[36] The Cut Podcast: Circumcision and HIV: A Conversation with David Wilton

Eliyahu Ungar-Sargon interviews David Wilton about the nature of the push to circumcise Africa, how this has affected the controversy over circumcising completely healthy infants, and in what ways the Intactivist Movement needs to evolve its organization. Here is the recording, and a transcript follows.

(slightly modified)

Eliyahu Ungar-Sargon

From the White Letter Productions studios in Los Angeles, California, I'm [Eliyahu] Ungar-Sargon, and this is The Cut Podcast.

Welcome back to another special edition of The Cut Podcast. I'm very happy to be sitting here with David Wilton. David, why don't you introduce yourself and explain to our audience a little bit about how you come to this subject.

David Wilton

Well, I came to this subject probably as a teenager when I first realized what circumcision [is] and [then] began to understand and realize the differences between intact and circumcised [penises].

At that time, there wasn't a lot of [Intactivist] activity going on; most of it was on the West Coast, and I was in Texas, so I wasn't really able to participate—and [I] was really not mature enough at that time to partipate, [anyway]. It wasn't really until 2006—probably 10 or 15 years later—that I began to really get involved [in the Intactivist Movement].

That's when I started living in San Francisco and participat[ing] in the activities of the Bay Area Intactivists, which are in the East Bay for the most part, and it was sometime [around then] that I [first] attended [in Seattle one of the International Symposia on Genital Integrity], the ones that are put on by Marilyn Milos and sponsored by NOCIRC (and are now beginning to be sponsored by Intact America).

That incidentally was the same year that HIV and circumcision began to be associated with each other when the 3 African RCTs ([Randomized] Controlled Trials) were published, allegedly showing [that circumcision has] a protective effect against infection with HIV. [Consequently], it was that year that I began the blog Male Circumcision and HIV, a blog that is named exactly as what I intended to write about when I first started it, [but it] has now evolved into [what] I would say [is] more of an Intactivist site than just a site that's focused on HIV and how it's impacted by circumcision.

Eliyahu Ungar-Sargon

Yeah, absolutely. One of the main reasons that I wanted to have this conversation with you is because—as I touch on in [my] film, [Cut], and [as] anyone who is familiar with the history of circumcision in the United States knows—every generation has a new medical rationale for continuing the practice of male circumcision, and without a doubt, the rationale—the medical rationale—of our age is prevention of HIV.

As you mentioned: In 2006, we started to see some studies being done in Africa around this [rationale]. I want to get into a little bit more detail about these studies, and [it would be great] if you could share with our audience how that started, who the main players are, etc.

We should also mention that you are a lawyer by training.

David Wilton

I'm a lawyer; I began practicing law in 2000.

My area of focus has not been in the area of circumcision or anything like that. I know there are some lawyers who have done a lot of lawsuits on circumcisions around the issue of consent and botched circumcisions and that kind of thing [(see the interviews with Peter Adler, Zenas Baer, David Llewellyn, and Paul Mason)], [but] my focus has been criminal defense for the most part.

[However], I've consulted a little bit on these issues [of circumcision] with The Attorneys for the Rights of the Child, [of] which I was just recently invited to be a member of the board; so, I've joined their board at this point. I've also consulted a little bit with some of the issues related to the [MGMBill] ballot measure that ocurred this summer here in San Francisco.

[So], yes, I'm a lawyer, but [in that capacity I] have not focused that much on the issue of circumcision until more recently.

Eliyahu Ungar-Sargon

We'll come back to some of the events of the summer, because I think you have a unique perspective that will be [really] interesting; you can give us a blow by blow [account] on what happened around the legal battles surrounding the ballot initiative.

[However], let's start with the recent push around circumcision and HIV. How did this start? Who were the players involved? Tell our audience a little about the randomized [controlled] trials, where they ocurred, what they said, etc. We'll go into some analysis of them in a little bit, but [it would be great] if you could just [provide some background] for someone who is unfamiliar with the recent history of this: How did things happen?

David Wilton

Well, for many years, circumcision has been touted as a kind of procedure that could at least slow down the infection rates of HIV. That, I believe, has been in the literature since the 1980s, but all of those studies and papers and discussion of that has been primarily through observational data.

It wasn't until some time in the early 2000s that there were a number of people who got some grants to do some studies in Africa; those were:

  • Bertrand Auvert, who is a French [epidimiological] researcher.

  • A guy named Robert Bailey, who is an American up in Illinois.

  • Another gentleman by the name of Daniel Halperin, who I believe at the time was working at the Department of Public Health here in San Francisco and [then] at Harvard's School of Public Health; [he] eventually consulted somewhat with UNAIDS, as well.

So, these 3 individuals (along with their coauthors) began to work towards getting grants to do [randomized] controlled trials in Africa. By roughly 2003, they had gotten the grants, they had designed the studies, and they had gotten all of the various parts in place to begin [in] 2003 [to follow men in]:

  • South Africa
  • Kenya
  • Uganda

By 2006, they had reached the point where they felt like they had enough data—incidentally, without completing the studies [as designed]—to go ahead and publish [their results].

So, that's really kind of the background of how these studies got from the idea popping up in the 1980s with the observational studies showing some countries with lower rates of HIV among the circumcised and higher rates among the intact, [all the way] to the point of actually doing the [RCTs that were published] in 2006.

All of these people that have been involved, they've been involved from the beginning: Daniel Halperin has been quoted in media basically discussing this issue back when he didn't have the grants in place, talking about how it was a travesty that the HIV/AIDS community was not jumping on [circumcision]; even at that time, before the [RCTs] were done, he believed that circumcision would have this huge impact on the rates of HIV, particularly in Africa.

So, that's kind of a very short background on where this came from.

Eliyahu Ungar-Sargon

What did their studies show? Also, you mentioned they didn't actually finish them, so why didn't they finish them?

David Wilton

The way they set it up is like any [randomized] controlled trial: They had one group of men [on whom they performed circumcision at the beginning], [and] another group of men [on whom they delayed performing circumcision]. Supposedly and allegedly, they gave [both groups] equal amounts of instruction on safe sex practices and avoidance of HIV, [and] provided them with unlimited numbers of condoms. [Then, they] circumcised one group, left the other group intact, and sent them out to the world with periodic followups (I believe it was every month they would come in); [the researchers] would keep track of those who seroconverted and those who didn't.

Again, it's been a couple years since I've read and re-read these studies, so I may have the numbers off a little bit, but I think there was one [study] where there [were] 3000 [men] in one [group] and 3000 [men] in the other [group], and then there was another [study] where they had 1500 [men total] and [they were] divided up [such that] roughly 800 [men were] circumcised [at first] and the other 700 were not.

The studies [had] different [numbers of] people involved who were subjects of the studies, but they were operated as any standard [randomized] controlled trial is. [However], [the studies] weren't double-blind [in nature], because they couldn't be; if you're circumcised, you're going to know it, [and] if you're [left] intact, you're going to know it. [Nevertheless], they were [randomized] and they were controlled (they had a control group, and they had an experimental group, the experimental group being those who were circumcised).

Typically, across all 3 studies, the reduction [in HIV acquisition supposedly due to circumcision] was somewhere between 50% and 60%, which translated into—again, I don't have my numbers [exact]—something like 20 and 25 seroconversions more in [the intact] group than [in the circumcised group]. So, you might have had, let's say, 3000 people in [each] group, [and] 70 of them seroconverted in the intact group, and 50 of them seroconverted [in the circumcised group]; you had a difference of roughly 20 actual seroconversions in this group of 6000 men.

So, when you look at it like that, the actual reduction [in HIV due to circumcision] was somewhere in the single percentile; I mean, [circumcision provided maybe] a 1% or 2% actual reduction [in HIV infection], as opposed to this 50% to 60% [relative] number that they were throwing around, which had to do with relative changes. So, that's kind of how the studies were done and conducted. [See this analysis and this analysisi and this discussion.]

Now, the reason they stopped [the studies early] instead of going the full 22 months (in the case of one of the studies, they stopped it at 18 [months]) was because they said [to themselves]:

Well, our results have been so great and so wonderful and this prevention “technology” has been so successful that it would be unethical to go to the 22 month period, because at that point, all these other [“uncircumcised”] men are going to seroconvert, and if we can circumcise them now, [then] they won't seroconvert. Therefore, we [must] stop the study now and circumcise everyone who wants to be circumcised.

Eliyahu Ungar-Sargon

I'm sorry, it just sounds so ridiculous, especially [the notion that these researchers] grow a conscience at that point, as if the people who had seroconverted before for their experiment—like, who cares about them! It's just so twisted.

David Wilton

Right. Right.

Yeah, I mean it's crazy, and the funny thing about all of this is that the re-interpretation and the churning of the data that's ocurred after the studies were stopped in 2006 [have] done nothing but [make] the numbers [suspiciously] better and better and better and better [in favor of circumcision].

[There has been] no accounting for such things as non-sexual transmission [of HIV], loss to follow up—there were several hundred participants who were lost to follow up [from both groups]; [we] don't know what happened to them! [According to this analysis, it would require only less than 25 seroconversions among the circumcised men lost to study in order to render the results insignificant.]

With such small numbers—a number of 20 actual men [in] difference (that's not a huge number), and if you've lost 300 people to follow up, you don't know what happened to those people—you really can't say with any certainty what's happened.

Eliyahu Ungar-Sargon

What's their hypothesis as to a mechanism of action? Why is it that cutting off the foreskin in their view [could even reduce] the transmission of HIV?

David Wilton

Well, in the studies themselves, they are very careful to say that they didn't know why the circumcised group had lower rates of seroconversion versus the intact group, but in follow up commentaries, [the authors] have often resorted to speculation, [such as]:

  • The keratinization of the [tissue remaining after circumcision] makes it tougher for HIV to penetrate the skin

  • The [destruction] of Langerhans cells (cells that they say are particularly vulnerable to HIV) [creates] less of an entry point [for HIV].

They speculate.

What's interesting about the Langerhans cells [hypothesis] is that roughly at the same time that the RCTs were published, there was a Dutch group that published a paper on Langerhans cells, saying that [these cells] are very effective at destroying HIV. The thing about it is [the Dutch researchers] postulated that the reason that men—and women, who also have Langerhans cells in their genital mucosal tissue—are still vulnerable is because [these] cells are [overwhelmed] by the sheer number of HIV viruses [to which] they are exposed [during sexual transmission]. It has nothing to do with them being [inherently] vulnerable; it has to do with [the fact that these cells by themselves] are just not up to the task of creating the barrier [to HIV] that would be needed. [Condoms, on the other hand, are extremely effective as barriers against sexually transmitted HIV.]

So, there's contradictory research out there, and of course the circumcision advocates are not particularly interested in addressing that [fact], and to my knowledge, [they] really haven't addressed that very well, although I will say that they have actually often times conformed their message to the objections that they've heard in the research community—and also just among layman (on the various Intactivist [web] sites). A good example of that is [the worrisome reality of] risk disinhibition; [pro-circumcision researchers] have done several studies in Africa [supposedly] showing that men who are circumcised do not become [more likely to forgo] condoms and other [safe sex methods].

So, they've been very careful to go out and look for studies and to design studies (mostly questionnaire studies), where they give a little bit of [a] speech on what's [safe] sex, and then go out and question people at various intervals about [whether they are in fact] practicing safe sex. They've actually published some studies saying there is no risk disinhibition [due to circumcision], but [that belief stems from] questionable [data] in my opinion, because they obviously already have quite a bias towards trying to get new data that supports them and supports what they're doing, which has become a very lucrative area of research and HIV prevention programming and whatnot.

Eliyahu Ungar-Sargon

It's true also—if I'm not mistaken—that in the studies, they speak of circumcision in their conclusions as a form of “surgical vaccine”. Is that right?

David Wilton

We have heard that quite frequently; they talk about [circumcision] as a vaccine with a 50% to 60% efficacy, and they like to think of it that way, but of course it's not, because vaccines typically don't become less effective the more you're exposed [to some pathogen], and circumcision definitely does not help if you're practicing unsafe sex [regularly]; the more times that you engage in unsafe sexual practices, the more likely you are to be infected with HIV, and that doesn't matter whether you're intact or circumcised (they are [actually] very careful to point that out in the original studies).

So, [circumcision] doesn't really fit that [analogy of a vaccine]. I think they often times hedge their language; they use very precatory language, where they say “This is like a vacine”—they don't say “This is a vaccine”, but they say “This is like a vaccine”, [implying that] it behaves like one [and that] it has the kind of result that is sort of like a vaccine, but I think often times they are careful not to say that it is in fact a “surgical vaccine”. But, you know, once you put that vision out there—that idea—it takes on a life of its own; the media, of course, [runs] with it, and a lot of journalists who aren't experts in this area take that [kind of statement] and [misinterpret] it [when] they write their stories.

I think that's calculated, too; I think that [misinterpretation is] something that the people who are involved in these studies would like to be out there.

Eliyahu Ungar-Sargon

Now, what's their motivation? It would seem from all the things we're talking about, they went out and did something that I think is ethically questionable to begin with—this sort of randomized controlled trial on a group of unsuspecting native Africans; in my estimation, I don't know [whether] that sort of study would ever pass an ethics board in [the United States]—

David Wilton


Eliyahu Ungar-Sargon

So, there's something ethically questionable going on there. According to what you're saying, [the researchers] had a sort of predisposing bias to suggesting that circumcision [is] important, and it seemed almost like they were going out to prove an idea that they had, and not really approaching this as objectively as they might have.

But, I mean, it's not just these researchers we're talking about; the Bill and Melinda Gates Foundation now has glommed onto this notion that circumcision is an important tool [for defeating HIV]—they're more careful with the way they talk about it: They say it's an important tool, [and that] of course, you also need to teach safe sex practices and use condoms and all that, but [they are still throwing their name behind the notion that circumcision] is an important sort of adjunct tool.

So, what would the motivation for doing this be? Why are they doing it?

David Wilton

Well, I think it's important to be very careful about divining the motivations behind why someone has an interest in a particular area of research; it's hard to know unless the people involved actually tell you, and I don't think we have any definitive statements from the pro-circumcision side.

[However], I think we can speculate a little bit: I think it depends on who we're talking about; the fact that most of these researchers are Americans and the United States is a majority-circumcising society (it is a country where circumcision has become part of the culture) has something to do with it.

  • I think when you look at a guy like Robert Bailey, well, [he] is an American researcher (I don't think he's Jewish); I think he's a guy who has gone on record saying that he circumcised his own son; I'm aware of one conversation where he mentioned to an Intactivist who had approached him and spoke to him at one point, and I think he said there were at least a dozen or more reasons why he circumcised his own son. I mean, clearly if you're emotionally invested in a procedure, and you are for whatever reason in a position to [promote] that procedure, you're going to do it! In a way, I think it's just a cultural thing.

  • When it comes to Bertrand Auvert (another one who was behind one of these RCTs), he approached [our Intact America booth] when we were at the International AIDS Conference in Rome this last summer, and he asked us if we were circumcised—there were 3 of us there at the table—and I was so taken aback [by that question] because it didn't seem relevant to our discussion, so I asked him “Are you circumcised?” and Bertrand Auvert said no he wasn't; so what is his motivation? I have no idea what it could be, but I suspect it has something to do with careerism; it might have something to do with his view that circumcision is an acceptable practice in a place like Africa—he's from the “First World”, and he's swooping into the “third world” (or into an underdeveloped world) where he can sort of be someone's savior. I don't know what his motivations are; we just don't know. But, clearly, there's something going on there, and it would be nice to have some answers as far as that goes.

  • [As for] Daniel Halperin, the only thing I can really say about him is that he has actually stated—on the record in a media report around the year 2000—that he feels that it is his lot in life to go out and spread the practice of circumcision, something that [he believes his] forebearers as Jewish men introduced to the world! (At some point, all of that's not true; I think circumcision has popped up in a lot of different cultures, but that is what he said!) He said his grandfather was a mohel and this has kind of become a motivating factor for him.

So, we've got sort of an answer from Daniel Halperin, but [as for] the other 2, we really don't know other than what we can speculate.

Eliyahu Ungar-Sargon

These people are using the data that they collected from the randomized controlled trials to promote routine infant circumcision? Is that correct?

David Wilton

Well, that has been the next step. When UNAIDS and the WHO came out and said:

We are now recommending circumcision

  • for adults
  • under sterile conditions
  • with “informed” consent

and all of that, they were very careful to say that [circumcision] is something that should be applied to adult males—men who are sexually active. They said nothing about infant circumcision.

Well, most of us in the Intactivist community—being skeptical as we have been sort of trained to be with this issue—knew that this was going to start moving in [the] direction [of infant circumcision, anyway]; it wasn't [even] a couple of years [later] that they started talking about how we should do this to infants:

We should incorporate [routine circumcision] into prenatal care and postnatal followup; we should make [circumcision] something that is like vaccination, where we go [into a community] and vaccinate and circumcise, and where men don't have to be convinced (which is code for saying “[where] we don't have to worry about informed consent”).

[The rationale is that pushing circumcision] becomes so much easier [when infants are the ones being put under the knife].

  • They often say that [circumcision is] “safer” for infants—which is news to the roughly 100 [or more] infants [who] die every year in the United States from circumcision! But, still, they say [infant circumcision] is safer.

  • They say it's programmatically easier [to implement than adult circumcision].

They have all of these things that they say. So, this last summer, when we were in Rome with Intact America, there was a guy there who had just been hired by Johns Hopkins in their programming arm—it's part of the university, but it's essentially their programming arm that goes into Africa and rolls out these various HIV programs, including [a] circumcision program. He's from Eritrea (and he [has] a name that I couldn't pronounce much less remember precisely, so I won't offer it, but I can find it for you if you need it), and he said that he had been hired specifically to begin to roll out infant circumcision—to get the programs in place, to begin to incorporate them into the prenatal and postnatal programming of the various countries in East Africa (where circumcision is fairly uncommon except in parts of Kenya).

So, yeah, I mean this infant circumcision thing is really starting to be pushed [as policy], and they're starting to create the programs that are going to be at the forefront of this effort. I think what's really happened is that they've found that it's very difficult to circumcise adult men; it's going to be very hard to convince the majority of adult men to be circumcised. Yeah, they may be doing hundreds of thousands of [adult circumcisions per] year [in Africa], but we're talking about tens of millions of men [whom they want to target], so [with] a hundred thousand every year, you're just not going to get [where you want if you're in the pro-circumcision lobby]; you're going to have to be doing a lot more than that, and so I think what they've decided—and [what they use as] one of their selling points—is that infant circumcision is the way to go if you're really going to cover vast numbers of people.

Eliyahu Ungar-Sargon

I think one of the most remarkable and disturbing things to me about this—I mean, we'll get into some of the flaws with the randomized controlled trials in a little bit here, but just [for] this move from the RCTs to infant circumcision, there is no evidence [of which] I'm aware—direct evidence—that circumcising infants reduces HIV anywhere.

In fact, we have quite a bit of evidence to the contrary if you look on a population basis; if I'm not mistaken, the UNAIDS report from 2009 looked at 18 countries, and [in] a majority of those countries, the inverse was true! The cultures in which infant circumcision [is] a norm (or a more normative practice) tended to have higher rates of HIV, which would tend to suggest that as a public health measure, [circumcision is] a complete failure.

So, not only do we not have any direct evidence that infant circumcision prevents the acquisition of HIV later in life, [but also] we have quite a bit of evidence to the contrary!

I mean, it's just—

David Wilton

Right. Right. Yeah.

If you start from their [pro-circumcision] perspective, what they are saying is that if we circumcise these infants, [then] by the time they get to the point of sexual debut, they will already be prepared without any other interventions; [men who were circumcised as babies will] already have that protective… whatever it is… in place.

[However], the fact of the matter is [that] between the time a child is born and the time a child enters the age of sexual debut [is] a lot of time to acculturate and teach and educate and kind of prepare [boys] (and girls as well) to avoid HIV. I mean, it's not like circumcision at that age will sort of obviate the need to do the education part of it.

But, [I think the pro-circumcision lobby has] this idea that with very high rates of HIV—let's say anything over 6% is considered epidemic levels—that [genital surgery is going to be more effective than education]. At the same time, if you're talking about trying to bring down those levels to “First World” levels, then you're right: Circumcising a person as an infant doesn't have any kind of—there's no evidence to prove or to show or to support doing it at that age.

I think a more sort of apples-to-apples comparison would be the United States [compared] to Europe: [In Europe], the rate of circumcision is quite low and so is the rate of HIV. [In comparison], [in] the United States, we have the highest rate of circumcision and (comparatively) we have higher rates of HIV.

[Looking] at Africa, take a country like Malawi or Zimbabwe versus some other country that has higher rates of circumcision like South Africa, and I think you'll find that in those countries you've got lower rates of HIV among the intact than you do [among] the circumcised.

[However], I don't want to sort of overstate the case [or] sort of confuse the issue, because this is a very complicated area. I'm not entirely clear in my own mind exactly where the evidence is and exactly what the justifications of circumcising infants versus adults are (except for just the shear ability [to force it on infants] versus not being able to do it as [widely] among adults). There [are] a lot of issues that [do] need to be explored and studied and [considered].

Eliyahu Ungar-Sargon

Yeah. To my eyes, and to anybody who is sensitive to the history of circumcision in the United States, this just seems like another sort of rationalization for continuing what really is a cultural practice more than anything else.

David Wilton

I totally agree, [but] I think we can't discount the role of money.

I mean, this is all about programming! This is all about going into a community and trying to provide them something they allegedly don't have—a level of healthcare, a level of attention to a particular disease. There's lots of grant money available for [such “services”], and if you're trying to work on microbicides [to thwart HIV, you're just not going to get the money as easily].

For example, in a study, they were giving girls money to delay sexual activity, and testing that approach to see whether or not it [could reduce] the rates of HIV. [Well], that actually worked! They had a study [where] they actually gave girls money [to turn down] sex until a certain age, and they showed that [it] reduced the rates of HIV.

Is that something that's really going to get a lot of grant money to implement? I mean, it seems like kind of a welfare approach to HIV reduction, and it's something that doesn't seem to me would appeal much to the powers that grant these kinds of large chunks of money [to implement prevention]; it's not as sexy [as surgery]; there's just something about it that's not quite as exciting as giving money to mobile circumcision units that are going to roll into a community and throw parties and encourage boys to come in to be circumcised.

So, I think we can't discount also the role of money.

[Also], to say we're going to implement an infant circumcision program, and we're going to cover 90% of all baby boys born [is a notion that leads to dubious metrics for success]: You can't measure [such a program's impact on] HIV until 15 [or] 20 years later when [the boys] become sexually active, so the measurement or metric becomes:

[The number of] circumcisions performed

[rather than the actual intended outcome]:

The [number of] cases [of HIV] prevented.

So, there's a lot of stuff going on [here]; this is a very complex [subject].

Eliyahu Ungar-Sargon

What are some of the problems that people have pointed out with the way that this data was collected? I've heard many people (Ryan McAllister, among others) look at the methodology of the randomized controlled trials and they've offered a number of criticisms. What are some of the central criticisms of these studies and their conclusions?

David Wilton

Well, some we've mentioned.

  • One was loss to follow up: I don't think they took adequate account of the loss to follow up to be able to determine whether their numbers are solid or not.

  • Another is selection bias: All of these men who participated in these trials were of a mind that they wanted to be circumcised at some [point], and they all went into it with the promise that at the end of the trial that they could be circumcised if they wanted to be.

  • There was 6 weeks [worth] of [unaccounted] healing time: [This] gave the intact group a head start in terms of the actual amount of time that they could be exposed to HIV.

  • There was researcher bias that was often talked about: Researchers have interpreted the data in such a way as to support their hypothesis.

These are some of the big ones. [Again, see this analysis and this analysis and this discussion.]

Eliyahu Ungar-Sargon

There was also some follow up, and if I'm not mistaken, one of the things they found was that the partners of the men who had participated in these studies had higher rates of HIV after the circumcision. I think that some of the researchers chalked this up to “Oh, well, they had sex before their wounds had healed” or something like this, but that's also a very troubling trend.

David Wilton

Right, and that's the other thing I was thinking that kind of went out of my mind. I think that was unaccounted for and it was kind of glossed over as being not that important, but I think what a lot of critics [pointed out] was an indication that some of these infections were not [sexually transmitted]; they weren't related to sexual activity. In fact, they were [possibly] related to surgical and other types of medical intervention like getting shots and whatnot—iatrogenic infections that [were the unintended result of some] medical treatment.

So, as I understand it (again, [we're] dealing with so many numbers in these studies and in subsequent studies, it's hard to keep them all straight), there were a number of individuals who seroconverted in both groups [but] reported no sexual activity, [and yet] they were included [in the results]. So, it's kind of like that implicates one of 2 things: One, it implicates that [circumcision] does not account for all of [the] infections, or what [the participants] were reporting is not reliable. So, [there are] a lot of questions there, [and] I think that probably accounts for what you're talking about, where the partners were infected more frequently after the circumcisions or there were more infections after the circumcisions among partners than there were prior.

Eliyahu Ungar-Sargon

It seems clear to me that you're taking this practice [of circumcision] into a culture, you're not fully educating them—I know that the people who were involved in these trials supposedly got safe sex education, but the folk wisdom around [circumcision] now is that if you're circumcised, you don't need to wear a condom when you're having sex, [which] is extremely dangerous and very much counterproductive [with respect to] the other efforts to educate [people] about safe sex and that sort of thing.

David Wilton

Absolutely. I agree.

I think it's kind of like you've got a message with nuance: Circumcision is protective, BUT it is not 100% protective, and you still have to take measures to protect yourself. That's a message with a very fine nuance to it; I mean, how do you tell people who are not that well educated—who do not have access to the kinds of information flows that we have here in the West—that [they] are to undergo this surgery that is going to change [their] sexual experience, that is going to be painful in its own right, and yet [they] still [must] where condoms! You're not fully protected! I mean, anyone who submits to circumcision who is convinced to do it as an adult is going to have to really believe in [the vast protective properties] of this procedure, and [he is] going to really have to have some kind of emotional investment in going under the knife.

That, to me, seems to be something that would just obliterate all nuance in the message that [circumcision] is not a 100% preventative measure. I think we've got a lot of anecdotal evidence now coming out of Africa—we've seen a number of reports where men have said:

Well, I'm circumcised. I don't have to wear a condom!

You know, even if they say “I'm circumcised, and I don't have to wear a condom as often”, we've still got an issue! You're right, it very much could counteract any of the other messages put out there that [say]:

  • You [must] wear a condom every time.
  • You've got to be faithful to [your partner].
  • Know the status of [your partner].

and all of these other messages that [people have been] putting out there. Circumcision really complicates [those messages].

Eliyahu Ungar-Sargon

It occurs to me also that a big part of what's going on now with this push to circumcise African men—and babies now—is a symptom of a kind of desperation around the AIDS epidemic; we thought we'd have a vaccine by now; we thought we'd have the magic bullet by now, and we just don't, and maybe I'm optimistic, but I think that in my lifetime we will have something like that, and I wonder how we'll be looking back at this push [for widespread destructive genital surgery] in light of an actual vaccine. What do you think about that?

David Wilton

Well, a couple of things: One, in 2003 (when these studies were getting rolling), I think that there was a lot of frustration in the research community about vaccines and prevention, and the programming that they already had going didn't seem to be working as effectively as they thought it would; there [developed] this idea that any prevention technology that could come along in combination with other prevention technologies would achieve this goal of getting [HIV] into kind of an endemic stage—that is to say, where it's stable, [and] not growing.

As time has gone on since 2006 (we're 5 years later), the whole scene has become much more optimistic; we've actually [cured somebody]—we've had a guy in Germany who was cured through a bone marrow transplant. Now, that's not something that can be rolled out to everybody, but it is a kind of an idea that possibily could lead to other therapies. We've had this real push to find antibodies that are very effective against HIV that's had a lot of promising developments in the last 2-to-3 years.

I mean, we've had a lot of stuff happen in those 5 years, and I think now what we have is a situation coming up where circumcision in fact could be something that maybe is not as attractive to the [funding] donors. [Unfortunately], the result from that has been these same researchers coming up with papers based on the same data that say that HPV is reduced among the circumcised—you have lower rates of other types of STDs, and all these other things. I think that as you look at the data out there, as you look at the literature, you're seeing that these [pro-circumcision] researchers are starting to compensate for these positive developments in the HIV research community, [in order] to try to bolster circumcision as being still relevant.

We saw a lot of that in Rome; we saw a lot of studies showing that men [are] less vulnerable to certain STDs—and on top of that, [these men who were circumcised are portrayed as being] more satisfied with their sex [lives], and [their] women liked it more, and we had all these things that [don't] seem to be really related to HIV, but were being presented [nonetheless].

[So], what you're talking about in terms of a desperation, I think that was very much the case 5 years ago, [but] I think that's less the case today, and it's kind of what we were all sort of saying when these studies came out: You may think this is a good idea now, but in a few years—call it a decade—we may have a vaccine, and then what? All of these men have been circumcised, and now it has become part of the culture, and now it's a sponge for resources because men think of it as essential (if you believe the studies) even when at that point it may not be essential any longer.

Yeah, I agree in some respect, but I think the landscape is changing—I think it's changing fairly rapidly.

Eliyahu Ungar-Sargon

Just a final point on this: It's so interesting to me that there isn't a single one of these researchers who would ever talk about the loss of sexual function as a side effect—it's just not even on their radar, and that to me is also ethically problematic; I mean, you get into issues of informed consent here, because you're pushing this on [an] adult population and there's just no mention whatsoever of the sexual function effects of circumcision.

David Wilton

Right, and well, I wouldn't quite agree to say it's not on their radar; I think they've in some sense gone out of their way to show or to argue that [circumcision] has no sexual effect; [I recall] there have been a number of papers published by these same researchers, saying that sexual function is not affected and that satisfaction levels [after circumcision] have [actually] gone up!

[However], these papers typically do not talk in any way, shape, or form about the function of the foreskin; they just talk about [subjective satisfaction] before and after [circumcision], and so they don't say “The gliding mechanism of the foreskin during intercourse is somehow compensated for by the provision of lubricants”, or something like that. [Also, nobody mentions that because circumcision alters a man's sensory input, it also alters the way he performs the sex act, such that he naturally makes less contact with a woman's clitoris and tends to dry out her vagina, thereby reducing her pleasure.]

Actually, we talked to some people in Rome [who said they are telling men that] “If you come in to be circumcised, we'll provide you with unlimited amounts of lubricants”. There was a woman [in Rome] who was in charge of a program [where] that was actually one of their selling points: We will provide you with unlimited amounts of lubricants. [I mean], this is unbelievable!

I think you're right that the function of the foreskin is not even on their radar; they don't understand it—they're not really even interested in it. [However], I do think they are sensitive to the argument that [circumcision] does change the way that [a person] experiences sex, and they've gone out of their way in taking great pains to [state] that “No. [Sex] is even better after you've been circumcised!”

Eliyahu Ungar-Sargon

Right. The satisfaction number that they publish: 87%—I mean, some crazy, completely implausible numbers about sexual satisfaction. I mean, there are 2 problems I see here:

  1. All of this sort of sexual satisfaction data that I've read is very fuzzy; what is sexual satisfaction? How does a person know [whether he is more] sexually satisfied before or after [circumcision]? The person is actually going to go through [with having] surgery; how reliable is [his] testimony on [his] sexual satisfaction or the function?

    I recently had a conversation with Glenn Callender in Vancouver, [Canada], and he was telling me that [even] as an intact guy, it wasn't until he became really aware of his foreskin that he could even appreciate what it was contributing to his sex life and to his sexual satisfaction. So, all of these [things] combine into a sort of very unreliable soup of supposed data.

  2. I take your point that [these researchers] see it as part of their rhetorical function to demonstrate in some way “scientifically” that there's no detriment to sexual experience, but in a very loose and non-scientific way—to my eyes, in any event.

David Wilton

I agree.

I can't really think of a more subjective area of human experience than the perception of one's sexual satisfaction. The shear variety of sexual tastes and acts ([about which you may] readily [read] if you were to google any of it) is an indication that [sexuality and sexual satisfaction and sexual tastes are] such a difficult things to measure. Because of that [fact], I [only] feel comfortable saying that an adult [should choose for himself whether or not to undergo destructive genital surgery].

I mean, you know, it's not the case that Intactivists or that I personally believe that circumcision has got this inherent evil to it; you know, it's not that! [Rather], it's that [something like circumcision should be] an individual's choice, an individual's decision. To complicate [that choice] with these claims that [circumcision] is going to protect you from HIV is just wrong! It's being dishonest!

You know, the satisfaction studies that they've done—and of course, the Intactivists can point to other studies that have been done that support our side as well—I mean, frankly, both sets of studies are what they are, and that is the measurement of a given group of people who participated in that study, and it's like a lot of the studies having to do with circumcision and disease and whatnot: There are studies that support both sides, and it's because the researchers are individuals, and they bring researcher bias into this very difficult, complex, highly nuanced area of human experience.

So, I just don't think that it's a good thing to make absolute claims about a person's satisfaction [after or even before] circumcision; I think that's just hard to make that into a science [or] to give it any kind of solid metric.

I think the real issue here for me is that to circumcise infants is essentially to rob them of their basic human right to make this decision for themselves.

Eliyahu Ungar-Sargon

So, switching gears a bit: Can you share with our audience a little bit of a blow by blow [account] of what happened this summer in San Francisco? This was a very eventful summer here for this city and for Intactivism in general.

David Wilton

Yeah. Well, this summer, we had a ballot measure added to the city ballot, [which] was applicable only to the city of San Francisco. It was a proposition to make circumcision of infants a misdemeanor, and I believe I got the numbers right: [Performing circumcision on a completely healthy minor would be] punishable by a $1000 fine and six months in county jail, and it had one exception: Medical need. It had no exception for religion.

Several different individuals here in town, namely Rick Carillo, Lloyd Schofield (who was the [principal] proponent), and a few others were involved in getting this thing organized, collecting and submitting [the required] signatures [of the citizenry], and complying with all of the different rules and regulations that apply to putting something on the ballot. They collected signatures all through the spring, submitted the ballot measure in (I believe) May or June, and it was accepted a week or so later; they had 12 500-odd signatures, of which [the government] verified 7500 [and of which the government only required] 7100 (something like that).

So, the [proposition] was put on the ballot, and then very shortly [thereafter], we had all kinds of backlash in the media and elsewhere. A coalition of Jewish groups and medical groups here in the city got together and eventually filed suit to remove it from the ballot based on business and professions [legal] code, section 460, subsection B, which is a statute that essentially preempts any regulation of the so-called “healing arts”, which includes the practice of medicine, of which [circumcision] was considered a part. Ultimately, that lawsuit ended up being decided in late July against the proponents, so that the ballot measure was removed from the ballot, and [that decision] was based solely on 460B of the business and professions code. It wasn't based on any of the religious objections, which were all part of the petition. That's kind of how it went down.

There's a whole bunch of [nuanced] detail that [I would be] happy to go into—

Eliyahu Ungar-Sargon

Yeah. Let's do it—

David Wilton

Of course, I have my opinion of whether this was a good thing or a bad thing.

When I first heard about this [ballot initiative], I was initially approached to be the proponent, and I felt like I couldn't do it; it had to be someone living within the city and county of San Francisco; I felt like I couldn't be the proponent at the time—not because I had any objection to going this legislative route, but because I felt like for me to be the proponent would put me at odds with a lot of people [with whom] I work—and not just Jewish colleagues, but others as well. My fear was that this could have a real detrimental effect in undermining my business, a very selfish reason why I decided I didn't want to be the proponent, but one I felt like I had to [accept] to protect my income—my livelihood.

So, they got Lloyd Schofield to be involved, and he lives here [in San Francisco]; he's retired, so [he] doesn't have that issue—the issue that I had. He stepped up right away: “Fine! I'll do it!” So, he and Rick got together (and Jonathon Conte, I believe, was also involved) in collecting some of these signatures; they consulted somewhat with Matthew Hess of mgmbill.org (down in San Diego), although I don't think Matthew was that involved in terms of the day-to-day collecting of signatures and whatnot.

At that time, you know, I guess I didn't think about it very deeply, because at the time I thought “Well, OK, let's see what happens.” So, they get this thing on the ballot, we had this backlash, and [then] I began to have some doubts; I began to think this could have a lot of [negative] impact on the work that we [Intactivists] have been doing for years, in that it could bring a lot of kind of negative feeling down on us, and it was right about the time when I was sort of mulling this over—not in a [really] serious way, but just thinking about it—that [the second edition of Matthew Hess's comic], Foreskin Man, happend upon the scene.

[At the time, this] latest issue of Foreskin Man was about Monster Mohel and all of that, and we started getting all of this press about how this was a very anti-Semitic move and [thus all] the people involved [must be] anti-Semitic, and all these things. There was even a rabbi—I think he's from back east somewhere—who somehow decided that I was deeply involved in this and was linking to my website and saying “See, here he is! He's part of this as well!” and I tried to engage him a little bit online, [but] he wouldn't really engage with me; I was shocked, because I really wasn't part of this—no more than just being in town and encouraging [the ballot initiative] and everything else, but my name [had] never really [come] up, [and yet] all of a sudden, I was sort of a minor target in all of this. I was just thinking: Wow, this is something that could really do a lot of damage to us.

[However], somewhere in Rome (when I was there at the International AIDS Conference), I was talking to some of the people [with whom] I was [working], [and] I began to think:

You know, we've been stuck at [a] 60% circumcision rate in [the United States] since the 1990s; maybe [even negative publicity] isn't such a bad thing:

  • It's getting a lot of press.
  • We're on the nightly news.
  • It's getting into major newspapers.

I mean, people are [finally] talking about this [issue]. This is really an important development; it has become a national issue, whereas before, it was a very kind of “local” or “personal” issue, and it was an issue that wasn't getting so much attention in the national press.

Then, when the lawsuit happened; our side was completely unprepared, and the result was that—

Eliyahu Ungar-Sargon

Did you just not see it coming?

David Wilton

You know, this is very touchy, because there are a lot of feelings involved with some of the participants, and I want to say that this is my belief—this is my thought: The people who were really behind this [ballot initiative] (who were really doing the footwork and the legwork, who deserve lots of credit for the courage and the financial investment and the time investment) did not think this through; they didn't consult anybody other than themselves, which is not uncommon in the Intactivist Movement.

I think a lot of [Intactivists] do their own thing—and that's laudatory; I think it's the only way that a lot of this work would have ever gotten done (people were just [individually] willing to do it). That's how they approached this ballot measure: What they [and I] didn't foresee is that when you start trying to make illegal something as touchy as [circumcision], there is going to be an inevitable backlash, and that backlash often translates into litigation, and we didn't have anybody lined up [for our legal defense]; we had no attorneys on board—it was one guy consulting up in the North Bay, who is an attorney who [already] had a full-time job working for the state (a super smart guy, very intelligent, very engaged, lots of good advice), but [he] couldn't put his name on anything.

We had a situation where there was no time to respond. [In comparison], the law firm [of our opponents] was Morrison Foerster, an international law firm that was doing this pro-bono and had a partner involved in writing up the petition and filing it. They had a full-time associate working on it.

What did we have? We had a bunch of part-timers who weren't even really involved, and no one wanted to put [his or her] name on anything because [we] were all afraid—including myself! Ultimately, I did put my name on an amicus bief that I signed and filed for DOC (Doctors Opposing Circumcision), but the fact of the matter is that we just were not prepared for the backlash, ultimately.

You know, whenever we bring this [up]—whenever I have brought it up—with people [who have] a vested interest in it, it's a very difficult, touchy issue, because when you put your ass on the line and you expose yourself to not just abuse, but real threats—I mean, Lloyd had people coming to his house, knocking on his door—it's hard to take [the] criticism [that] “Well, we [should] have done this differently.”

The real question that I was asking was what are the lessons? This happened. Fine. What are the lessons for the next time we try to go this route or we try to do something else? An idea that I thought was interesting: How about just a referendum on the issue?

Do you believe [cutting children's genitalia] is a good or a bad thing?

In California, we can put these things on the ballot; they often do for things like the [wars in Iraq and Afghanistan]. “We as a city don't support this or do support this.” Berkeley has had this [sort of thing] on their ballot; why couldn't we do this for circumcision? [With such an approach], no one's ox is gored, so to speak; no one's [supposed] rights are infringed; no one is told what [he or she] can or cannot do. It's just a way of getting media attention, which is really initially what we were all thinking: “[The ballot measure] is not going to pass, but we're going to get people talking about this issue.”

Eliyahu Ungar-Sargon

You know, a lot of this centered around Foreskin Man

David Wilton


Eliyahu Ungar-Sargon

What's your take from that whole thing?

David Wilton

Well, on the one hand, [one obviously thinks] “What horrible timing!”, and on the other hand, I mean, how sort of tone deaf can you be [to publish something like that?] In my heart, I don't believe Matthew is any kind of anti-Semite; I think he is genuinely an arch enemy of any advocate of circumcision—it doesn't matter whether it's from a Jewish perspective or just a plain old redneck American perspective (which is kind of my background).

The fact of the matter is he should have known better; I mean, what can you say about it? The first [installment of Foreskin Man] is about the medical profession [involving "Doctor Mutilator"], the second one is about mohels, [and] the third one is about [African] tribal circumcision [(including female circumcision)]. I mean, yeah, OK, but there are levels and layers of sensitivity about this practice in different contexts, and you just have to be sensitive to it.

You know, all of [us have the] objective to reduce the level of circumcision in society—to try to reduce this act on unconsenting babies. If that is our objective, then we ought to be very careful about how we approach it, and we shouldn't have any kind of sort of rigid agenda [to go] after all people equally.

You know, there was a big, almost angry kind of discussion about whether there should have been a religious exemption in the ballot measure. My view is why not? There were a number of people who said:

Religious exemption is out of the question, because it wouldn't work; everyone [must] be protected, or no one is protected.

If the equal protection argument is going to work, then it's got to be applied to everyone; you can't say you've got to have equal protection for girls and boys but exclude certain boys.

[To me], that's perfectly logical and it makes great legal sense, but does it conform with the real world? I mean, ultimately if we were able to get something on the ballot—and keep it on the ballot—and it got this discussion going without triggering these accusations of anti-Semitism, ultimately the result, the fallout, the outcome is a reduction in [forced] circumcision, because you're bringing people into the conversation [who] maybe have not been part of the coversation before, and some of those people are going to take your side, and that is the objective:

Bring down the number of [forced] circumcisions of infant boys!

So, to me, if that's our objective, it's easy to say “Yes! We [should] put in a religious exemption!” But, there were a lot of detractors [of that position]. A lot of people felt like that's just unacceptable.

Eliyahu Ungar-Sargon

Do you believe that had there been a religious exemption, things would have played out differently?

David Wilton

Yes. I do.

I think the religious exemption would have undercut the idea that anyone's religious beliefs or practices were being tread upon. That likely would have made it less likely, I think, that we would have this coalition come together to file suit. Maybe they would have filed suit anyway. I mean, who knows? But, at least it would have made their argument a lot less plausible. I mean, ultimately, the reason they took it off the ballot was based on this preemption statute—it wasn't because the religious stuff—

Eliyahu Ungar-Sargon

It had nothing to do with the religious stuff—

David Wilton

Yeah. So, [it's true that] the grounds [on which it was struck down would not have been affected]. But, to say that it doesn't have any impact [is a notion that] I know is just not true, because that's not how law works; I mean, law is highly subjective, and in all of the [legal] practice [that] I've done (in criminal law), the statutes are, most of the time, a kind of guide—if there's a particular objective or outcome that someone wants to [achieve], he can probably legally reason his way to that objective, and I'm thinking that this is no different.

But, you know, again, we're second guessing, and that I think upsets some people—to second guess what the outcome could have been. But, I don't think we would have been second guessing ourselves so much if we had had a kind of planning period, and a kind of period where we had brought in people who could think this through [and] try to come up with various scenarios that might play out [so that we could have been] prepared for it.

Eliyahu Ungar-Sargon

If you could talk to the Intactivist world now, what would your advice be?

David Wilton

Well, I have opinions on that, and I have opinions [at] an even broader overview of the Intactivist Movement. What I think in terms of a ballot measure or any kind of discrete effort [to change], let's say, the law or the practices of hospitals (how they promote or don't promote or carry out the procedure of circumcision on infants)—whatever it is you're trying to change that has a very discrete, definable objective, I think [it] needs to be thought out.

I think that there needs to be a period of reflection that would allow us to anticipate what's going to happen, and if you can anticipate what's going to happen, [then] you can have mechanisms and people in place to respond. I'm not saying it's going to change the outcome—it may or may not—but the point is that if you've got some way to fight back—if you're going to stand a fighting chance—you've got to have thought about it prior, and you've got to plan.

This whole period of Intactivism of the last 30 years [has] been ad hoc; it's all been individuals just working on their own little projects—which is fine and is important and needs to continue. [However], we have to mature out of that [phase]; we have to get into a period where we are actually working in concert with each other, taking advantage of each of our strengths and dividing the labor.

  • We've got those who are working on the legal side.
  • We've got those working on the legislative side.
  • We've got those working in the arts.
  • We've got those working in media.
  • We've got those working in grassroots.

We've got all these bases in areas and places where you can fit in and you can come to Intactivism and say “What do I want to do? Where do I fit?” and then choose an area and work towards that. [We need to think about] formalizing our efforts and channeling them into defined institutions in a way, and that gets to the larger issue: For years, this has been a kind of pay-as-you-go, self-financed, activism-from-the-heart, highly personal, highly emotional approach to making [a] world where infants are not subjected to circumcision any longer, and I think [that nature of our approach has] got to change.

I think we are at a point where we've got enough critical mass of interested people—people with energy, talents, resources—so that we've got to start to make the “business” of Intactivism pay in some way; so, when people are out there doing this work, they aren't doing it evenings and weekends, [but rather, they are] doing it as their day jobs.

Believe me! [There are] lots and lots of people doing [some] kind of non-profit work (or doing it and being paid for it), and we have got to be the same way. Whether it be disease eradication (such as the HIV/AIDS efforts in the world), whether it be alleviating hunger or malnutrition among children, whether it be getting vaccines to the developing world—whatever it is—the mechanisms and the institutions—the path to success in those efforts—[have] grown up in a defined, understood, and received way, so that when [people] go into this [work], they know how to do it; they get their degrees in “Public Health” and they go out into the field, and they join the NGO that does that kind of work. We've got to do the same thing.

When we were in Rome, we saw all these people arrayed against us, [and] we're there on our own dime! You know, we are paying for our own way on donations and out of our own pockets to be there to say “You can't be circumcising the world and expect HIV to stop in its tracks! You can't do that!”, and all these people are coming up to us, and they're part of UNAIDS, they're part of WHO, they're with universities—they're with all these different groups, and their airfairs were paid, their lodging was paid, [their admission to the] conference itself [was paid], [and these people are] on salary! I mean, we cannot compete with that any longer! We just can't!

If we're going to have an effect long-term—if we want this to be more than just a ragtag bunch of people (admittedly with our hearts on [our] sleeves), we've got to start to formalize what we're doing, and I'm hoping that's starting to happen.

Eliyahu Ungar-Sargon

David Wilton, thank you so much for joining us on The Cut Podcast. Where can people learn more about your work?

David Wilton

Well, my work is all through my website:


That's kind of my platform, and so if you want to know what I'm doing at any given moment in Intactivism, that's where you can go. [NOTE: David appears to spend more time these days communicating via his twitter account.]

Eliyahu Ungar-Sargon

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