NATURE|
Vol 447|28 June 2007

Circumcision for HIV needs follow-up

1. Auvert, B. et al. PLoS Med. 2, e298 (2005).
2. Bailey, R. C. et al. Lancet 369, 643-656 (2007).
3. Gray, R. H. et al. Lancet 369, 657-666 (2007).
4. Talbott, J. R. PLoS One 2, e543 (2007).
5. Vandepitte, J. et al. Sex. Transm. Infect. 82 (Suppl. 3), iii18-iii25 (2006)

Letter to Pediatrics (Official Journal of the American Academy of Pediatrics)
June 27, 2007

Use of Federal Funds for Medicaid Non-Therapeutic Circumcision is Unlawful

In a letter to the editor of Pediatrics, George Hill, (Vice-President for Bioethics and Medical Science of Doctors Opposing Circumcision) with John V. Geisheker and Dr George C. Denniston answer a claim that Medicaid should pay for medically-unnecessary non-therapeutic infant circumcision. They say there are clinical, ethical, and legal problems with the claim.

They say the most fundamental problem is that proxy consent necessary for the non-therapeutic circumcision of children exceeds parental power, citing a landmark British case in which it was ruled that "...parental rights are derived from parental duty and exist only so long as they are needed for the protection of the person and property of the child.”

With no clear and present medical indication of need, they say, no parental duty or right to consent to circumcision can exist, and medical indications for male circumcision never exist in the newborn period. Parental permission is limited to diagnosis and treatment of disease.

They rebut claims that infant circumcision is of value in preventing HIV and STDs and argue that instead it exposes infant boys to increased risk of CA-MRSA infection, and to the risk of death.

They argue that because Medicaid is paid in part through federal funds, and by law these funds must be used for medically necessary services, non-therapeutic circumcision does not qualify for federal funds. "The 16 states that have stopped paying for non-therapeutic circumcision are in compliance with the law. The 34 states that have not changed their policies are out of compliance."

SABC News
June 25

Boy found dead after botched circumcision

June 25, 2007, 06:15

A 15-year-old boy has been found dead by fellow circumcision initiates near Orange Farm, in the Vaal Triangle. Police say the boy was among nine initiates circumcised by an illegal surgeon.

A postmortem will be conducted to establish the cause of death.

The other boys aged 15 and 16 have been sent home, while police search for their surgeon. Yesterday, another initiate died in Potchefstroom in the North West.

Since the start of the circumcision season, five initiates have died from botched circumcisions in the Eastern Cape.

Yesterday, police arrested an initiation surgeon in connection with the deaths of two of the five boys near Port St Johns. His accomplice, a 17-year-old boy who's believed to have run the illegal initiation school, was arrested on Saturday.

Villagers believe witchcraft is to blame for the boys' deaths.

AAP
June 28, 2007

Egypt officials ban female circumcision

By MAGGIE MICHAEL, Associated Press Writer

CAIRO, Egypt - The death of a 12-year-old Egyptian girl at the hands of a doctor performing female circumcision has sparked a public outcry and prompted health and religious authorities to ban the practice.

The girl, Badour Shaker, died this month while undergoing the procedure in an illegal clinic in the southern town of Maghagh. Her mother, Zeniab Abdel Ghani, told the Al-Masry Al-Youm newspaper that she paid about $9 to a female physician to perform the procedure.

The mother also told the paper the doctor tried to bribe her to withdraw a lawsuit accusing the physician of murdering her daughter, in return for $3,000, but she refused.

A forensic inquiry into the case showed the girl's death was caused by an anesthesia overdose.

...

On Thursday, the Egyptian Health Ministry issued a decree stating that it is "prohibited for any doctors, nurses, or any other person to carry out any cut of, flattening or modification of any natural part of the female reproductive system, either in government hospitals, nongovernment hospitals or any other places."

It warned that violators would be punished, but did not specify the penalty. The ban is not as enforceable as a law, which requires passage in the national legislature.

Female genital mutilation usually involves the removal of the clitoris and other parts of female genitalia. Those who practice it say it tames a girl's sexual desire and maintains her honor.

It is practiced by Muslims and Christians alike, deeply rooted in the Nile Valley region and parts of sub-Saharan African, and is also done in Yemen and Oman.

The ban by the Health Ministry marks a return to a 1950s government order prohibiting hospitals and doctors from carrying out the procedure.

After that order, the practice continued in Egypt, mostly carried out by barbers, midwives and other amateurs. The order was reversed in 1995, shortly after the CNN documentary, with only medical staff permitted to perform the procedure.

Although the documentary embarrassed Cairo internationally, it failed to propel the parliament to pass legislation penalizing female circumcision.

...

While top clerics insist the practice has nothing to do with Islam, parents, especially in villages and Cairo slums, believe they are helping their daughters. They think circumcision is necessary for cleanliness and to protect a girl's virginity before marriage.

Opponents say girls can bleed to death, suffer chronic urinary infections and have life-threatening complications in childbirth as a result of the procedure.

The Al-Masry Al-Youm daily reported the doctor in Shaker's case denied allegations of malpractice and said the girl was in a "bad condition" to start with, and was immediately transferred to a regular hospital where she died. The doctor was not identified.

Egypt's renowned feminist activist, Nawal el-Saadawi, 76, who has published a biography on her own experience with circumcision, wrote: "Badour, did you have to die for some light to shine in the dark minds? Did you have to pay with your dear life a price ... for doctors and clerics to learn that the right religion doesn't cut children's organs."

POZ
July/August 2007

Gimme Some Skin

by Jeremy Proctor

In defense of the foreskin: One writer argues that using circumcision to combat AIDS gives prevention the shaft

Try this exercise: Find a 3x5 index card. One side, 15 square inches, equals the average surface area of a man's foreskin-about half of the total surface area of his penis.

Now fold the card in half lengthwise and bring the two short ends together to form a cylinder. The outside of the cylinder represents the external foreskin, a more sensitized, retractable extension of the skin on the penile shaft. The inside represents the delicate, lubricating mucosal lining that sheathes the glans, or head, of the penis.

These outside and inside folds are comparable to the external and internal aspects of the foreskin's closest anatomical analog, the eyelid. And, like the eyelid, the foreskin bristles with nerve endings: about 36% of the total penile allotment.

With this simple overview, you probably already know more about the foreskin than your doctor does. What most American health professionals are taught about it is even more succinct: It's the part of the male anatomy removed in a circumcision.

Despite its highly articulated, specialized physiology, the foreskin is commonly considered as disposable as the paper version you've just created. Every year the foreskins of an estimated 1 million U.S. infants end up in the trash.

Medical arguments for circumcision have always centered on hygiene and prophylaxis. Victorian-era authorities associated carnality with a wide range of mental and physical disorders; the pain of unanesthetized circumcision (for infants of both sexes) was deemed salutary "aversion therapy" against masturbation.

Morals shifted, but the foreskin became implicated in a new set of perils: renal cancer; urinary tract infections; cervical cancer in the female partners of uncircumcised men.

Today the main argument against the foreskin is its supposed correlation to sexually transmitted disease, especially AIDS. And especially AIDS in Africa.

With American funding, thousands of adult African males have recently undergone circumcision to study their subsequent HIV infection rates compared with those of uncircumcised counterparts. HIV infection rates among uncircumcised control groups (often before studies had run their course) led researchers to conclude that the foreskin significantly contributes to seroconversion.

There is ample cause to question this conclusion. First, a hard reckoning: Several African countries with some of the highest rates of HIV/AIDS in the world (Nigeria, Ethiopia, the Ivory Coast, Gabon) already circumcise at rates exceeding that of the United States.

Moreover, efforts to export American genital norms expose a glaring hypocrisy: The United States has both the highest HIV infection rate and the highest circumcision rate of any industrialized nation. By comparison, Australia, New Zealand and the Netherlands could take a more plausible "intactivist" stance. Their predominantly uncircumcised men have some of the world's lowest HIV infection rates.

Many developing countries, such as India, Thailand and Brazil, have successfully combatted AIDS not through circumcision but through aggressive health- and condom-education programs. While hardly rid of HIV, these nations have dodged the devastating mortality rates of, say, Uganda or Botswana.

Surely there is as much to learn from intact Dutch and Thai men as there is from circumcised Ugandan men, but American medical/cultural bias has preempted this line of scientific inquiry. Indeed, the zeal to circumcise has eclipsed the study of whole categories of prophylaxis that may be as effective as circumcision-or even more so. Some of the most promising HIV preventives in development are microbicides administered topically-to the very type of mucosal tissue that circumcision destroys.

How circumcision bears on long-established safer sex guidelines is uncertain, but consider the basics: The procedure slices off more than one third of the penis' nerve endings, toughens the unnaturally exposed glans and negates built-in lubrication and stimulation. Is it logical to expect enthusiasm among circumcised men for further-desensitizing latex barriers?

No one is promoting circumcision as a license for unprotected sex, but inevitably, in Africa and elsewhere, circumcision will be used not in concert with condoms but instead of condoms, potentially wiping out more than two decades' worth of safer-sex intervention. Also, in an environment where "cut" = "clean," women, who already constitute the majority of AIDS deaths in Africa, will have far less bargaining power to insist on safer sex with circumcised partners, and may seroconvert in even greater numbers.

Ironically, all arguments for prophylactic circumcision as a successful harm-reduction strategy may be built on a fundamental diagnostic flaw. Existing scientific data demonstrate that adult circumcision typically causes a marked overall decrease in sexual pleasure and erectile function. Statistics citing circumcision's efficacy against HIV may not reflect the foreskin's contribution to infection so much as demonstrate its contribution to sexual performance-and the potential risks therein. (Chalk one up for the Victorians.)

Confronted with complex, real-world dynamics, the limited scope of circumcision research may not help to stem HIV infection rates at all, but may actually sustain or even accelerate them. The president of Uganda and the Brazilian secretary of health have already reached this conclusion, denouncing recommendations for adult circumcision in their respective countries.

Even American public health officials admit that the arguments for circumcision are, at best, debatable. Still, proponents believe that they are doing something to counter AIDS. Bucking America's frustratingly puritanical aversion to condom-based HIV education, they may even feel comparatively progressive for taking a pro-circumcision stance. Nonetheless, most, if not all, of these proponents don't know what they themselves are missing, cannot understand what is lost to circumcision, and cannot appreciate how this loss may compromise other HIV prevention strategies. For them, the procedure is quick, easy, cheap-a potentially major impact derived from minor surgery.

But how minor, exactly? Look again at your index card, and imagine that amount of tissue being cut from anywhere on your body.

Minor surgery, so the quip goes, is surgery performed on somebody else.

The Scotsman
June 24, 2007

Egypt mufti says female circumcision forbidden

CAIRO (Reuters) - Egypt's state-appointed Grand Mufti said on Sunday that female genital cutting was forbidden by Islam after an 11-year-old girl died while undergoing the procedure at a private medical clinic in southern Egypt.

Genital cutting of girls, often referred to as female genital mutilation or circumcision, is banned in Egypt although the practice remains widespread as a rite of passage for girls and is often viewed as a way to protect their chastity.

"The harmful tradition of circumcision that is practised in Egypt in our era is forbidden," Mufti Ali Gomaa was quoted as saying by the Egyptian state news agency MENA.

The statement was the strongest yet against the practice by the Mufti, who is the government's official arbiter of Islamic law. The Grand Sheikh of Cairo's prestigious al-Azhar mosque, Mohamed Sayed Tantawi, had previously described the practice as un-Islamic although some other clerics have supported it.

Both Tantawi and Coptic Pope Shenouda, the leader of Egypt's minority Christian community, have said that neither the Koran nor the Bible demand or mention female circumcision, which is usually performed on pre-pubescent girls.

The statement came after Budour Ahmed Shaker died on Thursday while undergoing the procedure in the southern province of Minya after she was given a large dose of anaesthetics, security sources said.

Egypt's doctors' syndicate has launched an investigation into the death, an Egyptian newspaper said. The girl's father has filed a lawsuit against the doctor for negligence and the doctor could face up to two years in jail, the security sources said.

The practice involves cutting off part or all of the clitoris and other female genitalia, sometimes by a doctor but also often by a relative or midwives. Side effects can include haemorrhage, shock and sexual dysfunction.

The practice is performed on both Muslim and Christian girls in Egypt and Sudan, but is extremely rare in most of the rest of the Arab world. It is also common in Eritrea, Ethiopia and Somalia.

A 2005 UNICEF report on the practice showed that 97 percent of Egyptian women between ages 15 and 49 had been circumcised. Egypt's campaign to end female cutting has included television programmes aimed at persuading parents to abandon the ancient practice.

The Oregonian
June 22, 2007

High court takes up boy's circumcision
Religion - Justices are likely to delve into how much power the custodial parent has

Friday, June 22, 2007 ASHBEL S. GREEN and ANDY DWORKIN The Oregonian

The Oregon Supreme Court on Thursday stepped into a legal dispute between a father's wish to circumcise his 12-year-old son and a mother's belief that the procedure is harmful.

James H. Boldt, 60, a former Grants Pass resident who converted to Judaism, says he wants his son to undergo the procedure for religious reasons.

Lia Boldt, 44, charges that the boy is afraid to tell her ex-husband that he does not want to be circumsised.

The lower courts have sided with the father, who has custody.

The state's highest court will sort out not only whether the boy will be circumcised, but also indicated a willingness to take on a broader issue: the longstanding practice of giving great deference to the decisions of custodial parents.

Beyond the legal implications, the case spotlights a surgery that is hotly debated between a small group of advocates even as the practice loses favor in the Western United States.

The Boldts married in the early 1990s. She filed for divorce in 1998. He started studying Judaism in 1999 and eventually converted. The boy initially lived with his mother, but his father later gained custody.

James Boldt, an attorney, did not return a message seeking comment.

Lia Boldt's attorney declined to comment.

In court papers, James Boldt claims his son wants to convert to Judaism and is prepared to be circumcised.

Dr. Steve Skoog, head of pediatric urology at Doernbecher Children's Hospital, said circumcising older boys for cultural reasons "is a little unusual," Skoog said.

For one thing, adolescents face a greater risk.

Adults get circumcised with a strong local anesthetic. Infants usually get some local anesthetic, too. But adolescents get a general anesthetic for pain relief and to keep the patient still during the procedure, Skoog said.

General anesthetic adds risk and recovery time to surgeries, he said.

Lia Boldt says in court papers that she wants a hearing to provide evidence that circumcision could cause her son physical and psychological harm.

And a Seattle-based group called Doctors Opposing Circumcision has taken up her cause.

The debate over circumcision is fierce but confined to select groups.

Opponents say that circumcising most boys is unethical because it is unnecessary surgery. Proponents claim many medical benefits, [irrelevant to the present case] especially in light of recent studies in Africa linking circumcision to fewer HIV infections.

The passion masks the fact that, medically, circumcision is a small-stakes game. The procedure has risks and benefits, but both are relatively minor.

Infections and excess bleeding [which can be fatal] occur in 1 percent to 3 percent of cases, studies show. Serious problems, such as penile bends or a condition known as "trapped penis" are less common.

Benefits - lower risks of penile cancer and urinary tract infections - also are minimal.

For example, men circumcised as infants are thought to get penile cancer at about one-third the rate of uncircumcised men, but only one man in 100,000 [a year] gets penile cancer in the United States [and then only at a great age].

The hottest circumcision topic involves sexually transmitted diseases.

For years, studies conflicted over whether or not circumcised men had lower rates of syphilis and HIV infection, in particular.

But last year, scientists stopped a U.S.-funded trial early after finding that circumcising adult men in Uganda and Kenya cut their risk of getting HIV from heterosexual sex by about 50 percent.

Those findings aren't perfectly relevant to the United States, where most men are circumcised as infants and men mostly get HIV from gay sex or sharing needles. Still, the National Institutes of Health says the findings "are likely to be broadly relevant regardless of geographic location: A man at sexual risk who is uncircumcised is more likely than a man who is circumcised to become infected with HIV."

Skoog said the Oregon Supreme Court ruling could affect other medical procedures. Older children have genital surgeries for a range of medical conditions.

The legal implications are bigger than circumcision as well.

James Boldt says a custodial parent has a constitutional right to raise his son in his religion.

Mark Johnson, a Portland family law attorney not involved in the case, said the circumcision dispute raises an important question about the power of custodial parents.

Elective surgery may be an unusual dispute, but an issue that comes up frequently is a custodial parent's desire to move out of state, Johnson said.

"The historical rule was that that's what custody means: You make the decisions," Johnson said. But "judges are now taking a closer look at what custodial parents do. And how far they are going to wade into that is an open question."

In the midst of the debate, infant circumcision remains one of the most common surgeries in the United States -- even while the procedure loses popularity in the West.

About two-thirds of U.S. boys have been circumcised at birth since the late 1970s, according to the National Hospital Discharge Survey, run by the Centers for Disease Control and Prevention.

That penciled out to almost 1.2 million circumcisions in U.S. hospitals in 2003, according to another federal body, the Agency for Healthcare Research and Quality.

But population trends have driven circumcision rates down dramatically in the West, largely due to increase in ethic groups that do not routinely practice it.

In 1979, 63.9 percent of newborn boys in the West were circumcised, according to the CDC. That fell to 36.7 percent in 1999.

Ashbel "Tony" Green: 503-221-8202; tonygreen@news.oregonian.com
Researcher Kathleen Blythe contributed to this report.

VILLAGE VOICE
Jun 19, 2007

Pucker Up
Schlong Song
Circumcision: Health-conscious procedure or unnecessary sexual amputation?
by Tristan Taormino
June 19th, 2007 8:53 PM

A father-to-be recently sent me a letter asking for advice: He and his wife are expecting a baby boy and debating whether to have him circumcised. He wrote,

Medical News Today
June 20, 2007

Male Circumcision Overstated As Prevention Tool Against AIDS

New study finds the key to understanding the global spread of AIDS is the size of the infected prostitute community around the world.

In new academic research published today in the online, open-access, peer-reviewed scientific journal PLoS ONE, male circumcision is found to be much less important as a deterrent to the global AIDS pandemic than previously thought. The author, John R. Talbott, has conducted statistical empirical research across 77 countries of the world and has uncovered some surprising results.

The new study finds that the number of infected prostitutes in a country is the key to explaining the degree to which AIDS has infected the general population. Prostitute communities are typically very highly infected with the virus themselves, and because of the large number of sex partners they have each year, can act as an engine driving infection rates to unusually high levels in the general population. The new study is entitled "Size Matters: The Number of Prostitutes and the Global HIV/AIDS Pandemic" and is freely available online at the PLoS ONE publication website at www.plosone.org/doi/pone.0000543 .

The study has a number of important findings that should impact policy decisions in the future. First, male circumcision, which in previous studies had been found to be important in controlling AIDS, becomes statistically irrelevant once the study controls for the number of prostitutes in a country. The study finds that the more Muslim countries of North Africa do indeed suffer much less AIDS than southern and western Africa, but this lower prevalence is not due to higher numbers of circum[cis]ed males in these Muslim communities, but rather results from the fact that there are significantly fewer prostitutes in northern Africa on a per capita basis. It appears that religious families in the north, specifically concerned fathers and brothers, do a much better job protecting their daughters from predatory males than do those in the south. A history of polygamy in these Muslim communities does not appear to contribute to higher AIDS prevalence as previously speculated. In a frequently cited academic paper, Daniel Halperin, an H.I.V. specialist at the Harvard Center for Population and Development and one of the world's leading advocates for male circumcision, weighted results from individual countries by their population. When this artificial weighting was removed Talbott found that circumcision was no longer statistically significant in explaining the variance in AIDS infection rates across the countries of the World.

Second, to date, there has not been an adequate explanation as to why Africa as a continent is experiencing an AIDS epidemic far in excess of any other region of the world with some African countries' prevalence rates exceeding 25% of the adult population and tens of millions dying from the disease on the continent. Talbott's new study suggests that the reason is that Africa as a whole has four times as many prostitutes as the rest of the word and they are more than four times as infected. Some southern Africa countries have as many as 7% of their adult females infected and working as prostitutes while in the developed world typically this percentage of infected prostitutes is less than .1%. If these 7% of infected prostitutes in Africa sleep with five men in a week that means they are subjecting 35% of the country's male population to the virus weekly. The virus is not easy to transmit heterosexually, but over time with multiple exposures, infection is inevitable. These men then act as a conduit to bring the virus home to their villages, their other casual sex partners and to their wives.

The study has important policy implications. Several international AIDS organizations have begun to provide funding for male circumcisions as a deterrent to AIDS. While male circumcision may indeed reduce the risk of transmission by some 50% to 60% in each sexual encounter, reducing single encounter transmission rates alone cannot control the epidemic. The reason is that individuals in highly infected countries have multiple contacts with the infected so reducing transmission rates only defers the inevitable.

The real question is what can be done with the prostitute community. Outlawing the world's oldest profession would most likely prove to be ineffective. If the profession can be legalized and treatment and care provided to the practitioners, there would be much more reason to be hopeful. But, and this is the key, programs of action can not just be voluntary. Too many innocent people are dying and there is too much disregard for human life among infected prostitutes to leave treatment decisions solely up to them. A program of testing and treatment for prostitutes must be mandatory and those that refuse treatment must be held liable. [This conclusion does not necessarily follow from the available facts.]

Many international aid organizations are against such mandatory treatment programs for prostitutes as they find them to be discriminatory, violate the individual's human rights and are perceived as an attack on female prostitutes who are viewed as victims of gender and income inequality. Such organizations do not properly weigh the loss of human rights and life itself that this virus, unleashed on a community, is causing. This virus, itself, is a violation of human rights and we must do everything in our power to stop it.

...

... John R. Talbott is an author and a former investment banker for Goldman Sachs. ... He lives in New York City and writes about finance, economics, politics, AIDS and society.

...

Citation: Talbott JR (2007) Size Matters: The Number of Prostitutes and the Global HIV/AIDS Pandemic. PLoS ONE 2(6): e543.

Conclusions/Significance
This paper provides strong evidence that when conducted properly, cross country regression data does not support the theory that male circumcision is the key to slowing the AIDS epidemic. Rather, it is the number of infected prostitutes in a country that is highly significant and robust in explaining HIV prevalence levels across countries. An explanation is offered for why Africa has been hit the hardest by the AIDS pandemic and why there appears to be very little correlation between HIV/AIDS infection rates and country wealth.

Talbott responds to criticism.

canada.com
June 13, 2007

Ontario boy dies after complications from circumcision
Mark Brennae, CanWest News Service
Published: Wednesday, June 13, 2007

OTTAWA — A one-week-old Ontario infant died from complications after undergoing a circumcision in a provincial hospital.

Information about the case was published in the April edition of Paediatric Child Health.

The baby, whose name has been withheld by the parents, passed away after his kidneys [no, bladder] became enlarged to seven times their [its] normal size.

The child was born at an unidentified Ontario hospital “sometime in the last three years,” said Dr. Jim Cairns, Ontario’s deputy chief coroner. “The family wants to keep this anonymous.”

No charges were ever laid and no legal action was ever taken in the case.

According to the Paediatric Child Health article, the boy was “bottlefed and was reported to be doing well when he was circum[cis]ed.”

Five hours later, the parents returned to their family doctor with the infant, who had become “irritable and had blue discolouration” below the belly button.

Doctors noticed the discolouration and slight swelling of the penis, but sent the child home.

Fourteen hours after the circumcision, according to Cairns, the child was brought to another hospital where doctors noted he was extremely irritable with marked swelling of the penis and bruising to the scrotum.

The child was then transferred to a paediatric centre, where his bladder was diagnosed, Cairns said, to “seven or eight times its normal size.”

The PlastiBell ring, which is used to hold back the foreskin after circumcision, was removed and drained and the child went into shock.

“If the PlastiBell had been taken off five hours after he got there, he would be alive,” said Cairns. [Perhaps. If the PlastiBell had never been installed he would be alive.]

The child’s death was attributed to septic shock — “an overwhelming infection, leading to multi-organ failure,” Cairns said.

“Death is rare after circumcision,” said Cairns. “But complications can happen.” [How common is rare enough?]

The case was brought to Cairns’ attention because the circumstances of every death of an Ontario child under five years of age must be reviewed by the provincial coroner’s office.

media release
LONDON - 11 June 2007

X-Man Nixes Circs

To coincide with Fathers' Day in many countries, movie, TV and stage actor Alan Cumming has announced that he is to become a patron of NORM-UK, the British charity concerned with education about the male foreskin and circumcision.

"Our foreskins aren't a mistake" said the star of X-Men 2, Spy Kids and Goldeneye, a humanitarian and activist who wants the world to understand the importance of this most under-appreciated body part, "Circumcision is genital mutilation, so why is it condoned and encouraged? I support NORM-UK's efforts to educate and illuminate. May the foreskin be with us and remain with us all!".

Referring to a recent study published in the British Journal of Urology, NORM-UK vice-chairman Dr Peter Ball said, "The foreskin contains the five most sensitive parts of the penis, and we are honoured that Alan recognises the importance of NORM-UK's work. We are all concerned that men and parents are being pushed into unnecessary surgery without understanding the full consequences."

Dr Ball went on to express his concern at the recent push to use male circumcision as a weapon against the HIV/AIDS epidemic in Africa, "Reports are already coming through that some men are seeing circumcision as an alternative to condom use", he said, "this strategy will make the problem worse, not better, and permanently leaving men with less sensitive genitals is a serious side effect that must not be ignored".

Alan joins art critic Brian Sewell as a patron of the charity, which also helps treat men and boys with tight foreskins.

BBC
June 8, 2007

S[ierra] Leone bans child brides not FGM

Sierra Leone's parliament has passed a child rights bill, which bans under-age weddings but controversially dropped a clause to outlaw female circumcision.

The BBC's Umaru Fofana in Sierra Leone says girls as young as 11 are often married off to wealthy men but this is now banned until they are 18 years old.

However, the press and public were asked to leave parliament during the debate on female genital mutilation.

When they were allowed back, the section on FGM had been removed.

The local representative of UN children's agency Unicef said the passing of the bill was the best day for Sierra Leone's children since the end of the civil war.

But campaigners are not happy that FGM was not banned.

Senior MP Alassan Fofana told the BBC that there was a general consensus in parliament not to outlaw FGM.

He said that measures had been introduced to control it and pointed out that this was more than previous parliaments had done.

"They were afraid to be tagged as calling for a ban on FGM. For a lot of people, this would have cost their political career," he said.

Last year, a woman from Sierra Leone successfully claimed asylum in the UK on the basis that she feared being forcibly circumcised - a decision condemned by the Sierra Leone government.

Up to 90% of women have faced the procedure in the West African country, which sees part or all of the clitoris surgically removed, often resulting in reduced or no sexual feeling.

FGM is practised in many West, North and East African countries.

...

Yahoo news
June 7, 2007

Doctors urge mass circumcision for AIDS-hit South Africa

by Fran Blandy Thu Jun 7, 5:50 AM ET

DURBAN, South Afrifa (AFP) -
AIDS experts have called for a mass circumcision programme in South Africa, condemning a "deafening silence" from policy makers since studies revealed it sharply cut infection rates.

As scientists this week questioned a lack of movement on using male circumcision as a preventative method, delegates at South Africa's national AIDS conference called for the rollout of a mass circumcision programme.

Earlier this year the World Health Organisation (WHO) recommended the procedure after three studies in Africa showed it reduced chances of contracting HIV by up to 60 percent. [Note that "up to" - like a sale with price reductions of "up to" 50%]

But although countries such as Kenya, Malawi, Swaziland, Zimbabwe, Mozambique and Tanzania have drawn up plans for widespread circumcision, the South African government has done nothing to date.

"I think by now I would support people starting to think about a mass circumcision campaign," said Neil Martinson of the Perinatal HIV/AIDS research Unit.

Martinson said concerns over whether South Africans thought it was a culturally acceptable practice that would lead to risky sexual behaviour were not proven to be valid.

"In South Africa, high proportions of men and women find it acceptable [for adult men] to be circumcised, people (in the studies) weren't going around and sleeping around more because they didn't have a foreskin."

With an AIDS vaccine years away, the focus has turned to HIV prevention and the conference aims to build consensus about ways to do this.

"I am surprised there is no action on male circumcision. Where are the male activists? Studies show a 60 percent reduction (in risk) but there is silence," Glenda Gray, who will oversee the first HIV vaccine trials run in the country, told a panel discussing prevention research.

The primary investigator into the first circumcision trial held in South Africa, Bertran Auvert of the French Institute of Health and Medical Research, told AFP it was time for implementation.

"It's not even my opinion. It's now a WHO recommendation," he said. [But who in WHO?]

The circumcision debate revealed one of the biggest challenges was getting the message across that being circumcised was not foolproof.

In some cultures in South Africa circumcision is seen as a rite of passage into adulthood, and boys go to initiation schools where they are circumcised with a spear-like instrument. [And some tens of them die each year.]

Critics of the mass use of male circumcision to combat HIV, like Tim Quinlan from the University of KwaZulu Natal's Health Economics and HIV/AIDS Research Division (HEARD), said there were dangers of jumping into the use of male circumcision without it forming part of a larger package of measures.

He questioned the fact that circumcision only protected men, and not women who were at greatest risk of contracting the virus.

However Professor Alan Whiteside, also based at HEARD, called for the "routine offer of circumcision for every male child born in a public hospital." [To have its effect on the epidemic in 15+ years, if ever.]

"It is so blindingly obvious that there are real reasons for circumcision. It is going to happen. What we need is informed advocacy and communication." Circumcision involves the removal of the foreskin which contains cells to which the HI Virus clings more readily. [...according to some weak experiments.]

South Africa has the second highest number of HIV sufferers in the world, after India, with some 5.5 million people living with the disease.

"There has been a deafening silence from policy people in this country, what else should we do, what else is there?" asked Martinson.

"The protective effect is long lasting, it's almost like a vaccine."

He said that research may be needed on how to increase the demand for circumcision.

"Must we target sexual partners, so women say 'I won't sleep with you if you are not cut?" [While simultaneously trying to spread the message that circumcision is "not foolproof"...?]

Breitbart.com
May 24, 2007

Top medical journal blasts "designer vagina" craze

May 24 07:03 PM US/Eastern
One of the world's most prestigious health journals has lashed a fast-growing trend in the United States and Britain for "designer vaginas," the tabloid term for cosmetic surgery to the female genitalia.

The fashion is being driven by commercial and media pressures that exploit women's insecurities and is fraught with unknowns, including a risk to sexual arousal, the British Medical Journal (BMJ) says.

Known as elective genitoplasty, the surgery usually entails shortening or changing the shape of the outer lips, or labia, but may also include reduction in the hood of skin covering the clitoris or shortening the vagina itself. ...

Not only is there a disturbing lack of data about the phenomenon, there has been negligible assessment about surgical after-effects -- and almost zero reflexion as to whether a labial "problem" exists in the first place, the BMJ says angrily. ...

Plastic surgery to the labia carries risks, for this zone carries nerve fibres that are highly sensitive and are a key pathway of sexual arousal, the article warns sternly.

"Incision to any part of the genitalia could compromise sensitivity," it says.

The BMJ piece suggests genitoplasty is a classic example of where commercial, media and social pressures artificially create a problem, fuel concern over it and then put forward a solution for it.

"There is nothing unusual about protrusion of the labia," it says.

"It is the negative meaning that makes it into a problem -- meanings that can give rise to physical, emotional and behavioural reactions, such as discomfort, self-disgust, perhaps avoidance of some activities and a desire for a surgical fix."

EARTHtimes.org
18 May 2007

Belarus government rejects mass circumcision as HIV control measure

Posted : Fri, 18 May 2007 14:14:00GMT
Author : DPA
Category : Health

Minsk - Officials from Belarus' Ministry of Health on Friday formally rejected the idea of circumcising most men in the former Soviet republic as a means of controlling the spread of the HIV virus. "This is not something we are considering," said Mikahil Rizhma, a government spokesman, according to a Korrespondent magazine article. "In our opinion using a condom is much more effective."

Rizhma had been responding to reports in local media of a secret Health Ministry review of studies showing chances of HIV infection fall by up to 60 per cent, if most men in the country are circumcised.

News reports of a possible plan to mandate circumcision operations for most men had caused consternation in Belarus, as the state-run health system routinely administers flu vaccines en masse to government workers, whether they wish it or not.

"There is no such plan," Rizhma said. "We recommend conventional means of prevention."

Circumcision is rare in Belarus, with an estimated one per cent of men having undergone the operation.

HIV-consciousness is low in the country, with most health officials treating the disease as an infection endangering intravenous drug users, but not the general population.

HIV infection approaches epidemic levels neighbouring Russia and Ukraine. Belarus' government has released statistics purporting to show only a tiny portion of the Belarusian population is infected - a position considered questionable by most international health organizations.

Mail & Guardianonline
May 18, 2007

Male circumcision 'no silver bullet' against Aids

Cape Town, South Africa
18 May 2007 04:51

Male circumcision should not be seen as a "silver bullet" in fighting HIV infection, University of Cape Town researchers said in a paper published in the latest issue of the South African Medical Journal.

The evidence for the preventive benefit of male circumcision is "rather modest", and does not warrant "heroic policies or practices", humanities student Alex Myers and co-author, public health professor Jonny Myers, said.

"The current zeal and naive enthusiasm for promoting circumcision as an Aids-prevention tool show lack of regard for the limited degree of benefit likely," they said.

Potential harm includes the possibility that newly circumcised men will feel less inhibited about having risky sex.

There is also the threat of surgical complications "and worse" from the operation itself, and increased costs and strain on thinly stretched health services.

Recent research has shown that HIV infection is about three times more likely as a result of the circumcision procedure itself in three African settings -- Kenya, Lesotho and Tanzania.

One should also not lose sight of the ethical issues of circumcising non-consenting infants.

The authors said that in the Eastern Cape, where most men are circumcised, the HIV prevalence rate is not meaningfully lower than in KwaZulu-Natal, where most are not.

They also said it is useful in weighing up circumcision to ask how consistent attitudes are on preventive surgery.

A Tanzanian study has found that female circumcision reduces HIV transmission. Biologically, the explanation for this is probably the same as for male circumcision.

If female circumcision is medicalised in a similar way to male circumcision, it can be made safer and less damaging.

"The downplaying of these facts in the media is a powerful reflection of Western cultural attitudes," they said.

"We have already decided that female circumcision is an appalling human rights violation and so do not even flirt with the idea of using it as an HIV prevention tool.

"Similar arguments apply to mastectomy in teenage girls, even though this would be effective to prevent breast cancer in later life.

"The difference with male circumcision is that it is still tolerated in Western and other parts of the world, rendering it politically acceptable."

This tends to lower ethical barriers to recommending male circumcision as an HIV/Aids prevention measure. -- Sapa

Sunday Times ()
May 13, 20007

Circumcision is not the solution in HIV battle

Promoting the procedure is not an effective health strategy, writes Tim Quinlan

A NEW answer to the scourge of HIV/Aids is doing the rounds in Africa: scientific experiments show that circumcised men are less likely than uncircumcised men to get infected with HIV; therefore, promote circumci­sion to help prevent the virus spreading further.

However, this idea is neither as sensible nor as simple as it might seem,

First, the connection between the evidence and the proposed answer is confused. Male cir­cumcision is being promoted as if science provided that answer. Science did nothing of the sort; it simply showed a correlation between HIV-infection rates and circumcision. In so doing, it said that this information deserved creative thinking on how to make good use of it. That makes circumcision programmes some­thing to consider, not an obvious answer.

Second, the experiments' re­sults do not actually justify starting programmes. The experiments showed that circum­cision was 50%-61% effective in preventing HIV infection over a period of 18 24 months; in other words, for every 10 uncircumcised men who got infected, four circumcised men got infected.

In science, the evidence has to be compelling to justify a par­ticular application. Compelling evidence would be that eight or nine out of 10 circumcised men do not get infected, irrespective of the time period.

Third, male circumcision programmes art being justified on the grounds of the difference they would make to the spread of IIIV,

Estimates have been made to show that several million infections could be prevented within the space of three to four years, presuming the successful implementation of programmes.

However, many factors influence the sexual transmission of HIV/Aids and, with the excep­tion of condoms, preventative technical solutions have not yet proved themselves Even per­suading men to use condoms has been difficult; why, I wonder, would men be more keen on circumcision?

HIV/Aids is a social and a health problem. Medical science has been steadily improving the efficacy of antiretroviral treat­ment but that counts for little without ensuring that people are well informed, get tested, change their behaviour adhere to treatment and are able to get help - and those are social challenges.

One challenge is to get the message right - and it is complicated. It has to be about making sex "safer” for circum­cised men, but also ensuring that individuals know this does not mean they are "safe" from infection, and that sex is not necessarily "safer” for women and the gay partners of circumcised men.

Sex without a condom is like playing Russian roulette for any individual who does not know for certain the HIV status of his or her partner.

To encourage male circum­cision at birth would be absurd if the aim is to reduce the spread of HIV/Aids within the next few years.

Much depends on how doctors communicate the the right of the individual to make the decision. In the case of infants, inevitably, parents fears will be used to get their sons circumcised.

That would ignore the 12- to 16-year period in which parents and schools can inculcate appropriate sensibilities in their sons; in short, life skills.

This is aside from the fact that, in Africa, being circumcised or uncircumcised is still a powerful symbol of cultural values and social identities.

It doesn't get easier where circumcision is practiced - for instance in initiation rites for boys. The risk of infection is reduced if a penis is fully circumcised. That is not always the practice; there will be a need to ensure that full circumcision is properly done. Not an easy task. South Africa has experience with efforts to stop the damage occurring at some “initiation schools”.

So why is this way of preventing the spread of HIV/Aids being touted in Africa? It is an idea born of deperation: “Nothing else is working, so let's try this.”

There is bound to be interst in any idea that promised to change the situation. But warning lights should flash in the face of promises made in desperation.

Male circumcision works but, as a public health strategy, it has very little going for it.

Profesor Quinlan is research director at the Health Economics and HIV/Aids Research Division, University of KwaZulu-Natal, Durban. He writes in his personal capacity.

SomaliNet
May 10, 2007

Kenya: US gives Kenya Sh25bn to fight Aids, promote male circumcision
Thu. May 10, 2007 06:59 am.- By Bonny Apunyu.
(SomaliNet) The United States (US) has given Kenya over Sh25 billion [$US 372,000.000] to fight Aids and promote male circumcision, a source has revealed.

Mr Michael Ranneberger, the US ambassador to Kenya, said on Wednesday that Sh350 million [$US 5,200,000] would be used in a campaign for male circumcision as a way of preventing HIV infection.

Meanwhile, the United Nations (UN) recently recommended that circumcision be made more accessible to men in African countries following a study conducted in South Africa and Kisumu in Kenya. [No mention of the Rakai, Uganda study where the HIV rate among intact men was lower than among the circumcised men in Kenya] The findings showed that the operation could halve vulnerability to the virus causing Aids among heterosexual men.

The US ambassador to Kenya said the money would be channelled through Pepfar, the US President’s Emergency Plan for Aids Relief. The programme seeks to enrol at least two million people on anti-retroviral treatment and prevent new infections. It also seeks to give care and support to 10 million people infected and affected by Aids in Kenya and 14 other countries.

He encouraged Kenyans to test for HIV to reduce infections, especially among the youth. He spoke at a press conference at the US embassy in Gigiri, Nairobi. Pepfar country coordinator, Mr Warren Buckingham, attended the conference.

According to Mr Ranneberger , in the last six months, about 380,000 pregnant women had tested for the virus while attending antenatal clinics in public hospitals in Kenya.

“Out of these, more than 24,000 who tested positive were enrolled on ARVs, which protected their infants from contracting the virus at birth,” he said.

In the same period, more than 1 million condoms were distributed while 1.2 million youths were provided with information on prevention of the disease. [So 200,000 youths didn't even get one condom?]

The ambassador said the US had increased funding to Kenya more that 10 times in the last four years due to integrity of Pepfar partners. -Nation

Sydney Star Observer
May 10, 2007

THE CRUELLEST CUT by Sunny Burns
FOR MANY YEARS THE PENIS HAS BEEN VIOLATED IN THE NAME OF RELIGION, HYGIENE AND AESTHETICS.

It’s been a hard road for the uncut population, with many being seen as dirty and ugly and subject to insulting slurs.

Recent studies have revealed that fewer than one in 10 boys are now being circumcised in Australia, as society is slowly understanding the benefits of this vital piece of skin. With its main function being a type of protective armour for the glans, the foreskin also keeps the skin of the penis soft, maintaining pH balance and optimal warmth.

Dr Murray Drummond, senior lecturer at the University of South Australia School of Health Science, also says the sexual experience is enhanced when the foreskin slips back [and forth] for sexual intercourse.

“Researchers have identified that having a foreskin makes the tip of the penis more sensitive, so when the penis [foreskin] is drawn back it makes sex more pleasurable as the senses are heightened,” Drummond said. [If he's talking about the Sorrells study, he's missing out the most important part, that the foreskin itself is the most sensitive part of the penis.]

One of the most common myths about circumcision is that it makes the penis hygienic. Eyes without eyelids would not be any cleaner; the circumcised penis is constantly exposed to abrasion and dirt, making it, in fact, more unclean. The loss of the shielding foreskin leaves the urinary tract defenceless against invasion by bacterial and viral pathogens.

“Really young boys should be taught how to look after the foreskin and learn how to clean it. Boys should take responsibility and begin cleaning underneath the foreskin at a young age,” Drummond said. [But not before it retracts by itself.]

Research has shown that depending on the amount of skin cut off in circumcision, up to 80 percent of the penile skin is desensitised. This amputation of the foreskin means severing the rich nerve network and all the nerve receptors in the foreskin itself.

Circumcision alters the appearance of the penis drastically as it leaves a large circumferential surgical scar on the penile shaft.

“It’s still an invasive procedure to an individual that possibly doesn’t need to be done,” Drummond said.

“I think it needs to be discussed a little more and talked about freely. We need to get the message across that just because dad is circumcised doesn’t mean you have to circumcise your child.”

In fact some men who were circumcised as children are now attempting, with the help of modern surgery, to recreate what they were born with. In essence the foreskin is recreated by slowly elongating the remaining penile skin. If these men had been able to make the decision for themselves as children, they might [would, obviously] have not have chosen to be “cut”.

Circumcision is also a hot issue for many in the gay community. On Gaydar.com it rates its own mention on any profile of users of the website, highlighting the preferences and prejudices that some have. Some will argue that sex is better with one or the other. However, Dr Drummond thinks that we should be considering individuals rather than their appendages. This may be a great challenge for many in our community.

In today’s modern society circumcision still holds a place. “However,” he says, “the decision to circumcise should be an individual choice based on health and religious issues. It really shouldn’t be based on cosmetic appeal. The body should not be seen as a vehicle for someone to ogle at.”

Earthtimes.org
April 18, 2007

Alleged circumcision injury prompts suit

Posted : Wed, 18 Apr 2007 22:24:00GMT

MORGANTOWN, W.Va., April 18 A West Virginia couple has filed a medical malpractice lawsuit alleging that their son was injured during a routine circumcision procedure.

Scott and Sherry Dumire allege that their son, Hunter, was injured during a circumcision he underwent Oct. 20, 2005, The West Virginian Record reported Wednesday.

The suit -- filed April 9 in Monongalia Circuit Court -- names the West Virginia University Medical Corporation and the West Virginia University Board of Governors as defendants.

The couple alleges that due to negligence, their son was physically disfigured and has required medical care a a result of the surgery.

The newspaper said the plaintiffs are seeking compensation and all related damages, along with reimbursement for costs associated with the medical treatment their son has required.

City Pages (Minneapolis)
May 2, 2007

A local lawyer fights to save babies from circumcision
Wave of Mutilation

by CP Staff
May 2, 2007

Since 1996, Zenas Baer has been waging a legal battle against circumcision. You can count the Hawley attorney among those not impressed by growing evidence that circumcision reduces the likelihood of HIV infection.

"Why stop at the foreskin? If you lop it all off, you won't have any sexually transmitted diseases," Baer says. "It's an absurd notion to think you can stop the spread of AIDS by cutting off a little piece of skin."

In an attempt to stop what he calls "genital mutilation," Baer filed suit against health-care behemoth Allina Health Systems. The case involves a circumcision performed at Unity Hospital in Coon Rapids in January 2000. After complications from the procedure required a second surgery, Dawn and David Nelson, the boy's parents, sued both the physician who performed the procedure, Dr. Stephen Beretska, and Allina, on the grounds that the hospital failed to obtain informed consent in writing.

Beretska settled out of court for an undisclosed sum. Allina filed a motion for dismissal, arguing that it did not have a legal responsibility to get consent from the Nelsons. The motion was granted, but Baer, undeterred, has taken the case to the Minnesota Court of Appeals.

"The largest health-care system in the state is generating millions of dollars from cutting babies, but it doesn't want to shoulder any responsibility for informed consent," he says indignantly. "I think that's a scandal that needs to be exposed." —Mike Mosedale

Newsweek
May 7, 2007

BeliefWatch: First Cut

By Lisa Miller
Newsweek

May 7, 2007 issue - Poor "Misha." Caught in a terrible custody war, this 12-year-old boy from Washington state has become a cause célèbre for a diverse group of activists. Here are the facts, in brief: Misha lives with his father, who has sole custody and who recently converted to Judaism. The father wants Misha to convert as well, and so he wants Misha circumcised. The boy's mother, who is Russian Orthodox, is against it. Doctors Opposing Circumcision, an activist group, started circulating Misha's story online, asking for donations for Misha's defense. A lower court affirmed the father's right to circumcise his son but has allowed the mother to exhaust her legal options before he does so; now the mother hopes that her case will be taken up by the Oregon Supreme Court. The boy's own desires remain unclear. [No, unknown, but he's reportedly against it.]

Two weeks ago, Richard Dawkins, the Oxford don, noted atheist and author of "The God Delusion," posted Misha's story on his Web site. Dawkins was irate, calling Misha's father's intentions "religiously inspired child abuse." While court documents clearly paint a picture of a marriage and divorce so acrimonious and bizarre as to strain credulity, the questions Misha's case present remain interesting. What is the contemporary religious justification for circumcision? How do couples deal fairly with religious differences in situations of divorce and remarriage? [And whose penis is it?]

Jews are generally circumcised as a symbol of Abraham's covenant with God. But as circumcision rates in America have declined dramatically over the past 40 years, from 90 percent to about 60 percent by some estimates—and as the debate about the health benefits of the practice continues to inflame parents-to-be—a few Jews, especially in affluent, assimilated quarters, have begun to wonder if it's necessary. DOC [no, this site] posts a list of rabbis nationwide who will perform a religious ritual welcoming boys into the world without cutting. More to the point, though, is how couples work out their religious conflicts in divorce agreements. Raoul Felder, the Manhattan divorce attorney, says he's seen several custody cases in which one parent confesses to having had a baby baptized in secret. But "it's a little hard to hide a circumcision." Perhaps Misha's parents need to step back and consider the case of Schmidt v. Niznik, decided last fall. In that instance, a divorced mother wanted to circumcise her 9-year-old son over the father's objections. The judge asked her to wait until the boy was old enough to decide for himself. Misha may well need a lawyer, but what he needs more are parents who will cease inflicting pain upon him, psychic or otherwise.

The Oregonian
April 27, 2007

Divorced parents clash over 12-year-old son's circumcision

Three-year fight - The father, a convert to Judaism, sees it as a matter of religious observance
Friday, April 27, 2007
ASHBEL S. GREEN

A former Medford man who converted to Judaism wants his 12-year-old son to do the same. That requires circumcision -- something the mother adamantly opposes.

The divorced couple has been battling over the issue for three years, including whether the boy wants to undergo the procedure. So far, Oregon courts have squarely sided with the father, who has custody.

That doesn't surprise Kathy T. Graham, associate dean for academic affairs at Willamette University College of Law.

"The primary custodial parent is the one that makes the decisions about religion and education and about matters of child-rearing," Graham said.

Other family law experts agree, but say the courts should at least look into the situation to make sure the surgery is in the best interests of the child.

"You're talking about not just religious instruction or whether you're going to send the child to parochial school or public school," commented Lawrence D. Gorin, a Portland attorney. "This is a matter of permanent change of bodily structure. And it's irreversible."

The mother is running out of legal options.

The Oregon Supreme Court has been briefed, but has not decided whether to take the case.

Mark Johnson, a Portland lawyer commenting on the case, said the court shouldn't let the case be decided based only on the legal papers filed on behalf of the mother and father.

"Frankly, the child should have a lawyer," Johnson said.

The Oregonian is not identifying the family members, in order to protect the privacy of the minor.

The couple married in the early 1990s. She filed for divorce in 1998.

The man started studying Judaism in 1999 and eventually converted. He now lives near Olympia . The child initially lived with his mother, but the father later gained custody.

In court papers, the father claims the boy gradually concluded that he also wanted to convert to Judaism and understood that this required circumcision.

The father also claims as the custodial parent he had a constitutional right to raise his son in his religion.

The father made an appointment for a circumcision in 2004.

The mother responded by going to court, saying her son told her that he was afraid to defy his father, but didn't want the procedure.

She asked for a hearing where she could present evidence that the circumcision would be dangerous. She also sought custody of her son.

But Jackson County Circuit Judge Rebecca G. Orf sided with the father.

"I am still of the opinion that the decision of whether or not a child has elective surgery, which this appears to be, is a call that should be made and is reserved to the custodial parent," Orf said in a hearing.

More than a million U.S. infants are circumcised each year, but circumcising adults or teens remains relatively rare.

Despite her ruling, Orf ordered the boy not be circumcised until the legal proceedings were done.

The Oregon Court of Appeals affirmed Orf's decision without an opinion, often an indication that the three-judge panel found no merit to the appeal. The lawyer for the mother has asked the Oregon Supreme Court to take the case, and gained an ally called Doctors Opposing Circumcision, which filed a brief last week.

There is no schedule for when the court will decide whether to review the case.

The mother's attorney declined to comment.

The father, an attorney who is representing himself, did not return a phone call seeking comment.

Oregon legal experts agree that judges generally defer to the choices of custodial parents.

"Judges traditionally have stayed away in getting involving decisions about the day-to-day upbringing of the child," said Gorin, the Portland attorney.

Still, there are limits.

"It may be that the religious belief is to engage in human sacrifice or kill animals, but we don't do that," he said.

But Julie H. McFarlane, a supervising attorney with the Portland-based Juvenile Rights Project, said that the child's consent for a medical procedure is not required until he turns 15.

[But it's not being proposed as a medical procedure.]

"I think the dad has the legal right as the custodial parent to make those kind of religious or medical decisions," McFarlane said. "It's not much different from cosmetic surgery."

[Actually it's more like extreme body modification, such as tongue-splitting.]

The bottom line, McFarlane said, is that "when you lose custody, you lose a lot of those things that go with custody -- deciding whether the kids go to school and the rest of the day-to-day parenting decisions."

Andy Dworkin of The Oregonian contributed to this report. Ashbel "Tony" Green: 503-221-8202; tonygreen@news.oregonian.com

New Scientist
April 26, 2007

Does circumcision harm your sex life?

Does circumcision harm your sex life? This question has become more pressing than ever with the recent endorsement by the World Health Organization of circumcision as a means of reducing HIV infection in Africa (New Scientist, 31 March, p 7). But as two new studies show, it's proving tricky to resolve.

Kimberley Payne of the Riverside Professional Centre in Ottawa, Canada, and her colleagues tested the sensitivity of 20 intact and 20 circumcised men's penises as they watched erotic movie clips, by touching the penises with filaments that press down with predetermined amounts of pressure (The Journal of Sexual Medicine, DOI: 10.1111/j.1743-6109.2007.00471.x). They found no difference in penile sensation between circumcised and uncircumcised men.

However, when Robert Van Howe of Michigan State University used a similar method to measure sensitivity at 19 points along the penises of 163 men, he found that the five most sensitive points were all in portions of the penis removed by circumcision, especially those in folds exposed as the penis becomes erect (BJU International, vol 99, p 864).

Van Howe says Payne's team might have had similar results if they had tested more men and made measurements at more than two points [and including the foreskin]. He denied that funding by the National Organization of Circumcision Information Resource Centers, which opposes circumcision, influenced the result. "It would be hard to fake," he says. He hopes other groups will try to replicate the findings.

From issue 2601 of New Scientist magazine, 26 April 2007, page 17

iafrica.com
Aprl 26, 2007

Does circumcision affect your sex life?

FRANCE
Thu, 26 Apr 2007

Two studies have thrown up conflicting evidence as to whether circumcision could harm a man's sex life, New Scientist reports in its next issue.

iol.co.za
Aprl 26, 2007

Does circumcision improve your sex life? [Huh?]
April 25 2007 at 07:52PM

Paris - Two studies have thrown up conflicting evidence as to whether circumcision could harm a man's sex life, New Scientist reports in its next issue.

AllAfrica.com
April 10, 2007

Uganda: HIV - Circumcision Isn't Enough

The Monitor (Kampala)
April 10, 2007
Posted to the web April 9, 2007

Jan Ajwang

Experts argue that circumcision alone can never prevent the spread of HIV/Aids but it is yet to be understood by the layman.

37- year old Mukasa is not circumcised but is considering it seriously. "I have heard that if you get circumcised, you cannot catch HIV/ Aids. I don't have to use a condom or worry about all those other ways of keeping safe. I finally get a method that suits me..." he says. Mukasa is obviously oblivious of the almost negligible but very important fact surrounding the hyped circumcision as an option to HIV/Aids prevention.

Experts argue that circumcision alone can never prevent the spread of HIV/Aids but it is yet to be understood by the layman. In Uganda, many people are storming clinics, hospitals and quack 'surgeons' for circumcision, barely informed or sensitised in detail about how exactly they will survive HIV through it.

It can't be ruled out either that the many local 'surgeons' who circumcise within the community could also be as ignorant. While many are excited about this information on circumcision, others still grapple with understanding basic knowledge on HIV/Aids.

Yet it is now official from WHO and UNAIDS, the United Nations joint programme on HIV/Aids that male circumcision is recommended as an option to fight against the scourge.

A joint statement by the two bodies, recommended that male circumcision be included as part of a comprehensive HIV prevention package.'Countries with high rates of heterosexual HIV infection and low rates of male circumcision now have an additional intervention which can reduce the risk of HIV infection in heterosexual men," the statement quotes Dr Kevin De Cock, the Director of HIV/ Aids department in WHO.

Adding that 'scaling up male circumcision in such countries will result in immediate benefit to individuals [This is dangerously wrong.]. However it will be a number of years before we can expect to see an impact on the epidemic from such investment."

This came from evidence after an international expert meeting earlier in the month. It comprised experts who had carried out randomised trials on circumcision that had proven that it reduced the risk of acquired infection of HIV/ Aids by 60 percent.

The trials were done in Kisumu in Kenya, Rakai in Uganda and Orange Farm in South Africa. The recommendations come with the need for extensive sensitisation. "It has been known that male circumcision is good and many men have done it, however recommending it as a measure is quite controversial because some people may think that it is the only way and may not consider the other options of prevention," says Dr Vincent Karuhanga of Friends' Poly Clinic, Kampala Road.

He argues that under some circumstances the promotion of circumcision could down play the important ABC crusade. " The best way it can work is by first carrying out massive education on circumcision and emphasising that the practice alone cannot save them," Karuhanga says. Compared to Abstinence, Being Faithful and Condom use, circumcision at sixty percent still gives a forty percent risk exposure, which must not be ignored.

"People should not rush for circumcision as the ultimate, because there are many circumcised men who have been affected by HIV. Although they are less likely to acquire HIV/ Aids that doesn't necessarily mean that they are totally safe.

WHO and UNAIDS however recommend that there should be counselling for men and their sexual partners, 'to prevent them from developing a false sense of security and engaging in high risk behaviours that could undermine the partial protection provided by male circumcision.'

They also advise that the health services need to be strengthened to provide quality services. Circumcision under the best clinical and hygienic conditions comes at a high price and many Ugandans cannot afford it. For instance Kibuli Muslim Hospital charges between Shs30,000- 60,000 [$US17.30 - 34.60] depending on the condition of the patient.

In other private clinics the cost is even higher at an average of Shs50,000 to 100,000 [$US28.80 - 57.60].

This leaves the local 'surgeons in the community or at the mosque as an option because they are supposedly cheaper.

According to Dr Mahmoud El- Gazar, the Kibuli Hospital Director, the hospital also receives many casuality cases of circumcision gone wrong, courtesy of untrained personnel or poor hygienic conditions.

Dr Jacinto Amandua the Commissioner of clinical services acknowledged the reception of the report and recommendations but said that it would require consideration first. "There is some evidence that circumcision can prevent the spread of HIV to a certain extent, but we shall have to adopt it depending on the decision of the government," he told Daily Monitor in an interview.

He also argued that although circumcision is a common practice it has been recommended before for health and hygienic reasons so recommending it for HIV prevention is as controversial as condom use. It is not good for it to be thought to work alone and therefore a lot has to be done for people to eventually understand it's new role.

Reprinted in a blog
April 9, 2007

NYC Health Commissioner: The Times "misrepresented" comments on circumcision

THE CITY OF NEW YORK DEPARTMENT OF HEALTH AND MENTAL HYGIENE
Michael R. Bloomberg, Mayor
Thomas R. Frieden, M.D., M.P.H., Commissioner
nyc.gov/health

April 9, 2007

Dear Community Member:

Recent media reports misrepresent the Health Department’s response to recent studies showing that circumcision significantly reduces HIV transmission in some contexts. We do not yet know what impact circumcision could have on HIV transmission in New York City, and we have not suggested or planned any initiative or campaign. Quite to the contrary, I indicated in an interview with the New York Times (the source of the misrepresentation) that I very much doubted that even 1% of men at high risk in NYC would undergo the procedure.

As a result of rigorous studies, we now know that circumcision reduces risk of female-to-male spread of HIV by about 60%. There is some evidence, but no proof, that circumcision may reduce male-to-female transmission. There is also some evidence, but again no proof, that it may protect men who engage in insertive anal sex from male-to-male transmission.

Our goals are the following:

• Inform the community of the facts regarding what is known and what is not known about circumcision’s effects on HIV transmission;
• Promote discussion among community groups and health care providers to explore how circumcision may be relevant in New York City;
• Increase access to circumcision for men who want the procedure.

In These Times
May 4, 2007

News > May 4, 2007

Circumcision Promotion Divides AIDS Activists
Should results of African AIDS study be applied in the United States?
By Dana Goldstein

The last time circumcision made headlines in New York City, the city Department of Health and Mental Hygiene was objecting to an ultra-Orthodox Jewish practice in which mohels-professional circumcisers-sucked blood out of the wounds of newly cut infants. After three babies contracted herpes, the city tried to ban the obscure ritual in 2005, provoking an angry response from the Orthodox community and a media dust-up.

Now circumcision is news again in New York, but this time the city is promoting the practice. The April 5 New York Times reported that the city health department has decided to encourage male circumcision as an HIV-prevention method among at-risk populations, particularly gay and African-American men. The move comes after several clinical studies in Africa showed that circumcision of an adult male can decrease his likelihood of infection by as much as 60 percent.

But New York's campaign brings up thorny questions for AIDS researchers and activists. Many are concerned about extrapolating prevention methods for American high-risk men, many of whom are bisexual or gay, from the African circumcision studies, which were conducted primarily among heterosexual groups. Meanwhile, others question how a male partner's circumcision affects a woman's susceptibility to HIV.

Two decades of research show women are less likely to contract a variety of sexually transmitted infections when their male partners are circumcised. But a recent Johns Hopkins University study examining 997 men in Uganda found that their female partners were more likely to contract HIV following a circumcision if the men ignored doctors' orders to abstain from sex until their wounds were fully healed, which usually takes about a month. And with the continued lack of a female-controlled HIV-prevention method-microbicide gels have yet to advance out of the trial phase-any HIV education effort must include a heavy emphasis on condom use. Spokespeople for the New York City Department of Health and Mental Hygiene and the Health and Hospital Corporation, which operates public clinics and hospitals in the city, say the city hasn't established any formal procedures for encouraging HIV-testing prior to circumcision in light of women's increased risk, but stress that any public circumcision efforts will be just one part of a multi-pronged HIV-prevention program.

Cultural stigma against circumcision also remains, especially among immigrant groups like Caribbean Americans. Though about 60 percent of American men are circumcised, the practice is relatively rare worldwide. And it has become less popular in recent years as parents have come to see circumcision as a painful surgery that removes an integral part of the male sexual anatomy. According to the CDC, in 2003, the American circumcision rate dropped to a postwar low of 55.9 percent.

Marjan Hezareh, scientific director of the Los Angeles-based AIDS Research Alliance, is cheered by New York City's decision to explore circumcision as what she terms an "additional prevention strategy" to condoms. For Hezareh, the health benefits for women of having a circumcised partner have been sufficiently proven and the medical benefits should outweigh any stigma against both adult and infant circumcision.

"We must disassociate circumcision from a sign of belonging to a specific religion or culture, and show it to people as another medical prevention strategy," she says. "I bet people will be very open about this."

But Tokes Osubu, executive director of Gay Men of African Descent in New York, is not so confident. He says he is baffled by the city's decision to focus on circumcision. "We might be sending the wrong message to people who are already circumcised," he says. "They might think, 'Oh, because I'm circumcised, I might be okay!' We are still dealing with the effects of HIV being misunderstood 25 years ago as a gay disease. Now I'm afraid people will say, 'I don't have a problem because Mayor Bloomberg said so.'"

AIDS activists also fear that a circumcision drive will undermine their long-term strategy to emphasize condom use. Indeed, homosexual anal sex is so risky that doctors agree circumcision provides little protection against HIV for gay men.

Ronald Goldman, a psychologist and founder of the Circumcision Resource Center, makes the point that "the U.S. has the highest circumcision rate and the highest HIV-infection rate in the developed world." A longtime anti-circumcision advocate, Goldman says, "If you're treating a problem, medical ethics would say use the least invasive method available. And condoms are more effective, plus they're cheaper."

But in battling a disease that continues to grow at alarming rates in urban areas (one in 20 Washington, D.C. residents is HIV-positive, and in New York City, African-American and gay men have infection rates as high as 10 to 20 percent), New York City's proposed circumcision drive is at the vanguard of public health efforts. Whether HIV/AIDS activists will get on board remains to be seen.

New York Times
April 5, 2007

New York City Plans to Promote Circumcision to Reduce Spread of AIDS
By DONALD G. McNEIL Jr.
Published: April 5, 2007

New York City’s Department of Health and Mental Hygiene is planning a campaign to encourage men at high risk of AIDS to get circumcised in light of the World Health Organization’s endorsement of the procedure as an effective way to prevent the disease.

Vivirlatino
April 3, 2007

Brazil says no to circumcision

A recent report by the World Health Organization (WHO) indicates that the practice of circumcision could be effective in preventing the transmission of HIV. Reacting to these findings, the technical advisor for the Brazilian Health Ministry says that her country will not begin practicing circumcisions due to what she considers misleading information:

"I find the recommendations of the WHO and U.N. HIV/AIDS program a little surprising and even frightening," Simao told Agencia Brasil.

...This proposal gives a message of "false protection" because men might think that being circumcized means that they can have sex without condoms without any risk, which "is untrue", she said.

20 minutos
April 3, 2007
Brasil rechaza recurrir a la circuncisión como método preventivo contra la transmisión del sida