Spotting contradictions between circumcision promoters on Al Jazeera’s “On The Stream: To Cut or Not To Cut”
If you are outside the U.S., you can watch the video here: https://www.youtube.com/watch?v=GitOnW-nzck&sns=fb
If you are in the U.S., this link may work: http://bc19.ajnm.me/864352181001/201404/3132/864352181001_3492775214001_FULL-to-BC-AJE-0421.mp4
At 8:25 Richard Wamai denies risk compensation
Richard Wamai: There is no evidence out of Sub Saharan Africa where male circumcision is being promoted to prevent millions of men from getting infected with HIV that somehow there is disinformation and that men get circumcised and reduce using condoms or change behavior, we don’t have that evidence, it simply does not exist.
At 20:21, after a YouTube blogger argues that we don’t need to amputate every tissue that becomes infected, and calls for “our bodies, our choice”, Richard Wamai responds:
Richard Wamai: I totally disagree with that. First off all, if we talk about human rights, adult men can determine whether they want to keep their foreskin or not. If I know the benefits of circumcision, then I have the right to make the decision. For somebody to say that it is amputation, that is not quite accurate at all.
[Richard Wamai is co-author of "A snip in time: what is the best age to circumcise?" where he, along with Brian Morris and other circumcision advocates, argues that infancy presents a "window of opportunity" for circumcision. Infants cannot provide informed consent.]
At 22:25 approximately:
Moderator: I don’t understand if you are circumcised as a man, you are still putting a condom on. Why don’t you put a condom on in the first place?
Richard Wamai: Well, why, you don’t, because, you know what the rate of condom use is in South Saharan Africa?
Moderator: But you have to use it to have protection
Richard Wamai: You know what it is? Very few people ever use a condom consistently so we need to do something, that’s why we are doing studies, that’s why we are doing studies to test whether there could be a microbicide, a vaginal stuff, gel that women can use…
Moderator: Because men don’t like to wear condoms?
Richard Wamai: Well, that too, but I mean, we know that condom use is very low…
At 23:22 Brian Morris tries to interrupt, I have not been able to figure out what he says. The show goes to a commercial break. Upon return, John Geisheker from Doctors Opposing Circumcision presents his critique of the African circumcision trials.
Brian Morris and John Geisheker
John Geisheker: (…)For one thing, the figure of 60% does not rise to the level of immunization, which must, by standard of bioethics, be in the high nineties. A 60% protection of anything is merely a roll of the dice. All that a person is doing who is circumcised and then not bothering to use the usual protection of ABC [abstinence, be faithful, condoms] is playing bio-roulette, Russian roulette. (Continues explaining the real meaning of the 60% figure)
Brian Morris: John is a lawyer, he is not a scientist, he is not a doctor [never mind that Brian Morris is not a medical doctor either], trials are not about following people for ever and ever, trials follow people until they find a statistical difference and in this case the statistical difference happened so soon that the monitoring body stepped in and stopped the trials because it would be unethical to continue them since the evidence showed such a strong protective effect
Moderator interrupts for a back story. Then Brian Morris continues
Brian Morris: I also completely dispute John’s misunderstanding of immunology and vaccines. Vaccines some are quite effective, but look at one of the more common vaccines, the flu vax, the effectiveness of that in the population is about 80%, which is also about the effectiveness of condoms, and with the long, long term follow up of HIV trials and roll out, the protective effect of circumcision has risen over the years, so it’s now approaching that 80% mark, and in public health we advocate [I keep missing this word, sorry] interventions, not just condoms, not just circumcision, but also a behavioral practice, anything else that we can show does work. We don’t say oh let’s just go this way because we like it. We use all of the effective methods and circumcision is one of THE MOST effective [vocal emphasis], and as Richard pointed out condoms cannot be used but once a man is circumcised he is circumcised for life and that is significant. Condoms have to be put on the penis before any sexual contact…
So, let’s point some issues here. In Richard Wamai’s view, condom use rate cannot be increased significantly, so it seems better to go on a crusade to circumcise millions of men, even though men are not running to take the offer. And while Wamai denies risk compensation, he also denies that condom use rate can be increased (which is a risk compensation behavior on its own). And yet he seems to put hopes on hypothetical future gels for women to use, when men cannot (in his mind) be expected to use condoms.
Brian Morris on his end appears to be doing what he usually does: inflating the benefits and overlooking the risks. In his mind the protective effect has been increasing and is close to the 80% mark.
About this increasing protective effect, I’m reminded of this text by Des Spence (BMJ 2010;341:c6368) (we highlighted some keywords):
“Study design—Study populations are biased by design. Only high risk, unrepresentative populations are studied because they are the most likely to show an effect. These data are then extrapolated to low risk populations of people who never benefit—statins are studied in Scotland and prescribed in Surbiton. The inverse care effect also means that people at low risk are more likely to seek treatment and comply with it.”
The same article indicates:
“Statistical trickery—There is systematic and cynical use of statistics to manipulate results [see following paragraph]. This dishonesty—the dark magic of surrogate and composite end points, “validated” questionnaires, the premature ending of studies, the reporting only of relative risks , and the lack of long term follow-up—is just cheating.”
The famous 60% figure is a relative risk, a comparison between two very small percentages, as John explained in the debate until Brian Morris interrupted.
One fact often overlooked about the African trials is that the number of individuals lost to follow up was 3 times more than the total number of sero-converted individuals. This alone casts serious doubts over the “statistical significance” of the results.
Trying to listen to Brian Morris and Richard Wamai, we are reminded of the technique known as Gish Gallop: “The Gish Gallop is the debating technique of drowning the opponent in such a torrent of small arguments that their opponent cannot possibly answer or address each one in real time. More often than not, these myriad arguments are full of half-truths, lies, and straw-man arguments - the only condition is that there be many of them, not that they be particularly compelling on their own. They may be escape hatches or “gotcha” arguments that are specifically designed to be brief, but take a long time to unravel.”
Another important detail, Richard Wamai argued that to call circumcision amputation is wrong because every adult man has the right to decide over his body. John Geishener made clear that he and his organization (Doctors Opposing Circumcision) agree that every adult man has the right to do anything to his own body, and that their opposition is to forceful circumcision of infants and children, and to using the African trials as rationale to push for infant circumcision in the United States (extrapolation). Brian Morris and Richard Wamai are, however, coauthors of a paper called “A snip in time: what is the best age to circumcise?” where they argue that infancy presents a “window of opportunity” for circumcision. So how would Richard Wamai defend his argument that circumcision is not amputation, after arguing in writing for circumcision during infancy?
But please dear readers, don’t take our word; watch the video, do your best research, evaluate the evidence, evaluate the advocates one way or another, and formulate your own conclusions.
ZIMBABWE: Men are not buying circumcision…
ZIMBABWE: …so they’re doing it to babies
UGANDA: Myths about circumcision help spread HIV
ZIMBABWE: Circumcised men abandoning condoms
Evidence that “simply does not exist” – according to Wamai:
Botswana – There is an upsurge of cases of people who got infected with HIV following circumcision.
Zimbabwe – Circumcised men indulge in risky sexual behaviour
Nyanza – Push for male circumcision in Nyanza fails to reduce infections