The UNAIDS has just released a report (story | report) saying that "between five and fifteen men will need to be circumcised to prevent one HIV infection in the ten following years, at a cost of between $150 and $900 per infection prevented." Their conclusion: circumcision is a "cost-effective" intervention strategy for HIV prevention. In this report, there is no consideration for whether this procedure is ethical. Nor is there any consideration of what kinds of cultural meanings might be attached to the foreskin in communities they're ready to scalpel -- or how a mass program to remove their foreskins might be interpreted and expressed culturally.
I like to use the example that reader Thomas Kraemer provided a few weeks back in the comments: We could cure breast cancer tomorrow if we could just institutionalize double mastectomies for young girls. Or as my professor cynically joked the other day, "Why stop at the tip of the penis? If we could remove the whole shebang we could rid society of any number of not just medical, but social ills as well!" Oh, sure, some folks out there will resent the comparisons. "The breast is more important than the foreskin!" To this response, I have just one question: "Says who?"
I think we desperately need to be mobilizing against this movement towards circumcision. It's wrong-headed, poorly thought-through, and is really aimed at circumscribing any need for creative prevention approaches by creating a biomedical intervention. The crisis is clear: Prevention specialists -- trained in the too-often culturally incompetent fields of health and biomedicine -- are just downright flummoxed by the inability of their interventions to stem the rise in new infections. If you've ever worked in the field, you've undoubtedly seen their red-faced angst before: "Why won't these people just use condoms, goddammit?" Nevermind the structural constraints of poverty and gender. Nevermind the meanings implicitly and inadvertently attached to condoms by Western medicine (e.g. distrust, fear, etc.).
Thus, in an era when classical prevention strategies are failing globally, old-school prevention types have opted to search for a biomedical intervention that would avoid any need for dealing with the messy realm of the social. "If we can just chop something off, then we won't have to deal with compliance!" Ta-dah! The magical solution! Obviously, this logic is outrageously problematic. It presumes that circumcision will not be rife with cultural meanings and dilemmas, and it also presumes a hostile population that is "non-compliant." It never allows for the consideration that perhaps it is prevention that is the problem -- not the communities it seeks to change.
I am amazed by the number of studies in epidemiology -- the sheer mass of publications -- that continue to rely on behavioral survey instruments that unreflexively presume a set of concerns worth asking about that stem from an understanding of the epidemic in which it is people's behaviors that fuels the HIV/AIDS epidemic. This is downright shameful given the massive amounts of data that demonstrate how obviously correlated new infections are with social-structural factors like race, class, gender, and sexuality. It's like trying to telling people in Detroit to eat better when there is no grocery store -- not a single one -- within city limits.
It's past the point of naivety -- since the amount of data demonstrating the epidemic's social-structural roots is so compelling. It amounts to a kind of willful ignorance to continue trying what you know will likely fail because it is easily funded and requires little critical thought. It's easy. It's lazy. It would all be a bit humorous if it wasn't resulting in a body of prevention literature that does very little to actually work towards meaningful prevention. People are dying. Scientists are laughing their way to the CDC-NIH bank.
Removing foreskin in the name of health promotion is unconscionable. It amounts to a kind of cultural imperialism that will undoubtedly stir up backlash against Western Public Health. The idea is not seen as radical because we in the US already practice it so commonly. But believe me: If circumcision was virtually unknown in the United States as it is in other areas around the Globe, we would not be having this debate. But because it is such an institution here, the idea of promoting it elsewhere seems totally sensible. It's the worst kind of ethnocentrism, and it needs to stop.
Trevor -
Your comments regarding the ethical and cultural considerations of voluntary male circumcision are well-intended. However, the blanket assumption that this practice a) does not have a historical basis in Africa and b) is not wanted by men in Africa is not evidence-based.
Consider the following report from the health ministry of Kenya: http://www.malecircumcision.org/programs/documents/KenyaMCguidance.pdf
This report details the cultural history of male circumcision as an initiation rite in some traditional Kenyan cultures. Specifically, over 90 percent of men are already circumcised in four provinces, and 84 percent of men nationwide are already circumcised. While this behavior is not generalizable to all of sub-Saharan Africa, it violates the assumption that male circumcision is a Western practice that is being unduly imposed upon African peoples.
Furthermore, the report released by UNAIDS does not recommend mandating male circumcision. Instead it advocates for an increase in the availability of voluntary male circumcision services in sub-Saharan Africa, particularly where there is strong demand for services. UNAIDS and the WHO already have strong guidelines with adequate human rights protections for the implementation of voluntary male circumcision:
http://tinyurl.com/ndd6cc
http://tinyurl.com/no7klg
These guidelines were created in response to high demand for male circumcision by men who wanted to reduce their risk for HIV. This demand, particularly in South Africa (http://allafrica.com/stories/200907220206.html) and Kenya (http://www.plusnews.org/Report.aspx?ReportId=85082), has overwhelmed the available services. Indeed, many providers are worried that if men are circumcised, they will believe that this protects them from HIV and will reduce their condom use. Similarly, demand among MSM for circumcision is also problematic, as it is not effective in reducing HIV infection from anal sex. These are two strong arguments against promoting voluntary male circumcision, and they must be weighed against the considerable benefits population-wide of increased male circumcision.
I do not disagree with your hesitation about recommending a permanent surgical procedure to reduce HIV infection. I do, however, take issue with the idea that it is entirely ethnocentric and unwanted by men in sub-Saharan Africa. My work in HIV prevention with MSM in Burundi and the general population in other countries in the Great Lakes region of central Africa has demonstrated to me that individuals are willing to go to extreme lengths to protect themselves from HIV while still not using condoms. Offering a voluntary surgical method with some efficacy as an option to reduce HIV infection is one tool that both empowers men to make their own decisions about how to protect themselves from HIV and may reduce the prevalence of some non-prophylactic prevention methods that may increase HIV infection (washing the penis with bleach, among others). A naive view of voluntary male circumcision as Western imperialism does little to advance the cause of HIV prevention.
Trevor,
It is COMPLETELY unethical. I cannot agree with your more on what you have just posted. Thank you for speaking out, and doing it so well. What's going on now with this circumcision hysteria is barbaric. Condoms and testing are the only HIV prevention strategies that are known to work. If people aren't using them, we need to find out why and address it.
Also, you will probably like this blog
circumcisionandhiv.com
and this Youtube channel
http://www.youtube.com/user/Bonobo3D
Of the movies, Dr. Dean Edell is particularly vocal in explaining all the flawed logic with the HIV studies.
What's more of a problem is that it simply won't work. There are six African countries where men are more likely to be HIV+ if they've been circumcised: Cameroon, Ghana, Lesotho, Malawi, Rwanda, and Swaziland. Eg in Malawi, the HIV rate is 13.2% among circumcised men, but only 9.5% among intact men. In Rwanda, the HIV rate is 3.5% among circumcised men, but only 2.1% among intact men. If circumcision really worked against AIDS, this just wouldn't happen. We now have people calling circumcision a "vaccine" or "invisible condom", and viewing circumcision as an alternative to condoms.
The one study into male-to-female transmission showed a 50% higher rate in the group where the men had been circumcised btw.
ABC (Abstinence, Being faithful, Condoms) is the way forward. Promoting genital surgery will cost African lives, not save them.
Well said, Trevor. It amazes me that the African trials are even seen as legitimate within the medical community, when they failed to control for the HIV status of the men's partners before the study began. That's just shoddy science.
And then there's the pesky problem of empirical evidence, which shows that majority-circumcised USA has higher per-capita rates of just about every STD (including HIV) than non-circumcising Europe and Japan. If male circumcision were really as effective as its proponents claim, we would not see this in real-world situations.
We cannot apply the results of an odd (and many would say faulty) study in Africa to the industrialized west. There are far too many cultural, educational and hygiene factors to consider -- beyond the fact that there's a huge difference between a consenting adult participating in a study and a non-consenting minor being welcomed to the world by a mutilating surgery.
@ Mark: Did you read the entry? Clearly I disagree with you very strongly over the ABC approach. That -- just as much as circumcision -- is a reflection of ethnocentric / unethical prevention strategies.
@ Caroline: I would note that treatment is being added to the prevention arsenal and has very much been shown to be effective. Condoms work, but of course using them is the trouble. I'm amazed at reading studies regarding condom interventions with married women in Africa, and the study authors being disappointed when they got very poor results in terms of condom use. Imagine telling married American women to use condoms! Good luck! Obviously the search for new kinds of prevention technologies (e.g. vaginal microbicides) is part of the attempts here. But I just think we have gone into these countries applying a logic developed in the West and totally expecting it to map onto these communities without problem. That's the ethnocentricism, and that's why interventions here see very poor results.
Excellent commentary, Trevor, thank you.
Wow thanks Sean! :)
Good post. I would add that the push to circumcise in the name of HIV prevention follows the century long pattern of looking for a reason to perpetuate a practice that has no obvious medical use. You correctly identify circumcision as a social/cultural practice deeply embedded in the American milieu. Therefore, it isn't surprising that the American authors of the African studies, problematic as they are in the African context, also seek to apply them in America during a time of decreasing circumcision rates and where the HIV epidemic is not driven by heterosexual transmission, the only mode of transmission that circumcision is claimed to reduce risk. This is dishonest, inappropriate, and a misuse of science and science publishing.
Now I'm no Obama fan since he has appointed Thomas Frieden to head the CDC. Frieden as head in New York had promoted circumcision for all males including infant boys based on the African studies but even before these studies were published. It doesn't take take a leap to foresee what is going to come out of the CDC concerning male circumcision. Our first taste is what was shown by Operation Abraham, Israeli doctors keen on showing US doctors how to do mass circumcisions to the US male population. At this CDC sponsored infectious disease conference, Operation Abraham showed up on the conference screen an intact black man's penis with added drawing about it of a elephant making the penis the elephants trunk. Further adding the words "Yes! Please circumcise me." Operation Abraham proposes to help mass circumcise all African American and American-Hispanic males. Talk about Imperialism. Thomas Frieden has yet to apologize for allowing this.
Note too the African studies did not account for gays because supposedly there were no gays or down low behavior as it is against this culture meme.
http://twitter.com/KOTFrank/
You would think we should fix our own broken wagon where condoms are 30% used incorrectly by application and size; where the CDC reports US male teens are mistaken about their own penis status, intact and circumcised, at 30% and 35%.
Are we capable of educating other countries and not our own?