[41] Cutting Culture: Tuskegee Redux? Legal and Ethical Problems of the Ramp Up to Male Circumcision in Africa

Travis Wisdom, a student of Women's Studies at the University of Nevada, Las Vegas, organized a daylong conference on male circumcision and the issues surrounding identity and body ownership. The second speaker of the day was John Geisheker of Doctors Opposing Circumcision, who discussed the dubious nature of the 3 African studies that are now being used to promote circumcision in the name of HIV prevention. Here is a recording of the presentation, 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.

Christina Hernandez[?]

Our next presenter, John [D.] Geisheker, is the Executive Director and General Council of Doctors Opposing Circumcision. [He] is a powerful ally in the medical field, promoting awareness of and mobilization against [non-therapeutic neonatal] circumcision. Please join me in welcoming him.

John Geisheker

Thanks very much.

Many of you will have read—because it's become a commonplace meme in the American journals of all kinds—that HIV can be solved in Africa by circumcision. The [risk reduction] number that's commonly [claimed] is 60% [to] 63%. [However], you probably don't know the backstory [behind those figures], and I'm going to give it to you now.

Now, you'll have to be a little tolerant of this; it's a little “word heavy”, it's a little abstract, and it's a little statistical—and I'm not a stats expert, but I kind of know bad statistics when I see them by instinct. So, what I've done here is distill the work of Dr. Robert Van Howe, the pediatrician in Marquette, Michigan, who has done extensive [analyses] on the 3 African RCTs, as they're called: The Random[ized] Controlled Trials in Africa, [which have been used to promote circumcision].

First, the nature of the crisis, so you understand it: HIV is indeed a scourge in Africa—there's no doubt about it.

  • 15 million Africans have died since the beginning of HIV, which by the way, extends all the way to the 1930s when the virus first crossed from the monkey community into the human community. So, we have lost 15 million, and probably many more actually, because no one knew what the disease was in the 1940s and 1950s.

  • 1.3 million Africans die each year [due to HIV].

  • 22.5 million of them are living with AIDS currently.

  • That leaves 14.8 million children who are orphans or who have lost at least one parent.

Currently, only 25% of [infected] Africans get what's called the antiretroviral therapy [(ART)]. The highest number is [in] South Africa, which has switched from being a country where they were very slow to get started on this, to being the country that's the most aggressive about fighting HIV in Africa (and you'll see why in a second); so, 37% of infected South Africans get the antiretroviral therapy—which, by the way, [is a therapy that] not only saves your life, [but also] makes [it] virtually impossible [for you] to transmit the virus to a partner, which is a very useful feature of the ARTs.

Look at the graph of what's happened since 1988 in Africa; you can see that [the HIV prevalence starts around] 1%-to-5%, [and then later], it goes up to 5%-to-10%, and here in 1998, you can see especially in South Africa and [various] areas [that] it's beginning to [rise to] 20%-to-30%. There are regions of Africa where the [prevalence] is 40%! [It's] unbelievable if you think about it. Here's a graph showing the [prevalence]. Notice it's flattening out a little bit; it actually has slowed down in its virulence in Africa.

Here's the U.S. situation by contrast. Now, these numbers are high, but they are a tiny percent of what's happening in Africa.

  • We have 0.5 million people who have died since the early 1980s when it was first discovered in the U.S.

  • About 1 million people are infected, and 20% of those are unaware that they are infected.

  • 54 thousand people acquire the infection each year, but we have a country of 350 million people, so that's not exactly a huge epidemic at this point.

  • The [prevalence] is 0.6%, which means 6 people in a thousand in the population [have] HIV, and we have a high ART [usage]—a [large number] of people [are] covered by antiretroviral therapies.

    There are hotspots like Washington, D.C., which for cultural reasons [has an incidence of] 3% and even towards 6% in the poorer regions of Washington, D.C.

  • It's disproportionately, alas, a disease of men having unprotected sex with other men, and of people who inject illegal [intravenous] drugs.

Now, since 2005 ([with] the beginnings of the studies in Africa), the notion that HIV can be stopped by circumcision has sort of risen on our cultural radar. It's in the form of a meme. How many of you know the term “meme” or use it casually? A meme is a unit of culture—I think the term was invented by Richard Dawkins in his various books on [evolution]. [A] meme is a unit of culture that gets transmitted from person to person [in a folkloric way] without the backup analysis of why that might be the case. It is, in a sense, a free-floating idea or belief.

Here are the RCTs and the individuals responsible for them:

  • In Rakai (Uganda) in 2005, Ronald Gray began a study of some individuals (we'll see in a second how many).

  • In Kisumu (Kenya), Robert Bailey ran a study

Those are both [mid-east African] countries. [Lastly]:

  • In Orange Farm ([South] Africa), Bertrand Auvert, who is a French epidemiologist, ran another study.

The Ugandan study had almost 5000 participants, [the one in] Kenya [had] almost 3000, and [the one in] South Africa [had] a little over 3000.

I want to thank here Dr. Van Howe [for his] statistical [analysis], and also Hugh Young, a fellow New Zealander (I'm from New Zealand)—an aside by the way: New Zealend abandoned circumcision; New Zealand's rate of circumcision in [the] 1950s went to 99.9% (nobody escaped; very few escaped. Maoris did by the way; the indigenous polynesian people escaped completely, because they have very strong beliefs about having to need [the] entire body [throughout] life, [which] is very sensible in my opinion). [Nevertheless], they dropped circumcision in the 1960s like a hot potato! There have been no infant circumcisions in New Zealand since [the] mid-1960s; it's amazing, and yet, a whole generation of grandfathers [were] completely circumcised. The fathers are sort of hit and miss, and the sons wonder: What happened to their poor fathers and grandfathers?

OK. Here's the method they used in Africa to do this study: They took groups of HIV-negative men and divided them randomly into 2 groups:

  • A control [group].
  • An experimental group.

The control group was offered an immediate circumcision (and we'll talk later about the problems [with] that), and the experimental group was promised a free circumcision later on, perhaps 2 years later (but it never quite got there, actually). Then the [numbers of] seroconversion[s] [within the groups]—that is, the number of [people who became] infected [with HIV]—were compared[.] Now, here's a little warning for you about statistics (I love this quote):

The American mind seems extremely vulnerable to the belief that any alleged knowledge which can be expressed in figures is in fact as final and exact as the figures in which it is expressed.

Richard Hofstadter, Anti-Intellectualism in American Life

Also, there's a common statistical thing you will all notice, and that's the deep decimals: [If] somebody says something happens 10.003% of the time, you're inclined to think that just because there's a thousandth of a percent in there [(".003%")], somehow that suggests the accuracy of the statistic, but statistics can lie gloriously, as we know.

So, here [are] the results:

  • The number of men who were circumcised [as part of the control group], [and] who got infected [with HIV] after 12 months was 1.5% of the [group]—I've combined the stats to make [conveying the information] easy, but the studies were very similar.

  • The intact [group]—that is, the men who were not circumcised—their infection rate was higher: 3.38% of their group.

So, the absolute risk reduction you could argue [that circumcision provides] is 1.8%. This is the stat you should be reading in your newspaper, not this 53%, because that's the relative risk reduction—comparing the 2 little groups. So, one of the commonest [tricks] in statistics is for people to jack up their results by talking about relative changes and not talking about absolute changes.

I sometimes joke that I could protect you by 1000% from being hit by a meteorite by insisting you live in a coal mine, and you'd say:

“But geeze, I don't really have a very high risk of getting hit by a meteorite—”

“But listen to me! I'm talking about protecting your life! 1000%! Are you not interested in that?”

and, of course, you really shouldn't be [interested in that].

All right, here's what the graph looks like if you do an honest graph of the difference between the absolute benefits between circumcision and not-circumcision. It's pretty unimpressive, isn't it?

Here's another way of looking at it (the green are the HIV-negative people): A good number were lost from the study, and the HIV-positive is the small red group at the bottom; once you look at the overall picture of the number of people, and the number of people who actually seroconverted, it doesn't look very impressive—it certainly has nothing to do with 60%.

Here's my favorite cartoon on the subject (this is courtesy of Hugh Young, a fellow countryman):

“Thanks to circumcision, HIV has decreased 60%!”

and I love the comment:

"Question. Are you asking a room full of engineers to be excited about a big percentage decrease over a trivial base!?"

It's a good question! Then the final panel:

“[Answer]. You leave me no choice but to call you an anti-circ zealot; nobody listens to them.”

So, that's great.

All right. Now let's go through the flaws. This gets a little statistical—hang in there; it'll get interesting. It is interesting.

  • Flaw number one: Over half the infections were non-sexual. One of the biggest secrets of the RCTs in Africa is that an awful lot of African HIV infections are caused by physicians!

    • Reusing one-use medical supplies.

    • Not autoclaving the equipment.

    • Attending people who have HIV, but not worrying about the next person who might get HIV from the tools they just used on the first person.

    So, iatrogenic transmission of HIV is itself a huge and scandalous event in Africa. If you remove all the non-sexual infections—that is, those that came from blood transfusions and medical care—all the Africa RCTs disappear, because [then] their results are not statistically significant.

    Here's my favorite quote on this; it comes from Dr. Jennifer Vines up in Oregon:

    In the article by Auvert et al regarding incidence rates of HIV infection in circumcised versus uncircumcised men, the finding of 60% fewer infections among the former group is compelling [1]. I must echo the comments submitted by others and question these findings in light of the fact that the authors did not control for other sources of HIV transimission such as blood transfusions or exposure through infected needles.

    While the literature supports sexual (primarily heterosexual) activity as the main route of HIV transmission in South Africa, the behavioral factor of “Attending a clinic for a health problem related to the genitals,” initially reported by approximately 10% of both the intervention and control groups, corresponds to a significantly elevated HIV incidence rate. It is plausible that these men presented with urogenital complaints that resulted in antibiotic or other therapeutic treatments administered with unsterile needles. This could represent a significant confounder in that the uncircumcised men, if indeed more prone to sexually transmitted infections (STI), were more likely to present for STI care and become infected through the health care setting rather than through unprotected sexual intercourse.

    Controlling for this route of infection could result in a smaller difference between HIV infection rates in the circumcised versus uncircumcised groups, indicating that circumcision may not be as effective at decreasing HIV transmission as the article suggests.

    "Reader Response" to Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, et al. (2005) Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: The ANRS 1265 Trial. PLoS Med 2(11): e298.

    I would say “Indeed.”

  • Flaw number two: Researcher expectation bias.

    Remember, these can't be double-blind studies; I mean, you know if you've been circumcised, and the doctor knows if you've been circumcised. There's no sense [in] pretending. You can't [explore] a placebo effect in this kind of a study.

    [The researchers are] known [to have been] proponents of male circumcision prior to [their interest in] HIV. In a sense, I have [just] said—it's a bit cynical—that the HIV crisis in Africa was a gift to male-circumcision proponents; their claim is that there is sufficient evidence to recommend universal circumcision, which is frankly what they're really looking for.

  • Flaw number three: Participant expectation bias.

    What did the participants in the trial[s] expect? Well, they were told that circumcision [is] protective, which [is information] that would affect their behavior. There was a lack of blinding, [as just described], and there was a desire for circumcision.

    Why an African man would submit to circumcision without being campaigned on this subject (if he's an adult) is an interesting question. Remember a lot of African cultures have already existing traditions of bush circumcision, which are both dangerous and painful, and I can see a 16 year old African man saying [to himself]:

    “Geez, do I want to have a circumcision that at least provides anesthesia and has a semblance of Western medicine to it, or do I want to go to the bush and have one of those initiation rites that my friends tell me are horribly painful?!

    Well, I know the choice that I [(and most of you)] would make.

    The RCT authors created a demand for male circumcision among unemployed young men by bribing them, frankly. Participants were interested in the promise of a free male circumcision and other benefits—and we'll get to that in a second.

  • [Flaw number four: Statistical overpowering.]

    [This] is a bit tough to understand. The study, claims Van Howe, was overpowered; that is to say, it was big enough (at more than 10 thousand individuals) that you could find some correlation between something.

    If you gave me 10 thousand people, I bet I could prove that people [who] own brown hats have small dogs, because there would be enough people [in the group] that [I could find a sizeable number of them for whom that correlation is true].

    So, the more individuals you have, the more you can data mine for your particular conclusion (if you work at it). [Dr. Robert Van Howe] says this is large enough to find identifiable differences that are clinically unimportant; in other words, you could do a gigantic drug study and still find correlations that don't mean anything medically.

    [This can be seen in the frequent flip-flopping with which we are all familiar]. You know: Butter is bad [for your health], butter is good, butter is bad, butter is good. You have to read a newspaper to see what [the “consensus”] is today.

  • Flaw [number] five: Selection bias.

    Only men interested in male circumcision were included [in the study], so that automatically excludes others who might have been at lower risk [of HIV infection] because of behavior or genetics—we don't know. So, that's a flaw of this study itself.

  • [Flaw] number six: [The participants] were well paid.

    [Most] were unemployed [and living in the Orange Farm]—Orange Farm, South Africa, is a horrible horrible slum with an employment rate of like 50% and worse, and frankly, the young men were desperate, and [joining the study there was a way that]:
    • They would get cash.

    • They would get a free circumcision.

    • They would get free healthcare for a year or 2, which in the U.S., would be like giving you 12 thousand dollars.

    So, just the very structure of these studies makes them unethical in the U.S., but you can get away with it if you can work it in black Africa.

  • [Flaw number seven]: Now, here's the geographical bias.

    This is intriguing to me. No studies were done in:

    • Ghana
    • Cameroon
    • Tanzania
    • Lesotho
    • Malawi
    • Rawanda
    • Swaziland

    [These are] places where circumcised men are more likely to be [HIV infected]. Just look at Ghana and Cameroon to make it easy:

    • The HIV prevalence in Ghana among circumcised men is 1.6%; [among] intact men, it's actually lower.

    • Now, Cameroon is interesting, because the HIV prevalence [among] circumcised men is like more than 3 times the [prevalence among] intact men!—exactly the opposite of the claims of the RCTs.

    and so on. Each of those countries has the same problem, which is: How do you explain that [in these places], circumcised men actually have more HIV?

  • Flaw number eight: Ethical problems.

    We've already hinted at these. South African men were not told their HIV status. The claim of the people who did the studies was that the men are from cultures where being HIV positive would stigmatize [them], and so [the researchers] didn't want to tell the men that they [have] HIV, because that would be embarassing [and problematic] for them.

    [So], as a “practical” matter, they sent men home to infect their partners, and that's exactly the problem that we had with Tuskegee. Some of you may know the history of Tuskegee; I know that my colleagues here do. In [the] 1930s, the CDC in conjunction with [the U.S. Public Health Service] designed a study of syphilis among black males, and [the researchers] didn't tell them [when] they had syphilis, because they wanted to see what would happen long-term.

    So, hundreds and hundreds of people got tertiary syphilis—which, by the way, is not just the genital disease; it eventually affects your brain, and is a horrible way to go at the end. [This incident] is the gold standard for unethical behavior in medicine and bioethics, and precisely that same condition happened in the RCTs in Africa, and they haven't been called to account for it!

    There was no full disclosure with informed consent. Basically, it was a scanty consent, as you can imagine; the men were circumcised that same day. Certainly, they were never ever told the sexual effects of the kind that Marilyn so articulately described for this surgery.

    So, in other words, if you were doing a lawyerly analysis of the accounts here, it would be that the participants were placed at risk in a study with built-in biases, which guaranteed the investigators the results they wanted, and the benefits were coerceive and unethical.

  • [Flaw number nine]: Lead-time bias.

    This is an interesting one; it requires a little thinking for a second. The [group circumcised in the beginning] were told to avoid sex for 4 to 6 weeks, so what happened was if you compare the results over 1 year, somebody got a 2 month head start; the men who were circumcised early [on] got a 2 month head start where they didn't have sex, so they weren't put at risk [for sexually transmitted HIV during that time], and that affects the result entirely. The [bias-based] overestimate according to [Dr. Robert Van Howe] is on the order of 10%, which wipes the whole studies out.

    Yes mam?


It was suggested in a—

John Geisheker

In the 3rd study they adjusted it somewhat.


Yeah, it was suggested the men themselves might have gotten longer because of the effects of the circumcision, too.

John Geisheker

I hadn't heard that, but I'm not terribly surprised. Mind you, it could also be counter balanced by men who were desperate enough to have sex when they still had something of an open wound, and you know, that would kind of counterbalance the notion, but in any case, it's not a very good study if you're looking for purity of results.

  • [Flaw number ten: Cultural differences].

    In [the] South Africa study, the 2 groups differed by age, religion, and tribe (and that tribe makes a big difference in Africa). There was no attempt to reconcile that.

  • [Flaw number eleven: Loss from study].

    For every participant infected, a huge number were lost [from the study]. At the highest, 7.4 for every individual that was [infected] was lost. You have to wonder what would have happened had those people stayed in the study. For every sexually transmitted infection of HIV, up to 17.6 participants were lost. Small differentials in the loss group could negate these [RCT] findings, too.

    All of these flaws are cumulative! The more flaws you have in the study, the more the results of the study (especially when they're small) are called into question.

    Now, here's my favorite quote about ignoring dropouts, and it comes from Bad Science by Goldacre (drug studies are an example):

    People who drop out of trials are statistically much more likely to have done badly, and much more likely to have had side-effects. They will only make your drug look bad. So ignore them, make no attempt to chase them up, do not include them in your analysis.

    Bad Science by Ben Goldacre, Fourth Estate, London (2008), p. 209

    That's a great quote. That's a great way to run a drug study—and by the way, there's a scandal that just came out this week about how Africa is being used by Big Pharma and big American institutions like Johns Hopkins University of Illinois, etc., to do studies that they couldn't run ethically in the United States. They're [basically using] Africa as a guinea pig for whatever drugs and whatever procedures they can come up with. I think [this] is a huge scandal; it's definitely going to hit the wall.


They can't run [such studies] ethically there either; they just do it anyway!—

John Geisheker

Well, they do it, because they can get away with it. Frankly, there is so much money free-floating [in Africa] (provided by the Gates Foundation and others) that local African officials who are poor—and even if they're the honest chief medical officer of a small African colony, country, or tribe, they can't turn down scads of American money, which they could use for other kinds of things. So, of course, they're going to say “Yeah! Let's start a circumcision campaign!”, so they can get the money into their system, so they can use it for useful things (we're hoping they'll use it for more useful things), but you can't blame poor countries for being attracted by American cash. You simply cannot.

  • [Flaw number twelve: Unequal crossovers].

    This is a bit abstract, too, but let's hit it:

    • The number of men [randomly] assigned to be circumcised who were not, and

    • The number of men [randomly assigned] to wait [to be circumcised], but got circumcised early for whatever reason (maybe they elected to)

    [were] not equal[.] [That suggests that] the men who did not receive the immediate, free [circumcision] they wanted dropped out. So, that affects the accuracy of the study as well.

  • Flaw [number] thirteen: [Unequal Treatment].

    (Are you getting saturated on the flaws here? Have I convinced you!?)

    Men [who] were [randomly assigned] to early circumcision had follow up visits. Now, I actually think this is very criticial; if I were [Dr. Robert Van Howe], I would put this on the front end, because I think it's the biggie (along with the relative/absolute [percentages] problem).

    Men [randomly assigned to] early circumcision had follow up visits, [and] this allowed the staff to influence them—to urge them, to provide safe sex advice, etc., etc. So, they were continually being educated, which [surely affected] their behavior.

  • [Flaw number fourteen]: Early termination.

    The proponents quit the study after one year, saying it would be unethical to continue it because the results were so overwhelmingly positive in favor of circumcision that even waiting would be unethical.

    Well, isn't that convenient?

    If the study had been big and long, maybe the benefits they saw would have roughened out, and [maybe] the stats [would have] come to nothing at the very end, but that's not exactly the result they wanted.

    [Ending the study early] also amplifies the lead-time bias. If you have a short study, that 8-week lead time [which] the men who were circumcised got [is] a bigger percentage of the [study time]; if you run [the study] out 2 years, [a 2-month lead time] is only one twelfth [of the study time]. If you run the study for only a year, that lead time is a full one sixth [of the study time]—quite a difference.

So, here [are] some anomalies for you:

  • Why did participating increase risk?

    • Medical exposure? (asks [Dr. Robert Van Howe]).

    • Or [was it a] self-selected population at a higher risk to begin with? That's certainly possible, too.

  • In South Africa, the intervention was not consistent between tribes, for probably cultural reasons.

  • In Kenya, the intervention was effective for one group of young men, but not [for] the 18 year olds. Why is that? We don't know.

Facts that don't make sense:

  • Why is HIV [prevalence] higher [among circumcised] men than [among] intact men in South Africa?

  • Why is the [prevalence] of heterosexually transmitted HIV so much higher in the U.S. than it is in Europe? The answer could be that Americans don't like condoms because they're circumcised. There are lots of different things you could ask about that.

  • If the increase in protection [provided] by a 90% circumcision rate (which they'll never get to in our lifetime) can be undone by a 5% decrease in condom usage, then what's the point [of the circumcision]?

  • If antiretroviral therapy—which, remember, prevents seroconversion even between what's called discordant partners ([one of them is infected, while the other is not])—and treating STDs [are together a] more effective, less costly, and less invasive [way to prevent HIV than circumcision], then why bother with circumcision?

Here are [some contradictory] studies—including 3 by the authors of the African RCTs! [These are] studies, in other words, that show that the effect [of circumcision] is not as good as [they] would hope [for reducing the transmission of HIV to men], or (and we'll talk about it in a minute) [circumcision] endangers women! There's a remarkable number of them; we won't go through [all of] them, but they're available to you if you want to look; [they are] fully explained in a wonderful website you should know about called Circumstitions (once again by Hugh Young, the guy [who] did the Dilbert cartoon).

[Dr. Michel Garenne] authored:

Long-term population effect of male circumcision in generalised HIV epidemics in sub-Saharan Africa.

Michel Garenne, who is at the Institute Pasteur in Paris, says:

In most countries with a complex ethnic fabric, the relationship between men's circumcision status and HIV seroprevalence was not straightforward, with the exception of the Luo in Kenya and a few groups in Uganda. These observations put into question the potential long-term effect of voluntary circumcision programmes in countries with generalised HIV epidemics.

Well, it's worse than that, Dr. Michel, because it's not going to be “voluntary” circumcisions. That's what they talked about in 2005 and 2006, but I have watched very carefully (so has Marilyn, so has Gillian, [etc.]) as they've gone from “voluntary” circumcision for men, to semi-voluntary circumcision for young men, to involuntary circumcision for infants, which is plan C, and was, I think, the plan all along.

Here's my comment on this. This is epidemiology and anthropology 101. First of all, the biggies:

  • The risk avoidance by confident, [circumcised] men.

    A lot of health officers in Africa are themselves concerned that young men are cheerfully lining up for circumcision so they can avoid using condoms, and so they can tell women that they're HIV-negative and will stay so because they [were] circumcised. In other words, they're going to use their circumcision status to give up on the only thing[s] that [prevent] HIV:

    • Abstinence
    • Condoms
  • So they are putting themselves and their partners at risk, and the risk to women is substantial, because here what I haven't mentioned and could have mentioned upfront: All the RCTs only say that the male is protected from an infected woman; she is not, however, [necessarily] protected if he's HIV [positive]. In fact, she's even more at risk, according to the Wawer study.

    Does that make sense?

    So this is the most sexist plan for almost a billion African people that you can imagine. This is just a recipe for a gigantic epidemic disaster.

  • The other thing is [that the] 60% protection [for men], even if it's true, is not 95% (the gold standard for all immunizations). It is what I call viralette—viral roulette; you're basically just playing with time, and infection will occur eventually. It just may take longer.

  • We should mention is that the effort against HIV in Africa is a zero-sum game. Male circumcision, which is expensive (95 times more expensive than condoms would be), is draining the dollars away from more effective programs.

  • Bush circumcisions (in other words, circumcisions [outside of a sterile, medical environment]) of men are not going to be [performed] by doctors, because there aren't enough doctors to [circumcise] 900 million black Africans; they're going to be done by traditional “healers”.

    I was in Mexico in 2008, and I talked to people who were proposing this program, and they freely admit [that] there aren't enough doctors, [and] that they're going to have to train locals to do one procedure only [(namely, circumcision)], and there's going to be no follow up! The van pulls [into] town, they [circumcise] the whole village, and [then] drive away! There's no follow up, and there [are] plenty of opportunies for iatrogenic HIV infection.

  • Condoms have other uses, too!

    • Preventing pregnancy.

    • Preventing HPV (which we've already mentioned is one of the vectors for cervical cancer), and other sexually transmitted infections.

  • Now, something you may not know is that this idea (a white-people's invented idea) that circumcision solves the HIV problem in Africa has been pitting tribes against tribes; in Kenya, for instance, the Luo (which is the tribe of Barack Obama and his father), do not circumcise, and haven't historically.

    [However], the Kikuyu—anybody see the movie Out of Africa? That's the tribe that's featured in there, the Kikuyu. They do have a long standing tradition of circumcision.

    [The Kikuyu] have been accusing the Luo of being the problem, because they've been told that uncircumcised—intact—men transmit HIV, so they've been capturing—waylaying—Luo men who are found alone, and [then] circumcising them traumatically right in the street, as kind of a tribe against tribe [act of domination].

    By the way, there's probably pretty good odds that—this is an aside, of course—there's probably pretty good odds that Barack Obama is himself intact.

    • His mother was a hippie atheist.
    • His father was an upperclass Luo.

    So, it's very likely that [his mother] either honored his request (or he insisted) that the boy be left intact, but we're not going to know until he's retired.

  • Cutting as a first line disease control defense always strikes me as dodgy. The human body has evolved for many hundreds of thousands of years, and if we take the notion that the way to solve disease is to start lopping parts off, there [is] no [end] to [the number of] surgies you could invent that solve problems [in that way].

    I mean, I don't have any tonsils, because some doctor made a car payment in 1958 off of them. I mean, it was fantastic fraud in the 1950s; play this game sometime at a party: Ask all the people who have had tonsillectomies to put up their [hands], and you will find that everybody [who raises his or her hand] is [in his or her] 50s and 60s. Almost nobody in [his or her] 20s and 30s is without [tonsils]. It's interesting. It was just the “fashion” of the day!

  • Male genital-cutting and female genital-cutting traditions are self-sustaining; the cut become cutters. This is an anthropology rule—a fixed rule. Once someone has had a genital mutilation, [he or she seems] to have some embedded, psychosexual need to have the next generation [undergo] that same initiation right (or that same limitation). There are thousands of explanations for this; I'm fantastically beyond my pay scale by even speculating on any of them, but I leave you with that thought, in any event.

  • This is [Dr. Robert] Van Howe talking about how circumcisions [are] a wasteful distraction. This is Hugh Young's illustration; if the African studies are correct—if everything I've said about their flaws is inconsequential, and [these studies] are correct—it's still going to take 56 circumcisions to prevent one HIV case per year, and it will [still] fail to prevent one—not much of a gain, and that's true in Uganda, [where there is] a 4% HIV [prevalence]; we have a 0.6% HIV [prevalence] in the U.S.—6 in 1000. Statistically, it would take 380 circumcisions to stop one HIV case—so, at huge expense.

To give you a flavor of the professionalism that surrounds the RCTs in Africa, [consider] these quotes:

  • “We're hacking away. Those foreskins are flying!” That's Robert Bailey [of the] University of Illinois, quoted in the New York Times barely a month ago. It's amazing to me; I can't see how a man could possibly have that casual an attitude toward a surgery that serious on so many people and be able to keep this in his head. It just appalls me to my core.

  • The other [quote] that struck me was one from Dr. Renee Stein [of] St. John's Emergency Medical Center in St. Louis talking about their circumcision rate there: “We whack 'em all!” she said. Wow. What a treat. You can imagine how cold I was when I saw that in the Times.

  • Here, one of my colleagues, David Llewellyn of Atlanta, Georgia, went to a meeting at the CDC in Atlanta. [One of] the presenters to the CDC on how circumcision should be proposed for Africa made fun of intact men (David is intact and proud of it) by using this slide, showing the man as an elephant. So, question of taste? Do you think there's any taste problem there?

  • Here's Israeli Inon Shenker (whom I met in Mexico in 2008) with the Zulu chief, Goodwill Zwelithini kaBhekuzulu. I talked to Inon Shenker for quite a long time in Mexico, and frankly, I said to him:

    You're Israeli, and you're calling your [plan to circumcise Africans] “Operation Abraham?” Why didn't you call it “Operation Sterile Procedure” or “Operation HIV Prevention”? Why did it get called “Operation Abraham”? It has a slighly religious connotation for some of us.

    and [his response was that] he was offended by that, [and] it wasn't his choice, [and so on]. He generally thinks that this is an opportunity for the Israelis[;] his claim is that Israelis have a unique expertise in adult male circumcision, because they did them wholesale to Russian immigrants to Israel in the 1970s when there was a huge outpouring of Russian Jews into Israel. So, he's on a quest for the business, as it were.

  • Now, here's a picture I found:

    “The operation is a good chance for safe sex education”

    One of the things that Shenker and colleagues talked about in Mexico in 2008 when I met them was that the circumcision procedure itself [is] a marvelous opportunity for the man to have “a quiet reading moment”, where he could read about safe sex [in] brochures they were going to have him read.

    Well, I don't know what your attention span is like during surgery—even surgery with a decent local anesthetic—but I don't think I'd be reading much. At the time, it struck me as a very thin reason to perform a procedure—you could also put him up on a table, all stand around, not cut him, hand him the brochure, then have [a test afterward] to see if he read the material, and you [would] get the [same] benefit.

  • Here's a billboard on the Ethiopian–Sudan boarder, showing that you should get circumcised, and there's a ton of these in Africa—tons and tons of them, put up by the local health authorities and by individuals who have much to gain.

  • Here's Orange Farm in South Africa:

    The young men have flocked by the thousands to this clinic for circumcisions.


    “I've done 53 in a seven-hour day, me, myself, personally,” said Dr. Dino Rech, who helped design the highly efficient surgical assembly line… for cutting off foreskins.


    Well, I submit to you that if you do 53 procedures in a day, your first one might be decent, but I wonder about your 53rd. I think I'd want to be the mid-morning appointment—somewhere where you're back in the swing of it, but [aren't] yet exhausted, do you know what I mean? I mean, it's just insane to think you can do 900 million circumcisions in Africa without a single problem. We have hard enough problems doing circumcisions to a decent standard in U.S. hospitals that are first rate, let alone in bush clinics and vans all over sub-Saharan Africa.

So, thanks very much.

I actually have 2 more slides. This is me sailing rather than talking about penises [laughter], and this is my houseboat out in Seattle, which I built.

Thank you. Any questions?


Can you explain how you calculate the absolute reduction in risk vs. the relative reduction?

John Geisheker

Well, they're not my numbers for a start (they're [Dr. Robert] Van Howe's), and I will happily give you his handout, which he would be delighted if we shared. In fact, I thought I had given it to Travis to reproduce. Is it here? Ah! That's excellent. Why don't you check those numbers in there.

Marilyn Milos

[NOTE: Marilyn Milos previously threatened legal action for transcribing her words. Therefore, they have not been reproduced here.]

John Geisheker

Oh, relative and absolute?—


Well, just how are they calculated in general? How does one calculate an absolute risk versus a relative risk?

John Geisheker

Well, let me give you an example [which] is a bit closer to home.

One of the claims of people who propose circumcision is that it solves urinary tract infections for boys under 1 year [of age]. But, the actual rate—and even this I think is questionable for reasons I may mention in a minute—the absolute rate, if you believe it, of UTIs in [male] infants is 1% (1 boy in 100). Now, the proponents [of circumcision] claim that if you circumcise boys, only 1 in 1000 will get a urinary tract infection. So, rather than saying to a parent:

You know, he has only a [1 in 100] chance of having a UTI, [but] we could marginally improve on that by circumcising him, so then it will go down to 1 in 1000.

Instead, what they do is they say:

Circumcision confers a 10 times protective effect!

So, they use the relative difference between 1/100th and 1/1000th, and [they sell circumcision using] that [relative] scale, rather than using the absolute, which is the 1 in 100 that you should be talking about as the “high” risk side.

Does that make sense to you?


Yeah, but—

John Geisheker

The same thing is happing in the RCTs.


Right. It just [seems] like the absolute reduction was really low then. It was like 1.8%, and so in a population when HIV is so much more prominent, it just seems like it [is] a strange number. So, I was just curious how they kind of got that.

John Geisheker

This is the slide you're talking about, right?



John Geisheker

Yeah, well, see, [among] those who got a circumcision [early on], out of every 100, a little over 1.5 of them got HIV, whereas [among those not circumcised until later, out of every 100, a little over] 3.3 [of them got] HIV, and it's the [proportionality] between those 2 that gives you your big number if you're dishonest about it.

Yeah, I'll stick with [the word] “dishonest”, because I frankly think these studies are rankly dishonest, and they have been marketed at their highest point of possible [benefit], and none of the shades—none of the nuances—have been [discussed]. [Unfortunately], [their results] are so deeply embedded now, you could walk out on Marilyn's street here, stop a cab, and [the driver] will tell you [that circumcision confers a] “60% protective effect”. You know, it's deep; it's in place.

Marilyn Milos

[NOTE: Marilyn Milos previously threatened legal action for transcribing her words. Therefore, they have not been reproduced here.]

[NOTE: The audio ends abruptly here.]

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