disclaimer: the author wishes to stress she is not advocating or disavowing circumcision, this is just information to chew on

A DEADLY TRIAD: Circumcision Status, Genital Ulcer Disease and HIV Transmission

AIDS scares me.  I remember the first time I ever heard of it. It was a day in 1983 or 1984, and my father, who is a physician, picked me up from summer camp with a grim look on his face.  He told me that doctors had found a new disease called AIDS, and that he was really scared for my generation.  He didn't know how many of us would live, he said.  He told me I needed to be careful, because when I started having sex, a man could give me AIDS.  It was my first condom speech.  I was eight.  I can still remember the exact location on Vine St. in Berkeley, CA that we were driving on as he informed me of this terrible turn of events.  I was terrified.

Since that day, millions of people worldwide have died of AIDS.  And despite my father's fears for the children of America, most of those AIDS deaths have not occurred in the heterosexual population of the United States.  Although heterosexual women are now the highest growing segment of the American population becoming infected with HIV, the rate of heterosexual transmission in this country remains relatively low, in comparison to the far more tragic transmissions rates for American gay men and IV drug users.  These were the majority of the thousands upon thousands of AIDS deaths in this country in the 1980s and early to mid-1990s.  Since then, new drug combination anti-retroviral therapies have been developed that have transformed AIDS from a death sentence to a chronic lifetime disease - in the Western world.  Now virtually all HIV+ Westerners, be they gay, straight, bisexual, IV drug using or clean, have access to combination anti-retroviral therapy, provided, of course, that they have access to health insurance.  There is still no cure for AIDS, but the disease is much less of an automatic death sentence now than it was considered to be 10 years ago.  We've bought time for our citizens and those of other industrialized nations, while we continue the search for a cure.  Things are looking up.  How often does a friend or family member of the average American citizen die of AIDS?

A Zimbabwean would say, "Yesterday."  When I visited Zimbabwe in 1996, there was a funeral every few days among the community of the ten home-stay families who housed the ten exchange students, of which I was one.  And since then it has only gotten worse.  While AIDS is still largely a gay and IV drug using disease in the Western world, 80-90% of HIV/AIDS cases in Africa and Asia are heterosexually transmitted, with little IV drug use or homosexual activity involved.  In these regions, women are dying at the same rate as men.  These epidemiological trends are drastically different from those seen in the Western world.  In most of America and Europe, the rate of heterosexual transmission, and especially female-to-male transmission, is remarkable low, especially when compared to the statistics from Africa and Asia.  Yet this huge discrepancy in numbers has been virtually ignored in the public discourse about AIDS.  The overriding opinion seems to be that people get it more in Africa, yes.  But they're always dying over there, that backwards country, what can be done about those people anyway?  But women, so many women, dropping like flies?  How is this possible? The discrepancy between heterosexual female acquisition of the disease in the Western world and in Africa and Asia has brought nearly no attention to this great epidemiological public health mystery. 

However, in the realm of medical research, natural and social scientists have been attempting to unravel this mystery for over ten years.  In the course of my research, I noticed a chronological evolution of the way AIDS in Africa has been talked about.  In the late 1980s, when much scientific information regarding AIDS was still lacking, there was a trend to associate the high rates of heterosexual transmission with cultural practices occurring in Africa.  In the 1990s, more epidemiological approaches became utilized.  As time went on, a clear "x-factor" began to emerge from the picture, one that explained this discrepancy in transmission rates.  This "x-factor" was male circumcision. 
 
History of AIDS Research

In a 1987 study coming out of UC Davis, DB Hardy advances current theories about risk factors for HIV transmission in Africa.  The sexually related factors listed are (1) promiscuity, (2) high rates of homosexuality and anal intercourse, and (3) cultural practiced such as female circumcision and infibulation which possible increase virus transmission.  Non-sexual factors included (1) blood sharing rituals (including "blood brotherhood" establishing rituals and the ever popular "ritual and medicinal enemas"), (2) sharing instruments (group scarification and "shaving of body hair") and (3) "contact with nonhuman primates."  The author comes to the conclusion that "promiscuity seems to be the most important cultural factor contributing to the transmission of HIV in Africa."  Male circumcision is not mentioned. (Hardy 1987)   

In a 1988 study conducted on heterosexual men in Nairobi, Kenya, genital ulcers are first mentioned in connection with HIV transmission.  63% of HIV positive men reported a past history of genital ulcers, compared to only 31% of the HIV negative men.  Chancroid was and continues to be the main genital ulcer disease (GUD) of import.  The author connects genital ulcers and HIV transmission, and suggests that control of STDS, specifically GUD "may offer one very feasible approach" to reducing HIV transmission.  Although the authors mention that uncircumcised men have higher rates of HIV infection, they do not connect lack of circumcision with GUD. (Greenblatt, et al 1988) 

In 1990, a study came out of the University of Manitoba that concluded, "Over 95% of attributable risk [for seroconversion] in men with STD was either genital ulceration or the presence of a foreskin."  The authors hypothesize that "genital ulcers are the major portals of entry for HIV infection and also increased shedding of virus infected cells into the vaginal secretions.  However, circumcision status is still not linked with GUD. (Jessamine, et al 1990) 
Five years later, in a 1995 study in Kigali, Rwanda, it was found that even though uncircumcised men typically had a lower risk profile than circumcised men (due to fewer sexual partners and residence in rural areas), uncircumcised men had 29% rate of HIV infection compared to 21% in circumcised men.  In addition, although uncircumcised men were less likely to report a history of STDs, they were more likely to report GUD. (Seed, et al 1995)  In a 1996 study, similar results were reported, and the recommendation was made that "male circumcision should be considered as an intervention strategy for AIDS control."  It was suggested that lack of circumcision was connected to HIV through the mechanism of other sexually transmitted diseases, but is not conclusive. (Tyndall, et al 1996)l

In 1998, an article was published that states, "[T]here is substantial evidence that circumcision protects males from HIV infection, penile carcinoma, urinary tract infections, and ulcerative sexually transmitted diseases.  We could find little scientific evidence of adverse effects on sexual, psychological or emotional health." (Moses, et al 1998)  Although this study is conclusive on the topic of male circumcision, STDs and HIV, I am not sure if the authors considered the ramifications of saying that there is no evidence for adverse effects from circumcision.  Certainly it is painful, especially when it is performed without drugs.  There can be long term psychological effects on the male who has been circumcised when he was completely vulnerable and trusting of his caretakers, who choose to have their babies mutilated.  And there is evidence to show that sex is not as pleasurable without a foreskin.  However, if male circumcision is the "x-factor" in the heterosexual transmission of HIV, these side effects of male circumcision could be more properly contextualized as harmful, certainly, but may also be a necessary harm in protecting male children and adults in the context of the AIDS world.  I will discuss the implications and politics of male circumcision in America further later in the paper.

In March of 2000, a study was published that supports "the contention that male circumcision may offer protection against HIV infection, particularly in high risk groups where genital ulcers and other STDs 'drive' the HIV epidemic." (O'Farrell 2000).  Then, on March 30, 2000, the New England Journal of Medicine released a study of heterosexual couples in Uganda.  The emphasis of the study was on viral load and heterosexual transmission of HIV.  The study received a lot of media attention, because it was the first to prove conclusively that the higher the level of HIV in a person's blood, the more likely it is to pass on the virus through sex.  It also received attention because of the study's ethics:  HIV infected individuals were not treated for HIV and the partners of HIV positive individuals were not informed about their HIV status.  But the most remarkable statistic, I think, is the one that was virtually ignored.  "Forty of the 137 uncircumcised men in the study got HIV over the two-year period.  Not a single one of the 50 circumcised men in the study was infected.  Not one."  (Slack 2000)  The conclusion is also advanced that "the rate of male-to-female transmission was not significantly different from the rate of female-to-male transmission (12.0 per 100 person-years vs. 11.6 per 100 person-years)."  (Quinn, et al 2000)

These are staggering results.  The fact that women can transmit HIV virtually as easily as they can contract it has huge implications.  In the West, where female-to-male transmission is rare, men will most likely be infected by homosexual sex or IV drug use (of course this is not always the case).  Therefore, heterosexual women will usually only contract HIV from her male partner if he is infected through these mechanisms; the likelihood of his having contracted HIV from his other female partners is very low.  This is what keeps the heterosexual transmission rates as low as they are here.  It is basically a one-way transmission route, from infected men to women.  The fact that it does not usually go from infected women to men means that the exponential explosive growth and spread of the epidemic that we see in Africa and other regions does not occur in the West.  When women can pass it to men who pass it to women who pass it to men... it makes perfect sense that in Africa AIDS is a primarily heterosexual disease. 
 
The Case for Circumcision

The presence of the male foreskin seems to be the most important factor when looking at HIV transmission rates throughout the world.  It accounts for all the major geographical discrepancies.  In an article published in the East Bay Express (May 19-25, 2000) Gordy Slack discusses these discrepancies in further detail.  For example, the HIV infection rate in Thailand is 2.23%, while in the nearby Philippines, the rate is only .06%.  In the Philippines, they circumcise male children.  In Thailand, for the most part, they do not.  In California, they have found "very few cases of female-to-male transmission of HIV... among a population born at a time when about ninety percent of males were being circumcised."   In fact, circumcision was popular throughout the US during the 1970s, which might well be the reason for the low rates of heterosexual transmission in this country, especially female-to-male rates. (Slack 2000) 

In Europe, where most men are not circumcised, there is a relatively higher rate of female-to-male transmission.  This points even more conclusively towards circumcision as the elusive "x-factor," since economic and cultural factors are virtually constant in the United States and Europe.  However, the rate of female-to-male transmission in Europe is tiny compared to that of Africa.  This illustrates that there are more factors than simple circumcision to examine.  The economic state of a country has much to do with the health care available to its citizens.  Africa is much poorer, in general, than Europe.  The health resources that are available in the West, especially to treat chronic STDs, are not available to them.  The cultural position of women is also a factor.  Often they are not educated about how to take care of themselves and their families within the context of the AIDS epidemic.  Men are not educated about this either.  Another factor could possible be that cleaning facilities and customs do not allow for "proper" cleaning of the foreskin, which can lead to increased rates of infection.   

The lack of male circumcision is also positively associated with urinary tract infections (UTIs).  In 1987, a study was performed that showed that uncircumcised boys were 20 times more likely to have UTIs in their first year than their uncircumcised counterparts.  Motivated by this data, the American Association of Pediatrics put together a Task Force on Circumcision in late 1987.  In addition to the UTI data, they found evidence to show that being uncircumcised gives men a higher risk of developing penile cancer.  The task force also found that circumcision significantly reduces men's chances of contracting various STDs. Clearly, there are major health benefits to be had from circumcision, which predate the AIDS epidemic.

So if we have known that circumcision status and HIV transmission are correlated for over ten years now, why hasn't anything yet been done about it?  For example, the Johns Hopkins Media/Materials Clearinghouse, with a collection of over 30,000 publications, has not one publication that mentions the connection between male circumcision and AIDS.  As Slack says, "What the hell is going on?  Why is everyone ignoring the elephant-sized foreskin in the living room?"  (Slack 2000)

There are several factors that Slack proposes for this rather major oversight.  First, he says, there is a kind of "biomedical fixation" extant in the medical research community.  The focus is on new drugs, new treatments.  Something as "soft" as circumcision does not fit into the current cultural context of the medical research community.  Also, there is new emphasis on clades.  It is currently being researched whether or not different clades are more easily spread through heterosexual contact.  I would propose that the African clades themselves are not more specific to heterosexual contact, it is more likely that we see these clades expressed in an overwhelmingly heterosexual population, because of other factors.  But more research must be done for a conclusive answer to that question. 

The second, and more culturally oriented factor that Slack says is holding back the circumcision information is cultural sensitivity regarding circumcision.  It is a hotly debated topic.   Most people assume that since Jews and Muslims are so adamant about circumcising, people from other cultures would be just as adamantly opposed to it.  However, Slack cites the words of medical anthropologist Daniel Halperin from UCSF's Center for AIDS Prevention Studies, who states that this is usually not the case.  His research shows that men, specifically those living in these hard-hit African nations, are often excited to get the procedure done.  "'For men in Africa who are at risk of dying of AIDS, keeping their foreskin is the last thing in the world they are worried about,'" says Halperin.  Slack goes on to venture that while the American anti-circumcision movement has a kind of romantic, back-to-nature feel to it, "circumcision has a kind of urbane modern appeal in some parts of uncircumcised Africa." (Slack 2000) 

Although the circumcision issue is being largely ignored in the US and Europe, traditional doctors in Africa are beginning to take notice of this phenomenon.  This makes sense, since they are the ones living amongst the epidemic and have first-hand knowledge regarding which people most commonly gets infected.  Traditional healers are beginning to recommend circumcision as a preventative measure.  And in Tanzania, Kenya and Uganda, "private clinics... are advertising foreskin removal as 'a way to alleviate chronic STD infection and prevent AIDS.'"  People in their own communities are beginning to effect change, and I think that this is essential to a global effort to fight this disease.  A South Africa traditional healer leader told an anthropologist, "'When tradition and the health of our people are in conflict, it is tradition we must sacrifice.'" (Slack 2000) 

This is compelling information.  If people in Africa are willing to get this procedure (circumcision) done, and if it will stop the spread of HIV, then it seems logical that educational information about circumcision should be distributed among people who do not have access to such information.  It is a simple procedure, and it takes only 15 minutes.  Under anesthesia, it doesn't hurt.  Certainly there can be serious psychological effects for men undergoing this form of sexual mutilation.  But when compared to the psychological effects of contracting HIV, well, one must choose.  Additionally, in terms of low-cost prevention, while circumcision isn't free, it's a lot cheaper than combination regimens of anti-retroviral drugs and other medicines to control opportunistic infections. 

There has been much debate recently about American pharmaceutical companies and the availability of their drugs to people in Africa and other "third world" countries.  Several companies lowered their prices last month (May 2000) to try and accommodate Africans who need their medications, specifically in South Africa.  However, a decrease from $600 a month to $250 a month will not mean much to the person who makes $1 a day.  South African President Thabo Mbeki has argued that South Africa does not need expensive drugs as much as it needs economic support.  He has indicated poverty as the main factor for the explosion of HIV in his country.  This position has sparked much debate, but it is not difficult to see the truth in what he is saying.  But the focus is still on the pharmaceutical companies.  Today on the CNN website, Reuters said this: "South Africa said Monday it would lobby international drug companies to implement promised price cuts and provide technical assistance to help combat the AIDS epidemic." (CNN website, 6/5/00)  These costly political battles look striking in the news, but whom they are really helping?  Besides the media and the American government?  In order to stop the AIDS epidemic in Africa, more drastic, grassroots steps must be taken.  It is prevention that should be the focus, not treatment.  Treatment is important, but each one of the 4.3 million HIV positive people living in South Africa alone could not possibly receive sufficient drug treatment.  There simply aren't the resources for that.  While drugs are a good band-aid, more needs to be done.  It is amazing to think of the implications of circumcision as a preventative measure to prevent the transmission of HIV.  Think how much money would be saved if this were true.  Think of the ease of the procedure.  Think how many lives would be saved.
In the wake of this new information, it is even more fascinating that circumcision has been practiced for so many thousands of years.  The Jews and Muslims must have noted the health benefits in terms of UTIs and STDs, for why else would they begin such a practice?  Even the covenant of Abraham with God may have arisen out of this practice, which began for public health reasons.  Some scholars have suggested that circumcision entered Christian culture in the last century because it stops little boys from masturbating.  While this may have seemed like a good solution, it has not proven very effective (as any of my male circumcised friends could attest to).  And although circumcision may be used sometimes as a mechanism of sexual control, just as female circumcision can be, I believe the health aspects are still essential to examine, especially in the context of the AIDS epidemic.

A Brazilian oncologist that Halperin spoke to had similar ideas about circumcision as an ancient practice arising from public health needs.  This oncologist has to amputate cancerous penises every week, and it strongly in favor of circumcision.  He told Halperin, "Those Jews were so smart; thousands of years ago they figured out this way to prevent health problems."  Halperin expresses that this was one of the things that changed his conception of circumcision from a savage ritual to a "health/cultural innovation ahead of its time." (Slack 2000) 
Circumcision faces its own struggles in this country.  An integral part of the men's movement, the foreskin restoration movement, insists that the prepuce represents "nature, wholeness, and freedom from authoritarian control."  Theoretically, I support the men in this struggle.  Indeed, the idea of cutting a baby boy's penis seems horrifying.  I actually had vowed that I would never circumcise my boy children before I began my research.  But now, I feel differently.  The men in the foreskin restoration movement must also understand that what to them represents freedom and nature represents to millions of others suffering and death.  This is another case when those people who have economic control (middle to upper class American men, in this case) also control the information and popular ideas about important issues.  But here, I hope, the scientific evidence will eventually be heard over the drumming and Iron John stories.
 
Impacts on Development

However, if circumcision becomes proven to be the "x-factor," the question arises of what we will do with that information.  How will we distribute this information in Africa without forcing men to get circumcised?  That would clearly be against any ethical norms currently established in the medical research community.  We could not force anyone to get circumcised.  But there is a potential for cultural insensitivity in this context.  Just as missionaries introduced concepts of hell and shame, and Western colonialists helped to introduce capitalism, will we similarly introduce male circumcision as the right way?  Humanitarians would say that we are helping the Africans.  But so would the missionaries and capitalists say that about themselves.  There is a problem with cultural colonization in any development work.  Those of us who want to do development work must constantly be aware of that potential.  How will we educate people about circumcision without imposing our own cultural norms and constructs onto the affected society? 
 
Female Genital Mutilation

It is ironic that a focus on male circumcision as protection against HIV infection in Africa should come now, right in the midst of the attention given to female circumcision in Africa.  Female circumcision, or female genital mutilation (FGM), however, is a very different procedure.  Instead of merely the removal of some skin, the entire clitoris is excised.  In 15% of the cases of FGM, the women are infibulated as well, the opening to their vaginas sewn up to make them tight and virginal, and to ensure that the woman will be faithful.  This is necessary so their husbands can know that their wives' children are genetically their children as well; and this is necessary for the passing down of property from father to son.  Essentially, the nature of the economic patriline is reliant on the excision and infibulation of women's genitalia.  This is also a practice that has gone on for thousands of years, but unlike, male circumcision, there has been no scientific evidence to show that FGM is in any way beneficial for women's health.  Perhaps this evidence will surface in a few years, the way this information about male circumcision is surfacing now.  However, that seems less likely (unless the inability to achieve sexual pleasure could be considered beneficial to womens health). 
However, even if there are no health benefits from FGM, and even if it adversely affects women's health, FGM, within the context of these African communities, is an integral cultural concept upon which many culturally specific norms and traditions are established.  It lays some of the foundation of some African cultures.  When humanitarian health workers in Africa try to stop the occurrence of FGM, they must also be aware that the practice is deep rooted in metaphor and culture.  In my opinion, the best way to approach this problem is through working with an already established group of African women who are working to effect change within their own communities. 
 
The Importance of Cultural Sensitivity

Just as we utilize post-modern culturally sensitive theoretical frameworks to deal with female genital mutilation, so must we now use these same frameworks to view the issue of male circumcision.  Although it may seem like a miracle cure (just one cut and you're safe!) it is much more complex than that.  There are intricate cultural structures already in place in most African societies.  And humanitarian health workers must be extremely careful not to disrupt these structures, to the fullest extent of their abilities. 
 
A Final Thought

I wonder, incidentally, what the relationship has been between HIV and other STDs over the years.  Since HIV seems to pass most easily through STD sores, and since HIV and STDs are often found to be prevalent in the same places, I wonder if HIV evolved mutualistically with STDs, especially genital ulcer disease.  It would make sense; HIV is a highly sensitive virus that dies upon any contact with air.  GUD ensures that the virus can pass from body to body, undisturbed.  If this hypothesis could be proven, it would have to be said that this was a brilliant move on the part of HIV, to hook up with GUD like that.  Now that the relationship between the two is in the public discourse about AIDS, perhaps someone will research that aspect of the development of HIV.
 
Conclusion

Male circumcision, GUD and AIDS.  What a triad.  These three synergistic elements are only now beginning to be truly connected in the scientific literature.  Now, all we can do is wait and see.  Once this information is passed on to the affected communities in Africa and throughout the world, we will see if circumcision becomes more popular in these regions.  If it does, then we will see if circumcision really is the long sought after "x-factor."  Of course, this could all be hypothesized falsehood.  It could be that economics have everything to do with the discrepancies in AIDS rates between the West and the "Third World."  However, the information discussed in my paper is compelling and important enough to present.  The connection between HIV and male circumcision can no longer be ignored, and I think that it is essential to examine this connection to look for possible preventative strategies for the management and treatment of the AIDS epidemic.  This information has been dismissed for too long.  As Halperin says, "The anti-circ people ask us how history will judge is for circumcising so may kids.  Well, I wonder how history will judge us for allowing such a potentially powerful HIV intervention to go unexploited."

Lia Goloff