Male circumcision and HIV: Non‐blindedness and biases in RCTs; female
preferences; penile sensitivity, satisfaction and ambient stimulation; risk
compensation; acceptance of insufficient condom use and personal hygiene
and related externalities
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ABSTRACT
GJMEDPH 2018; Vol. 7, issue 1
Literature was reviewed in order to examine what the likely efficacy of male *Corresponding Author
circumcision in combatting HIV‐AIDS might be. There is no reasonable doubt David J Vance
that male circumcision in the absence of other measures does reduce the Independent Researcher
[email protected]
transmission of HIV. Due to very substantial non‐blindedness in RCTs and Telephone No. +86 – 15261001593
elsewhere, there is substantial uncertainty regarding the extent to which male
circumcision in the absence of other measures could ultimately reduce HIVConflict of Interest—none
transmission into the future, such that the Odds Ratios usually given of about
0.4 for incident HIV infection of males with medical circumcision cannot be
Funding—none
taken to be as applicable in contexts other than RCTs. The potential of non‐
blindedness in studies and in societies, to effect things like reporting bias and
subjective and actual sexual and behavioural outcomes is very generally very poorly understood and
insufficiently included in analysis and projection of outcomes. Risk‐adjustment / disinhibition, such that
circumcised men react to the partial protection of circumcision against HIV infection by engaging in riskier
sexual behavior than they would have otherwise is almost certain to occur to substantial extent in most
contexts. It seems very likely that circumcision does result in keratinization/ cornification of the glans, and
also removes sexually‐sensitive skin, both of which result in reduced intensity of coital pleasure,
notwithstanding the various benefits of this in prolonging the coition. Already even uncircumcised men prefer
coition without a condom due to the greater intensity of sexual sensation, and it is logical that this preference
for coition without a condom would be greater in circumcised men. Already there is great under‐use of
condoms by African men. There is therefore a very real question of the extent to which male circumcision will
result in substantial failure to achieve sufficient use of condoms in combatting HIV infection. This is offset by
the possibility that it may be realistic to accept that sufficient use of condoms is not achievable in any case,
because substantial non‐compliance is inherent. Also there is the very under‐examined question of how
thorough sexual personal hygiene (if at all achievable) would modify the efficacies of both circumcision and
condom use, and what the externalities of such thorough sexual hygiene might be when generalized to other
infectious contexts improvable by better hygiene.
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