Circumcision pseudo-science

The possible benefits and drawbacks of male circumcision have been argued over for decades, centuries, probably millennia. The coincidence that a procedure originating as a religious ritual should turn out to have beneficial, health-protective side-effects is by no means impossible, though no one argues that case for the religious ritual of female circumcision. What’s clear is that medical opinion has been and continues to be divided [David L. Gollaher, “From ritual to science: the medical transformation of circumcision in America”, Journal of Social History, 28 #1 (1994) 5-36]:
“Ironically, but predictably in the context of the history of medical arguments for circumcision, some doctors have conjectured that removing the foreskin may protect men from the most dreaded epidemic of the post-modern world: the human immunodeficiency virus (HIV). Using retrospective data (the epidemiological equivalent of empiricism) from a venereal disease clinic in Kenya, for example, researchers observed that there were higher rates of HIV infection in the home communities of uncircumcised than circumcised men. Ignoring racial, ethnic, and sociocultural variables — the chief factors dictating whether or not an African boy is circumcised in the first place — they hypothesized that circumcision might serve to inhibit the transmission of the AIDS virus. One wonders whether this theory will endure. But within a medical community desperate to find some weapon against AIDS, its appeal is understandable. Even a physician who is a sober skeptic of the methodologies behind such studies allows that they ‘do suggest that HIV may be more infective during heterosexual intercourse if the male partner is uncircumcised and has a mucosal or cutaneous ulcer.’ [77] AIDS, the nemesis of modern science and medicine, remains a mystery. By some equally mysterious process, it is surmised, circumcision may help”.
[77: Simonsen et al., “Human Immunodeficiency Virus infection among men with Sexually Transmitted Diseases: Experience from a Center in Africa,” NEJM 319 (1988) 274-8; Cameron et al., “Female to male transmission of Human Immunodeficiency Virus Type I: Risk factors for seroconversion in men,” Lancet 2 (1989) 403-7; Marx, “Circumcision may protect against the AIDS virus,” Science, 245 (1989) 470-1; Poland, “The question of routine neonatal circumcision,” NEJM, 322 (1990) 1312-5”]

It is worth noting that circumcision as a way of avoiding becoming “HIV-positive” was mooted already in the late 1980s, and enthusiasts have continued to pursue definitive evidence for that for some two decades, despite contraindications no less probative than the pro-indications: a number of studies have found circumcision to be NOT associated with a lower rate of “HIV-positive”; see, for example, those cited in “Rwanda: Circumcise all men — even if it means more ‘HIV’ ‘infection’” [3 February 2008].

I’ve commented before on the remarkable similarities between HIV/AIDS and topics often labeled pseudo-science [“Science Studies 102: Burden of proof, HIV/AIDS ‘science’, pseudo-science”, 22 July 2008;  “HIV/AIDS and parapsychology: science or pseudo-science?”, 30 December 2008;  “Mainstream pseudo-science good, alternative pseudo-science bad”, 25 February 2009]. The failure after two decades of effort to find conclusive proof that circumcision prevents “HIV-positive” is somewhat reminiscent of decades of enthusiastic seeking of evidence for the reality of UFOs or the existence of Nessies; though one might have imagined, perhaps naïvely, that it might be easier to observe circumcision and frequency of “HIV-positive” than to investigate objects like UFOs or Nessies that cannot be brought under observation on command. Still, as Scientific Explorers like to say, “absence of evidence is not evidence of absence”.

At any rate, two decades of observational studies have been inconclusive as to whether there is an association between circumcision and “HIV-positive” status. A recognized problem is the number of potentially confounding factors in these observational studies, primarily cultural and religious characteristics that are often correlated with genetic characteristics.

A powerful argument that CIRCUMCISION DOES NOT PROTECT against “HIV-positive” status comes from solid and consistent observational data on cohorts of gay men. Universally, the groups most frequently testing “HIV-positive” are drug abusers and gay men; in the official jargon, injecting drug users (IDU) and men who have sex with men (MSM). Since IDU are supposedly infected via needles that do not normally make contact with the foreskin, MSM are the group most at risk for acquiring “HIV-positive” status via the foreskin; therefore this would be the ideal group for detecting any preventive effect of circumcision. But a review of 18 such studies found no preventive effect of circumcision against “HIV-positive” among MSM: Millett et al., “Circumcision status and risk of HIV and sexually transmitted infections among men who have sex with men”, JAMA, 300 [2008] 1674-84.

How then does it come about that the HIV/AIDS Establishment has accepted as an article of faith that circumcision reduces by half the risk of becoming “HIV-positive”? For example,

“CDC mulls routine circumcision of infants to reduce spread of HIV” (Tracy Miller, 25 August 2009)
“In an effort to reduce the spread of the AIDS-causing HIV virus, the Centers for Disease Control are currently mulling routine circumcision for all baby boys born in the United States . . . . The controversial recommendations, scheduled for a formal release by the end of the year, come on the heels of research that shows circumcised men in African countries hit hard by AIDS had half the risk of getting infected as those who were uncircumcised.
Critics say that focusing on newborns in the United States would only have an effect years down the road, and that circumcising infants subjects them to medically unnecessary surgery without their consent.
But CDC experts maintain that any step to reduce the spread of HIV is worthy of serious consideration.
‘We have a significant H.I.V. epidemic in this country, and we really need to look carefully at any potential intervention that could be another tool in the toolbox we use to address the epidemic,’ Dr. Peter Kilmarx, chief of epidemiology for the CDC’s division of HIV/AIDS prevention, told the Times. ‘What we’ve heard from our consultants is that there would be a benefit for infants from infant circumcision, and that the benefits outweigh the risks.’
Experts acknowledge that a new circumcision policy is unlikely to have a dramatic effect in HIV infection rates, as most adult men are already circumcised. Additionally, scant evidence exists to prove circumcision protects homosexual men from getting HIV.
79 percent of adult American men are already circumcised, according to public health statistics, though circumcision of newborns has dropped to about 65 percent in recent decades” [emphases added].

Note the usual bureaucratic prevarications:
— Unnamed “experts” and “consultants” are cited in the attempt to outweigh the actual scientific evidence;
— “a significant H.I.V. epidemic” is asserted to exist in the USA, contrary to fact;
— however, insofar as there may be an appreciable frequency of  “HIV-positive” instances in the USA, a large proportion is among MSM, who have been found NOT to benefit in this respect from circumcision;
— and that fact is euphemized or obfuscated by saying “scant evidence exists” instead of that the evidence speaks clearly against any benefit from circumcision.

Note too, “on the heels of research”: It is elementary that new research is not to be relied on until it has been confirmed over time by independent investigators and in a variety of circumstances. This rush to judgment is junk science. REAL SCIENCE ISN’T NEWS [Scientific illiteracy, the media, science pundits, governments, and HIV/AIDS, 15 January 2009].

Since HIV/AIDS theorists do not hesitate to swallow absurdities wholesale, they do not blink at the suggestion that “While circumcision may help protect heterosexual men in Africa from contracting HIV, . . .  it does not appear effective in doing so for American gay men, according to the largest study yet on the issue. . . . Circumcision ‘is not considered beneficial’ for gay men concerned about lowering their risk of becoming infected with HIV, Dr. Peter Kilmarx of the CDC told the Associated Press. He released the study findings at a conference on Tuesday. . . . But circumcision may not offer the same protection when it comes to anal sex, Kilmarx said.” [“Circumcision won’t shield gay men from HIV: Study” ].
Here once more the HIV/AIDS gurus would like to swing both ways, or perhaps every way. On the one hand, it is an hoary shibboleth that gay men are particularly at risk because anal sex is more conducive to “HIV transmission” than is vaginal sex, because of a greater likelihood of skin breakage and blood contact. But in order to justify a program of universal circumcision, it becomes expedient to take somehow the opposite view.

Why would circumcision be preventive?
“Scientists think circumcision can protect against HIV because the tissue of the foreskin has a high number of target cells for HIV infection and is susceptible to tearing during intercourse, providing an entry point for the virus” [“Circumcision: Change in medical opinion possible”].
But, again, anal sex is supposed to pose a greater risk for tearing skin than does vaginal sex. “I also find it fascinating that the male prepuce has gone straight from being an inconsequential ‘flap of skin’ to being a complex immunological organ, just in time to be infected by a virus that targets immune cells” [Winkel, “Rush to judgment”, PLoS Medicine 3(1) (2006) e71].

So the official conclusion is not only highly implausible, it is contrary to the facts accumulated over some twenty years or so. Yet all that is jettisoned by reliance on 3 brand-new clinical trials in Africa, all of them stopped prematurely after a year, that have supposedly shown definitively that circumcision reduces by about 50% the risk of becoming “HIV-positive” — among African heterosexual men, that is, though not among American gay men [Gray et al., “Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial”, Lancet, 369 (2007) 657-66; Bailey et al., “Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial”, ibid., 643-56; Auvert et al., “Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: The ANRS 1265 trial”, PLoS Medicine 2(11) (2005) e298].
A detailed deconstruction of these reports has to be deferred to a later post, this one is already longer than I prefer, but at least one feature of them is readily cited and adds greatly to the implausibility of the conclusion drawn:
In all three trials — in South Africa, Uganda, and Kenya —, the purported effect of circumcision was essentially the same at 50-60%, and it was independent of all other observed variables, among them number of sexual partners, non-marital relationships, condom use, paying for sex, drinking alcohol before sex, age, marital status, education (so stated specifically in Gray et al.).
Think about that. The probability of acquiring any sexually transmitted infection must depend on the probability of intercourse with an already infected person, which itself depends on the prevalence of the infection in the population; also influential will be the number of acts of intercourse and the number of partners, and whether sex is “social” or paid for, because prostitutes are by shibboleth supposed to be a reservoir of HIV and STDs; important too must be the care taken to protect via condoms, which is supposedly influenced by the state of sobriety or lack of it. Yet in 3 different cultures, in 3 widely separated regions of Africa, with groups of different age ranges, and where the incidence of “HIV-positive” in the control groups differed  significantly, somehow all those variables turn out to balance one other so precisely that the overall effect of the studied treatment is almost exactly the same. This strikes me as about as likely as 2 blue moons in the same year, or as Nessie surfacing just as I’m greeted by an alien emerging from a landed UFO.

There is quite a good reason, actually, why all 3 studies should have delivered the same apparent effect of circumcision, but it has nothing to do with “HIV” or sexual transmission: Surgery is well known to suppress immune function. Now the standard test for “HIV” is actually a test for antibodies, and the evidence is ample that “HIV” tests are highly non-specific, reacting “positive” when large numbers of a variety of antibodies are present. Since post-operative antibody production is lower as a consequence of surgery, post-operative apparent “HIV” incidence will be lower.

These clinical trials have demonstrated only that surgery cuts by about half (50-60%) the production of non-specific antibodies.

Trying to think about the Unthinkable

“Unthinkable” connotes different things in different contexts; it’s often value-laden — “an unthinkable horror” — but I’m using it here in the most basic sense of “inconceivable, impossible to imagine, not possible — impossible to think about”.

I had ascribed to cognitive dissonance, my difficulty in seeing that mortality (rate of death) among PWAs has nothing to do with individual deaths (median age of death) among PWAs [Cognitive dissonance: a human condition, 26 December 2008]; but my difficulty stemmed not only from the human penchant for cognitive dissonance, it was also owing to the logical impossibility of making sense of things that make no sense, trying to think about things that are unthinkable because there’s nothing to think about. If you try, you tangle your mind into Gordian knots.

The specific trouble here is that “mortality” and “death”, in general, in ordinary circumstances, when applying both to the same population, go together; “rates of death” and “average age of death” obviously ought to be related in some way. So it’s understandable that one begins by assuming that they also go together when it comes to “HIV” and “AIDS”. But since the latter aren’t definitive “things”, the populations of people classed as having “HIV” or “AIDS” aren’t “natural kinds”. You might equally try to compare the mortality among Andaman Islanders with the average age of death among the Sami. Since the  normal connection between mortality and death for a definite population doesn’t apply with “HIV/AIDS”, trying to think about the data brings up only mind-bending conundrums; until one finally realizes that there’s nothing there to think about, because “HIV” has nothing to do with “AIDS”.

The mortality among people defined as “PWAs” has changed in a manner that shows there is no functional relationship between “being a PWA” and the individual risk of dying for a person classified as “PWA” (reflected in the average age at which “PWAs” are reported to die). Therefore the basis for classifying someone as “PWA”, namely, “risk of dying from HIV disease, a.k.a. AIDS”, is wrong. Being classed as “having AIDS” has no functional connection to “risk of dying from AIDS”. Seems crazy, makes no sense — until you thoroughly absorb the fact that “HIV”, the criterion for “at risk of dying from AIDS”, actually has nothing to do with “AIDS”.

But if you’re stuck in the belief that HIV=AIDS, you’re doomed to attempt impossible explanations and to make nonsensical statements. So I occasionally get comments like the following from the ilk of Köpek Burun, The Snout, pseudo “Hank Barnes” at Change.org, Chris Noble, etc:
“There is a difference between two things being unrelated and them being inconsistent or contradictory.”

That boggled my mind. Of course there’s a difference, but we’re not talking about the definition of words. The point is that mortality and age of death are unrelated among “PWAs”, which demonstrates that “risk of death from HIV disease”, the criterion for being in the group of PWAs, doesn’t equate with the actual “risk of death from HIV disease” as experienced by individual PWAs. So “HIV”, being unrelated to “AIDS”, cannot be the cause of “AIDS”. It’s then utterly meaningless to attempt to consider whether “HIV” is consistent with or contradictory of “AIDS”; they just have nothing to do with one another. That disproves HIV/AIDS theory. Case closed.

Then KP-ilk continued:
“There may be no functional relationship between the price of sardines and size of oranges but this does not logically correspond to them being inconsistent or contradictory.”
Exactly. It’s meaningless to attempt to consider whether (sardines-price)-“HIV” is consistent with or contradictory of (oranges-size)-“AIDS”; they just have nothing to do with one another. That disproves (sardines-price)-“HIV”/(oranges-size)-“AIDS” theory. Case closed.

But KP-ilk went yet further:
“If you are claiming that the median age at death data contradicts the mortality data then you are obliged to show us what the relationship should be.”
But I’m not saying the mortality and death data contradict one another, I’m pointing out that they are not related. That disproves HIV/AIDS theory. Case closed.
Beyond that, here KP-ilk asserts a generalization that’s empirically baseless and illogical to boot: that when two things are not related, and therefore one is not the cause of the other, that cannot be recognized without postulating what the relationship between them should be if they were related!

Continuing in that vein, KP-ilk concludes with a statement that, pace Wolfgang Pauli, is “not even wrong”:
“If you are claiming that the median age at death data are not simply and directly related to the mortality data then this is not a disproof of the causal relationship between HIV and AIDS.”
Except, of course, the lack of any functional relationship between “at risk of dying from HIV disease, a.k.a. AIDS” and “at risk of dying from HIV disease, a.k.a. AIDS” does disprove the assertion that being a PWA, i.e. suffering from “HIV disease”, puts one at risk of dying from “HIV disease a.k.a. AIDS”. If there could be a clearer disproof of the claim that HIV causes AIDS, I’d like to know what it could be.

***************************************************************************

This aspect of HIV/AIDS, trying to think the unthinkable, is yet another similarity between HIV/AIDS and subjects that are often called pseudo-science: typically one is looking for explanations for which no explanation seems available, at least one consistent with logic and contemporary knowledge.

The topic of this sort that I know most about concerns Loch Ness “monsters”, a.k.a. Nessies. There’s a film of unquestioned authenticity that shows a large animal swimming in the Loch. Innumerable sonar contacts have been recorded with large moving underwater objects. A few still photos of underwater objects are consistent with several thousand eyewitness reports. BUT there is no explanation so far offered that is consistent with contemporary knowledge within biology. The apparent shape of the animals is like nothing except species (plesiosaurs) extinct for tens of millions of years; which, moreover, were air-breathing and would be seen at the surface far more often than Nessies are. Perhaps that’s what makes the mystery so universally fascinating.

Parapsychology affords similar conundrums. If it’s possible to glimpse the future, then one could do something to change it, transgressing common sense; or, it would mean that we don’t have the free will that subjectively we are sure we do have. Or, if the claims of above-chance psychokinesis or precognition are warranted, even at only a few percent above chance, then it would be possible to break casinos and win the sums of money that parapsychologists claim to need to further their research, which hasn’t been done even by those who claim to have successfully made money by above-chance predictions; why ever did they stop?

However, with Nessies and psychic phenomena and UFOs and the like, there are many evident gaps in empirical knowledge, so there exists the possibility (somewhere in the “unknown unknown” *) that future observations could provide satisfactory understanding of the empirical data. As concerns extrasensory perception, there’s even a plausible analogy in the phenomenon of quantum entanglement at the sub-microscopic level. With HIV/AIDS, there’s no such hope, because data in hand have already disproved decisively the notion that HIV causes AIDS.

———————————

* for a discussion of the “unknown unknown”, see my book, Science or Pseudoscience: Magnetic Healing, Psychic Phenomena, and Other Heterodoxies, University of Illinois Press, 2001