Although the World Health Organisation has hailed circumcision as the "great white hope" against AIDS and poured billions into programs of mass circumcision of African men, many Africans, including doctors, are sceptical of the effectiveness, the ethics and the cost of such a strategy. On this page we summarise papers recently published in African medical journals and provide an update on South African efforts to protect boys from circumcision. Oddly enough, despite the advice of the new white witchdoctors, South Africa is one of the very few countries to have passed legislation making it an offence (in certain circumstances) to circumcise a minor.
Clutching at straws to control the African HIV/AIDS epidemic has included strident advocacy for circumcision of males (MC) from some (mainly American) quarters, especially following three trials held in South Africa, Kenya and Uganda in 2006-2007. These seemed to show that circumcision did have a limited protective effect, and they were quickly hailed by the circumcision lobby as justifying an immediate “roll-out” of a massive circumcision campaign. Three contributions in the October 2008 edition of the South African Medical Journal, including an editorial, vigorously contest the usefulness, cost and ethics of circumcision in the prevention of HIV and condemn the indecent haste with which the Word Health Organisation, under pressure from American money, has sought to enforce mass circumcision on African men.
Objective. To investigate the nature of male circumcision and its relationship to HIV infection.
Methods. Analysis of a sub-sample of 3,025 men aged 15 years and older who participated in the first national population based survey on HIV/AIDS in 2002. Chi-square tests and Wilcoxon rank sum tests were used to identify factors associated with circumcision and HIV status, followed by a logistic regression model.
Results. One-third of the men (35.3%) were circumcised. The factors strongly associated with circumcision were age >50, black living in rural areas and speaking SePedi (71.2%) or IsiXhosa (64.3%). The median age was significantly older for blacks (18 years) compared with other racial groups (3.5 years), p <0.001. Among blacks, circumcisions were mainly conducted outside hospital settings. In 40.5% of subjects, circumcision took place after sexual debut; two-thirds of the men circumcised after their 17th birthday were already sexually active. HIV and circumcision were not associated (12.3% HIV positive in the circumcised group v. 12% HIV positive in the uncircumcised group). HIV was, however, significantly lower in men circumcised before 12 years of age (6.8%) than in those circumcised after 12 years of age (13.5%, p=0.02). When restricted to sexually active men, the difference that remained did not reach statistical significance (8.9% v. 13.6%, p=0.08.). There was no effect when adjusted for possible confounding.
Conclusion. Circumcision had no protective effect in the prevention of HIV transmission. This is a concern, and has implications for the possible adoption of the mass male circumcision strategy both as a public health policy and an HIV prevention strategy.
Full article here. PDF available on request.
Catherine Connolly, Leickness C Simbayi, Rebecca Shanmugam, Ayanda Nqeketo, Male circumcision and its relationship to HIV infection in South Africa: Results of a national survey in 2002, South African Medical Journal, Vol. 98, No. 10, October 2008
A second article by Sidler et al argues that there are profound objections on grounds of effectiveness, cost and ethics to the use of circumcision as a a tactic against AIDS. The article opens as follows:
Non-therapeutic, non-religious circumcision is the surgical procedure most commonly published about, but for which substantive indications are lacking. Since its introduction to the USA during the Victorian period, when it was thought that it prevented masturbation, medical justifications for the procedure progressed to prevention of various infective conditions (sexually transmitted diseases, penile and cervical cancer) and controlling of the sexual drive. Recent Joint United Nations Programme on HIV/AIDS/World Health Organization (UNAIDS/WHO) policy proposes male circumcision for the prevention of HIV/AIDS.
HIV/AIDS in Africa is mainly spread by multiple concurrent heterosexual relationships, compounded by female subjugation and poverty. Condoms, although highly protective, are infrequently used, particularly among circumcised males.
The HIV/AIDS crisis demands extraordinary curtailment measures. It is, however, questionable how circumcision, and particularly neonatal circumcision, could achieve such a goal. A rational and critical analysis of the scientific evidence ought to conclude that non-therapeutic infant circumcision is merely the medicalisation of an old ritual that should not, in the 21st century, be advocated as prevention strategy for HIV/AIDS. Repeated publications of matching opinions do not necessarily lead to solid scientific evidence and policies.
They rather suggest that the peer review process of journal publication may be unreliable. Information overload can cause limitations, for example influencing expert and public opinion with ideological and pseudoscientific content. This context and such therapeutic misconceptions contribute to circumcision still being practised as a non-therapeutic infant procedure. This mainly applies to English-speaking countries, where circumcision appears to have become a medicalised ritual. In contrast, in Europe non-therapeutic circumcision is not the norm.
Many reviews question the necessity of non-therapeutic infant circumcision, showing it to have neither short- nor long-term medical benefits. It has been suggested that parents should be granted responsibility and final decision making authority after having thoroughly considered all the relevant facts. The reported increase in demand for preventive circumcision, long before publication of results of the three randomised controlled trials (RCTs) in South Africa, Kenya and Uganda that have shown that circumcision is partially protective against HIV, suggests that informed proxy consent, within the context of the HIV/AIDS epidemic and the prevalence of poverty and ignorance, has to be seriously questioned. The desperate hope and need for action of people ravaged by HIV/AIDS, rather than solid scientific evidence, may be driving the increased demand for preventive circumcision.
A recent Centers for Disease Control (CDC) and WHO report confirms previous reports that circumcision does not prevent sexually transmitted diseases (STDs). Teens 15 years and older in the USA have the highest rate of STDs in any industrialised country and half will contract a sexually transmitted disease by age, despite two-thirds of young males having been circumcised. Such reports suggest that the social experiment of circumcision to prevent STDs, including HIV, has already failed in the USA, which has the highest rate of non-therapeutic infant circumcision in industrialised countries and the highest rate of HIV in the developed world.
Rest of article here with references. PDF available on request
Conclusion
Male non-therapeutic infant circumcision is neither medically nor ethically justified as an HIV prevention tool. Circumcision is not equivalent to successful immunisation, is being practised with decreasing frequency in English-speaking countries, and is becoming illegal in South Africa under the new Children’s Act. There are far more effective prevention tools costing considerably less and offering better HIV reduction outcomes than circumcision.
Finally, the WHO and UNAIDS appear to be basing these multi-million-dollar prevention programmes on limited and in some instances biased information. In order to prevent confusion and parents making misguided decisions on behalf of their infants, and to offer effective help in alleviating the suffering that is being created by HIV/AIDS, a much broader review process would be called for. Such a process would involve more objective scientific opinion, and the involvement of a representative panel of African experts, such as paediatric surgeons and neonatologists.
D Sidler, J Smith, H Rode, Neonatal circumcision does not reduce HIV/AIDS infection rates,
South African Medical Journal, Vol. 98, No. 10, October 2008, 764-766
Two articles [1, 2] published in this issue address male circumcision (MC). Connolly et al.1 show in a national survey that MC, whether pre-pubertal or post-pubertal, has no protective effect on acquisition by males of HIV infection as measured by prevalence.
Sidler et al. [2] state that neonatal MC continues to be promoted without adequate justification as a medicalised ritual, via an HIV prevention rationale. They caution that for MC to be a therapeutic as opposed to a non-therapeutic procedure, it is necessary to gather more corroborative and consistent evidence of its benefit, consider the potential harms (psychological, sexual, surgical and behavioural/disinhibition), examine the ethical implications, and examine effectiveness and efficiency (costs and benefits) at the population and societal levels. They point out that MC is not just a technical surgical intervention – it takes place in a social context that can radically alter the anticipated outcome. At the 2008 International AIDS Conference [3] in Mexico cultural, political and educational issues raised by the intervention, such as decreased condom use and marginalisation of women, were hotly debated. Some cultural interpretations may view MC as a licence to have unprotected sex. A case in point is Swaziland, where men are flocking to be circumcised with the understanding that this means they no longer need to use other preventive methods (e.g. wear condoms or limit the number of sexual partners). [4]
The 2003 Cochrane review5 of observational studies of MC effectiveness concluded that there was insufficient evidence to support it as an anti-HIV intervention. Three randomised controlled trials (RCTs) from South Africa, Kenya and Uganda in 2006-2007 show a protective effect of MC. However, Garenne [6] has subsequently shown from observational data that there is considerable heterogeneity [inconsistency] of the effect of MC across 14 African countries. Despite the South African RCT showing a protective effect, he reports for the nine South African provinces that ‘there is no evidence that HIV transmission over the period 1994-2004 was slower in those provinces with higher levels of circumcision’. Interestingly, in both Kenya and Uganda, where two of the RCTs were done, a protective effect of MC was observed, but a harmful effect was observed in Cameroon, Lesotho and Malawi. The other eight countries showed no significant effect of MC.
These somewhat discordant findings are difficult to interpret. While RCTs are theoretically strong designs, it is conceivable that their findings are not generalisable beyond their settings. Furthermore, there have been no trials of neonatal MC. Study flaws such as inability to obtain double blinding, and loss to follow-up in RCTs, may effectively degrade their quality to that of observational studies. Meanwhile other disturbing findings referred to by Sidler et al. are emerging, including the reported higher risk for women partners of circumcised HIV positive men, disinhibition, urological complications, relatively small effect sizes of MC at the population level, and relative cost-inefficiency of MC.
Not all objections to MC as an HIV intervention have to do with evidence of effectiveness or cost. Sidler et al. raise ethical objections. Owing to the current climate of desperation with regard to the HIV epidemic, evidence in favour of MC frequently seems overstated. This reduces the scope for informed consent and autonomy for adult men considering the procedure. Further problems arise in the case of neonates whose parents may be considering the procedure. Whereas informed consent is at least possible for adult men, it is clearly not possible for neonates. Parents can only guess what the child’s wishes would be if he were presented with the information they have at their disposal.
If it could be shown that circumcision was necessary in the neonatal period, parental consent on behalf of the neonate would be justified. But since no valid surgical indications for circumcision exist in this period, and the future benefit to the child in respect of HIV avoidance is not relevant before sexual debut, the duty of parents may well be to err on the side of caution, and defer the procedure until the child can make an autonomous decision. In the absence of compelling indications, a procedure such as circumcision could also be seen as a violation of the child’s right to bodily integrity. Furthermore, the ethical principle of non-maleficence cannot be upheld as there are clear harms attached to this practice, to which Sidler et al. refer in their article. Lastly, at a societal level MC may be unjust insofar as it could compete for resources with more effective and less costly interventions [7] and disadvantage women.
Despite a strong pro-circumcision lobby driven by enthusiasts who have been promoting MC as an (HIV) intervention for many years, and impatience expressed by protagonists about the long delay after the 2006-2007 RCT results and the UNAIDS/WHO policy recommendations8 of March 2007, few mass campaigns have been launched in African countries. Given the epidemiological uncertainties and the economic, cultural, ethical and logistical barriers, it seems neither justified nor practicable to roll out MC as a mass anti-HIV/AIDS intervention.
A Myers
Humanities student, University of Cape Town
J Myers
School of Public Health and Family Medicine University of Cape Town
Corresponding author: J Myers (jmyers@iafrica.com)
References
1. Connolly C, Simbayi LC, Shanmugam R, Nqeketo A. Male circumcision and its relationship to HIV infection in South Africa: Results from a national survey in 2002. S Afr Med J 2008; 98: 789-794.
2. Sidler D, Smith J, Rode H. Neonatal circumcision does not reduce HIV infection rates. S Afr Med J 2008; 98: 764-766.
3. Male Circumcision: To Cut or Not to Cut (dedicated session, 7 August). AIDS 2008 – Mexico City 3-8 August 2008 – XVII International AIDS Conference. http://www.aids2008.org/Pag/ PSession.aspx?s=41 (last accessed 8 August 2008).
4. Swaziland: Circumcision gives men an excuse not to use condoms. http://www.irinnews. org/Report.aspx?ReportId=79557 (last accessed 7 August 2008).
5. Siegfried N, Muller M, Volmink J, et al. Male circumcision for prevention of heterosexual acquisition of HIV in men. Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD003362. DOI: 10.1002/14651858.CD003362.
6. Garenne M. Long-term population effect of male circumcision in generalised HIV epidemics in sub-Saharan Africa. African Journal of AIDS Research 2008; 7(1): 1-8.
7. New study shows condoms 95 times more cost-effective than circumcision in HIV battle. http://www.prweb.com/releases/2008/08/prweb1151894.htm (last accessed 7 August 2008).
8. WHO/UNAIDS Technical Consultation Male Circumcision and HIV Prevention: Research Implications for Policy and Programming. Montreux, 6 - 8 March 2007. Conclusions and Recommendations. http://data.unaids.org/pub/Report/2007/mc_recommendations_en.pdf (accessed 25 August 2008). October 2008, Vol. 98, No. 10 SAMJ
See also A. and J. Myers, Male circumcision: The new hope?, South Africa Medical Journal, Vol. 97 (5), May 2007
The following editorial was published in the Ugandan newspaper Daily Monitor in December 2009.
A few days ago I found it necessary to restate my position, calmly and quietly, that my sons – two so far – should under no circumstances be circumcised. Two very simple and I am persuaded, logical reasons. First, while I respect the standpoint of those who argue for circumcision, I personally do not believe in it. Circumcision is such a personal affair; nobody has the right to decide for anybody else whether or not they should undergo it. And since kids are too young to appreciate the merits (probably lack of them) of a matter as personal and important as losing their foreskin, I argue that it is improper for somebody else (parent though they be) to make that decision for them, unless it is a medical emergency that has implications on their immediate survival or potency. If as adults they decide to submit to the knife, that is their responsibility.
The other reason is that the advocates of circumcision in Uganda today are advancing very lame, wrong and wholly incompetent reasons for it. Their message is two-fold: that circumcision will help protect men from contracting HIV – the virus that causes AIDS.
Secondly we are told that circumcision promotes hygiene among men. As we speak, billions of shillings have been sunk into programmes about circumcision, telling every Ugandan that this is the new miraculous discovery that will keep them safe. This lie needs to be unmasked and exposed, because we are playing with fire. Who in their right mind would believe that a man can have unprotected sexual intercourse with an infected woman and come out intact just because he is circumcised? Any argument about how hardened a circumcised male organ is and how it is able to withstand whatever period of sexual intercourse and emerge without scratches and, therefore, without possibility of infection is purely academic … and deadly.
The truth behind circumcision is that it is just a new excuse invented by unscrupulous and incompetent scientists, plus bureaucrats in the United Nations, African governments and civil society to eat free money. They have not told us who did the research, what methodology they employed or which experimentation humans they used. In the end, therefore, the current campaign for circumcision has nothing to do with your health and safety. It is all about people making money. Our young men will now believe that you can sleep with whoever it is and you’ll be safe just because you are circumcised. And they will die. Our girls will be told, “I am circumcised” and they will presume they are safe. And they will die.
Strangely enough, the protagonists of circumcision argue that it affords only a 60 per cent chance at best of avoiding the virus and that circumcision should be used “in combination” with other safety measures such as condom use. I think the ABC strategy that Uganda had adopted is good enough to help us fight AIDS. Abstain from sex, or Be faithful to your (one) partner or if push comes to shove, use a condom. For hygiene I will encourage my sons to take a bath regularly. I will also take them through another course on how a man ought to keep himself clean. For now I find it important to put the country on notice: we are being duped and as your kids bleed all the way from hospital, a small clique is laughing all the way to the bank.
Unmasking the Lie: Circumcision, Sex and HIV/AIDS
By Gawaya Tegulle
Daily Monitor (Uganda) December 12, 2009
Despite the AIDS crisis about which we hear so much, South Africa is one of the very few countries in the world that has actually passed a law regulating and to some extent prohibiting circumcision of male minors. This is a fact about which we hear very little. The relevant sections of the Children's Act (2005) are as follows.
7. (1) Whenever a provision of this Act requires the best interests of the child standard to be applied, the following factors must be taken into consideration where relevant, namely -
(l) the need to protect the child from any physical or psychological harm that may be caused by ... (i) subjecting the child to maltreatment, abuse, neglect, exploitation or degradation or exposing the child to violence or exploitation or other harmful behaviour
12. (1) Every child has the right not to be subjected to social, cultural and religious practices which are detrimental to his or her well-being
(3) Genital mutilation or the circumcision of female children is prohibited. ...
(8) Circumcision of male children under the age of 16 is prohibited, except when (a) circumcision is performed for religious purposes in
accordance with the practices of the religion concerned and in the manner prescribed; or (b) circumcision is performed for medical reasons on the recommendation of a medical practitioner.
As you can see, there are problems with this. For a start there is gross gender discrimination, in that girls are given blanket protection against any kind of harm, but boys have to make do with qualified protection. The exception for "religious purposes" allows practising Jewish and Muslim parents to circumcise without constraint, but the failure to specify the religions accorded the exemption provides a loophole for anybody who wants to invent his own religion. More seriously, the reference to "medical reasons" fails to define what they are. If they mean a situation where circumcision is necessary to treat an injury, deformity or disease that has failed to respond to conservative treatment after reasonable efforts, that is one thing and will provide a significant level of protection
If, on the other hand, they mean circumcision performed in the belief that it will reduce the risk of contracting diseases to which the child may be exposed at some later date (i.e. prophylactic or precautionary circumcision), that is quite another, and will provide no protection at all against the circumcision promoters. Most non-religious circumcision is prophylactic circumcision, but it should not be confused with therapeutic (i.e. treatment for an existing problem). It is significant that in its paper on the legal status of circumcision of male minors the Tasmanian Law Reform Institute is careful to explain that prophylactic circumcision is not therapeutic.
Still, South Africa is way ahead of Australia and most developed nations in making some attempt to crack this difficult nut.
Interestingly enough, the South African Medical Association does not consider the AIDS crisis a sufficient justification for routine circumcision of male infants or other normal male minors. In response to an inquiry from Nocirc of South Africa, the South African Medical Association stated that there was no justification for routine circumcision of infants or children. In letter to Nocirc SA, dated 4 February 2005, and signed by Professor Ed Coetzee, Chairperson of the SAMA Education, Science and Technology Committee, the Association states:
“After lengthy DISCUSSION on the matter, the Committee RESOLVED that it be conveyed to NOCIRC-SA that, from a medical point of view, there was no medical justification for routine circumcision in males and children.”
In this conclusion, SAMA joins medical authorities in Britain, Canada, the USA, Australia and New Zealand in agreeing that there is no medical case for routine circumcision. In fact, it goes slightly further than the Royal Australian College of Physicians, which states that there is “no medical indication”; SAMA says there is “no medical justification”, an even stronger rejection.
Coming from a country with an extremely high incidence of HIV infection (and also a high incidence of male circumcision), this is a significant declaration.
South African Medical Association website
Policy statements by medical associations
One of the concerns driving the South African legislation is the sad fact that each year traditional ritual circumcision of Xhosa teenagers leaves a trail of devastation: dozens of boys killed and many more injured. Appalled by the general indifference to this toll, the South African Medical Journal in 2003 called for "action to stop the carnage".
“Circumcision leaves 24 dead, 10 in hospital”, read the headline in The Star of Kuala Lumpur, Malaysia, on 16 July 2002. The report continued: “South Africa’s initiation season ended this weekend with a gruesome toll of 24 deaths reported to police and more than 100 teenagers hospitalised with gangrene and septicaemia after botched circumcisions and severe beatings. One boy’s penis dropped off as a result of gangrene, at least one other had to have his penis amputated, and another will have to have both legs amputated, authorities said”.
Similar horrifying circumcision outcomes have been observed again this year, with reports of the deaths and mutilations being beamed across the world by all the major news services. No one understands why we as a country – or as communities – have seemingly stood by and done little or nothing as these deaths rock the country year after year. Anywhere else in the enlightened world, this kind of mayhem would have evoked community outrage and led to urgent and drastic action to prevent it.
Why are we not sufficiently agitated by the slaughter to find ways to stop it? Perhaps in today’s South Africa, where violence constitutes one of the leading causes of death (including 23,000 officially acknowledged murders per annum), we have become hardened against the horror of needless death. In any event, deaths due to ritual circumcision largely occur in the impoverished and faceless rural and peri-urban communities, and those of us north of he railroad are in denial about this, just as we are about much of the other misery in that quarter. The communities themselves have perhaps come to accept these occurrences as part of their fate, along with unsafe minibus taxis and random street shootings. Middle class families from circumcising backgrounds ensure that their sons are circumcised in safe and nurturing environments. Unless this elite is moved and inspire to do something about the circumcision deaths among the less privileged, nothing will change.
A further reason for playing down the deaths may be a deep-sated fear among the affected communities (largely in the eastern Cape and the Limpopo provinces) that this hallowed ancient tradition is under threat of extinction, and that any move to modernise it may push it over the edge. Certainly, some voices coming through on radio talk shows seem much more concerned with the survival of the ritual itself (often rather broadly if inaccurately labelled “our African culture”) than about the reported deaths and mutilations.
Daniel J. Ncayiyana, Editor
South Africa Medical Journal, Vol. 93, No. 8, August 2003
In 2006 the British Medical Journal reported:
Fourteen boys have died as a result of botched circumcisions in the past month in the Eastern Cape province of South Africa. Hundreds more boys have been maimed and mutilated in the same process which takes place annually at “circumcision schools,” usually conducted in the bush, away from towns and villages. In South Africa, in many groups, boys are circumcised between puberty and adulthood, and it marks the ritualised passing from boyhood to manhood.
In the past few years, however, this “circumcision season” has been marred by untrained and bogus traditional surgeons trying to make money but whose technique lacks expertise and hygiene. The provincial department of health says that 243 deaths and 216 genital amputations from circumcisions were recorded between 1995 and 2004. Last year there were more than 20 deaths. Laws and regulations in the Eastern Cape were passed in the hope of controlling the practice and ensuring hygienic conditions. Traditional surgeons have to be officially recognised and register with the department. Surgeons caught running initiation schools without authority can be sent to prison.
Pat Sidley, Johannesburg
British Medical Journal, Vol. 333, 8 July 2006, p. 62
Further information
South African Medical Association calls for action to “stop the carnage”
And the story is much the same this year: see news reports at CIRP and Circumstitions. According to the latter, there have been 53 deaths so far this year in Eastern Cape Province. Not much evidence there that circumcision is improving child health.
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