Saturday, April 27, 2013

CIRCUMCISION "RESEARCH": Rehashed Findings and Misleading Headlines

So I log on to Facebook and read my news feed to find that intactivists have their panties in a bunch because some "new study" is about to be published, which suggests that a causal link between circumcision and a reduced transmission in HIV may have finally been found.

"This I've got to see," I thought to myself.

So I follow the links, and sure enough, there it was.

(Original press release can be seen here.)

Some "researchers" claim to have made the discovery that circumcision exposes the glans and internal mucosa of the penis, drying it out, thereby changing its bacterial environment, or "microbiome," along with the hypothesis that this new finding "might" explain why "circumcision reduces HIV transmission."

(Readers should find it peculiar that 7 years after the famous African "trials" that prompted the WHO to endorse circumcision as HIV prevention in Africa, a demonstrable causal link between the foreskin and facilitated HIV transmission has yet to be established.)

But something told me I had seen this "microbiome/bacterial environment" mumbo-jumbo before, and after a quick Google search, I knew that I was right.

Back in 2010, the same group of "researchers" tried to push this "discovery" as a possible explanation for the supposed "results" in the African circumcision "trials."

(2010 PLOS ONE study can be seen here.) 

In other words, the so-called "researchers" aren't presenting anything "new;" they're merely re-hashing an old "discovery" and trying to present it as if they've only just "found" it yesterday.

But then, this wouldn't be the first time circumcision advocates have tried to re-hash old crap to make it appear as if it were "new" and "innovative"; they're trying to modernize a religious ritual that dates back millennia for crying out loud.

The press release has spawned news articles with ridiculously misleading titles.

Reads one CNN article:

"Why circumcision lowers risk of HIV"

The title isn't substantiated by the body of the article.

Yes, "researchers" have found that circumcision changes the bacterial environment. (Douching does the same in women, in some cases causing PROBLEMS.) No, they are not anywhere closer to presenting a causal link between circumcision and a reduction in HIV transmission.

That a change in the bacterial environment causes a decrease in HIV transmission is an unproven hypotheses, but the title leads readers to believe that scientists have reached a final conclusion.

(Why is nobody "researching" to see if changing the bacterial environment in the female vulva "reduces" HIV or other STD infections? Answer: Because such research is deemed politically incorrect, especially if the findings are positive.)

Why are they rehashing this "finding?"

Is it that nobody cared the first time?

The Missing Causal Link
In 2006, three "studies" that claimed male circumcision "reduced the risk of HIV transmission by 60%" were published. They were instrumental in getting the WHO to endorse male circumcision as HIV prevention in high-risk areas in Africa. The WHO endorsement, along with the "research" that was used to author it, has been bandied about by circumcision proponents to promote *infant* circumcision in America, of all places. 

Most people don't know this, but while they are paraded around as being "the gold standard," well-known African circumcision "trials" are horrendously flawed. One of their biggest flaws, perhaps their biggest, is the fact that they are missing a vital, core component; a scientifically demonstrable causal link.

If one examines the wording of the so-called "trials" in Africa, they all say that their purpose is to "measure the effect of circumcision in reducing HIV," an "effect" that has never actually been demonstrated to be true; it has only ever been *assumed* apriori, without any demonstrable proof whatsoever, that a causal relationship exists, without question.

Trying to measure a phenomenon without a causal link is logically fallacious. It is like trying to run a computer without a processor, a time machine without a flux capacitor.

Indeed, the (carefully selected) data presented in the African "studies" show that there may be a (far-fetched) correlation between circumcision and a (very slight) reduction of HIV, but correlation does not equal causation; just because two things are correlated does not mean that one causes the other.

A correlation simply means that a relationship exists between two factors, but it tells you nothing about the direction of that relationship; the relationship could very well exist by mere virtue that biased observers decided to juxtapose them. Westboro Baptist Church draws a correlation between the presence of homosexuals and natural disasters, for example.

Without a demonstrable causal link, one could claim that an absence of vampires in the vicinity of garlic is "proof" that garlic keeps them away, that countless sightings "prove" UFOs exist, or that dead exsanguinated cows are "proof" that the chupacabras exists, without ever actually showing you a vampire, UFO or chupacabras.

Without a causal link, the African "trials" are meaningless statistics embellished with correlation hypothesis. Circumcision "researchers" merely juxtapose carefully chosen statistics and assume a causal relationship exists as a matter of fact, perhaps hoping nobody will notice.

So far, it has worked, because few people have bothered to notice that, despite the claims that "circumcision reduces the risk of HIV transmission by 60%," and assertions that this is a foregone conclusion "beyond reasonable doubt," the "researchers" who authored those "studies" never did present a scientifically demonstrable causal link.

Like a car without a motor, the African trials, and all work based on them are simply worthless junk, and all of what is happening in Africa, the AAP's latest attempt to endorse infant circumcision in America, etc. is not evidence-based, but myth-based medicine, which is why intactivists are keeping a close watch on circumcision "research" and claims of finally discovering the fabled causal link between circumcision and HIV transmission "reduction."

A Brief History of the Circumcision/HIV "Correlation" 
The African "studies" may have been published 7 years ago, but few people are aware that circumcision "researchers" had been groping for a causal link between circumcision and a reduced likelihood of HIV transmission, since the idea was first promoted in 1986 by a man named, Aaron J. Fink, who was distressed at the overall falling popularity of infant circumcision, hoping to reverse the trend.

During the 1980s, some physicians were condemning circumcision as "barbaric and unnecessary," and only "advocated by the uninformed." In 1986, Blue Shield providers in several states decided to discontinue coverage of neonatal circumcision. In reaction to this, Fink sent a manifesto entitled "In Defense of Circumcision" to the New York Times and the San Francisco Chronicle, repeating antiquated claims of benefits; many of which weren't even published.

In 1986, Fink wrote a letter titled "A possible Explanation for Heterosexual Male Infection with AIDS," where he argued that the hard and toughened glans of the circumcised male resisted infection, while the soft and sensitive foreskin and glans mucosa of the intact male were ports of entry. Fink proposed in his letter: "I suspect that men in the United States, who, as compared with those in Africa and elsewhere, have had less acquisition of AIDS, have benefited from the high rate of newborn circumcision in the United States," regardless of the fact that the United States has one of the highest circumcision rates, and one of the highest HIV rates, in the western (industrialized) world (compare with European countries, Canada, and Australia).

Fink's proposal appeared in media throughout the US and Canada. Asked about his idea by a United Press reporter, Fink replied "This is nothing I can prove." This didn't stop other physicians from conducting "research" leading to a steady stream of widely publicized articles arguing that circumcised men were less likely to contract HIV--with the result that prevention of HIV infection has now surpassed even cancer prevention as the most popular claim of circumcision advocates.

"This is nothing I can prove."
~Aaron J. Fink

Fink abandoned the circumcision/HIV controversy in 1991, and he died in 1994, but he left behind an indelible legacy nonetheless; researchers and scientists continue efforts to establish a causal link between increased HIV infection and the presence of anatomically correct male genitals to this day.

The Quest for a Causal Link
Since Fink proposed that circumcision prevents HIV transmission in 1986, various hypotheses for a causal link have been suggested. They all either remain unproven, or have been completely debunked, however, and thus far, circumcision "research" claiming a decrease in HIV transmission remains unsubstantiated by a scientifically demonstrable causal link.

Hardened Skin Hypothesis
Perhaps the oldest hypothesis for a causal link between circumcision and HIV reduction was Fink's theory that the keratinized surface of the penis in circumcised male resists infection, while the mucosa of the glans and inner of the intact male are ports of entry.

Recent studies, however, disprove this hypothesis. One study found that there is "no difference between the keratinization of the inner and outer aspects of the adult male foreskin," and that "keratin layers alone were unlikely to explain why uncircumcised men are at higher risk for HIV infection." Another study found that "no difference can be clearly visualized between the inner and outer foreskin."

Be that as it may, some circumcision advocates continue to preach Fink's hypothesis as gospel, the last time that I talked about it on this blog was when news outlets were publishing paid ads for the PrePex device.

"A person living without shoes, they have very hard skin. They are walking on stone every day, without any wounds. So it's the same thing with the penis."
Langerhans Cell Hypothesis
Szabo and Short proposed that the Langerhans cells were the prime port of entry for the HIV virus. According to the hypothesis, circumcision was supposed to prevent HIV transmission by removing the Langerhans cells found in the inner mucosal lining of the foreskin.

deWitte et al. found that not only are Langerhans cells found all over the body and that their complete removal is virtually impossible, they also found that Langerhans cells that are present in the foreskin produce Langerin, a substance that has been proven to kill the HIV virus on contact, acting as a natural barrier to HIV-1 transmission by Langerhans cells.

This theory would also apply to females, where the mucosa in the vulva is also laden in Langerhans cells, but for whatever reason, no circumcision "researcher" has suggested "circumcision trials" for women, to see if the removal of mucosal tissue would "reduce" the likelihood of HIV transmission. There are two studies that suggest a connection between female circumcision and a reduced likelihood of HIV transmission.  (See here and here.)

An interesting note, while Szabo and Short propose that the Langerhans cells are the prime port of entry for HIV, Weiss argues that there aren't *enough* Langerhans cells in the foreskin. Of course, both "studies" conclude that circumcision protects men against HIV and AIDS. 

Bacterial Environment Hypothesis
And here we are today.

Price et al. observe a difference in the bacterial microbiome on anatomically correct and circumcised penises, and propose the hypothesis that this change in the bacterial environment of the penis may be responsible for the reduction of female to male sexual HIV transmission.

Rather far-fetched, the argument is that the change in bacterial environment after circumcision makes it difficult for bacteria that cause diseases to live; there are less chances for penile inflammation, a condition that facilitates the transmission of viruses. The chances for penile inflammation are reduced, thereby reducing the chances of sexually transmitted viruses, such as HIV.

Presenting this hypothesis presents a two-fold problem. First, it presents an irrelevant conclusion; the randomized control trials were measuring frequency in HIV transmission, not for frequency in penile bacterial inflammation, and whether said inflammation facilitated sexually transmitted HIV. And secondly, circumcision advocates give themselves the new burden of proving the newly introduced hypothesis, that a change in bacterial infection does indeed result in a significant reduction of HIV transmission. Were the men who acquired HIV sexually, suffering bacterial infections at the time? (Did they actually acquire HIV sexually?)

And how did the circumcised men in the studies (64 out of 201) who acquired HIV, acquire HIV?

This hypothesis was first published in 2010, and it is now being published again as a "new discovery" in 2013.

An interesting note; co-authors include a list of usual suspects who have published other pro-circumcision "research," namely Aaron A.R. Tobian, David Serwadda, Godfrey Kigozi, Maria J. Wawer and Ronald H. Gray. (Surprise, surprise, Wawer and Gray are married; Gray authored one of the big three "trials" in Africa.)

Perhaps the biggest flaw in any "research" that tries to establish a "correlation" between anatomically correct male organs and an increased HIV transmission is that of a missing, scientifically demonstrable causal link.

It was missing when the idea that circumcision prevents HIV was first invented in 1986, and it continues to be missing today.

The original "studies" that the WHO used as a basis for their endorsement for circumcision as HIV prevention in Africa never did provide an established causal link; the researchers only asserted, and continue to assert, without demonstrable scientific proof, that one exists.

Circumcision "researchers" have presented a cart, but can't seem to produce the horse that pulls it.

Hypotheses of a possible causal link between circumcision and HIV reduction have been posited, but so far they have either been disproven or completely debunked.

This is the second time the "microbiome" hypothesis has been posited, and the "researchers" aren't anywhere closer to explaining how the presence of anatomically correct genitals increases the likelihood of HIV transmission, and how circumcision is supposed to reduce said transmission.

A scientifically demonstrable causal link remains elusive, like a unicorn or the Loch Ness Monster.

Without a demonstrable causal link, circumcision "research" attempting to link circumcision with a reduced transmission of HIV lacks scientific validity, and the efforts to promote mass circumcision in Africa and in the United states are all myth-based, not evidence-based.

The results of the so-called "research" have been accepted as bring "beyond reasonable doubt." The WHO has issued it's "recommendation" of what is essentially male genital mutilation as HIV "prevention." Entire "mass-circumcision campaigns" have been launched in Africa by the US government on the taxpayer's dime in the so-called name of "foreign aid," and AAP fellows salivate over the idea of endorsing routine infant circumcision in the US, but the fact that a causal link has yet to be established has somehow slipped by unnoticed.

Researchers grope desperately for causal link, before a critical mass gets wind of the fact that one doesn't actually exist, which is why we're going to keep seeing press-releases like these, boasting to have finally found it.

Even if
There are other problems with "research" that claims that circumcision reduces HIV transmission.

Another big problem, for example, is the fact that the data in the "research" simply fails to correlate with reality. In spite of having an adult circumcision prevalence rate of 80%, the USA has a higher HIV transmission rate than 53 countries where circumcision is rare (less than 20%), according to the CIA fact book.

The thing is, even *if* a scientifically demonstrable causal link between male circumcision and a reduction of HIV transmission could be established, there are ethical problems with promoting what is essentially genital mutilation in the name of disease prevention.

Does it not strike anyone else as odd that people are busy trying make surgery indispensable, as opposed to making it obsolete?

How would we react to similar "research" if the subjects were women?

The Langerhans cells hypothesis, if it were valid, could also apply to women, where Langerhans cells also line the mucosa of the female vulva. Women also have a bacterial environment which, if changed, may or may not reduce HIV transmission. For whatever reason, no plans for "circumcision trials" in women exist.

If a causal link could be established between a reduction in HIV transmission and the removal of labia from women, how would we look at "circumcision trials" that involved thousands of women?

What if the WHO endorsed female genital cutting as "HIV prevention," and it had the "research" to prove it?

How would we react to the AAP endorsing female genital cutting?

Well. We already know the answer to that question, don't we.

Would there ever be enough "scientific evidence" to vindicate female genital cutting as "tradition?"

Read the banner on my blog.

Genital mutilation, whether it be wrapped in culture, religion or “research” is still genital mutilation.

It is mistaken, the belief that the right amount of “science” can be used to legitimize the deliberate violation of basic human rights.

Related Posts:

Politically Correct Research: When Science, Morals and Political Agendas Collide

Where Circumcision Doesn't Prevent HIV

Where Circumcision Doesn't Prevent HIV II