In an African environment or any country in the sub-Saharan setting, there are weak institutional set-ups to disclaim research carried out by Europeans.
The recent controversies brought into medical male circumcision by Dr. Gregory J Boyle and George Hill reminds me of Andrew Wakefield, the one time well-respected British doctor who contributed positively to the medical fraternity and had written highly respected research until his ill-fated 1998 study claiming that there was a link between autism and the combined jab for measles, mumps and rubella (MMR). This particular study caused a decrease in vaccination rates, particularly in Britain, but fortunately his study was later discredited.
The British Medical Journal, which prides itself in helping doctors to make better decisions not only found erroneous methodological aspects in Wakefield’s research into MMR/autism wanting, but they also rubbished all his recommendations. To date, the medical fraternity is still licking its wounds from Wakefield’s 1998 study, which convinced thousands of parents that vaccines are dangerous and led them to skip the recommended triple shots. It is estimated that immunisation rates in Europe and America, have never gone back to the rate before Wakefield’s research. This has consequently been blamed for the ongoing outbreaks of measles and mumps to date.
My greatest relief is that Andrew Wakefield made his revelations in an advanced country setting, like Britain. Not Uganda. A UK environment with a strong Medical Association and a research base, where spirited challenges were made against such research, is far different from Uganda and sub-Saharan Africa.
In an African environment or any country in the sub-Saharan setting, there are weak institutional set-ups to disclaim research carried out by Europeans. For instance, one can imagine how damaging Boyle and Hills (2011) paper “Sub-Saharan randomised clinical trials into male circumcision and HIV transmission: methodological, ethical and legal concerns”, can be in a region where people are getting infected with HIV and do not even have knowledge of what to eat, are battling with malaria and institutional failures. There is no time to disclaim such research findings. These guys proclamations are going to hurt Africa real bad.
In addition, the claims made by Dr. Gregory J Boyle and George Hill with their organization “Medical Doctors Opposing Circumcision” will drastically reverse the efforts of medical male circumcision, because most African media do not have resources that would necessitate them to take time to validate sources of research. This is evidenced by the rush with which The Monitor Newspaper published the claims by these two doctors.
I am surprised that Boyle and Hill have chosen to ignore the pool of evidence. Strong evidence which suggests that male circumcision reduces HIV infection from HIV positive women to circumcised men by almost 60% as seen by Baily, et al., 2006; Gray, et al., 2006; Auvert, et al., 2005 and other studies. Prior to that, several behavioural studies have also consistently suggested lower HIV infection among circumcised men (Drain, et al., 2004; Reynolds, et al., 2004; Buve, 2002).
I believe they are more concerned, not about the methodological issues in randomised trials for male circumcision, but the ethical and legal parameters to be followed when carrying out circumcision. My bet is that even with these legal and ethical issues addressed, the “doctors opposing circumcision” would not be brought on board.
In my recent book, “HIV/AIDS: integrating medical male circumcision (MMC) into developing countries’ health systems – Perspective of Uganda’s HIV/AIDS policy”, I suggest that, consent which is “agreeing, to give permission, to accede; to comply” and informed consent based on “full information on what will happen” should always be considered for the good of autonomy, beneficence and justice in male circumcision operations. Whereas autonomy gives the patient the right to make free decisions; beneficence promotes the moral basis for the practice by inflicting no harm, preventing harm, removing harm and promoting good; justice on the other hand, means that, people will be treated with fairness, appropriately and equitably.
I also argue that, consent can always be guided by ethical guidelines of medicine, such as the capacity to consent (age, maturity and cognitive ability), voluntariness and patients receiving sufficient information to guide consent. Most of these and similar guidelines are already in place in the medical discipline.
My only major worry to date is that, Boyle and Hill’s claims on medical male circumcision, which I have observed being conducted in sterile hospital settings, will do a lot of harm to medicine, just as Andrew Wakefield’s opinions have already done.
References
Auvert,B.,Taljaard,D.,Lagarde,E.,Sobngwi-Tambekou,J.L.,Sitta.R.,et al. (2005) Randomized Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: The ANRS 1265 Trial. Plos medicine 2(11), e298.
Bailey,R.C.,Moses,S.,Parker,B.C.,Agot,K.,Maclean,I.,Krieger,J.N.,et al. (2006) Male Circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. The Lancet 369 (9562), 643- 656.
Boyle, Gregory J.G & Hill, G. (2011) Sub- Saharan randomised clinical trials into male circumcision and HIV transmission: methodological, ethical and legal concerns. JLM (19) 316-334
Buvé, A. (2002) HIV Epidemics in Africa: What Explains the Variations in HIV Prevalence? IUBMB Life 53(4), 193 – 195.
Drain, K.P., Smith,J.S, Hughes,J.P., Halperin,D.T and Holmes,K.K. (2004) Correlates of National HIV Seroprevalence: An Ecological Analysis of 122 Developing Countries. J Acquir Immune Defic Syndr. 35(4), 407–420.
Gray, R. H G., Kigozi, G., Serwadda,D., Makumbi, F.R.,Watya, S. et al. (2006) Male Circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. The Lancet 369 (9562), 657- 666.
Kityo, J (2012), Integrating Medical Male Circumcision into Developing Countries’ Health systems: Perspectives from Uganda’s HIV/AIDS Policy.Saarbrucken, Lambert Publishing GmbH & Co. KG
Reynolds,J.S., Shepherd,M.E.,Risbud,A.R., Gangakhedkar,R.R.,Brookmeyer,R.S.,Divekar, A.D., Mehendale,M.S., Bollinger.RC. (2004) Male circumcision and risk of HIV-1 and other sexually transmitted infections in India. The Lancet 363 (9414), 1039–40.].
COMMENTS
That is just a rather sophisticed version of an ad hominem - attacking the person - argument. Wakefield is a disgraced fraudster with a financial motive. Boyle and Hill have no such ulterior motive and bring real facts to the table, which you ignore. The much touted “60% protection” (relative risk reduction) amounts to only 73 circumcised men in the trials who didn’t get HIV, while 64 did, less than two years after 5,400 men were circumcised. Several times as many dropped out, their HIV status unknown.
Your remarks about control of research by Europeans in Africa were better directed towards the poor ethical controls on the tight-knit coterie of circumcision advocates who populate your references, Bailey, Halperin, Gray, et al.
If men decline being circumcised but use condoms they will still be much better protected against HIV than if they get circumcised and abandon condoms, as many have said they will do, and as the Catholic Bishops of Malawi recommend - a recipe for many deaths.
Im most of the Medical male circumcision programmes Carried out now, just as it wass in the RCTs i quoted above, Full VCT and condom use were/are strongly encouraged.
I wonder whether Boyle and Hill’s views were published as Front Page Headlines in the Bristish and american Media, as they appeared in The Monitor of Uganda.
Yes, a condom is much smarter than laying open a persons healthy genitals causing him a lifetime of sexual and anger problems.
Sounds like a no brainer.
Condoms, Soap and Water vs Mutilating Penis Reducing Surgery.
It is clear the author has not actually read the latest critique. Most of the US men who have died of AIDS were circumcised at birth. It is mysterious why some are so eager to collude with the West in pushing foreskin amputations on Africans.
I think it would be a good idea for kityojames to actually read the paper by Boyle & Hill before he trashes it. That document is available at:
http://www.salem-news.com/fms/pdf/2011-12_JLM-Boyle-Hill.pdf
It is supported by another paper by Van Howe & Storms, which he should also read:
http://www.publichealthinafrica.org/index.php/jphia/article/view/jphia.2011.e4/pdf_22
Male circumcision may reduce the per coitus chances of a man aquiring HIV in heterosexual contact. But that is all the research proves. Observational studies, when viewed as a whole, provide differing conclusions with some.
To assert that deterring mass circumcision would “hurt Africa real bad” if part of the interpretation creep sufferred by this research.
That “in any country in the sub-Saharan setting, there are weak institutional set-ups to disclaim research carried out by Europeans” is true. And some of us suspect that the research to “prove” circumcision prevents HIV was done in Africa for that reason.
Yes, informed consent based on “full information on what will happen” is necessary, but it is also necessary for informed consent to be given a realistic appraisal of the chances of the treatment objective being achieved. This in absolute risk amounts to 1.3% less chance of becoming HIV infected in 2 years. In the long run it may make no difference at all.
And infants can’t give informed consent. Circumcision must be deferred until they are of sufficient age and maturity to do so. To do otherwise is to deny them their right to autonomy, the right which consent is supposed to protect.
Correction to the above, the second paragraph should have ended “…with some supporting the hypothesis that circumcision is protective while others contradict it”.
No, being circumcised pbbraoly doesn’t have any effect on premature ejaculation. People once thought it decreased premature ejaculation because the penis becomes desensitized, but if this were so, then very few circumcised men would be suffering with it; thus this can’t be true.Premature ejaculation has more to do with what’s going in the mind and control over one’s bodily sensations to control what happens, so it has little to nothing to do with circumcision status.
Circumcision removes the end of the nerve that mediates orgasm. In most men it causes delayed orgasm or difficulty reaching orgasm, but in other men it causes premature ejaculation. It just depends how nerves develop and exactly how the procedure is done whether there is too much or too little sensation as a result. Women who have had sex with both say intact feels better because there is less friction. (Foreskin acts like permanent lubrication.) Circumcised men are more likely to avoid using condoms. Also, it’s gender discrimination to say this should be done to men but not done to women. “Sunna circumcision” is the same procedure on the clitoris (prepucectomy). I respect the right of adults to circumcise themselves, but they shouldn’t do it to children. Everyone deserves the right to make permanent decisions about their own genitals for themselves.