- The health & public policy
- The cultural angle
The think the evidence is pretty clear from individual studies and cross-cultural comparisons: all things being equal, circumcision cuts down on the rate of HIV transmission (especially from female-to-male). On the other hand, there are the important cultural issues that are often not mooted with clarity, especially in the United States. You see, the USA is one of the few nations where adult circumcision occurs for a primarily medical, and not cultural/religious, rationale. In the late 19th to mid-20th century there was a medical “fad” which offered circumcision as a “cure” for a variety of ailments, from masturbation to insanity. During World War II American doctors found that circumcised men were less likely to get penile infections. Today, circumcision is normative, if less so than 20 years ago, within the United States. In the rest of the English speaking world it disappeared after World War II.
In the rest of the world circumcision has a more culturally loaded connotation. Circumcision in the Bengali language is termed mussulmanni, roughly, to “become a Muslim man.” One can imagine how Hindu Bengalis would react to a mass circumcision campaign initiated by any NGO. A few years ago Vladimir Putin recommended that some reporters get circumcised in a diatribe on radical Islam. Of course in the United States this sounded like a bizarre request, seeing as most males are circumcised, but one must remember that in Russia circumcision is a predominantly Muslim practice and so its associations are with being or becoming a Muslim (it seems that most Jews in Russia were not circumcised, as can be attested by the prevelance of circumcision of males for whole families of Russia Jews when he arrive in Israel). In Africa circumcision is common among non-Muslims, but there are variations from tribe to tribe. In South Africa the Xhosa are circumcised, but the Zulu are not. In Kenya the Luo are not circumcised, but the other tribes are. The pattern for HIV infection is pretty clear in all of these cases: the circumcised tribe tends to have lower HIV infection rates. The Philippines is a predominantly circumcised nation, Thailand is not, both have vibrant sex industries, but the latter is plagued by a greater rate of HIV infection.
This is also why Japan has a much higher HIV infection rate than South Korea (the latter practices circumcision in emulation of American customs). Or for that matter why Sweden has a much higher HIV infection rate than the United States. Without circumcision a high HIV infection rate is inevitable…oh, wait. That’s not true! You need to keep in mind all things being equal, and perhaps also necessary conditions. The same problems crop up in studies of cervical cancer rates due to lack of circumcision, or rates of infection of various VDs of circumcised vs. uncircumcised males. Context matters, it is important to note the caveats such as “high risk men” or “within low SES groups.” I think there is a great deal of evidence that circumcision can be protective against a host of ailments if you live a particular lifestyle or in a particular environment. HIV infection rate differences on the order of 50% between two populations where the penetration rates are 10 and 15 percent respectively are not trivial. But what about a difference between two populations of 0.01 and 0.015 percent? Is it worth it? Are there are no costs to circumcision? You can find many websites online which will tell you the exact costs in terms of various parameters such as sexual pleasure. Is this irrelevant? In the context of nations where sexual practices and HIV infection rates make the risks prohibitive the cost vs. benefit is clear. But in a nation like Japan, where infection rates seem to be very low, is it worth it to enter into a program of mass circumcision in the anticipation of an epidemic? What about Europe?
The reality is that there is a lot of politics and cultural baggage involved in this issue. Cost vs. benefit is not invariant from location to location, and cultural context matters. This seems common sense, but the emotional resonance of the issue and its symbolic significance make it hard to get the heart of the matter. More here from ScienceBlogs AIDS conference coverage.