must take precedence over the imposition of circumcision.

It is incumbent on the west to address the real problems of poor countries. Poverty itself is a risk factor for HIV and we must deal with this at source. We must ensure that African women are no so desperate that they have to sell sex to feed their children. We must ensure that condoms and pharmaceuticals are available to poor countries before we seek to impose American cultural practices - such as male circumcision - upon them. What are Africans to make of the fact that we demand that they don’t circumcise their girls but that they must circumcise their boys?

While Africa remains poor it could be a grave mistake to seek to introduce circumcision. The reality is that it will facilitate iatrogenic transmission of HIV, encourage male to female transmission[15]and bring about risk compensation. Another factor is that male circumcision may facilitate HIV transmission by reducing production of Langerin - a natural barrier to HIV transmission.[16]These factors could more than offset the 0.66 cases of HIV per hundred man years saved by introduction of male circumcision. We must never forget that the USA has the highest prevalence of male circumcision in the developed world and the highest prevalence of HIV. If in 20 years time male circumcision has made the HIV problems of Africa worse, it will then be very difficult to eradicate the practice.

References

1 http://www.bma.org.uk/ap.nsf/Content/malecircumcision2006, Accessed 8 March 2007.
2 Bailey RC and colleagues. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet,2007:369;643-656.
3 Gray RH and colleagues. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet,2007:369;657-666.
4 Williams N, Kapila L. Complications of circumcision. Brit J Surg 1993;80:1231-6.
5 Editors Choice. Knowing when not to operate. BMJ;318 (Anonymous leader).
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 Taves D. The intromission function of the foreskin. Med Hypotheses. 2002 Aug;59(2):180-2.
8 Mills E, Siegfried N. Cautious optimism for new HIV/AIDS prevention strategies. Lancet. 2006 Oct 7;368(9543):1236.
9 Kwak C, Oh SJ, Lee A, Choi H. Effect of circumcision on urinary tract infection after successful antireflux surgery. BJU Int. 2004 Sep;94(4):627-9.
10 Fox M, Thomson M. A covenant with the status quo? Male circumcision and the new BMA guidance to doctors. J Med Ethics. 2005 Aug;31(8):463-9.
11 Hodges FM, Svoboda JS, Van Howe RS. Prophylactic interventions on children: balancing human rights with public health. J Med Ethics 2002;28(1):10-16.
12 Dickenson D. Children's informed Consent to Treatment: is the law an Ass? J Med Eth. 1994; 20:205-206.
13 Law Commission Consultation Paper No. 139 Consent in the Criminal Law, 1995.
14 http://www.news.com.au/story/0,23599,21224181-401,00.html,acessed 14 March 2007.
15 http://www.foxnews.com/story/0,2933,257559,00.html, accessed 9 March 2007.
16 de Witte L, Nabatov A, Pion M, Fluitsma D, de Jong MA, de Gruijl T, Piguet V, van Kooyk Y, Geijtenbeek TB. Langerin is a natural barrier to HIV-1 transmission by Langerhans cells. Nat Med. 2007 Mar;13(3):367-71.

Conflict of Interest

None declared