A new breed of circumcision clamps are a clear menace to foreskins. Are they a boon to public health?
Habitual do-it-yourselfers, please turn the page.
But readers able to resist temptation to put new gadgets to the test might be curious to know: recent years have seen a proliferation of devices to excise foreskins without need of doctor or clinic. A lightly-instructed
practitioner and hut in the woods will do.
Will the noughts be remembered as a golden age of single-use, disposable plastic circumcision clamps?
The granddaddy of the category-- the Tara Klamp-- was developed with the help of the Malaysian government in 1993. Its innovations were assuring sterility, covering glans and shaft in scalpel-proof armor, and
compressing the wound until a penis healed-- all to minimize risk of error or infection.
The Tara Klamp is now joined by a veritable UN General Assembly of related products-- including the Dutch Smart Klamp, the Singaporean Pro Device, the Turkish Kirve Klamp, the Korean Good Man, the Malaysian
Sunathrone, and the Chinese Zhenxi Ring. In the works is a South African Tara-Klamp variant, designed to fall off the penis all by itself once healing's done.
The timing couldn't be better. The evidence that male circumcision dramatically cuts HIV transmission-- especially from women to men, but also for gay men-- has been gathering since the mid-1980s. Yet curiously,
circumcision until now has been almost ignored as an arrow in the public health quiver.
That's changing after three recent randomly-controlled studies in South Africa, Kenya, and Uganda with some 11,000 participants showed that being circumcised reduced the rate of seroconversion for men an average of
nearly 65 percent.
There are several biological reasons why keeping a foreskin and getting HIV might correlate.
The biggest factor is that the foreskin turns out to be a sponge for the virus. Its inner surface is a mucus membrane that's especially rich in the immune cells-- CD-4, Langerhans, and macrophages-- that HIV targets.
The foreskin's mucosa was found to be nine times as likely to pick up HIV as that of a woman's cervix.
Other factors may amplify the effect. Viruses or bacteria caught under the foreskin are trapped longer, and have more time to work mischief. According to a New Zealand study published last November, uncircumcised
men suffered 48 percent more sexually-transmitted infections-- entailing sores and inflammation that can in turn be portals for HIV.
It's a different mucus membrane-- the rectum-- that's implicated most in HIV infection among men-having-sex-with-men. But circumcision status matters here, too. A study published in 2005 in the
Journal of AIDS found circumcised MSMs ac-quired HIV at a rate half that of uncut men.
Defenders of foreskin bristle
In North America a burgeoning movement against circumcision has helped reduce rates among newborn boys. In bellwether California, the numbers fell from 64 percent in 1979 to 37 percent in 1999. Anti-circ activists say
that evidence that the opersation protects against HIV is suspect and anyway irrelevant. Circumcision, they contend-- at least when it's not undertaken voluntarily by adults-- is a cross between raping a fellow and knifing him in
The foreskin isn't just a vector for HIV, they note-- it's richly innervated tissue, alive to erotic pleasure, and guardian of the glans, the cock's sensitive tip. Removing the prepuce, critics contend, is an act of violence that
must be rejected out of hand-- like cutting off fingers as prophylactic for nail fungus.
And even a 65 or 70 percent reduction in seroconversion over a year leaves a wide window open as years-- and unprotected sexual encounters-- add up. Unless men don condoms and otherwise follow the dicta of safer
sex, circumcision alone won't protect them. Will men who get cut to stay healthy overestimate their invulnerability, and just behave more recklessly?
Those arguments aren't convincing, many public-health workers counter. The fight against HIV has so far involved a handful of partial measures-- antiretrovirals and condoms are themselves no magic bullets. And by the
logic of some anti-circers, using seat belts would only lead to more deaths in car crashes.
And as for the reputed wrong of circumcision, cut men are generally content with their status, and societies where males undergo the procedure routinely are happy enough with the results to keep doing it.
Some anomalies remain in the data linking circumcision to reduced rates of HIV. But on the largest scales, the connection seems to hold. For example, in the Philippines, Indonesia, and Bangladesh-- with near universal
male circumcision and despite plenty of condomless and commercial sex-- expected HIV pandemics have never materialized. And did the high rates of circumcision among sexually-active American men in the 1980s keep a
blooming of heterosexual AIDS, also predicted, from ever erupting?
"No nation where male circumcision is nearly universal has an HIV prevalence rate higher than about five percent," Daniel Halperin of Harvard's School of Public Health tells
Results so far are mixed as to whether the new clamps are better than more traditional techniques, especially for adults. Though in contexts where rank amateurs attempt circumcision-- as is sometimes so in South
Africa's Eastern Cape, where the operation is part of initiation rituals that can seem like deadly hazings-- the new clamps may save lives.
In Southern Africa, HIV-infection rates range upwards of a third of adults, as in Swaziland, where Halperin was based until recently as an HIV prevention advisor for USAID. Demand for circumcision is rising in Africa, he
says, confounding those who say the practice is too tied with culture and identity to budge. Making circumcision easier for guys who want it-- perhaps eventually abetted by gadgets that make the snip safer-- can't be a bad thing.
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