ARC's Adler and Svoboda Write Letter about HIV and Circumcision that NCFM Sends to Gates

Open Letter to The Bill and Melinda Gates Foundation

May 13, 2015

Everyone should applaud how your foundation is funding proven methods to slow the spread of HIV and AIDS in sub-Saharan Africa. These include testing, teaching the so-called ABC's (Abstinence, Be Faithful, and Condoms), retroviral therapy, treating schistosomiasis (which causes vaginal bleeding) and STDs, and helping to lead the search for an HIV vaccine. It is time, however, for your foundation to stop funding the campaign to circumcise a target 20 million African males as an HIV preventive strategy. The burden is on those wielding the knives, or in your foundation's case those funding them, to prove that the program will work and is working, that there are no better alternatives to it, and that it is ethically and legally justified, but that burden cannot be met.

1. The Program Is Unlikely to Work and May Backfire

a. Circumcision Offers Men Little or No Protection From HIV. The voluntary mass male circumcision program (VMMC) is being justified based on three randomized controlled trials (RCTs) conducted in sub-Saharan Africa which claim to show an impressive sounding 38% to 66% reduction in the rate of female to male transmission of HIV over 24 months.i In fact, circumcision provides men with little or no protection from contracting HIV. First, the RCTs have been criticized as scientifically flawedii,iii on so many grounds—including methodological bias, failure to determine the source of HIV infections, and early termination— as to raise serious, unresolved questions as to whether they prove anything. Second, the RCTs were only experiments. "Observational studies of general populations have for the most part failed to show an association between circumcision status and HIV infection."iv In fact, in several countries, circumcised men had a significantly higher prevalence of HIV than men who were not circumcised.v Third, even assuming that the trials were valid, the trials show that circumcision provides men with little or no protection from contracting HIV. 38% to 66% represent the relative risk reduction. The absolute risk reduction was only 1.31% and only during the two year period of the Thus, even assuming the results of the trials to be true, the trials show that circumcision does not prevent HIV in males; that it is largely ineffective in reducing the risk of it; and that 98.7% of African males will not benefit from circumcision. Thirty-eight distinguished physicians and ethicists primarily from Europe have written that the claimed health benefits of circumcising boys, including protecting them from HIV, are "questionable" and "weak".vii Garenne et al. have written that the protection provided by circumcision over a period of many years will be “negligible or nil.”viii Garenne writes elsewhere, "For highly exposed men, such as men living in southern Africa, the choice is either using condoms consistently, with extremely low risk of becoming infected, or being circumcised, with relatively high risk of becoming infected."ix

b. The Program May Increase the Spread of HIV. There are many reasons why a circumcision program to curtail HIV may in fact increase the spread of HIV. First, HIV can be spread by HIV-contaminated needles and equipment.x The risk of such contamination cannot be completely eliminated in the rush to circumcise up to 20 million males in multiple locations in lesser developed countries with a high turnover of personnel. Second, HIV-infected males who resume sexual intercourse during the wound healing phase risk infecting their female partners.xi Third, it cannot be ruled out that some males—told that circumcision reduces their risk of HIV infection by 60%—will mistakenly believe that they no longer need to use condoms, called "risk compensation".xii Fourth, circumcised men are less likely to use condoms anyway.xiii Fifth, circumcision increases friction during sexual intercourse, and due to diminution of sensation, circumcised men engage in more compulsive sex (i.e., substituting quantity for quality, or promiscuity)xiv as well as rougher sex,xv all of which increase the risk of tears in male and female bodily tissue and increase the risk of transmitting of HIV. Sixth, a Ugandan RCT showed that genitally intact men who wait at least ten minutes to clean their penis after sexual intercourse are 41% less likely to contract HIV than circumcised men.xvi If true, the foreskin that is improvidently removed by circumcision confers an appreciable level of immunity to HIV. Seventh, one of the RCTs produced evidence suggesting that circumcision may increase male to female transmission of HIV by 61%.xvii If true, any reduction in HIV infections in men will be offset by increases in HIV infections in women. Eighth, the VMMC program also implicitly encourages Africans to continue traditional male and female circumcision, which carry a higher risk of injury and death.xviii

In addition, the mass circumcision program takes scarce human and financial resources away from the safer, more effective, non-invasive alternatives described in the initial paragraph, especially condom use. Thus, the mass male circumcision program your foundation is funding is not the most efficacious method available to slow the spread of HIV and AIDS in Africa, and the program may well backfire.

2. The Risks and Disadvantages of Circumcision Exceed the Potential Benefits Claimed For It

Circumcision is painful with or without anesthetic, and African males will at best receive local and not general anesthesia. Circumcision also entails the risk of many minor injuries, serious injuries,xix and even deathxx in the United States, and the risks are even greater in Africa.xxi Moreover, medical personnel and facilities in Africa are comparatively less well prepared and equipped to handle the emergencies such as hemorrhage and infection, and probably unprepared or unavailable to perform the revision surgeries that are required to correct surgical errors. Circumcision also risks a poor cosmetic outcomexxii and may leave insufficient penile covering for a comfortable erection.xxiii Unnecessary invasive surgery,xxiv reducing the size of the penis,xxv radically altering its appearance, and leaving a scar all constitute forms of harm.

In addition, in the intact male, the moist foreskin glides back and forth with minimal friction, facilitating comfortable masturbation and sexual intercourse.xxvi Circumcision removes the vast majority of the penis's specialized erotogenic nerve endings.xxvii A 2007 study suggests that circumcision removes the most sensitive part of the penis.xxviii A 2013 Belgian study shows that circumcision decreases not only penile functioning and sensitivity but also sexual satisfaction for men, as well as for their female partners.xxix Promoters of the VMMC program have not proven otherwise, and the benefit of the doubt must go to protecting largely uneducated Africans from a procedure that they cannot fully understand and that will not effectively protect them from HIV.

3. The Program is Highly Unethical

a. The Program Violates Rules of Ethical Medicine. American physicians would refuse on ethical grounds to cut off parts of girls' and women's genitals in Africa, even though studies prove that such amputations could slow the spread of HIV and The same principle should apply to men. The VMMC program violates the cardinal rule of medicine, to "First, Do No Harm", and the rule of proportionality, whereby the expected advantages of any medical intervention for any individual must exceed its disadvantages.xxxi As stated, even assuming that circumcision reduces the risk of men contracting HIV during sexual intercourse by 1.3%, that means that this program will harm 98.7% of the African males circumcised without benefiting them at all (5.74 million males out of 5.82 million circumcised through July 2014, and 20.5 million males out of the 20.8 million targeted for circumcision).xxxii The program violates the ethical rule that when there alternative treatments are available, the most conservative treatment must be used.xxxiii It also is manifestly unethical to circumcise and protect some men from HIV infection when circumcision might infect an equal number of women with HIV during sexual intercourse. In addition, circumcision risks transmitting HIV, and Ebola during Ebola outbreaks,xxxiv to health care workers.

b. African Men Are Not Giving Fully Informed, Voluntary Consent. African men are being misled about circumcision. Informing them that circumcision reduces female to male transmission of HIV by 60% misleads them, even if it is true. This is the relative risk reduction, whereas the absolute risk reduction is only 1.3%.xxxv African men should be informed that there is a 98.7% probability that they will not benefit from circumcision, and that they can avoid HIV much more easily and effectively without circumcision by avoiding unsafe sex, by staying monogamous with an uninfected partner, and by using condoms, which are almost 100% effective. It is unlikely that Africans are being fully informed about the disadvantages of circumcision: pain during and after the surgery, the risk of injury and death, and that circumcision will or may impair their sex lives: many are being told that it will improve their sexual health.xxxvi Having fallen far short of the program's target (6 million out of 20 million)—after all, "it's not an easy sell"xxxvii—program leaders are placing increasingly intense pressure on men to get circumcised, including shaming and incentives such as free health advice, and there is even talk of paying men to participate,xxxviii which is coercive. The absence of fully informed voluntary consent and the presence of coercion each render men's consent involuntary and legally invalid. If African men were told the truth about circumcision and not coerced—e.g., told that circumcision offers little or no protection against HIV, that men must still use condoms during unsafe sex, and that circumcision removes highly erogenous tissue and does or may impair men's sex lives—far fewer African men would volunteer for it.

c. It is Unethical to Circumcise Boys and Infants. The African circumcision program began as a voluntary program for adult African men. Now boys are being specifically targeted,xxxix and even infants.xl The supposedly "voluntary" mass circumcision program is not voluntary for these infants or for the boys who are below the age of legal consent. The prevailing view of Western medical associations and physicians is that it is unethical to circumcise boys, many of whom will not engage in heterosexual intercourse for many years, if at all, and helpless infants. The correct rules of medical ethics are, "Do not operate on healthy children", and any important medical decision about a person's body such as circumcision that can be deferred must be deferred until the person who owns the body can make the decision for himself.xli

4. The Program Is Unlawful

Physicians and your foundation risk legal liability for every botched circumcision in Africa, and unless they were fully informed of the risks, for HIV transmitted to men during the surgery, HIV transmitted to men or women during the period of wound healing after the surgery, for the loss by men of sexual function, sensation, and satisfaction, and for poor cosmetic outcomes. Moreover, a consensus is emerging in the Western world that circumcision unlawfully violates the rights of every boy under United States and international laws, to safety, to bodily integrity, of which genital integrity is a subset, to liberty, autonomy, and privacy, and to the same protection from genital cutting that girls enjoy throughout the civilized world.xlii

Call to Action. The mass circumcision program in Africa that your foundation is funding is medically, ethically, and legally untenable. It is a pernicious new form of American imperialism, removing intimate body parts from millions of unsuspecting Africans by understating the risks to men and women, overstating the potential benefits, not disclosing the importance of the foreskin to male sexuality, and by not explaining that if men use a condom during unsafe sex—as they must still do—circumcision adds nothing. We call upon your foundation to immediately terminate its support for the program. Otherwise, the Gates Foundation and inevitably your own personal legacy will forever be associated with and tainted by what future generations will come to view as one of history's most harmful and unethical medical programs.

Respectfully submitted,
Harry Crouch, President
National Coalition for Men



Note: This is a letter and not an academic paper. A comprehensive discussion of these issues would require one or more books. The footnotes are intended for your guidance.

i Siegfried N, Muller M, Deeks JJ, Volmink J. Male circumcision for prevention of heterosexual acquisition of HIV in men. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD003362. DOI: 10.1002/14651858.CD003362.pub2, <>.

ii G.J. Boyle and G. Hill, “Sub-Saharan African randomised clinical trials into male circumcision and HIV transmission: methodological, ethical and legal concerns,” Journal of Law and Medicine, 19 (2011): 316-334 ("Boyle and Hill").

iii G.W. Dowsett and M. Couch, “Male circumcision and HIV prevention: is there really enough of the right kind of evidence?,” Reproductive Health Matters, 15, no. 29 (2007): 33-44,

<>; L.W. Green, R.G. McAllister, K.W. Peterson, and J.W. Travis, “Male circumcision is not the HIV ‘vaccine’ we have been waiting for!,” Future HIV Therapy, 2, no. 3 (2008):193-99; D.D. Brewer, J.J. Potterat, and S. Brody, “Male circumcision and HIV prevention,” Lancet, 369 (2007): 1597; D. Sidler, J. Smith, and H. Rode, “Neonatal circumcision does not reduce HIV/AIDS infection rates," South African Medical Journal, 98, no. 10 (2008):762-6; L.W. Green, J.W. Travis, R.G. McAllister et al., “Male circumcision and HIV prevention: insufficient evidence and neglected external validity,” American Journal of Preventive Health, 39 (2010):479-82; R.S. Van Howe and M.R. Storms, "How the circumcision solution in Africa will increase HIV infections", Journal of Public Health in Africa, Vol. 2, No. 1 (2011) ("Van Howe and Storms")


iv Van Howe and Storms, supra note 3.

v V. Mishra, A. Medley, R. Hong et al., “Levels and Spread of HIV Seroprevalence and Associated Factors: Evidence from National Household Surveys,” Demographic and Health Surveys Comparative Reports No. 22. Calverton, Maryland: Macro International 2009 ("There appears no clear pattern of association between male circumcision and HIV prevalence—in 8 of 18 countries with data, HIV prevalence is lower among circumcised men, while in the remaining 10 countries it is higher."),

<>; M. Garenne, “Long-term population effect of male circumcision in generalised HIV epidemics in sub-Saharan Africa,” African Journal of AIDS Research, 7 (2008): 1-8.

vi Boyle and Hill, supra note 2, at 326 ("What does the frequently cited '60% relative reduction' in HIV infections actually mean? Across all three female-to-male trials, of the 5,411 men subjected to male circumcision, 64 (1.18%) became HIV-positive. Among the 5,497 controls, 137 (2.49%) became HIV-positive, so the absolute decrease in HIV infection was only 1.31%."), cited in B. Earp, When Bad Science Kills, or How to Spread Aids, June 10, 2012

< >.

vii M. Frisch, Y. Aigrain, Y. Barauskas et al., “Cultural bias in the AAP’s technical report and policy statement on male circumcision,” Pediatrics, 131 (2013): 796-800 ("Cultural Bias").

viii M. Garenne, “Male Circumcision and HIV Control in Africa: Questioning Scientific Evidence and the Decision-making Process,” in T. Giles-Vernick and J.L.A. Webb Jr., eds., Global Health in Africa: Historical Perspectives on Disease Control (Athens, Ohio: Ohio University Press, 2013): 185-210, at 190.

ix M. Garenne, Male circumcision and HIV control in Africa. PLoS Med 3(1): e78 (2006), <>.

x D. Gisselquist, Points to consider: responses to HIV/AIDS in Africa, Asia, and the Caribbean, Adonis & Abbey Publishers, 2008. ISBN-978-1-905068-45-6.

xi "The World Health Organization currently recommends abstinence for at least six weeks after surgical male circumcision", <> and


xii Van Howe and Storms, supra note 3. George Gavin et al., Barriers and facilitators to the uptake of voluntary medical male circumcision (VMMC) among adolescent boys in KwaZulu-Natal, South Africa, African Journal of AIDS Research, 13:2, 179-187 ("Gavin") ([T]here is a still a problem with misinformation. 'There are people who still need more information because they think being circumcised gives you full protection against AIDS'"),


xiii R. Crosby and R.J. Charnigo, A comparison of condom use perceptions and behaviours between circumcised and intact men attending sexually transmitted disease clinics in the United States. Int J STD AIDS. 2013 Mar;24(3):175-8. doi: 10.1177/0956462412472444. Epub 2013 May 6. <>.

xiv Hammond T. “A Preliminary Poll of Men Circumcised in Infancy or Childhood, ” BJU International (83, Suppl. 1),  p. 85-92, January, 1999 < Poll 1999.pdf>; Global Survey of Circumcision Harm (2012), <>. Laumann E, Masi C, Zuckerman E. “Circumcision in the United States: Prevalence, Prophylactic Effects, and Sexual Practice, ” Journal of the American Medical Association, Volume 277, Number 13: Pages 1052-1057, April 2, 1997.

xv N. Ebdrup, ScienceNordic, Male circumcision leads to a bad sex life, November 14, 2011 ("Circumcised men prefer it rough"), <>.

xvi F.E. Makumbi, R.H. Gray, M. Wawer et al., “Male post-coital penile cleansing and the risk of HIV-acquisition in rural Rakai district, Uganda,” abstract from presentation at Fourth International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention, Sydney, 2007, <>.

xvii Wawer M.J., Makumbi F., Kigozi G., et al. (2009) Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial. The Lancet, 374, 229–237, <>. Accord, Johns Hopkins Medicine, "As Circumcision Wounds Heal, HIV-Positive Men May Spread Virus To Female Partners, Study Shows (April 28, 2015) ("There is a window of a few weeks after circumcision when the risk that an HIV-infected man could transmit the virus to a female partner actually increases ... [S]everal programs have reported that greater than 30% of the men have sex with female partners during the healing period ... Although we’re counseling men not to have sexual intercourse while their wounds are healing, we know that they are ...”).

xviii See, e.g., Clearinghouse on Male Circumcision for HIV Prevention, Male Circumcision News, "Call to ban unsterile male circumcisions", citing 38 deaths of initiates and 10 penile amputations in South Africa. <>.

xix American Academy of Pediatrics Task Force on Circumcision. Male circumcision. Pediatrics, 130, no. 3 (2012): 585-586 and e756-e785, <>.

xx KNMG, Non-therapeutic Circumcision of Male Minors (Utrecht, Netherlands: KNMP, 2010).

xxi See supra note 18.

xxii American Urological Association, Circumcision Policy Statement, <>.

xxiii J. Hunter, A treatise on the venereal disease, at 221, London (1786), <>.

xxiv Tortorella v. Castro, Cal. Ct. App. 2d (2006) ("any unnecessary surgery is inherently injurious in that the patient needlessly has gone under the knife and has been subjected to pain and suffering").

xxv The total surface area of the adult foreskin is estimated to be approximately 30-50 cm2. G, Kigozi, M. Wawer, A. Ssettuba et al., “Foreskin surface area and HIV acquisition in Rakai, Uganda (size matters,” AIDS, 23, no. 16 (2009): 2209-2213; P.M.N. Werker, A.S.C. Terng, and M. Kon, “The prepuce free flap: dissection of feasibility study and clinical application of a super-thin new flap.,” Plastic and Reconstructive Surgery, 102 (1998): 1075-1082.

xxvi S. Lakshmanan & S. Prakash, Human Prepuce: Some Aspects of Structure and Function, 44 Ind. J. Surgery 134, 134–37 (1980), <>.

xxvii J. Cold and J.R. Taylor, “The prepuce,” BJU International, 83, no. S1 (1999): 34-44; M.M. Landers, “The human prepuce,” in G.C. Denniston, and M.F. Milos, eds., Sexual Mutilations a Human Tragedy (New York: Plenum Press, 1997): 77-83; D. Taves, “The intromission function of the foreskin,” Medical Hypotheses 59 (2002): 180-182.

xxviii M.L. Sorrells, J.L. Snyder, M.D. Reiss et al., “Fine-Touch Pressure Thresholds in the Adult Penis,” BJU International, 99 (2007): 864-869, 864.

xxix G.A. Bronselaer, J.M. Schober, H.F.L. Meyer-Bahlburg et al., “Male circumcision decreases penile sensitivity as measured in a large cohort,” BJU International, 111, no. 5 (2013): 820-827,


xxx Stallings RY, Karugendo E. Female circumcision and HIV infection in Tanzania: for better or for worse?[abstract] Third International AIDS Society Conference on HIV Pathogenesis and Treatment. Rio de Janeiro, July 25-27, 2005.

xxxi See, e.g., Cultural Bias, supra note 7, at 797.

xxxii World Health Organization, WHO Progress Brief - Voluntary medical male circumcision for HIV prevention in priority countries of East and Southern Africa (July 2014), at <>.

xxxiii For example, the Medical Ethics Department of the British Medical Association (2006) advises use of conservative treatments whenever possible. Committee on Medical Ethics. The law & ethics of male circumcision - guidance for doctors. London: British Medical Assoc. (2006).


xxxiv See, e.g., For Ebola Health Workers, Risks and Duty Collide, The New York Times, October 16, 2014, <>.

xxxv See Boyle and Hill, supra note 2, at 330.

xxxvi See, e.g., Gavin, supra n. 12 ("The perceived increase in sexual pleasure for boys having undergone circumcision also mustered support for the procedure"; "There was a perception that circumcision enhances sexual pleasure and performance (for both males and females), which appeared to be a strong motivator for boys to undergo the procedure."; "[T]he majority of participants were well informed about the extent to which circumcision reduces risk and increases sexual health".)

xxxvii "'It's not an easy sell, you know? It's probably the greatest marketing challenge of all times,' says Dino Rech, head of the Centre for HIV and AIDS Studies Prevention, who has helped lead the effort to circumcise men in South Africa." <>.

xxxviii JAMA Releases for July 20, 2014, Providing Economic Incentive Results in Modest Increase in Medical Male Circumcision Performed to Help Reduce Risk of HIV ("Among uncircumcised men in Kenya, compensation in the form of food vouchers worth approximately U.S. $9 or $15, compared with lesser or no compensation, resulted in a modest increase in the prevalence of circumcision after 2 months, according to a study published by JAMA.").

xxxix U.N. AIDS, Joint Strategic Action Framework to Accelerate the Scale-Up of Voluntary Medical Male Circumcision for HIV Prevention in Eastern and Southern Africa (November 2011) ("Scale-up of early infant, adolescent and adult voluntary medical male circumcision is critically important to reduce the future burden of HIV in eastern and southern Africa.") See also Avert, Averting HIV and AIDS, Voluntary Medial Male Circumcision (VMMC) for HIV Prevention: "UNAIDS and WHO advise that the greatest public health benefit would result from prioritising circumcision for young males (between 12-30 years of age). One study has highlighted the benefits of prioritizing male circumcision among adolescents rather than adults. <>. See also Gavin, supra note 12 ("Timing of VMMC Interventions needs to be considered when targeting school-going boys").

xl Clearinghouse on Male Circumcision for HIV Prevention ("Parents embrace infant male circumcision"). <>.

xli Cultural Bias, supra note 7.

xlii See, e.g., P. Adler, “Is Circumcision Legal?”, Richmond Journal of Law and the Public Interest, 16, no. 3, 439-483 (2013), at 483, <> ("[U]nder any analysis, circumcision is illegal."); and J. Steven Svoboda, Circumcision--A Victorian Relic Lacking Ethical, Medical, or Legal Justification; The American Journal of Bioethics, Vol. 3, No. 2, Spring 2003 at 52-54 ("[M]ale circumcision is not a medically, ethically, or culturally neutral practice, suitable to be left to parental whim, but rather a clear violation of a number of central principles from the disciplines of medicine, ethics, law, and human rights.")



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