Our new index to circumcision resources launched today at http://www.circlist.info. This replaces the "Resources" section of the main website, which will close shortly and be replaced in due course by a new section "Academics Corner". The principal content of the new section will be musings about current and future research into the benefits of circumcision.

On 24th June we reported that the Circlist discussion group on Google had mysteriously gone off-line. Google have proved impossible to contact to obtain an explanation or reversal of their censorship; for example when one of our number attempted to visit their offices they were turned away at the door. The owners and managers of Circlist have therefore reluctantly decided not to try to revive it as an independent discussion group.

Founded in 1977 as a paper-&-ink newsletter, Circlist was the original pro-circumcision discussion group and the first to go online. It has always flourished but there are now many other good pro-circ groups. Some have a broad and international remit whilst others address more specific situations, such as the situation in certain countries. Others are aimed at particular audiences such as mothers of circumcised boys. Inter-Circ, a Yahoo group at http://groups.yahoo.com/group/Inter-Circ, is the closest in scope and worldwide coverage to Circlist and so we have decided to recommend that Circlist members now join Inter-Circ where we are assured they will be made welcome. Inter-Circ has agreed to add “incorporating Circlist” to the Introduction on its web page, thus keeping the heritage of Circlist alive. They have also appointed one of the managers of Circlist as a Moderator.

This web site http://www.circlist.com will continue to be a long-term repository of accurate information about all aspects of circumcision whilst a sister site at http://www.circlist.info is being developed as a small reference vehicle for links to the many other circumcision-related resources on the web. A further announcement will be made here when the new site is open for business.

Last Sunday the online edition of The Guardian newspaper published an article about the medical consequences of botched circumcisions within the UK’s Muslim community. Hidden away in the last paragraph is the following gem of an insight into the bureaucratic mind. PCTs are "Primary Care Trusts", the administration system for front-line medical treatment. Unstated is that the whole PCT system is about to be reformed, potentially destroying the very administrative mechanism being described as appropriate for local decisions about circumcision services.

The Department of Health said it was not going to change its policy, despite the evidence of some boys suffering medical damage as a result of unregulated circumcisions. "On the NHS, circumcision should be carried out only for medical reasons," a spokeswoman said. "However, PCTs are responsible for commissioning services to meet the health needs of local communities. In some areas, particularly where they feel children are at risk from unsafe procedures, PCTs do work with local providers and communities to ensure that a safe and affordable service is available."

The full article is here:
http://www.guardian.co.uk/society/2010/jul/11/doctors-urge-circumcision-on-nhs

Ironic, isn’t it? Muslim boys have to suffer botched circumcisions before anyone - be they Islamic or not - gets proper provision. And then it will only be on the basis of a "postcode lottery", covering only multi-cultural parts of the country. No mention in the Department of Health’s statement about the public health, personal health and hygiene implications of male circumcision that we could all enjoy if the NHS policy was reversed.

For some years it has been known that circumcision offers some protection - albeit imperfect - against HIV. Now a team based in France have shown why, at cellular level. In the process they have come up with the definitive proof that low styles protect better; the mechanism demonstrated applies only to inner foreskin and the frenulum, not to outer foreskin or shaft skin.

More here: Pubmed 20571487

CIRCLIST’s conclusion: Low styles with full frenulum removal are now proven to confer better protection against acquiring HIV-1 through sexual intercourse; the loose/tight parameter remains a cosmetic issue without epidemiological implications. Those who promote high styles really need to stop and think : there is a serious, proven downside to their recommendations.

For the second time in about six months, the CIRCLIST Google Group has gone offline without explanation. This is being investigated. A further announcement will be made as soon as definite information is available.

“Researchers found that, over two years, circumcised men were 39 percent less likely than their uncircumcised counterparts to report any type of penile injuries during sex.” - Reuters.

This raises the possibility that lower injury risk is one reason that circumcision lowers the odds of HIV transmission -- cuts, scratches or tears in the skin that could serve as a portal of entry for HIV are fewer in number. Further studies are needed to clarify the role penile injuries may play in the transmission of HIV or other sexually transmitted diseases. But this is a start.

Many research papers have been published showing that male circumcision reduces (but does not wholly prevent) the risk of a man contracting HIV during heterosexual intercourse. The contribution that circumcision has to make in curbing the HIV/AIDS epidemic has been placed beyond reasonable doubt.

But what about the cost-effectiveness of the procedure? In purely financial terms, is it worth a government investing in circumcision services in order to head off the health and social security costs associated with cases of AIDS at some time in the future?

The answer to that question will vary from economy to economy. In the context of Rwanda (a land-locked country in sub-Saharan Africa) the answer seems to be an unequivocal “yes”. Furthermore, there are strong indications that, despite the longer lead-in time before exposure to risk, infant circumcision pays the biggest financial dividend. More here:

Male circumcision at different ages in Rwanda: A cost-effectiveness study. Binagwaho A., Pegurri E., Muita J., Bertozzi S., 2010. Rwanda Ministry of Health, Kigali. [Pubmed PMID: 20098721]

Hot on the heels of the study we reported on 8^th April comes further evidence of the beneficial effects of male circumcision in relation to HPV, the virus responsible for cervical cancer in female partners. More here, in respect of HIV negative men: Pubmed PMID: 20370483, here in respect of HIV positive men: Pubmed PMID: 20370481 and here: Pubmed PMID: 20370482 (follow the onward link to full text of the article, where you will find Editorial Comment on the preceeding items).

CIRCLIST Editorial comment:  As with HIV, it seems as if circumcision gives imperfect protection against HPV. This underlines the need to educate the general population regarding the difference between individual healthcare and public health measures. Not an easy task, but one that will have to be addressed - and the sooner the better.

An interesting new slant has turned up in the relationship between circumcision and HPV infection rates. Research just published by the University of Hawaii, Honolulu, suggests that there is no statistically relevant difference in acquisition rates as between circumcised and uncircumcised men, but that the advantage of being circumcised comes instead from an enhanced ability to clear the infection if acquired. It remains to be seen whether these findings are replicated by other studies and whether there is relevance to other sexually transmitted viruses. More here: Pubmed PMID: 20350160.

The UK's Health Protection Agency has just issued an alert concerning a new, totally antibiotic resistant strain of gonorrhoea. Proponents of circumcision should be careful not to put enthusiasm before accuracy by recommending circumcision as a means of protection in this instance. Gonorrhoea is bacterial rather than viral; the portal of entry is different from HIV and HPV and there is scant evidence that circumcision helps either at an individual or at a public health level as far as protection against gonorrhoea is concerned.

The Human Pappilloma Virus (HPV) is back in the news. A problem first mooted in 2007 has now been shown to have real substance: Oral sex performed on an HPV-infected male can cause throat cancer in the “Cocksucker”. The mainstream press is touting vaccination as the public health remedy. So far, no reference in these articles to male circumcision as a means of controlling the spread of HPV.

It is reported that the anti-circumcision lobby’s latest attempt to outlaw male circumcision has just been defeated. The Judiciary Committee of the Massachusetts State Legislature threw out their “MGM Bill”.

The Centers for Disease Control and Prevention (CDC, Atlanta, Georgia, USA) has recently published a report entitled "CDC Report on Male Circumcision for HIV Prevention". You can read a copy here.

Regular readers of information relating to male circumcision will be well acquainted with the writings of Professor Brian J. Morris, one of the world’s leading academics in the field of research into the health benefits of male circumcision. A new edition of his work “CIRCUMCISION: An Evidence-Based Appraisal” is now online at http://www.circinfo.net. Over 1,000 references are cited, making this a must-see website for anyone taking a serious interest in the subject. Additionally, the whole presentation has been revamped to a more modern style. There is plenty there to interest the lay reader too.

Various members of the CIRCLIST Google Group (maybe others also) have received a fraudulent email purporting to come from Dr Tasron bin Surat of Sunathrone Technologies and requesting a loan of money. This email is from "Sunathrone BM Technologies Sdn. Bhd. <sunathrone@gmail.com>", is addressed to "unknown recipients" and entitled "Urgent Request".

We have spoken directly to Dr Tasron and learn that his email account has been hacked. This message is a forgery. DO NOT RESPOND TO IT.

The Daily Nation/allAfrica.com reports that 90,000 men have been circumcised since the government launched the national voluntary male circumcision drive in November 2008. “Kenya is one of 14 sub-Saharan countries that have expanded Voluntary Medical Male Circumcision programmes since ground-breaking randomised controlled trials conducted in Kisumu [Kenya], South Africa, and Uganda revealed that the procedure reduced men’s chances of HIV infection by 60 percent”, the news service reports.

A paper due to appear in the next printed edition of the medical publication AIDS is causing a bit of a stir. The researchers, based at the University of Chicago, claim to have shown that the inner and outer foreskins of adult males are equally keratinised before circumcision. That’s counter-intuitive, because the inner foreskin is mucosal tissue whilst the outer foreskin is not. The methodology of the study is already coming in for criticism both within Chicago University and also at Johns Hopkins. If the new research findings are upheld, it will force a re-think of the existing hypothesis concerning HIV transmission. Hence the intense academic interest.

AIDS. 2010 Jan 21. [Epub ahead of print] : Keratinization of the adult male foreskin and implications for male circumcision. : Dinh MH, McRaven MD, Kelley Z, Penugonda S, Hope TJ. : Division of Infectious Diseases, Department of Medicine, Chicago, Illinois, USA.

Details here: Pubmed 20098294.

On 23.Dec the Malaysian clamp manufacturer Sunathrone announced the launch of a page on Facebook. Between Christmas and the New Year the page vanished. It has now been re-established here:
http://www.facebook.com/pages/Sunathrone-International/229320298671.

Sometime between 13:45 and 18:15 UTC Wednesday the CIRCLIST Google Group went offline. Effective 04:00 UTC Thursday it reappeared. As yet, no explanation. [Update 23.Dec.09:] Since the outage, some members have not been receiving mail as normal. Please check your spam filter; Yahoo (for example) has, since the outage, been classifying the Daily Digests of the group’s correspondence as spam.

CIRCLIST understands that an independently assessed clinical trial of the Sunathrone Clamp commences in Kuala Lumpur, Malaysia, tomorrow. It’s the peak season for circumcision in SE Asia, on account of the timing of the long school holidays. Results should become available sometime in 2010; the study aims to compare this clamp with freehand circumcision in terms of training requirements, resource requirements and outcome.

[Update 18.Dec.09: 70 boys are involved in the trial, all of whom have now been circumcised. The outcomes will be independently assessed 7 and 60 days after surgery.]

Further analysis of the data from the Rakai study (reported here 25.October.2009, see below) shows that the observed reduction in HIV transmission rates does indeed result directly from circumcision and not from variations in the rate of HSV-2 infection (HSV-2 being the virus that causes genital herpes).

More here:  http://www.plosmedicine.org.

Apologies to anyone inconvenienced by our absence during Friday 20^th. This wasn’t either our fault or that of our Website Hosting service; the problem was further upstream and way beyond our control.

A study of 10421 boys under 18 years of age, conducted during 2008 in the municipality of Chongqing and just published in english, reveals zero circumcisions before the age of 2 years but 17.28% circumcised in the 11 to 18 year age group. More detail on our page about China and Chinese Culture.

A while back there was great excitement about a vaccine trial that claimed around 31% efficacy. Some scepticism was expressed at the time, but now the doubts have really set in. More here:

Nature 461, 1187 (2009).

CIRCLIST says: "Circumcision is the best form of prophylaxis that cannot be forgotten in the heat of a passionate moment".

Dr. Helen Weiss, a staunch supporter of male circumcision, has just published another gem:

Male circumcision and risk of HIV infection in women: a systematic review and meta-analysis.
Weiss HA, Hankins CA, Dickson K.

Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.

Male circumcision provides long-term indirect protection to women by reducing the risk of heterosexual men becoming infected with HIV. In this Review, we summarise the evidence for a direct effect of male circumcision on the risk of women becoming infected with HIV. We identified 19 epidemiological analyses, from 11 study populations, of the association of male circumcision and HIV risk in women. A random-effects meta-analysis of data from the one randomised controlled trial and six longitudinal analyses showed little evidence that male circumcision directly reduces risk of HIV in women (summary relative risk 0.80, 95% CI 0.53-1.36). Definitive data would come from a further randomised controlled trial of circumcision among men infected with HIV in serodiscordant heterosexual relationships, but this would involve enrolling about 10 000 couples and is likely to be logistically unfeasible. As circumcision services for HIV prevention are scaled-up in high HIV prevalence settings, rapid integration with existing prevention strategies would maximise benefits for both men and women. Rigorous monitoring is essential to ensure that any adverse effects on women are detected and minimised.

Lancet Infect Dis. 2009 Nov;9(11):669-77.
PMID: 19850225 [PubMed - in process]

Not only is there a link between HIV infection risk and circumcision status, but also it has now been demonstrated that there is a link between the surface area of foreskin and the risk of becoming infected. Furthermore, the prophylactic effect of 'high' styles of circumcision are thrown into some doubt too. CIRCLIST members have been saying this for years - at least since December 2002.

Investigators from the Rakai circumcision study hypothesised that the size of an individual’s foreskin may be associated with an increased risk of HIV infection, due to the larger surface area containing cells vulnerable to HIV infection. [This refers to Langerhans Cells - Ed.]

After adjustment for possible confounding factors, the investigators found that individuals with a foreskin area above 45.6 cm² had a significantly increased risk of becoming infected with HIV compared to men with the smallest foreskin surface area - under 26.3 cm² (adjusted risk ratio, 2.37, 95% CI: 1.05 to 5.31, p = 0.04).

The researchers conclude, "a larger foreskin area was associated with an increased risk of HIV acquisition", a finding which they suggest has implications for circumcision providers who "should avoid leaving excess residual foreskin tissue after circumcision".

Reference:
Kigozi G et al. Foreskin surface area and HIV acquisition in Rakai, Uganda (size matters). AIDS 23:2209-13, 2009.

More here: http://www.aidsmap.com/en/news/.

"The models predicted that, using a 10-y time horizon, one new HIV infection would be averted for every five to 15 men newly circumcised. For the most successful interventions, where almost all men are circumcised, HIV incidence could be reduced by approximately 30% to 50% over the same period..." More here: http://www.plosmedicine.org.

New figures concerning the proportion of the world’s population who are Muslim cause us to revise previous estimates of the worldwide male circumcision rate. Ten years ago, the inventors of the SmartKlamp produced a video giving a figure of 1 in 6, which is a little under 17%. This now looks like a major under-estimate.

Earlier this month a body called the Pew Forum published a carefully researched report suggesting that 23% of the world’s population are now Muslim. It being a reasonable presumption that by the time of their puberty all Muslim males are circumcised, it must follow that globally at least 23% of adult males are circumcised. But how many more besides, in a world population estimated to be 6.8 billion?

Well, the Jews for a start. And an estimated 70% of males in North America. Some overlap occurs there with the Muslim and Jewish count, so an allowance must be made to avoid double-counting. In the rest of the world, at least 2% must be added for medically-necessary circumcisions and about 24 million in respect of Coptic Orthodox Christian circumcisions globally. Not forgetting countries such as South Korea, where male circumcision takes place without religious motivations.

Then there is the great unknown, Communist China. Recent reports reaching the CIRCLIST newsdesk suggest that routine infant circumcision is now the norm in maternity units, introduced as part of the state’s long-term attempts to limit the spread of HIV/AIDS. The proportion of institutional births in China now exceeds 80% (Sufang, 2007) but it will take nearly two decades for these infants to appear in the statistics for circumcised adults.

Taking all these matters into account, the proportion of adult males who are circumcised now must be no less than one in three, double SmartKlamp’s estimate made ten years ago. If the reports from China are true, then the figure can only be heading upwards.

Links:

BBC: http://news.bbc.co.uk/1/hi/world/8296200.stm
Pew Forum report: http://pewforum.org/docs/?DocID=450
Sufang G. et al. Delivery settings and caesarean section rates in China.
Bulletin of the World Health Organisation 2007, vol.85, no.10, pp. 755-762.