AEGiS-MISC: Life or Death? Circumcision, Herpes, and AIDS

Toward Tradition - February 21, 2005
**Samuel Silver, Chairman, Toward Tradition

The national news media is abuzz with a story about the possible link between the tragic death of an infant Jewish boy from herpes and his circumcision. Reuters and the Associated Press spread the news, along with CBS, CNN, and MSNBC.[1] The story is about a traditional but rarely practiced technique where the circumciser draws blood from the circumcision site with his mouth! Sound barbaric? Not once you understand the rest of the story.

In early February 2005, news reports surfaced about the tragic death of a Jewish infant in October 2004 in New York, just ten days after his circumcision along with his twin brother. Both babies were infected with the herpes simplex virus type 1, which while not lethal in adults, can in very rare cases be lethal in infants. The source of the virus has not yet been determined, but New York City health officials suspect the virus may have been transmitted from the ritual circumciser (mohel in Hebrew) and an investigation is underway. The herpes virus in various forms causes cold sores on the lips (type 1), as well as genital herpes (type 2), and officials suspect the common "cold sore" virus may have been passed on by oral contact related to the circumcision procedure.

Ironically, once the circumcision is complete, the overwhelming weight of medical evidence indicates the man will be significantly less susceptible to viral infections such as herpes, HIV/AIDS, and HPV (Human Papillomavirus). Leading researchers believe millions of lives could be saved, yet it is doubtful that most people have even heard about this amazing benefit of male circumcision. Before explaining why this information is not more widely known, a review of the circumcision process is in order.

In the current New York case, the mohel used a traditional, but rare, technique of metzitzah b'peh, with which even many observant Jews are not familiar. Under Jewish law, all males are circumcised (bris milah) on the eighth day after birth as a sign of the covenant between God and the Jewish people. It is a three step process.

Metzitzah b'peh is a specific form of metzitzah where the mohel uses his mouth to draw off the excess blood.B'peh may be translated as either "in the mouth" or "with the mouth." Before you jump to the wrong conclusion and contrary to the ridiculous and baseless attacks by enemies of circumcision, there are no hidden sexual undertones or convoluted theories of barbaric blood-sucking associated with this very quick and otherwise unappealing procedure or any other aspect of Judaism.

The Talmud (tractate Shabbat 133) clearly delineates all three steps, but whereas no reasons are provided for the first two steps as would be expected with this type of "non-rational" commandment (mitzvah), a medical reason is provided for the metzitzah: leaving blood at the site of the wound would be dangerous for the person being circumcised – usually an infant. This was later codified by the great medieval Jewish philosopher and sage Maimonides, who was also a physician. Maimonides wrote that "one should suction the place of the circumcision until all the blood in the further reaches in extracted, lest a dangerous situation arise." Traditionally, the mohel also rinsed his mouth (and usually the site of the circumcision) with either wine or whiskey, another sign of medical concern.

Just think of how we sometimes cleanse a cut on our hands by putting our mouth on it and suctioning off any excess blood. The removal of the blood and possibly certain chemicals in the saliva may actually cleanse the wound and help prevent infection. This would especially be true in the absence of modern antiseptic cleansers and other medicinal products for sanitizing a wound.[2]

So there is good reason to believe that this technique in its time was of great net benefit in reducing risk of infection, especially when performed by circumcisers of the highest religious caliber, with unsurpassed concern for the health of the child. The extreme rarity of these infections and deaths can be attributed to this concern for safety and is attested to by the fact that this story is such news.

Under this system, the occurrences of dangerous infections have indeed been very rare, but now there are proven, although rare, risks of the transference of herpes virus from the mohel to the infant. There is also a potential threat of AIDS being passed from an infant to the mohel, which could then unwittingly be passed on to other children.

From Biblical times until the 19^th Century, the drawing was done by the mohel using his mouth to suction off the blood, and then spitting it out. Although mechanical methods of suction and gauze were later available, many rabbinic sages maintained that oral suction provided the optimum technique for removing the blood "in the further reaches."

However, neither the Talmud nor Maimonides specify b'peh, use of the mouth. The pressing question today is how the blood should be removed, and if there is a religiously required technique for its removal. Was the use of the mouth just the best medical technique available in Biblical and Talmudic times, or is there some specific religious requirement for direct oral contact?

In mid-19^th Century Europe, the newly emerging Reform movement of Judaism began calling for the outlaw of metzitzah b'peh as part of their attempt (later rescinded) to eliminate circumcision altogether. It appears that standards of hygiene and fastidiousness among some circumcisers may have become lax, and the number of post-circumcision infections increased.[3] In addition, a case of tuberculosis transmitted from an infected mohel to an infant was documented.[4] The reformers used these as a point of attack, and the traditional Jewish community in most cases reacted and possibly over-reacted with an extremely defensive posture. They saw the problem not with the technique per se, but with poor practices and personal hygiene by unqualified and inappropriate circumcisers.

In hindsight, science was on the side of metzitzah b'peh. Dr. Joseph Lister was the inventor of the first antiseptic methods to treat wounds and prevent post-operative infections. Prior to his 1877 discovery, post-operative sepsis infection accounted for the death of almost half of the patients undergoing major surgery. In an 1896 address to the British Medical Society, Lister declared, "I will reveal to you another amazing medical secret, so that you will see as clear as day that no infection can be transmitted via metzitzah either from the infant to the man performing it, nor the reverse. The blood that vigorously flows through due to the suction, kills almost all kinds of bacilli."[5]

This is indeed quite an amazing medical secret. Lister is saying that prior to his discovery of antiseptic methods, the Jews had been practicing an inherently antiseptic technique for over 3,000 years! So until modern medicine caught up with the Jewish tradition, metzitzah b'peh for medical reasons was fully justified and necessary.

In addition to defending metzitzah b'peh as a medical necessity, its current and past defenders point to esoteric/ kabbalistic explanations of why the b'peh technique should be used; however, it should be noted that the speculative kabbalistic role of metzitzah is not mentioned in the Talmud, by Maimonides, nor in the classic halachic (legal) codes.

During and after this heated debate, many rabbinic leaders stood firm that the metzitzah could only be performed by mouth (b'peh), while many others permitted newer techniques such as the use of a glass pipette which the mohel uses to suction the excess blood into gauze, which is then discarded, avoiding any direct oral contact between the mohel and the baby. In this alternate, the mouth is still used, possibly satisfying any kabbalistic concerns, but without the risk of direct contact. Others, especially in the non-orthodox community use just gauze to draw off the blood.

Many great orthodox Jewish leaders in the 19^th and 20^th Centuries, such as Rabbi Joseph Soloveitchik and his father, Rabbi Moshe Soloveitchik, held that the direct oral contact in metzitzah b'peh was not a requirement of Jewish law. On the other hand, many Rabbis, especially chassidim, held that the mouth should always be used unless prohibited by civil law or to avoid a known medical risk.[6]

The introduction of HIV/AIDS in the latter part of the 20^th Century created a new medical risk and rapidly accelerated the transition away from the oral b'peh procedure, even among chassidic Jews. Now that antiseptic techniques had become fully developed, the prior medical necessity for the full metzitzah b'peh was lessened. As a result, the weight of the argument shifted from preventing bacterial infection as a result of the procedure to preventing the rare transmission of a virus during the procedure.

Today, most circumcisers, even among Orthodox Jews, use alternate techniques to the traditional b'peh; however, certain Jews cling to the traditional technique. They place the burden of proof on those that want to change the tradition.

Proof is now available. Reported cases of serious infection are indeed rare; however, they do exist, and a recent study in the medical journal Pediatrics (August 2004), conclusively connects metzitzah b'peh with the transmission of the herpes (type 1) virus to infants being circumcised.[7] The report also discusses some of the scientific reasons for its rarity as an explanation for why these type infections are not more prevalent. In addition, the article points out that these incidents may be under-reported for cultural reasons.

The pressure on circumcisers to halt the traditional b'peh technique will only grow, especially since Judaism places the saving of a human life above all other commandments. One of the most powerful arguments for the maintenance of the metzitzah b'peh was made by the Hungarian sage, Rabbi Moshe Schick (1807-1879), disciple of a great sage often quoted on both sides of this debate, the Chasam Sofer, Rabbi Moshe Sofer Schreiber. As a mohel himself for over 40 years, Rabbi Schick was convinced that the elimination of oral suction would pose a risk to the child. He would not accept the recommendations of those that claimed metzitzah b'peh was unnecessary and superfluous, and according to Dr. Lister's 1896 statement, Rabbi Schick was correct.

"Even if doctors testify that metzitzah [b'peh] is superfluous, we of course do not accept their word to eliminate metzitzah [b'peh]."

"For, as my master [Chasam Sofer] the ga'on wrote, all their statements are based on probability."

"We have a halachic (Jewish legal) principle that whenever life is at risk, we do not rely on probability."

"We maintain in halacha that where there is even the slightest risk to life, we ignore what happens most of the time. If the doctors were to claim that not even one in millions would be endangered by lack of metzitzah [b'peh], and there is nothing to worry about, the statement would be meaningless because they have no way of knowing. Our sages, however, were concerned for even a miniscule risk; if even one in millions of babies were at risk, it would be permissible to desecrate the Sabbath for him. Thus one is obligated to suction the blood away, for in a case of even remotely possible danger to life, we ignore what happens most of the time."[8]

Just as metzitzah b'peh had been practiced to prevent a potentially high rate of infections prior to the development of modern sanitization and antiseptic techniques; now that we can avoid the risk of bacterial infection, Rabbi Schick would probably agree that it should be abandoned for the same reason– to avoid the newly discovered risks of viral infection, even if extremely rare. "Whenever life is at stake we do not rely on probability."

As more and more circumcisers abandon the traditional technique and use alternates such as suction through a glass tube, one possible alternative for Jewish parents who insist on the b'peh technique is for the father to perform that part of the procedure himself.

So far, this newsworthy story has been reported fairly, with the exception of Al-Jazeerah[9] and a few anti-Semitic websites. However, if history is any predictor, the bad news and bad reporting are about to begin. The secular mainstream media cannot help but exploit a negative story about something in the Bible like circumcision. Can a television expose with graphic video and chassidic Jews be far away?

On the other hand, the mainstream media have gone out of their way not to inform the public about the major medical discoveries in favor of circumcision over the past two decades. The fact that you have probably not heard about them attests to an effort to suppress otherwise astoundingly positive news about something with Biblical overtones.[10]

The question of medical benefits from circumcision was first raised in the early 1970's. A burgeoning anti-circumcision movement launched a major PR campaign to oppose circumcision under the guise of child abuse with no redeeming value other than "religious superstition." This ideological campaign continues today, especially on the Internet, with propaganda to falsely defame circumcision. Their goal is to outlaw circumcision, just as they want to outlaw kosher slaughtering of animals for food (shechitah). Both are serious violations of their religion – secular fundamentalism.[11]

The medical benefits of circumcision are not of major religious significance to a believing Jew's decision to circumcise a newborn son, but obviously, a parent would be concerned if the net effect were negative. Fortunately, God created a benevolent universe.

The medical evidence is now clear that neonatal circumcision offers positive medical benefits to males, both as infants and in later adult life.[12] The data is also clear that there is no measurable physiological reduction of sexual sensation or performance associated with neonatal circumcision, contrary to the widely reported anecdotal claims by the anti-circumcision movement.[13] And pain and trauma to the infant is minimal with the traditional Jewish method of circumcision, unlike typical hospital techniques, which can be painful and traumatic without recently developed pain reduction techniques.[14]

A good overview of the medical evidence is available online at www.medicirc.org. These are a few examples of major benefits to both circumcised men and their female partners:

Female partners of circumcised men, such as Jews and Muslims, have much lower rates of cervical cancer, "one of the most common gynecologic malignant tumors worldwide and a leading cause of death from genital malignancies in women." Researchers believe that that HPV (Human Papillomavirus) is the most likely pathogenesis of cervical cancers as well a penile cancer,[15] and HPV infection appears to be about 3 times more likely in uncircumcised men.[16]

Research also indicates that circumcision helps prevent transmission of genital herpes from men to women. A 2003 study in the journal, Sexually Transmitted Diseases concluded that women have roughly doubled odds of having herpes simplex virus type 2 infection if they have ever had an uncircumcised sex partner.[17]

The most spectacular of these new medical discoveries is the ability of circumcision to significantly reduce the risk of acquiring HIV/AIDS.[18]

The connection of AIDS to circumcision was first reported in the mid 1980's. According to the 1999 report on circumcision of the American Academy of Pediatrics, "there is a substantial body of evidence that links non-circumcision in men with risk for HIV infection."[19] A 1989 study reported that uncircumcised men had an 8.2 times greater chance of HIV infection than circumcised men, with 35 other studies finding from 2 to 8-fold greater HIV risk due to lack of male circumcision. Thirty-five out of 45 epidemiological studies have confirmed the association between lack of circumcision and HIV infection.[20]

In 2000, the head of the National Institute of Health's main HIV Research Division stated, "the link between male circumcision and lower HIV infection rates is now an absolute fact."[21]

The anti-circumcision movement tries to discard this critical information by saying circumcision is not a 100% foolproof method of preventing HIV/AIDS, obviously a different valuation of human life than the Jewish approach that says, "Whenever life is at stake we do not rely on probability."

They also attacked the initial reports on AIDS and circumcision, speculating that the strong correlation between AIDS and lack of circumcision could have been caused by behavioral traits of circumcised men. In other words, circumcised men may be less promiscuous, more moral, and lead healthier lifestyles! Not that there is anything wrong with that answer, but major long-term studies published in 2004(India)[22] and 2005(Kenya)[23] demonstrate that the correlation holds even when you account for demographics, cultural traits, and sexual behavioral. The results confirm the physiology of circumcision, in itself, can significantly reduce the risk of infection by the HIV/AIDS virus.

But not just any form of circumcision will work. It appears that the portion of the foreskin which allows the HIV and other viruses to enter the body is the mucous membrane of the inner foreskin – removed in the second step of the Jewish circumcision method known as periah.[24] Modern medical circumcisions performed in hospitals also remove the inner foreskin, although some historians and religious scholars speculate that in Biblical times, the practice of periah may have been unique to the Jews.

We now know that circumcision, far from being the kiss of death, is in fact a source of life. There is a growing body of research recommending circumcision as a major weapon against the scourge of AIDS, although you never hear about it. It was estimated in 2000 that if circumcision had been practiced in the African and Asian nations that are now in the midst of a massive plague of AIDS, over 8 million lives would have been already saved. And the epidemic has grown exponentially since then!

Organizations such as Bill Gates' foundation are funding studies on the impact of circumcision in reducing AIDS, and the U.S. government is also sponsoring research, but circumcision is just too politically incorrect to be talked about publicly.

President Bush's "ABC" preventative program for preventing AIDS in Africa focuses on: [25]

The Europeans and the President's political opponents in America have a field day ridiculing the President for his initiative, especially the recommendations of abstinence and marital fidelity, although the evidence is mounting, for example in Uganda, that this is a very effective approach.[26]

Can you imagine the uproar if George W. Bush adds another C to the program: Circumcision?

Unfortunately, circumcision is in the Bible, which makes it a serious violation of the religion practiced by the majority in academia and the mainstream media - secular fundamentalism. As such, it is politically incorrect.

Even as millions needlessly perish, the anti-circumcisionists and their allies in the mainstream media continue to oppose circumcision for ideological and political reasons. As secular fundamentalists, they believe it is their "duty" to misrepresent the evidence and prevent informed public discussion of male circumcision.

How differently they value human life than Judaism and the Judeo-Christian tradition.

**Samuel Silver is Chairman of Toward Tradition (www.towardtradition.org), a national movement of Jewish and Christian cooperation, fighting anti-religious bigotry and secular fundamentalism. He is currently writing a book in defense of circumcision tentatively titled: The Kindest Cut of All! Myths about Circumcision, Judaism, and Human Nature. He may be contacted at ss@towardtradition.org.

[10] To CBS' credit, they do hyperlink to a positive print story about the proven correlation between lack of circumcision and HIV/AIDS infections on the same webpage as the article about the herpes death, but I am not aware of any major televised stories touting these positive breakthroughs, especially about AIDS. In 1999, ABC's "20/20" ran a show titled "Cutting Controversy" that enlisted an outside medical expert who reviewed studies on both sides of the issue, and confirmed the positive medical benefits were indeed real. Only minor attention to AIDS was paid at that time. Curiously, the online report of this show that had been available on ABC Television's website for years has suddenly disappeared from the Internet.

[11] The modern anti-circumcision movement began in the early 1970's as a lay activist movement with their epicenter in the San Francisco Bay area, although Ronald Goldman's Circumcision Resource Center which targets Jews is in Boston. A few of their many websites are: http://www.noharmm.org, http://www.arclaw.org, http://www.cirp.org, http://www.jewishcircumcision.org, http://www.circumstitions.com, and http://www.jewsagainstcircumcision.com. There are just a few websites offering an alternative, positive view of circumcision. For example, http://www.circumcisioninfo.com and www.medicirc.org.

[12] The benefits of neo-natal circumcision documented in 1999 by the American Academy of Pediatrics (AAP) were protection against:

1.   UTI (Urinary Tract Infection)
2.   Penile cancer
3.   STD’s (Sexually Transmitted Diseases) and HIV/AIDS infection
4.   Balanoposthisis (infections of the glans)
5.   Phimosis (failure of the foreskin to retract)
6.   Ease of genital hygiene.

There was only one offset reported, the possibility of very rare and minor surgical complications. The AAP, like most scientific organizations today, is not immune to politics. An analysis of these politics is beyond the scope of this article, but in its conclusion, the Policy Statement added the strange and politically motivated statement, "however, these data are not sufficient to recommend routine neonatal circumcision." They then concluded that "parents should determine what is in the best interestof the child." Advocates on both sides of the argument have criticized this Policy Statement, but even with the strong political pressure from the anti-circumcision crowd, the AAP still concluded that circumcision has medical benefit for newborns. The 1999 AAP Circumcision Policy Statement, PEDIATRICS Vol. 103 No. 3 March 1999, pp. 686-693.

Also see a 2003 update by Edgar J. Schoen, MD, It’s Wise to Circumcise: Time to Change Policy PEDIATRICS Vol. 111 No. 6 June 2003, pp. 1490-1491.

[13] A full discussion of the "sensitivity" issue is beyond the scope of this article, but in short, these claims have all been anecdotal or based on unsound survey data. Only recently has scientific experimentation taken place to analyze this claim, and it appears that there is no detrimental effect on sexual sensitivity or performance related to circumcision.

The AAP in 1999 reported that although there were anecdotal reports of loss of sensitivity or performance, "Master and Johnson noted no difference in exteroceptive and light tactile discrimination on the ventral or dorsal surfaces of the glans penis between circumcised and uncircumcised men." And a leading psychiatrist and sex therapist, with more than 3,000 male patients at the Human Sexuality Program of New York Presbyterian Hospital, discounted the presence of large amounts of specialized nerve endings in the foreskin. "There's plenty of opportunity for sexual pleasure," he says, "even with the removal of foreskin." He states "none of his patients has ever linked circumcision to loss of sexual function. And that includes men who have been circumcised in adulthood and could compare pre- and post-surgery sensation." As quoted on ABC's 20/20, "Cutting Controversy," January 15, 1999.

In a report to the 2003 annual meeting of the American Urological Association, doctors from the Albert Einstein College of Medicine in New York reported on a study of 36 circumcised and 43 uncircumcised men. This appears to have been the first quantitative and objective study of its kind. "There's been a lot of controversy about whether or not circumcised men have greater of lesser sensitivity, and this is a scientific way of trying to answer that question," stated Dr. Clifford Bleustein, the lead researcher.

They performed a "comparative analysis between circumcised and uncircumcised men using a battery of quantitative somatosensory tests that evaluate the spectrum of small to large axon nerve fibers. We demonstrated that there were no significant differences in penile sensation between circumcised and uncircumcised men with respect to vibration, spatial perception, pressure, warm and cold thermal thresholds in both patients with and without erectile dysfunction." See Circumcision Does Not Affect Sensitivity, April 30, 2003 in WebMD Medical News at http://my.webmd.com/content/Article/64/72304.htm. Also see the report abstract.

Ironically, the anti-circumcisionists constantly point to Maimonides' speculative "opinions" about circumcision and sexual sensitivity in Moreh Nevuchim (Guide of the Perplexed, Part III, Chapter 49) as proof of their claim. Do they then accept the rest of Maimonides' work?

[14] The pain issue is a red-herring for Jews. The physical sensation of the circumcision is necessary to transform the concept from the spiritual realm into the material realm, i.e., the human body, but there is no requirement for intense physical pain. It appears that most of the pain at a traditional Jewish bris is the psychic "pain" of the parents who understandably are concerned for their new baby.

The anti-circumcision claims about pain are ALL based on hospital/medical circumcisions with the painful (usually Gomco) clamp, where the procedure lasts 6-40 minutes. During these hospital procedures, the baby is strapped down, spread-eagle, to a board. These have no relationship to a traditional Jewish bris where the actual circumcision lasts 20-30 seconds without painful clamps, and where the baby is not strapped down, but lies on a pillow in the lap of the Sandek (usually his grandfather or great grandfather). No valid comparisons about pain and trauma can be made between the two procedures.

Crying at a Jewish bris usually begins when the diaper is opened and the baby is exposed to colder air. The crying usually stops when the diaper is closed. He very rarely, if at all, cries because of the cutting, although some crying may be attributed to the pulling of the foreskin into position for a few seconds prior to the cutting. The cut itself is best described as virtually painless, as anyone who has ever cut themselves with a razor or other very sharp knife knows.

Medical research confirms that the Jewish approach involves significantly less pain and is not comparable to the hospital approach. For example, see Kurtis, DeSilva, et al, A Comparison of the Mogen and Gomco Clamps in Combination with Dorsal Penile Nerve Block in Minimizing the Pain of Neonatal Circumcision, Pediatrics Vol. 103, No.2, February 1999. Available at http://pediatrics.org/cgi/content/full/103/2/e23. Also see Taddio, et al. Combined Analgesia and Local Anesthesia to Minimize Pain During Circumcision, Arch Pediatric Adolesc. Med. 2000; 154:620-623 at http://archpedi.ama-assn.org/cgi/content/abstract/154/6/620

A discussion of anesthetics is beyond the scope of this article, but Jewish law allows a variety of medical options to minimize pain for the child (or the parents!) such as topical anesthetic cream and acetaminophen, even though the bris milah itself is not intensely painful. See: Anesthetics are effective in reducing the pain of circumcision in newborns, posted online by: News-Medical in Child Health News (Monday, 18-Oct-2004) at: http://www.news-medical.net/?id=5622. For discussions of the halacha (Jewish Law) concerning the use of anesthetics and other pain relief techniques, see Circumcision: The Current Controversy by Rabbi J. David Bleich, Tradition, 33, Summer 1999 and Modern Issues in Brit Milah – Part Three by Rabbi Howard Jachter at http://www.koltorah.org/ravj/britmilah3.htm.

[15] The anti-circumcision movement falsely claims that penile cancer is not a significant risk factor, with a low annual rate of only 9-10 cases per year per 1 million men. This is a highly misleading use of statistics! This annual rate they quote is for each year of a man's life and includes all men, whether circumcised or not, but the vast majority of all males in the U.S. are circumcised. When you adjust this data for average lifespan and the number of uncircumcised men in the U.S., you arrive at a fairly high rate of penile cancer in one per 400-600 uncircumcised men in the U.S.

See Wiswell, Neonatal Circumcision: A Current Appraisal, Pediatrics, Volume 1, number 2, 1995 at http://www.circumcisioninfo.com/wiswell.html, or Kochen and McCurdy, Circumcision and the risk of cancer of the penis. A life-table analysis, Pediatrics and Adolescent Medicine, Vol. 134 No. 5, May 1980, available online at http://archpedi.ama-assn.org/cgi/content/abstract/134/5/484 or Schoen, et al, The Highly Protective Effect of Newborn Circumcision Against Invasive Penile Cancer, PEDIATRICS Vol. 105 No. 3 March 2000, p. e36, available online at http://pediatrics.aappublications.org/cgi/content/full/105/3/e36.

[18] An excellent overview is Circumcision Prevents Human Immunodeficiency Virus (HIV) Infection/AIDS at http://www.medicirc.org/meditopics/hiv/more_info_hiv.html. For an overview from the U.S. government, see Research: Male Circumcision and HIV Prevention, U.S. Agency for International Development (USAID), August 2003, available online at http://www.usaid.gov/our_work/global_health/aids/TechAreas/research/

mcfactsheet.html. The complete text of this Issue Brief on Male Circumcision and HIV Prevention is available at http://www.usaid.gov/our_work/global_health/aids/TechAreas/research/mc.doc.

[25] For a comprehensive report on the ABC program, including discussion of circumcision, see The "ABCs" of HIV Prevention: Report of a USAID Technical Meeting On Behavior Change Approaches To Primary Prevention of HIV/AIDS, U.S. Agency for International Development, "ABC" Experts Technical Meeting Washington, D.C. | September 17, 2002. Available online at http://www.usaid.gov/our_work/global_health/aids/TechAreas/prevention/abc.pdf. This report on page 3 points out "the irony that an age-old traditional practice, male circumcision, has probably so far prevented more HIV infections in Africa than all the Western-derived interventions combined."

Always watch for outdated information. This article first appeared in 2005. This material is designed to support, not replace, the relationship that exists between you and your doctor.

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