A S S O C I A T I O N  for  G E N I T A L   I N T E G R I T Y 
June 23, 2000

Dr. Peter Piot
Executive Director, UNAIDS
Geneva, Switzerland

Dear Dr. Piot:

You were recently interviewed on the English-language television service of the Canadian Broadcasting Corporation in connection with the AIDS pandemic in Africa. I wish to inquire about the attitude of UNAIDS toward enlisting male circumcision in the fight against AIDS.

Circumcising boys to reduce the rate of HIV transmission presents a number of ethical difficulties. These difficulties were outlined in an article published on October 24, 1998, in the Montreal Gazette, one of Canada’s main daily newspapers. The author of the article was Dr. Margaret A. Somerville, director of the Centre for Medicine, Ethics and Law at McGill University and one of Canada’s top medical ethicists. Dr. Somerville was writing in response to an article entitled “Circumcision Helps in AIDS Fight” by Dr. Mark A. Wainberg, professor of medicine at McGill University and president of the International Aids Society. I enclose copies of both these articles for your information.

My questions are as follows:

  1. Does the UNAIDS secretariat believe that male circumcision is an acceptable strategy for reducing the risk of HIV infection?
  2. Does UNAIDS consider the removal of healthy sexual tissue from girls to be a human rights violation?
  3. Does UNAIDS consider the removal of healthy sexual tissue from boys to be a human rights violation? If not, please explain why.

Thank you for considering the above questions. I look forward to your reply.

D ennis H arrison

June 29, 2000

Dear Mr. H arrison,

Thank you for your letter of June 23 addressed to Dr. Peter Piot, Executive Director of UNAIDS, on the subject of male circumcision.

We have recently reviewed in UNAIDS all the articles published on the association between HIV and male circumcision in sub-Saharan Africa and found a strong association between the lack of circumcision and HIV. However, there are still a lot of operational and research questions that need to be answered before UNAIDS can make a policy statement on this issue.

Thank you for your interest.

Yours sincerely,
Michel Caraël
Prevention Team Leader
Department of Policy, Strategy and Research

March 13, 2007

Dr. Catherine Hankins
Chief Scientific Advisor, UNAIDS
Geneva, Switzerland

Dear Dr. Hankins:

Re: HIV and male circumcision

I’ve seen a transcript of the National Institute of Allergy and Infectious Diseases video conference on male circumcision, held Dec. 13, 2006, and would like to comment. Genital cutting has been a matter of concern to me for a number of years. My letters on the subject have been published in several academic journals, including the Lancet and the New England Journal of Medicine.

Maureen Taylor of the CBC asked whether—in light of the new evidence linking the foreskin to HIV infection—you would advise parents to have their baby boys circumcised. You replied, “as I think is currently the case in Canada, parents are basically provided with the facts and make a decision one way or the other.”

However, the appropriateness of performing discretionary surgery on babies has been questioned by top Canadian ethicists and by medical licensing authorities. As a rule, physicians can perform surgery without the personal informed consent of the patient only if the operation is deemed medically necessary. Since HIV infection can be avoided by less invasive means, such as practising safe sex, circumcision to prevent AIDS doesn’t meet the standard of medical necessity, especially in infancy.

I would also like to comment on some statements attributed to you in a UNAIDS feature article on circumcision[1]. You are quoted as saying that “uncircumcised men may be more vulnerable to sexually transmitted diseases.” Yet large cross-sectional studies in the US, Britain and Australia failed to find any evidence of such a link[2,3,4]. The authors of the US study reported “no significant differences between circumcised and uncircumcised men in their likelihood of contracting sexually transmitted diseases”[2]. It should be noted that the highest rate of sexually transmitted disease in the developed world is found in the United States, the country which also has the developed world’s highest rate of male circumcision.

You claim that “the region under the foreskin provides a moist, dark place in which germs can thrive.” Evidence suggests, however, that far from providing a haven for germs, the mucosal surface of the foreskin forms an important barrier to infection. A new study from the Netherlands has found that epithelial Langerhans cells of the prepuce produce a protein capable of destroying HIV[5].

The UNAIDS article assumes that circumcision has no significant negative impact on sexual function. But in a recent South Korean survey of 373 men circumcised in adulthood, 48 percent of respondents reported a decrease in masturbatory pleasure and 20 percent reported a worse sex life after circumcision[6]. Histological studies from the US, India and Canada have found that the foreskin comprises specialized sexual tissue[7,8,9]. It seems to me that an effective global policy on AIDS cannot afford to ignore questions of general sexual health.

In short, the UNAIDS feature on circumcision strikes me as simplistic and misleading. Although a significant protective effect of male circumcision has been observed in three randomized controlled trials, all of these trials were stopped early. A systematic review of trials stopped early for benefit found that they overestimated treatment effects[10].

Recent population-based surveys from Burkina Faso, Cameroon, Ghana, Lesotho, Malawi, Tanzania and Uganda detected no significant protective effect of male circumcision against HIV[11]. In Malawi, the district with the highest prevalence of HIV is the district with the highest rate of male circumcision[12].

I trust that the promotion of circumcision as an AIDS preventative by UNAIDS rests on a sound scientific and ethical basis.

D ennis H arrison

  1. Male Circumcision: context, criteria and culture.
  2. Laumann, EO, Masi CM, Zuckerman EW. Circumcision in the United States. JAMA 1997;277(13):1052-7.
  3. Dave SS, Johnson AM, Fenton KA, et al. Male circumcision in Britain: findings from a national probability sample survey. Sex Trans Infect 2003;79:499-500.
  4. Richters J, Smith AMA, de Visser RO, et al. Circumcision in Australia: prevalence and effects on sexual health. Int J STD AIDS 2006;17:547-54.
  5. De Witte L, Nabatov A, Pion M, et al. Langerin is a natural barrier to HIV-1 transmission by Langerhans cells. Nat Med 2007;13:367-371.
  6. Kim DS, Pang MG. The effect of male circumcision on sexuality. BJU International 99(3),619-622.
  7. Winkelmann RK. The erogenous zones: their nerve supply and significance. Mayo Clin Proc 1959;34(2):39-47.
  8. Lakshmanan S., Prakash S. Human prepuce: some aspects of structure and function. Indian J Surg 1980;44:134-7.
  9. Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996;77:291-295.
  10. Montori VM, Devereaux PJ, Adhikari NK, et al. Randomized trials stopped early for benefit: a systematic review. JAMA 2005;294:2203-2209.
  11. Way A, Mishra V, Hong R, Johnson K. Is male circumcision protective of HIV infection? (Presented at AIDS 2006.)
  12. Poulin M, Muula AS. Male Circumcision and HIV Infection: The Case of Malawi. (Presented at 2007 Annual Meeting of Population Association of America.)

March 22, 2007

Dear Mr. Harrison,

Thank you for your letter of 13 March 2007 and accompanying list of references. Your interest in the subject of male circumcision is welcomed.

On 28 March, the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) will release recommendations regarding male circumcision as an additional HIV prevention measure. These recommendations were developed during an international consultation on the Policy and Programming Implications of Research, held from 06 to 08 March in Montreux, Switzerland.

Among the participants were experts representing a wide range of stakeholders including government representatives, researchers, civil society representatives, gender experts, human rights and women's health advocates, young people, funding agencies and implementing partners. The recommendations cover a number of issues including policy, operational and ethical issues.

It is important to note that the public health impact of adult male circumcision for HIV prevention will be greatest in countries of high HIV prevalence, particularly in sub-Saharan Africa. You will be able to access the full set of recommendations for HIV prevalence and other countries shortly after the press conference on 28 March. UNAIDS has prepared human rights/ethical and legal guidance for countries which make it clear that informed consent is essential. If you would like to see the latest draft of these guidelines, I would be pleased to send them to you.

Male circumcision practised on medical grounds can in no way be equated to female circumcision or female genital mutilation which has serious adverse consequences for women and no medical benefits. With respect to protection from sexually transmitted infections, systematic reviews and randomised controlled trials (RCT) have found a clear association of male circumcision with lower rates of penile infections. These show that circumcised men are at significantly lower risk of urinary tract infections (UTI), HIV, syphilis and chancroid.

Finally, UNAIDS promotes combination prevention which focuses on encouraging individuals to combine different HIV prevention measures for better protection. Male circumcision must be part of a comprehensive HIV prevention package, which includes: promoting delay in the onset of sexual relations, abstinence from penetrative sex and reduction in the number of sexual partners; providing and promoting correct and consistent use of male and female condoms; providing HIV testing and counselling services; and providing services for the treatment of sexually transmitted infections.

I am pleased to enclose some key references for your review.

Yours truly,
Dr. Catherine Hankins
Chief Scientific Adviser to UNAIDS
Associate Director,
Department of Policy, Evidence & Partnerships

  1. Gray RH, Kigozi G, Serwadda 0, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet 2007,369:657-666.
  2. Bailey RC, Moses S, Parker C, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet 2007;369:643-656.
  3. Auvert B, Taljaard 0, Lagarde E, et al. Randomized controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 trial. PLoS Medicine 2005; 2(11):e298.
  4. Weiss, H.A., Thomas, S.L., Munabi, S.K., and Hayes, R.J., Male circumcision and risk of syphilis, chancroid, and genital herpes: a systematic review and meta-analysis. Sex Transm Infect, 2006. 82(2): p. 101-9; discussion 110.
  5. Singh-Grewal, D., Macdessi, J., and Craig, J., Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomised trials and observational studies. Arch Dis Child, 2005. 90(8): p. 853-8.
  6. Moses, S., Bailey, R.C., and Ronald, A.R., Male circumcision: assessment of health benefits and risks. Sex Transm Infect, 1998.74(5): p. 368-73.

April 11, 2007

Dear Dr. Hankins,

Thank you for your letter dated March 22, 2007, with references. As per your kind offer, could you send me the latest UNAIDS ethical guidance on male circumcision?

My concerns centre on the issue of consent. Among the various measures recommended by UNAIDS to stem the spread of sexually transmitted HIV, male circumcision is the only measure being proposed for use on infants and children—individuals unable to give consent for themselves. Discretionary surgery generally requires the personal informed consent of the patient. It seems to me that since the most effective way of avoiding HIV infection is to practise safe sex, every person should be able to exercise that option without having surgery imposed on them in infancy.

Dr. Margaret Somerville, one of Canada’s top medical ethicists, has addressed the issue of circumcising male infants to reduce their risk of contracting sexually transmitted HIV. I enclose a copy of an article by Dr. Somerville for your consideration.

I feel obliged to challenge your statement that a “clear association” has been found between male circumcision and lower rates of sexually transmitted infections. The evidence in this area is complex and conflicting. As I noted in my previous letter, a number of studies have failed to find any protective effect of male circumcision against STIs. A summary of three large population-based studies is enclosed for your reference.

According to the World Health Organization, the prevalence and incidence of STIs is significantly higher in the United States, where male circumcision is the norm, than in Western Europe, where circumcision is rare. Moreover, if circumcision protects against HIV infection by removing tissue rich in front-line immune cells, then it seems biologically implausible that circumcision could also protect the body against garden-variety infections.

In sum, although a link between male circumcision and lower rates of some STIs can’t be ruled out, calling the association “clear” strikes me as a bit dogmatic.

I have to say that I also detect some dogmatism in your statement that “male circumcision...can in no way be equated to female circumcision.” Only a few decades ago, the parallels between male and female circumcision were readily apparent to mainstream physicians in the United States. Writing in a 1958 issue of GP, the predecessor to American Family Physician, Dr. C.F. McDonald of Milwaukee asks: “If the male needs circumcision for cleanliness and hygiene, why not the female?” I enclose a copy of the first page of the McDonald article, as well as a later item called “Female Circumcision: Indications and a New Technique” by a Dr. W.G. Rathmann of Inglewood, California.

I would also like to comment on a WHO/UNAIDS publication titled Male circumcision: global trends and determinants of prevalence, safety and accessibility (accessed April 11, 2007). You are listed as one of the contributing authors.

On page 13 of the above document, a table puts the number of adult males in Australia at 24.22 million, a figure greater than the country’s total population. The numbers for Australia and the UK appear to have been reversed.

On page 34, under the heading “Male circumcision and female genital mutilation,” is found the following assertion: “There are no known health benefits associated with FGM and no research evidence to suggest that such procedures could reduce the risk of HIV transmission.”

The above statement ignores a paper presented at the 2005 International AIDS Society conference in Rio de Janeiro. The authors of this paper reported that a reduction in HIV infection in circumcised women remained highly significant after adjusting for confounding factors. The findings were based on a nationally representative sample of 5,297 Tanzanian women. A copy of the abstract is enclosed.

UNAIDS policy is ostensibly based on scientific evidence, yet implicitly biased towards male circumcision. UNAIDS creates a false distinction between male circumcision and FGM by downplaying potential harm from the former while rejecting any possibility of benefit from the latter.

Thank you for the opportunity to express my views.

Dennis Harrison

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