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The group blog of The American Prospect

HIV AND CIRCUMCISION...IN AMERICA.

Over the next year, the Office of National AIDS Policy, led by Dr. Jeffery Crowley, will come up with a strategy for fighting HIV in the United States. That project is long overdue. While the Bush administration devoted unprecedented resources to combating HIV/AIDS in the developing world, it largely ignored the epidemic here at home. Over 1.1 million Americans live with HIV. In 2006, over 56,000 new infections were recorded. And the disease is increasingly associated with minority communities and the poor; in Washington, D.C., the major American city with the highest HIV/AIDS rate, 4.3 percent of all African Americans are infected. Among black men in D.C., 6.5 percent are HIV-positive.

Internationally, the HIV-prevention method gaining the most momentum -- and attracting the most press -- is male circumcision. A series of studies conducted in Africa found that circumcision decreases female-to-male HIV transmission by as much as 60 percent. That is because the cells of the foreskin are especially susceptible to infection. (Women though, aren't any less likely to contract HIV from circumcised men.) Since 2007, the World Health Organization has strongly recommended circumcision, calling the new research on the procedure "an important landmark in the history of H.I.V. prevention."

Considering this evidence, should circumcision-promotion be among the policy levers the Obama administration considers? As New York City Mayor Michael Bloomberg learned two years ago, when he created a maelstrom by asking the city health department to encourage the procedure, American public health efforts must tread carefully around this issue. The promising circumcision research was conducted entirely in Africa, largely among heterosexuals. In the United States, HIV continues to disproportionately affect the gay community. In 2005, half of all new cases were among men having sex with men, compared to 33 percent among heterosexuals engaged in what the CDC calls "high risk" behaivor -- a woman who has unprotected sex, for example, with a man who is also having unprotected sexual encounters with other men.

American HIV/AIDS advocates have worked for nearly three decades to send the message that condoms are the best way to protect against the disease. That messaging has been effective, and it's important to double down on it within the gay community: Clinical studies show that gay sex is much more likely to lead to HIV infection than hetero sex. Among men having sex with men, circumcision is likely to offer very little protection against the disease. But the truth is, we don't have good research on that question -- and certainly not in an American context.

About 60 percent of American men are already circumcised. Those who aren't are more likely to be recent immigrants or first generation Americans, and to hail from cultures resistant to condom usage. For these men, a public health push on condoms is likely to reap far greater dividends than a pro-circumcision campaign, which is likely to be seen as even more radical and intrusive. What's more, condoms are far cheaper than circumcision. So when it comes to extrapolating American public health policies from the African circumcision research, we should proceed with caution. After all, the United States already has the highest circumcision rate in the developed world -- and also the highest HIV infection rate.

--Dana Goldstein



COMMENTS

Honestly, I've kinda given up on this debate-- even among liberal American men, usually the responses are a snickering, arrogant hey-I'm-circumcised-and-mine-is-AWESOME attitude. Since I don't expect to have a son who will grow up to be a truck driver in sub-Saharan Africa, the foreskin'll stay on and condom use will be emphasized, because I'm against cutting up people's genitals. I don't really care what adult men do, although it'd've been nice if there had been more variety in my dating pool.

Instead of suggesting that men cut off a part of their penis, perhaps Heterosexuals should reconsider what they teach their Gay children, particularly their Gay MALE children, about themselves.

Let me explain: See, insead of teaching our gay male children that they are worthless and evil and deserve to die, you could instead teach them to love themselves and teach them that they are worthy of being on the planet just as everyone else is. That way, when they go out into the world, they may have the ounce of self-esteem and sense of being a worthy human being that it would take for them to make the decision to unroll a condom over said penis.

Blaming gay men (who as young adults are sent out into the world feeling worthless and hated and listening to their very creators spew the 'move them all to an island and let them die' kind of rhetoric that gay men have to listen to every day in this country) for the plague of HIV in the US does not tell the whole story here, does it?

It is time for Heterosexual Americans to cut the bull sh*t and get real about this, as it is fast become a Heterosexual disease as well.

Time to get real, people.

Fix your last sentence! The United States does not have the highest HIV infection rate; the infection rate in the U.S. is quite low, as the table to which you link clearly shows.

Michael, I was comparing the US to other equally developed nations. We are the highly-developed nation with the highest infection rate.

What latts said. The hardest thing for me to accept about promoting circumcision is that it will likely encourage some men to not use condoms, which is the best course of action for reducing the risk of HIV, and which works whether one is circumcised or not. In subsaharan Africa perhaps the situation is so desperate it had to be tried, but European men by and large are uncircumcised and rates of infection are far lower than in the U.S.

Given that the victims of the first HIV/AIDS epidemic in the U.S. (gay men born after World War II) were overwhelmingly likely to be circumcised (the practice became de rigeur during the 1950s, with 90% of newborn males circumcised in the 1950s), I think if circumcision were really THAT beneficial we would have seen evidence to that effect in the 1980s and 1990s.

Given that the victims of the first HIV/AIDS epidemic in the U.S. (gay men born after World War II) were overwhelmingly likely to be circumcised (the practice became de rigeur during the 1950s, with 90% of newborn males circumcised in the 1950s), I think if circumcision were really THAT beneficial we would have seen evidence to that effect in the 1980s and 1990s.

I'm with latts.

Re "In 2005, half of all new cases were among men having sex with men, compared to 33 percent among heterosexuals engaged in what the CDC calls "high risk" behaivor -- a woman who has unprotected sex, for example, with a man who is also having unprotected sexual encounters with other men."

It's misleading to say that heterosexual sex includes sex between a woman and a bisexual man.

The latest research shows HIV infected circumcised men create a 50% greater infection rate in their partners. It is also unethical to circumcize an infant who cannot make an informed consentdecision. Whether you believe it or not the foreskin provides far greater pleasure than the glans. Has anyone ever heard of EDUCATION & PROPER CONDOMS USE?

Like Dana said, we have the highest HIV rate of the developed world. Circumcision has not worked. Condoms and testing, though, DO work. If people still do not have access to these, or are choosing not to use them, we need to put our efforts into finding out why.

Immunizations make sense for airborne diseases and other diseases that cannot otherwise be contained. However, HIV is a behavioral disease. An informed individual has full control over whether they get infected or not. Condom use and regular STD testing can stamp out HIV. Education programs are absolutely necessary.

These are all things that put the responsibility and the power into the hands of individuals. It gives them the ability to protect themselves.

Male circumcision assumes people are not capable of protecting themselves. Circumcising an infant assumes that child will not be capable of learning and practicing safe sex. It is not the right message. That doesn't even take into account the fact that its effectiveness is EXTREMELY questionable.

Circumcision removes healthy, sensitive, functional, erogenous genital tissue. It should play absolutely NO role in the otherwise POSITIVE and EMPOWERING fight to stamp out HIV and AIDS.

I agree with Joel.

HIV is a behavioral disease.
Education is the key.

Throwing hard earned tax dollars at circumcision is wasteful.

This article includes some misinformation. The studies in Africa found that circumcision decreases female-to-male HIV transmission but also found that circumcision increases male to female HIV transmission by 50%. The studies have some serious issues including the cut men having less time in the study for sex (they needed to heal) they got condom advice and they were eager to avoid HIV. It is really almost meaningless given several other studies could find no HIV circ correlation (US Nacy, US urban studies etc.). The real world study shows mostly cut USA with much higher HIV than natural EU, and JP.

ALso, there is no research to support the theory that the cells of the foreskin are especially susceptible to infection. Also there is research that shows Female circumcision FGM also lowers HIV by about 60% IN AFRICA. And BTW, it should be that Women are MORE likely to contract HIV from circumcised men -- that is what the data shows. Lets be fair about this and stop acting like the AFRICA studies are so meaningful.

wow I cannot believe people are promoting circumcision at this level to prevent such a serious disease when condom still needs to be used during sexual intercourse. I feel totally appalled at the idea of removing healthy tissue to 'prevent' the deadly HIV, when we know that circumcision has NOT work at ALL here in the USA. Seriously people! When HIV epidemic started here in the USA the majority of the men were circumcised at birth, this is totally misguided and dangerous! Please STOP!

I'll be really annoyed if they start advocating circ as a good HIV measure. The USA circ rates in the 1970's and early 1980's were very high - about 85%. These are the men that the current HIV rates are associated with. So what good would circing more men do? And I don't by the argument that the HIV rates would have been even higher if it wasn't for the high circ rates.
European countries have circ rates of near zero and much lower STI rates.
the foreskin has sexual functions:
xrl. us/foreskinfunctions
So we shouldn't remove healthy functioning parts without a serious medical need.

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