Stephen Moreton, PhD guest post
In July the National Coalition For Men (NCFM) sent an open letter to the Bill and Melinda Gates Foundation attacking the Foundation’s support for circumcision in Africa as part of the drive against HIV there. The letter was co-authored by Peter Adler and Steven Svoboda of “Attorneys for the Rights of the Child”, though signed only by Harry Crouch of the NCFM. You can see a copy here:
It is bad even by intactivists’ standards (assuming they have standards, not so sure having read this latest effort). They say it took months of painstaking research to write. It took me about ten hours spread over a week to demolish. Naturally I have sent a copy to the Foundation but am not optimistic they will take much notice (their website actually says not to send them unsolicited materials). As intactivists have begun linking to the NCFM open letter in forums there is a need for an on-line rebuttal.
Annotated version of the NCFM’s open letter to The Bill and Melinda Gates Foundation. Original text in normal font, annotations in bold.
Everyone should applaud how your Foundation is funding proven methods to slow the spread of HIVand AIDS in sub-Saharan Africa, including testing, teaching the so-called ABC’s (Abstinence, Be Faithful, and Condoms), retroviral therapy, treating schistosomiasis (which causes vaginal bleeding) and STDs, and helping to lead the search for an HIV vaccine. It is time, however, for your Foundation to stop funding the scientically, morally, ethically, and legally unjustified program to circumcise 38 million African men as an HIV preventive strategy. After seven years and 6 million circumcisions, your program has failed.
On the contrary, it is working (Auvert et al, 2013).
Biased, Deeply Unethical Trials and Buried Results. The mass male circumcision program is being justified based on four random controlled trials (RCTs) conducted in sub-Saharan Africa. The RCTs suffered from numerous ethical, scientific and methodological flaws that render the results meaningless. 1,2,
Here the author ignores multiple debunkings of these criticisms. They have been answered in painstaking detail by authorities in the field, and to the satisfaction of all professional bodies involved. For examples of comprehensive debunkings see Halperin et al (2008) and Morris et al (2012). Tellingly, some of the articles cited in the open letter at this point attracted debunkings specific to those articles. Thus Green et al (2010) in ref. 2 was refuted by two separate letters to the editor: Banerjee et al (2011) and Wawer et al (2011); Boyle & Hill (which the author neglects to provide the full reference for) were refuted by Wamai et al (2011); and Van Howe & Storms (2011) in ref. 2 were refuted by Morris et al (2011). Ignoring criticisms, and citing discredited studies, is a pattern in Harry Crouch’s open letter, as we shall see.
Worse, one of the RCTs produced evidence that was quickly buried suggesting that circumcision may increase male to female transmission of HIV by 61%.3
The reference given (no. 3) merely refers the reader to the list of discredited studies above it, leaving the reader with the tedious task of searching through them to find the primary source. (Bad referencing is a problem with this open letter). Presumably it is Wawer et al (2009) who found that the female partners of recently circumcised HIV positive men had a higher risk of becoming positive themselves. This was because some men resumed sex before they had completely healed. So it is really an argument for educating men about the need to wait for complete healing before resuming sex, rather than an argument against circumcision per se. Of course this problem would not arise if the men were circumcised at birth. It has just been announced at the recent International AIDS Society conference that circumcising men reduces the risk to their female partners by about 20 % (Jean et al, 2014).
Moreover, the African circumcision program may be completely unnecessary, as a Ugandan RCT4 showed that intact men who wait at least ten minutes to clean their penis after sexual intercourse are 41% less likely to contract HIV than circumcised men.5
Here the author refers to a study which found that men who were quick to wash themselves after intercourse were more at risk than those who took their time and eventually merely wiped themselves with a cloth. Intactivists have enthusiastically seized on this curious finding and promoted it as an HIV-prevention strategy. This is premature as it is not proven why waiting and wiping should be of benefit. Speculations about enzymes in vaginal fluids have been made but the truth may be far more mundane. If a man has sex with a stranger, a prostitute, or someone else he considers to be at high risk of having HIV, then he will be far more likely to wash thoroughly and quickly as soon as proceedings have concluded. On the other hand, if he is with his regular partner, or someone he knows to be at low risk, he will be relaxed, and may take some time before merely reaching for a cloth and drying himself off. In short, the difference is simply a reflection of the accuracy of the men’s perception of risk (Ndebele et al, 2013). In light of this simple, prosaic explanation, it is reckless and irresponsible to promote “wait and wipe” as an HIV prevention strategy.
Thus, the program’s targets could be achieved without a single circumcision and at minimal cost versus a projected cost for the current program of $16 billion. African men and women should have been informed of these facts critical to their health and safety.
As the author’s basis for this comment comprises discredited studies and an irresponsible instruction about waiting and wiping, it can be dismissed. What the author is presenting is not factual at all, but dangerously misleading pseudoscience.
Circumcision Offers Men Little or No Protection From HIV.
About 60 % reduction in female to male transmission as indicated by three randomised controlled trials, rising with time to around 76 % in the S. African trial, putting it on a par with influenza vaccine.
Some Africans are being told, and many will reasonably assume (why else are they being circumcised?) that circumcision will protect them from HIV, but that is false. Circumcision is no vaccine. Circumcised or not, men who have sex with HIV infected females risk becoming HIV positive. Africans should be informed as follows: “For highly exposed men, such as men living in southern Africa, the choice is either using condoms consistently, with extremely low risk of becoming infected, or being circumcised, with relatively high risk of becoming infected.”6
Getting African men to use condoms at all, let alone consistently, has proved very challenging despite massive condom promotion. Circumcision provides added protection for when condoms fail (as sometimes they do) and for those who don’t or won’t use them. The reference cited (no. 6) refers one to no. 5 above, which is a duplicate of no. 4, and is not the source of the quote. More sloppy referencing. Presumably it is intended to be Garenne (2006).
Even if circumcision did reduce the relative risk by 50%, Garenne concluded,” a 50% reduction in risk [if true] is likely to have only a small demographic effect. “Observational studies of general populations have for the most part failed to show an association between circumcision status and HIV infection.”7
Again the reference is wrong. In fact it comes from Van Howe and Storms (2011) in ref. 2 which, as explained previously, was discredited by Morris et al (2011).
Thus, the true protection that circumcision provides to men from HIV infection is negligible or nil.8
False, for reasons stated above.
Ironically, Circumcision Will Likely Increase HIV Infections Among African Men and Women. Experts have concluded that “circumcision programs will likely increase the number of HIV infections.”9
The reference given here is to husband and wife Van Howe and Storms, although confusingly it says “Supra n.12” which means “note 12 above”, when 12 is actually below. It should be n.2. Such repeated careless referencing does not inspire confidence in the author’s academic skills. And, as Van Howe and Storms have no relevant research background in African HIV, but are in fact prominent intactivists, and Van Howe has a history of shoddy scholarship (see below), the description of them as “experts” is misleading. As stated before, the article in question has been debunked (Morris et al, 2011). Some of the co-authors of the debunking were involved in the African trials – real experts.
First, only 30%-35% of HIV in African men is attributable to sexual transmission, not 90% as experts initially claimed.10 HIV in Africa is often blood borne, spread by contaminated needles.
Once again the author makes a bogus claim from a discredited source. In this instance he cites Gisselquist whose ideas about African HIV being mostly spread by vaccinations were thoroughly debunked in 2004 by the WHO (Schmid et al 2004). Gisselquist continues to be cited by anti-vaccination groups, HIV/AIDS deniers and, it seems, intactivists, but amongst the scientific community he has no credibility.
Circumcision surgery in Africa often causes HIV.
Having been regaled with discredited studies, and fringe sources like Gisselquist, we now have the other stock-in-trade of the pseudoscientist – the half-truth. Traditional African-style circumcision, by a shaman with a razor blade and no regard to hygiene, pain control or cosmetic outcome, does spread HIV (not “cause” it, how do you “cause” a virus?) This has been known for years (e.g. Brewer et al 2007) and is why in some African countries (e.g. Lesotho, Cameroon & Tanzania) circumcision actually correlates with HIV (something intactivists never tell their audiences when they gleefully point to such countries).
The problem will much worse when millions of Africans are circumcised in multiple, often unsterile venues on a rush basis by poorly trained workers.
Then see that they are trained and have the time and resources to do the job properly.
Second, volunteers, reasonably believing that they are completely or substantially protected from HIV, are less likely to use condoms,11,12 and circumcised men are less likely to use condoms anyway.
This is the “risk compensation” argument. As usual the references cited are both discredited studies by the unreliable Robert Van Howe. No. 12 in particular became a textbook example – literally – of how NOT to do a meta-analysis (Borenstein 2009). Undeterred, Van Howe went on to do a second meta-analysis (on circumcision & HPV) that was so bad that when experts from the Catalan Institute of Oncology examined it they concluded it ought to be retracted from the literature (Castellsagué et al 2007). But Van Howe didn’t learn and when his third meta-analysis came out (on circumcision & STIs) it was again found to be so bad as to merit retraction (Morris et al 2014). Whenever Van Howe gets on his anti-circumcision hobby-horse he attracts criticisms. These episodes are just a sampling of the impressive tally of rebuttals and critiques he has clocked up over the years. And he was described earlier in Crouch’s open letter as an “expert”! Readers are advised to be deeply wary of anything bearing the name Van Howe.
Of course the notion of risk compensation has already been well examined and found not to be an issue when men are given proper counselling. Here are the studies demonstrating this which Crouch ignores: Mattson et al (2008), Reiss et al (2010), L’Engle et al (2014), Westercamp et al (2014).
Third, mass circumcision diverts resources from the proven methods of HIV prevention listed in the introduction. Thus, your mass male circumcision program will not only fail but will backfire.
Circumcision Is Also Painful, Risky, and Harmful. Africans report surprised at how painful circumcision is. Even if local anesthetics are used and given time to work, they are largely ineffective, and pain continues during the healing period.
This is just false as millions of men circumcised in this way know. Where is Crouch’s evidence?
Even the American Academy of Pediatrics ‘Task Force on Circumcision concedes that circumcision risks a long list of minor injuries , serious injuries (including hemorrhage, infection, deformed penis, and loss of all or part of the glans or of the entire penis) and death. In the United States, the risk of injury is estimated to be between 2% and 10%.
In the largest study yet (n = 1.4 million) the CDC have determined the risk of all complications, whether serious or not, from infant medical circumcision to be 0.5 %, and about 10 to 20 times higher for those carried out later (Bcheraoui et al 2014).
In Africa, the risk of injury is much higher, estimated to be 17.7% clinically and 35.2% for traditional circumcisions.13
As usual Crouch does not tell the whole story. The clinical practitioners in the study had not the training or equipment to conduct circumcisions safely. Great efforts have since been put into developing safe methods and providing resources so it is misleading to base a complaint on one study of one district in one country which identified issues that have since been addressed. And to compare medical circumcision with crude traditional circumcision by a shaman is just absurd.
As the AAP conceded in its 2012 policy statement, the true extent of the risks associated with circumcision is unknown.
Bcheraoui et al 2014.
Circumcision Diminishes Every Man’s Sex Life. Circumcision removes one-half of the penile covering, the size of a postcard in an adult.
There is such variation in penile sizes and proportions it is not possible to give a “one size fits all” figure. Intactivists also count both inner and outer surfaces to make it seem larger.
The foreskin is replete with blood vessels and specialized nerves such as stretch receptors. The foreskin is, and circumcision removes, the most sensitive part of the penis.14
Here Crouch cites another dubious work by intactivists. Aside from the round of criticism (Waskett & Morris 2007), counter-criticism (Young 2007) and further criticism (Morris & Krieger 2013) it attracted, the study looked only at one kind of sensitivity – fine touch. But is this the right kind of sensitivity? Fine touch comes from nerve endings called Meissner’s corpuscles which are present in the foreskin, but even more so in the fingertips (Bhat et al 2008), and we do not consider fingertips erogenous. Pleasurable erotic sensations come from genital corpuscles which are concentrated around the glans, not the foreskin. So the whole study may be a red herring. It is certainly cherry-picked. Other studies find no difference between the circumcised and the uncircumcised. Like Bleustein et al (2005) who tested a broader range of sensation types (vibration, pressure, spatial perception and temperature) and found no difference between circumcised and uncircumcised. For every study the intactivists cherry-pick to suit their agenda, another can be found that contradicts it. Tellingly, the only meta-analysis to date, on the ten best studies, found that circumcision makes no difference to male sexual function (Tian et al 2013). An independent review found the same (Morris & Krieger 2013).
African men will be outraged to learn that circumcision not only has failed to protect them from HIV but has forever diminished their sex lives. Female partners of circumcised men also report reduced sexual satisfaction.15
More cherry-picking. There are studies which found that women report a preference for circumcised partners (e.g. Williamson & Williamson 1988) including a randomised controlled trial (table 2 in Krieger et al 2008).
Africans Are Being Misinformed, Coerced, and Exploited. African men are not being informed of the truth, that circumcision is painful, risky, and harmful; that in itself it gives little to no protection from HIV, and the surgery itself may infect them with HIV. Serious ethical violations are occurring as usually poor Africans are being offered valuable incentives to volunteer such as free medical care.16 Boys as young as fifteen years old are being coerced, such as being offered team uniforms and equipment in exchange for being circumcised.
As usual the reference Crouch cites here (no. 16) is one that was comprehensively debunked, as mentioned earlier.
Call For Action. Your Foundation’s mass circumcision program violates science, medical ethics, and the law. Your Foundation should immediately terminate its misplaced support of the African mass circumcision program. Your Foundation should also immediately initiate a comprehensive investigation into the program led by unbiased experts, ethicists, and of course Africans. Otherwise, the legacy of the Gates Foundation, and inevitably your personal legacy, will be that you and your Foundation funded one of the most harmful medical programs in human history, and also that you and your Foundation failed to stop it after being informed that it had failed.
Harry Crouch’s letter violates truth and reason. Although there is plenty of evidence in it for scholarly incompetence (such as the garbled referencing), the ignoring of detailed debunkings and the use of discredited studies, are so systematic from start to finish that it is difficult to see this as being due to mere ineptitude. The selectivity and use of fringe sources like Gisselquist add to the charge that Crouch’s open letter is agenda-driven anti-medical pseudoscience. I urge the Foundation to disregard it, and any future pressure from anti-circumcision groups, and to continue to back scientifically proven interventions, including circumcision, in the face of a deadly epidemic that has killed millions.
1 G.W. Dowsett and M. Couch, “Male circumcision and HIV prevention: is there really enough of the right kind of evidence?,” Reproductive Health Matters, 15, no. 29 (2007): 33-44; L.W. Green, R.G. McAllister, K.W. Peterson, and J.W. Travis, “Male circumcision is not the HIV ‘vaccine’ we have been waiting for!,” Future HIV Therapy, 2, no. 3 (2008):193-99; D. Sidler, J. Smith, and H. Rode, “Neonatal circumcision does not reduce HIV/AIDS infection rates,”. South African Medical Journal, 98, no. 10 (2008):762-6.
2 Robert S. Van Howe and Michelle R. Storms, “How the circumcision solution in Africa will increase HIV infections”, Journal of Public Health in Africa, Vol. 2, No. 1 (2011)
(http://www.publichealthinafrica.org/index.php/jphia/article/view/jphia.2011.e4/html_9 ); Boyle & Hill, supra n.1; D.D. Brewer, J.J. Potterat, and S. Brody, “Male circumcision and HIV prevention,” Lancet, 369 (2007): 1597; L.W. Green, J.W. Travis, R.G. McAllister et al., “Male circumcision and HIV prevention: insufficient evidence and neglected external validity,” American Journal of Preventive Health, 39 (2010): 479-82.
4 F.E. Makumbi, R.H. Gray, M. Wawer et al., “Male post-coital penile cleansing and the risk of HIV acquisition in rural Rakai district, Uganda,” abstract from presentation at Fourth International AIDS
Society Conference on HIV Pathogenesis, Treatment and Prevention, Sydney, 2007, available at
5 F.E. Makumbi, R.H. Gray, M. Wawer et al., “Male post-coital penile cleansing and the risk of HIV acquisition in rural Rakai district, Uganda,” abstract from presentation at Fourth International AIDS
Society Conference on HIV Pathogenesis, Treatment and Prevention, Sydney, 2007, available at:
8 M. Garenne, A. Giamland, and C. Perrey, “Male Circumcision and HIV Control in Africa: Questioning
Scientific Evidence and the Decision-making Process,” in T. Giles-Vernick and J.L.A. Webb Jr., eds., Global Health in Africa: Historical Perspectives on Disease Control (Athens, Ohio: Ohio University Press, 2013): 185-210, at 190 (“Garenne Male Circumcision and HIV Control”).
9 Van Howe & Storms, supra n.12.
10 Gisselquist D, Potterat JJ. Heterosexual transmission of HIV in Africa: an empiric estimate. Int J STD
AIDS 2003;14:162-73 (www.rsm.ac.uk/new/std162stats.pdf ).
11 Van Howe & Storms, supra n.12.
12 Van Howe RS. “Circumcision and HIV infection: review of the literature and meta-analysis”. Int J STD AIDS 1999;10:8-16.
13 Bailey RC, Egesah O, Rosenberg S. “Male circumcision for HIV prevention: a prospective study of
complications in clinical and traditional settings in Bungoma, Kenya”. Bull World Health Organ 2008; 86: 669-77.
14 Sorrells et al. “Fine-touch pressure thresholds in the adult penis”, BJU Int. 2007 Apr;99(4):864-9 at
15 Frisch et al, “Male circumcision and sexual function in men and women: a survey-based, crosssectional study in Denmark” (2011), at http://ije.oxfordjournals.org/content/early/2011/06/13/ije.dyr104.full ; and “Effects of male
circumcision on female arousal and orgasm”, New Zealand Medical Journal, Vol. 116, No. 1181: 595-96, September 12, 2003.
16 Boyle & Hill, supra n.1.
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