Dr Alex Wodak is the director of the Alcohol and Drug Service at St Vincent’s Hospital in Sydney. He’s a medical practitioner.

He published an opinion piece in The Australian recently, entitled “Circumcision can curb HIV rates” (the title may be the choice of the editorial team). According to the biographical extract on the Service’s website, he works on a harm minimisation basis (which is accepted to be the most useful way of working in this area). I’m assuming, therefore, that’s where he’s coming from in this article. In my entry, indented text and text inside “quotes” are quotations from Dr Wodak’s article.

Dr Wodak’s thesis is this (excerpted from the article):

Reducing the spread of HIV among non drug-using men and women around the world has been particularly difficult. Few have changed their sexual behaviour (including using condoms when having sex with casual partners).

Compelling evidence now shows that male circumcision, surgical removal of the foreskin of the penis, can substantially reduce heterosexual HIV spread. However, the rate of infant male circumcision in Australia may be as low as 20 per cent.

Australia should start trying to increase the rate of infant male circumcision to reduce heterosexual HIV spread in future decades.

Dr Wodak agrees that the question is difficult and controversial.

Dr Wodak asserts that the evidence regarding the protective benefit of circumcision in heterosexual men is clear, but notes that the evidence regarding benefit for gay men is less clear. He suggests that…

Male circumcision has many other benefits apart from reducing HIV. These benefits may include reducing some sexually transmitted infections (including syphilis, herpes simplex type 2 and chlamydia), urinary tract infections, penile cancer, prostate cancer and cervical cancer in female partners.

Dr Wodak goes on to suggest that:

• “…we have sufficient information now on both HIV and general grounds to amply justify revising the information provided to young parents about infant male circumcision”;
• the information supplied at the moment is biased and not objective;
• the “substantial” obstacles to infant circumcision in public hospitals should be removed;
• the Medicare rebates for circumcision be revised (presumably up) to “… reduce the current powerful financial disincentives to infant male circumcision”;
• Australia should aim for a return to the high rates of infant circumcision that existed decades ago;
• The “… technology of infant male circumcision has improved considerably in recent decades”.

Dr Wodak’s desire to work towards maintaining low HIV infection rates in Australia is, of course, laudable. His raising of the question is fair, coming as he does from his medical and ideological background. I would take issue with some of his assumptions, which I expect are based on recently reported studies, and most certainly with his conclusions and recommendations, which I think are misguided and unsound.

Dr Wodak makes the following statement:

There are always possible risks, and a particular concern here would be ‘‘risk compensation’’ — that is, gay circumcised men feeling safer and thus abandoning condoms and other hard-won safer sex strategies.

I’m not sure why only gay circumcised men would adopt “risk compensation” strategies – heterosexual men are also likely to do the same, I would have thought. The message to circumcised men is becoming stronger through this type of discourse: “You are safe”. This may lead to some really undesirable and unsafe behaviours, which in the context of HIV means death.

The evidence supporting Dr Wodak’s assertions is not as clear cut as it might appear. The studies he alludes to are open to criticisms on several grounds. His assertions about other benefits (reduction in rates of STIs, for example) are also open to debate or refutation. The assertion regarding reduction of risk for prostate cancer, for example, is based on studies that have been contradicted by other studies. The fact is, that almost all of the benefits claimed for circumcision are based on results of studies that can be critiqued for methodological or other reasons. We’re at the moment in a ‘battle-of-the-studies’ situation. The evidence is simply not clear enough to make definitive recommendations of the sort that Dr Wodak advances in his article.

The information provided to parents to which Dr Wodak refers presumably includes material such as the Royal Australian College of Physicians policy statement (which I note is under review). I don’t believe this statement is biased – I think it is based on the medical evidence available. The College is clear – “there is no medical indication for routine neonatal circumcision” (RACP).

Until there is clear benefit and utility, and until it is higher than other interventions (condom use, for example), then suggesting a poor preventative is at best misguided. I fear for those who will be lulled into a false sense of security, and for their sexual partners, and I see no reason why another generation of boys should be mutilated for such spurious reasons.

Edit: There is a much more useful article now available, by John Murray, an epidemiologist. Murray closes his article with this comment:

… although there is no room for complacency about the HIV epidemic in any country, male circumcision of newborns will have little impact on HIV risk in Australia. Male circumcision of infants may be considered on a number of grounds, but protection from HIV should not be one of them.

There is analysis of both commentaries available at the Circumstitions website and the Circumcision and HIV website.