Male circumcision could save thousands of lives. This was the message delivered by Bill Clinton this week at an AIDS conference in Toronto. But it will be a lot of trouble to get done, he added. Even if the science confirms what seems evident from the trials already undertaken, overcoming the cultural barriers to male circumcision will be a momentous challenge.
The debate around male circumcision is one that has long intrigued me. In the Muslim world it is done without a thought, it is the norm. We think of it as part of our religion, though strictly speaking it is a religious practice rather than a dictate. There are cultural variations as to how it is done. Within Saudi Arabia alone, there are regional differences, with some circumcising the child when he is only a few days old and others waiting until puberty and accompanying the circumcision with rites of passage and festivities.
We consider it appropriate to circumcise our sons not just for religious reasons but also because it is thought of as hygienic. The every-day word for circumcision "tahur" in itself suggests that it is a form of purification and purity is a big deal to us Muslims. But more than that we are convinced that male circumcision is healthy and will protect from disease and infection. We are convinced of this without the need for scientific evidence, in the same way most of us believe that keeping warm prevents us from getting colds. It is a given, something so obvious that the idea of questioning it seems ridiculous.
Not so female circumcision. That is genital mutilation, an abhorrent barbaric practice which we have fought hard - though not nearly hard enough - to banish.
If I had a son, I would not hesitate to have him circumcised. Yet when I hear of girls being "circumcised", whether it is a clitoridectomy, an excision, or a full-blown infibulation, I find myself screaming with anger. The two are clearly not the same. While male circumcision leaves a man able to enjoy a full active sex life and leaves no pain or long-term damage, female circumcision is horrific in every respect.
And yet, in principle some of the arguments put forward by the anti-circumcision lobby apply to both genders. Just as some of the justification for circumcision uses the same language for both genders. Is removing foreskin not mutilation in the strict sense of the word? Do parents have the right to surgically alter their child's genitalia without consent? Does religious belief justify physical mutilation? There is now a strong political movement - particularly in the US - against male circumcision. Some go as far as calling it child abuse. And within this backdrop, the medical profession has hinged its bets. Whereas paediatricians once recommended circumcision - for instance in Britain boys of Prince Charles's generation were often circumcised - they now at best say there is no harm in it but no medical grounds for undertaking it.
But the pendulum is starting to swing in the other direction once again. The idea that circumcision gives men - and consequently the women they sleep with - some protection from sexually transmitted diseases is not new. There has been a whole body of research pointing to differences in the prevalence of syphilis for instance among circumcised and uncircumcised men, with the former being significantly less likely to become infected than the latter. But the problem is that most of these studies were correlative in nature, just as the first studies identifying a link between circumcision and reduced rates of HIV infection in Africa were epidemiological. As a research method it is rather limited; correlation does not prove a causal link. Results can also often be muddied by the effect of other factors. For instance differences in the incidence of sexually transmitted diseases between circumcised and uncircumcised men may be more to do with differences in lifestyle and sexual habits, particularly if circumcision is associated with belonging to a particular religious or racial group. Even so, some studies that controlled for such factors did find that circumcision was associated with reduced rates of infection. But how?
And this is where it gets interesting. It seems it is due to the nature of the foreskin. Most skin on the body is keratinised: It has a thick protective layer of keratin that protects it from infection. The areas of the body's skin, which are easily infected, are those that lack keratin such as the soft mucous skin on the inside of your nose for instance. The inside of the foreskin has also been found to be low on keratin and hence an easy entry point for viruses. Furthermore, it is also loaded with a specific type of skin cell called Langerhan cells that normally act as a defense against infection. These cells trap viruses and send them directly to the immune system to be destroyed but in the case of HIV, a virus that destroys the immune system, they ends up doing the exact opposite. Through biology, we have an explanation of why the foreskin makes men vulnerable to disease.
But reducing risk is not the same as protection. There is a danger that promoting circumcision as a way to combat HIV and other sexually transmitted diseases could be counterproductive if people do not understand that the risk is not eliminated. It is only one line of defense but one which could potentially save thousands of lives in a continent like Africa where countries are being decimated by AIDS. At the end of the day though, the only way we will win the battle against AIDS is through committing enough financial, human and medical resources to undertake the cultural and economic turnaround necessary to give people the tools they need to protect themselves from infection and disease.
