The author’s apparent first order of business is to dismiss this attack on EBM because of its language. Apparently words such as “hegemony” are too complex and terms such as “intention-to-treat analysis,” and “logistic regression -derived odds ratio” are straightforward. Come now.

Next, the author presents the rather obvious rationale for EBM. If well constructed studies clearly show a treatment to be ineffective or harmful why would anyone choose the treatment? Come now. A 6th grader could figure this out. It is not EBM that is being attacked per se. It is the dominance of EBM that is being criticized. The author completely misses this point and consequently, instead of actually learning something goes into “counterattack mode”.

The dominance of EBM is clearly having widespread toxicities on the production of new knowledge and creative thought and secondarily, promotes a myopic biomedical approach to certain problems. For example, how many dozens of new antidepressants does EBM have to discover before we realize that depression is a much deeper problem, linked to our social and cultural toxicities, than to 5 of 9 symptoms for 2 weeks. Come now.

The article on the Kenyan study cites a 1% complication rate. Could it be said that the approximately 100 men with reported complications out of the approximately 10,000 men in the study would otherwise have contracted HIV?

MC is the only routine surgical procedure which is done for prophylactic reasons and not to treat pathology. The logistics of mounting a massive VMMC campaign in Africa are daunting. This is not to mention the prospect of the cited “assembly lines” and the empowerment of paraprofessionals to do surgery which would simply invite complications and provide incentive for unscrupulous individuals to victimize the male population for financial gain.

It seems imprudent to spend billions of public health dollars on an intervention involving a harmful surgical procedure with a significant complication rate, with questionable effectiveness. It seems even more imprudent to divert scarce resources from other interventions including hygiene, condoms, education, and an HIV vaccine.

,

• Risk avoidance by circumcised men who will now feel ‘invulnerable’ and will avoid condoms. This is especially true where the men feel a western ‘surgery’ confers extra immunity over tribal rituals.

• That trend, already identified, endangers millions of women and may even worsen the epidemic.

• VMMC will inevitably ensnare minors. In no world culture is MC entirely voluntary, that is, for consenting adults only. VMMC has always been a stalking horse for unconsented infant circumcision.

• In cultures which value displays of masculine bravery, MC will veer toward the gruesome rather than stay within clinical standards. South Korea is an example of this phenomenon.

• The initial clinical standards will soon decline in village settings where even clean water is a luxury. Indeed one of the unaccounted for factors in the RCT’s is the vector of iatogenic transmission via contaminated medical equipment.

• Once introduced, MC will prove difficult to eradicate when an HIV immunization is eventually found, as genital mutilations are self-replicating and self-sustaining. They need no reason other than, “They did it to me.” The Cut always become Cutters.

• An AIDS vaccine has already been found -in HAART- which reduces infection rates to near zero between discordant partners. HAART will surely prove less expensive than huge VMMC campaigns in the long run.

• VMMC will firmly plant the notion that amputations are the preferred solution to disease processes, a giant step backwards in both human rights and medical science.

• VMMC will slow attempts to control FGC, female genital cutting, and may introduce FGC, unbidden, where it is now unknown. Blaming female mucosal tissue is a small additional step after VMMC.

• VMMC may pit tribe against tribe. In Kenya, the Luo (the tribe of Barack Obama’s father), do not engage in MC. But the Kikuyu, who blame the Luo for HIV /AIDS at the urging of researchers, do so. This has led to kidnapping and forced MC of the Luo. This will surely escalate in multiple cultures across Africa, creating a fertile ground for regional conflicts.

John V. Geisheker, J.D., LL.M.
Executive Director,
General Counsel,
DoctorsOpposingCircumcision.org
Seattle, Washington, USA

A new review in the Australian Journal of Law and Medicine unravels some of the many reasons that may not be cause and effect:
researcher expectation bias;
participant expectation bias;
inadequate double blinding;
lead-time bias;
selection and sampling bias;
attrition bias; and
early termination.
Contacts were not traced so we don’t even know which if any of the men got HIV from women or even by sex

Wawer et al. (Lancet 374:9685, 229-37) started to find that circumcising men INcreases the risk to women (who are already at greater risk), but they cut that one short for no good reason (nothing they could then do or not do would prevent any new infections) before it could be confirmed.

This tiny reduction is completely overbalanced by a 61 percent INCREASE in male-to-female HIV transmission if the male partner is circumcised.

The premise on which these papers are based – that male circumcision reduces HIV infection – is false and the papers draw false conclusions.

Boyle GJ, Hill G. Sub-Saharan African randomised clinical trials into male circumcision and HIV transmission: Methodological, ethical and legal concerns. J Law Med 2011;19:316-34.

It is completely unethical in medicine or public health to base any investigation on the premise of mutilation. Whatever the alleged benefits, they cannot outweigh the fact that circumcision is a harmful procedure.

“First, do no harm.”