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Posted by plosmedicine on 30 Mar 2009 at 23:47 GMT

Author: John Geisheker
Position: Attorney at law
Institution: No affiliation was given
Submitted Date: October 28, 2005
Published Date: October 31, 2005
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.

Nothing frightens like HIV / AIDS, and thus optimistic claims that circumcision might provide a prophylactic effect have proved seductive and been widely circulated in both the popular and the medical press. The Auvert study claims that circumcision of male adults showed a prophylactic effect, and two similar RCTs are in progress at this writing.

The following practical, social and bioethical hurdles for all such studies must be considered:

- Foreskins, male or female do not cause disease and never have; unhealthy adult sexual practices do.
- The protective effect if not 100%, inevitably declines with time and frequency.
- Male circumcision only addresses the female-to-male vector, and not other vectors.
- If the male genital mucosa provides a portal for HIV, it is likely the much larger female mucosa does also.
- Another study showed that Female Circumcision or FGM also shows a protective effect against HIV. (Stallings 2004)
- Where even clean water is a luxury, let alone sterility, should surgery be proposed when condoms are safer?
- Two other studies suggest medical procedures are themselves a vector for HIV in Africa. (Gisselquist 2002, 2003, Brody 2003).
- Voluntary circumcision of adults has never proved popular at any time in history, in any culture.
- Infant circumcision poses bioethical problems, especially when other methods of disease control are available, proven and affordable, and the tissue has protective and sexual functions
- Well before today's infant males are sexually active, a universal HIV vaccine will very likely be available. A vaccine is very near. The latest Merck trials, 10/05, show promising protection against variants of HIV that are responsible for 75% of the strains in circulation.
- Circumcised males, perhaps because of reduction of sensation, may be disinclined to use condoms
- Circumcision proponents appear to disregard the sexual value of the natural male foreskin.
- The US has the highest rate of HIV infections in the West, and also its highest rate of circumcised males (70%).
- Circumcised males may view themselves as immune and engage in risky sexual behaviours
- Third-world countries cannot afford massive adult circumcision campaigns, while they could afford condoms and education.
- A vaccine has already been developed for HPV-16 and HPV-18, the commonest varieties of this associated virus.
- Bioethics obliges that less intrusive method of disease control be exhausted first
- In the Third World, FGM thrives where MGM does, as the two are related phenomena. The introduction of MGM may hamper the eradication of FGM, or initiate it where it is unknown.

John V. Geisheker, JD, LL.M.
Attorney at Law, Seattle, USA

Gisselquist D, Rothenberg R, Potterat J, et al. Non-sexual transmission of HIV has been overlooked in developing countries. BMJ 2002;324:235.[Free Full Text]
Gisselquist D, Potterat JJ, Brody S. Let it be sexual: how health care transmission of HIV was ignored. Int J STD AIDS 2003;14:148???61 ([CrossRef][Medline]
Brody S, Gisselquist D, Potterat JJ, et al. Evidence of iatrogenic HIV transmission in children in South Africa. Br J Obstet Gynaecol 2003;110:450-2 (
Female circumcision and HIV infection in Tanzania: for better or for worse?
Stallings R.Y.1, Karugendo E.2 1ORC Macro, Calverton Maryland, United States of America, 2National Bureau of Statistics, Dar es Salaam, United Republic of Tanzania.

Competing interests declared: The writer is a General Counsel for physicians