The Bay Area newspaper The Examiner reported Thursday an attempt to include on the November 2011 ballot a "Proposition" to ban male circumcision of minors in San Francisco. (For those not familiar with the local electoral system: A Proposition is added to the ballot paper in an election of local government representatives. It acts like a referendum, a 'win' binding whoever is elected to follow a particular course of action in respect of an individual issue.) To make it onto the November ballot, it would require the collection of 7,168 valid nomination signatures by April 26, 2011.

A lengthy statement released yesterday by the Health Department of KwaZulu Natal concluded with the following (the bold type emphasis is in the original):

At Northdale Hospital the KZN Health MMC [Mass Male Circumcision] team performs circumcision with a turnover of 50 to 100 per day using both the standard surgical technique and the clamp.

[Edit removing clinical detail]

Our experience at Northdale Hospital and other sites has been that complications with the above [Tara KLamp] procedure are rare, but sometimes inflammations and occasional wound dehiscence are noted (less than 2%) due to technical errors or the patient’s nutritional status or individual’s wound healing capacity which are managed without any consequence. Every patient is advised to attend to the clinic or to Northdale Hospital round the clock post-operatively if they have a problem but there has been no such incidence/need.

The MMC team is training staff from all parts of the Province and very soon a three day course will be introduced that will provide health care workers with the essential guidelines and training to successfully perform the procedure. To conclude, the KZN Health MMC team is not biased towards any one way to perform circumcisions, and is open to all methods and devices if the purpose is served for the huge task successfully completing the Mass Circumcision Program in the Province. However, any new method has to be evidently validated to be better than those currently being quite successfully used by the team.

In the main body of the statement one finds the following:

The standard surgical technique involves cleaning the organ, giving local anaesthesia, giving time for the anaesthetic effect, holding the prepuce with two forceps, clamping with forceps in the forceps guided method, cutting the prepuce, retracting the cut edges, re-excising the extra bit of inner prepuce (which can never be included because of glans penis being in the way of the forceps) to leave 5mm in adults and 3mm in children for a standard effective circumcision, finding the blood vessels, ligating/cauterizing the bleeding points, approximating the edges and putting the dressing etc. If even a layman adds up the time required to perform the above steps in a proper manner, it will result in a time far beyond the claimed 10 minutes (6 per hour).

Hidden away in this paragraph is some marvellous news... the good doctors of KZN have acknowledged the enhanced prophylactic benefits of the ‘low’ style of circumcision - note the words “re-excising the extra bit of inner prepuce... for a standard effective circumcision”. Positioned correctly, several makes of clamp can achieve this directly, without a second cut. Tara KLamp is one such device and, historically speaking, the first single-use device to have achieved this optimum style. More on our page about the Tara KLamp itself.

For some weeks, criticism of the Malaysian Tara KLamp has been building in the South African press. You can read a representative sample on the website of the Treatment Action Campaign. Notable is the absence of an opportunity being granted to the manufacturers to respond to the criticism, leading CIRCLIST to suspect that there is an ulterior motive at work somewhere. What must also be noted is this...

• Lagarde’s original trials were done without the team first attending Tara Medic’s training course. (This is not hearsay. CIRCLIST has obtained copies of correspondence that passed between the researcher and the manufacturer.) The omission of training was a serious flaw in Lagarde’s appraisal, which should not be quoted or referenced without a footnote pointing out this deficiency in the study.
  
  
• The device has since been modified; current production is not the same as that originally tested by Lagarde.
  
  
• The more recent tests by the provincial government of KwaZulu Natal (KZN) used the latest model of the KLamp and included proper training of those using it. These government tests (we are told) returned satisfactory results.

Update Wednesday 03.Nov.2010:  All four parts of this saga are now available via the TAC link above. If that server gets overloaded, try here for backup copies.

CIRCLIST Editor’s comment: It is beyond our capability, working from a base in London UK, to investigate the financial aspects of this matter. It is to be hoped for everyone’s sake that corrupt dealings are not a factor. The latest communciation received from the manufacturer reiterates their claim that the reported adverse outcomes associate with absence of training and consequent departure from the approved method of use.

More may follow as the situation develops.

The ABC Radio National programme is now available here: http://www.abc.net.au/rn/lifematters/. Two files involved; an edited version of the debate (43 minutes, condensed from 2 hours) and the predicted RACP comments. Reaction posted so far on Inter-Circ seems to be generally favourable.

The following reached the Editor’s mailbox overnight, sent direct to CIRCLIST by ABC: “Our broadcast on infant male circumcision will go to air tomorrow, Tues 26 October, 2010, from 9.05am-10am Australian east coast time. It will be repeated at 9pm that night. It will also be available as downloadable audio after that, indefinitely, at abc.net.au/rn/lifematters”.

Rumour has it that RACP have been granted the opportunity to add a tailpiece, not available for on-air challenge by either party to the debate. If you want to know RACP’s position, see this website’s page about Australia in the Rites section.

There appears to have been a last-minute change in ABC’s willingness to broadcast this undoubtedly controversial item. The following hit the Editor’s Inbox at 23:41 UTC Wednesday, sent by the programme controller: “The broadcast has been postponed. We do not have a date confirmed at this stage. - Ann”. No reason stated.

Back in August, the Australian radio programme “Life Matters” (ABC Radio) recorded a 2-hour debate on the subject of circumcision. Since edited to fit a smaller time slot, it is due to be transmitted at 09:00 Friday 15th October 2010 (Sydney time). The norm for this channel is to place such debates online following free-to-air transmission. The relevant page of ABC’s website is here.

To sort out your time zones, please visit  http://www.circlist.info/worldclock.html.

Due to a technical fault on the Internet (not involving our own equipment - the problem was elsewhere) no uploads to the CIRCLIST server were possible during the early part of this week. As a result, e-mails sent to Circlist may have got lost due to queue overflows. If you sent us an e-mail but have not received a reply, please re-transmit your original.

It looks as if the anti-circumcision tide has turned in Australia. Today’s edition of the Courier-Mail (a daily newspaper published in Brisbane) reports in an article by Janelle Miles "Despite official discouragement of the practice, Medicare statistics show a rise in the rate of infant male circumcision in Australia from 13 per cent in 1998 to 19 per cent last year".

Official discouragement in Australia has been severe; only in the State of Queensland is it currently possible to have a baby boy circumcised in a public hospital for non-medical reasons. Elsewhere, quasi-legal administrative restrictions have in effect made it impossible to obtain.

The Royal Australasian College of Physicians have long campaigned against infant circumcision, but are now reviewing their policy. It remains to be seen whether they will catch up with the good sense of parents now demanding circumcision, realising that infant circumcision is a surgical vaccination against a number of diseases and conditions.

UNAIDS has today published some encouraging news about progress in the fight against HIV/AIDS. Amongst other things, it acknowledges the successful scale-up of rates of male circumcision in sub-Saharan Africa as a contributory factor.

What a shame that the BBC could not bring itself to include circumcision in their news report. The main afternoon radio news broadcast, "PM" on Radio 4, listed factors such as later start of sexual relations, greater marital fidelity and increased condom use, but omitted to mention circumcision. Is it really that embarrasing a subject? Or a case of biased editing?

The full text of the UN document is here:
http://data.unaids.org/pub/Report/2010/20100917_mdg6_report_en.pdf.

Our new website www.circlist.info attracted 4,345 visitors in its first month, the average visitor consulting three pages. Most popular pages were Videos, Websites and Groups (in that order). Evidently this site has attracted the attention of a larger-than-usual proportion of non-English speakers; a significant number of the visitors accessed via autotranslators.

Our new website section "Academic Corner" went live at 07:35 UTC today.

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 "Academic 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. Yet 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.