A Little Off The Top And Sides–Should You Get Circumcised For World AIDS Day?

No country in the world has done a more thorough job of circumcising it’s newborn boys than the United States. In many places, if you don’t put a Do Not Cross Crime Scene tape across your new son’s genitals, he’ll get whisked off and trimmed before you know it. And yet, here we are with a rampant HIV epidemic. What gives with this news about circumcision preventing HIV?

First, let me extend my greatest Doc Gurley Air Kisses Award to Kennedy Gondwe, a Zambia-based reporter who has single-handedly brought the circumcision issue into the public’s consciousness–he not only got circumcised, he brought in a BBC film crew to share the experience with the world. This guy ranks right up there with Magic Johnson (who outed his infection himself at the cost of his career in order to destigmatize HIV and help others), and Katie Couric (who let the Today show videotape her colonoscopy and, by doing so, probably saved hundreds, if not thousands, of lives from colon cancer). So what’s the deal with circumcision?Does this mean you should let them whisk off your baby son? And if you’re a man, are you getting that sense of dread that makes you want to cross your legs and stop reading–because I might tell you something that makes you feel like you ought to make an appointment today?

Here’s the issue: 1) No. Circumcision does not stop HIV infection. Look around the States. Millions of circumcised men are HIV-infected. What stops HIV is meticulous attention to detail when having sex (an oxymoron, some of you might think, but nooo, says Doc Gurley). Attention to detail means abstinence or condoms, or alternative approaches to intimacy that are fun and creative. All you uncircumcised guys, don’t say whew and stop reading, because…

2) Circumcision seems, based on the best data available now (big qualifier, I know) to significantly reduce HIV spread (by 60%) in South Africa, when newly circumcised men are compared to uncircumcised men. Say what? Read this article for a superb, user-friendly review of the issue. The deal is, if you’re living in a world where clean water is a major issue, how likely are you to have a condom handy whenever you get the urge? We in the developed world take for granted many things, one of which is the ready supply of high-quality condoms.

So how does the circumcision thing help? What’s clear is that HIV (as we’ve known for a while) is a puny little opportunistic creep of a virus villain–it likes to surf into a new body on a pampered wave of blood or mucous or moisture. Left to fend for itself on dry skin (what we in medicine call epithelialized tissue), it crumples. Circumcision (done right with good sterile technique, and an adequate time to heal before sex) changes the meatus (or head) of the penis from moist mucosa (like the inside of the mouth) into epithelium (more like the skin on your palm), thereby making the head of the penis a relatively more hostile place for HIV.

For the guys who have an even greater urge now to cross their legs, there aren’t a lot of studies looking at changes in sexual satisfaction before and after circumcision in grown men. I wish that had been part of the study listed above. But, in a grim, worst-case-scenario viewpoint, I have to say–you don’t get much sexual satisfaction if you’re dying of brain abscesses from AIDS.

So, should you get your son circumcised? That’s clearly a personal decision–one that would optimally (based on Doc Gurley’s biases) be left up to your son to make. Once it’s done, it’s irreversible. In the developed world, what you want for your son is a bountiful supply of condoms and the knowledge and confidence to use them. In Africa, it’s a tougher call–both for your son, and for yourself if you’re an uncircumcised guy. Without an obsessive commitment to meticulous sex and a ready supply of condoms to match, maybe you should consider getting a little off the top and sides.

P.S. World AIDS Day is always an emotional time for me. I’ve lost way too many lovely patients and friends to AIDS. This year, my moment of remembrance is dedicated to the transgendered face of AIDS. Here’s what I’d say if I could: Honey, I miss your laugh, your staunch desire to not lose your dignity, and even your early morning fashion tips when I made rounds–you had a touching faith that if I only put in a little more effort, I could “work it, girl,” like you. Make-up, a haircut, or even a hot pair of stilettos–those things could never give me your panache and your courage. I wish you were still with us. The world is a dimmer place.

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