Africa

The AAP report on circumcision: Bad science + bad ethics = bad medicine

By Brian D. Earp

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UPDATED as of 27 May, 2013. See the bottom of the post.

The AAP report on circumcision: Bad science + bad ethics = bad medicine

For the first time in over a decade, the American Academy of Pediatrics (AAP) has revised its policy position on infant male circumcision. They now say that the probabilistic health benefits conferred by the procedure outweigh the known risks and harms. Not enough to positively recommend circumcision (as some media outlets are erroneously reporting), but just enough to suggest that whenever it is performed—for cultural or religious reasons, or sheer parental preference, as the case may be—it should be covered by government health insurance.

That turns out to be a very fine line to dance on. The AAP position statement is characterized by equivocations, hedging, and uncertainty; and the longer report upon which it is based includes a number of non-sequiturs, instances of self-contradiction, and cherry-picking of essential evidence.

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A fatal irony: Why the “circumcision solution” to the AIDS epidemic in Africa may increase transmission of HIV

By Brian D. Earp

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A fatal irony: Why the “circumcision solution” to the AIDS epidemic in Africa may increase transmission of HIV

1. Experimental doubts 

A handful of circumcision advocates have recently begun haranguing the global health community to adopt widespread foreskin-removal as a way to fight AIDS. Their recommendations follow the publication of three [1] randomized controlled trials (RCTs) conducted in Africa between 2005 and 2007.

These studies have generated a lot of media attention. In part this is because they claim to show that circumcision reduces HIV transmission by about 60%, a figure that (interpreted out of context) is ripe for misunderstanding, as we’ll see. Nevertheless, as one editorial [2] concluded: “The proven efficacy of MC [male circumcision] and its high cost-effectiveness in the face of a persistent heterosexual HIV epidemic argues overwhelmingly for its immediate and rapid adoption.”

Well, hold your horses. The “randomized controlled trials” upon which these recommendations are based are not without their flaws. Their data have been harnessed to support public health recommendations on a massive scale whose implementation, it has been argued, may have the opposite of the claimed effect, with fatal consequences. As Gregory Boyle and George Hill explain in their extensive analysis of the RCTs:

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