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A Surgical Strike Against AIDS

Author: Michael J. Gerson, Roger Hertog Senior Fellow
June 1, 2007
Washington Post

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Circumcision is an, ahem, uncomfortable topic. The traditional Jewish bris calls this medical procedure a sign of blessing on the newcomer. Ten out of 10 male infants seem to disagree.

During World War II, American soldiers were often circumcised to prevent the spread of sexually transmitted diseases. From the 1950s to the mid-1970s, the circumcision of American newborn boys became increasingly common. Then a minor backlash set in, and circumcision rates declined for a time. Today, the American Academy of Pediatrics has a hands-off policy, leaving the decision up to parents.

But suddenly, Uncle Irving seems pretty wise. Studies in Uganda, Kenya and South Africa indicate that circumcision halves the risk of adult males contracting HIV through heterosexual intercourse. An author of one of those studies, Robert Bailey of the University of Illinois, Chicago, told me, “There is nothing else currently out there in public health or HIV prevention with protection results this compelling.” Studies are ongoing to determine if male circumcision protects women from transmission; researchers suspect it might. The benefit for men, however, is increasingly undeniable.

Why does circumcision help prevent AIDS? Well, since we’re all adults here (and children reading the editorial pages are likely to be freakishly mature), I’ll be frank. The foreskin of the penis — the part removed in a circumcision — has a high concentration of cells that bring HIV into the body. A circumcised male is exposed to less of the HIV during sexual relations, and has less chance of being infected.

This helps to explain one of the great mysteries of AIDS in Africa: why infection rates vary so widely across the continent. The most mind-numbing levels of infection — sometimes upward of 30 percent — are concentrated in those regions of southern Africa where most men are uncircumcised. Massive infection rates seem to be associated with uncircumcised males, ulcerative STDs and many concurrent sexual partners. Researchers hope that broader circumcision will remove a contributor to this deadly cycle.

As you’d expect, there are cultural obstacles to broader circumcision in Africa. Circumcision, or the lack of it, can be a matter of cultural identity, distinguishing Christians from Muslims (who, like Jews, are traditionally circumcised), and even dividing ethnic groups within a country. But surveys in Africa indicate an openness to the procedure among uncircumcised Christians. One researcher, Dr. Maria Wawer of the Johns Hopkins University, says, “A response we got was, ‘Well, what’s the big deal? Jesus was circumcised.’”

There are also practical obstacles. Like any operation, circumcision presents the risk of infection. Much of Africa lacks the equipment and personnel to perform the procedure on a large scale. But similar arguments were made against the possibility of AIDS treatment. A concerted U.S. and international commitment proved that pessimism to be unjustified.

The main problem with circumcision is that it is only partially protective. If a newly circumcised male stops using condoms or increases his number of partners out of a false sense of invulnerability, his risk of getting AIDS increases, along with the risk of giving it. The Uganda and Kenya studies found no increase in risky sexual behavior after circumcision, but clearly a lot of health education will be required.

As circumcision scales up, the reductions in overall infection rates will be gradual. But the implications for the individual man in Africa are drastic. A $40 or $50 procedure can cut his risk of AIDS infection in half. And giving him that option is a matter of moral urgency.

That begins with African governments. Routine infant circumcision and adult circumcision must be considered. International donors need to aggressively support African circumcision programs with new resources. And European governments, which have refused to touch this issue, need to start respecting the scientific data and lend their support.

Circumcision has played a mixed role in history. During the worst days of the India-Pakistan partition in the 1940s, Muslims ambushed trains and murdered every uncircumcised male, because they knew these were Hindus. Hindus used the same method to identify Muslims for death.

Today, this source of division is becoming a source of hope that could eventually save many lives. When it comes to AIDS, circumcision is the kindest cut.

This article appears in full on CFR.org by permission of its original publisher. It was originally available here.

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