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The missing link in Africa's circumcision boom
Written by: Mercedes Sayagues
Reuters and AlertNet are not responsible for the content of this article or for any external internet sites. The views expressed are the author's alone.
Who's up for circumcision? Boys pose for the camera in Sao Tome. Photo by Mercedes Sayagues
Pull down your zipper. Pass the sterilised blade. One more foreskin removed. Good. We are closer to the target defined by (...insert name of your donor agency here). Next one, please. Welcome to the male circumcision boom in Africa, marketed as the new silver bullet in the arsenal of AIDS prevention. Swaziland has "circumcision Saturdays", for the convenience of the working man who does not want to miss work. Last year, teams of Israeli surgeons toured the tiny kingdom showing doctors how to snip foreskins nice and easy, fast and clean. Kenya, Rwanda and Zambia are rolling out male circumcision programmes and men are queuing at the clinics. Hang on there for a moment. Pull up your zipper. Let's have a second opinion. Last week, I heard Dr. Clive Evian present intriguing data at the Centre for the Study of AIDS at the University of Pretoria, South Africa. Since 2004, Dr. Evian has been doing second-generation HIV prevalence surveys among some 5,000 workers at an agribusiness state in Swaziland, a mine in Botswana, commercial farms and a manufacturing firm in South Africa - countries with the world's top five HIV infection rates. The South African farms surveyed employ mostly men in Limpopo province, where male circumcision is traditional. So Dr. Evian asked questions about it. A quarter of the 269 workers were HIV-positive. Of the HIV-positive, seven out of 10 had been circumcised. Those circumcised as children had lower infection rates than those circumcised as young men. Perhaps, says the study, circumcision as an HIV prevention strategy "is most effective the earlier the circumcision is done". Overall, the protective effect of male circumcision might be "somewhat limited" in communities where HIV is rife, said Dr. Evian cautiously (the statistical sample is too small; more studies are needed). Other studies have shown that areas in Mozambique and Kenya with high male circumcision have lower seroprevalence (the number of people testing positive) but not in South Africa, Lesotho and Malawi. While clinics are doing booming business, others question the value and wisdom of aggressively promoting male circumcision against AIDS. Scientists have pointed out limitations in the three main studies in South Africa, Kenya and Uganda (too few, too short) and the limited benefit of 50 to 60 percent protection afforded by circumcision. From the science journals to the bars, information gets diluted. In my reporting trips across Africa, I meet many men considering the surgery who believe they will get full, lifelong protection. Will the newly circumcised feel they have a permanent condom, like tattooed eyeliner, and ignore the 40 percent risk? Mass male circumcision could bring mass male smugness about safe sex. Counseling will persuade men to keep using condoms, say the circumcision missionaries. Well, if counseling hasn't succeeded in 25 years of the epidemic, why would it now? Would a young man voluntarily go through a painful procedure only to continue using condoms? I doubt it. Historically, male circumcision has branded religion, citizenship and tribe - those who do it and those who don't. It is central to the concept of masculinity and belonging to a community. Today, as clinics roll out the surgery, little thought is given to its effects on male identity, sexual pleasure, culture, and relations. The latest fad comes with pots of donor money. The West loves the idea (the illusion?) of a quick medical fix against AIDS, with numerical targets - counting pills, condoms and foreskins. Just one donor, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), budgeted $16 million for male circumcision in 2007, from a paltry $600,000 in 2006. And PEPFAR may spend US$30 million in 2008, says its website. The rollout requires training, equipment, statistics and personnel - diverting scarce human resources from the strained public health systems of Africa. Meanwhile, comparatively little money and effort go into making traditional circumcision safe. Why? Because this intervention is messy. It involves talking with traditional healers and elders, who might resist. It is not easily quantifiable. It takes time. It is not new. "It's much easier to throw money at new circumcision programmes that you can control," says Pierre Brouard, deputy director of the University of Pretoria's Centre for the Study of AIDS. Reaching traditional surgeons can be done, though, with little money but lots of community connectivity. Two years ago, Dr. Egidio Langa was the health director of the remote Montepuez district, in Cabo Delgado province in northern Mozambique - a Muslim region with high male circumcision. Community leaders approached Langa. They worried about botched kumbi, circumcision in the makhuwa language. They had seen boys go septic, hemorrhage; some had died. Langa made a plan. Come kumbi time, a team of nurses fanned out through the district. They trained the nekangas, or traditional surgeons, on hygiene, first aid and HIV. They gave medical supplies. And they negotiated a deal: the boys would be brought from seclusion one day to be circumcised at the local health post and would return to the bush to finish the initiation rite. Only now the nekangas could take better care of them. Daily for two months, the team circumcised up to 60 boys aged seven to 13. "With a small budget, we reduced a big risk and the initiative was well received because it was local," Langa recalled. Medical interventions should not be divorced from culture and social sciences. This link is missing in the circumcision boom.
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7 responses to “The missing link in Africa's circumcision boom”
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Mercedes Sayagues, a Uruguayan-born journalist, has lived in South Africa since 2001, when she was expelled from Zimbabwe, her home since 1992. Until May this year, she was the editor of the IRIN/PlusNews Portuguese service, and now freelances from her home in Pretoria.
17 Jul 2008 08:02:40 GMT
"Counseling will persuade men to keep using condoms, say the circumcision missionaries. Well, if counseling hasn't succeeded in 25 years of the epidemic, why would it now? Would a young man voluntarily go through a painful procedure only to continue using condoms? I doubt it."
It's about time that someone in the media exposed the PHALLACY of circumcision and the AIDS epidemic. America has some of the highest circumcision rates, and that hasn't stopped AIDS here either. Thank you for publishing this article!17 Jul 2008 08:16:21 GMT
So Why Do It? The foreskin is there for a number of reasons. It is there for the comfort of the woman on the other end of the penis where it eases entry and acts as a one way valve retaining vaginal lubrication and preventing the vagina from drying out during sex. A circumcised penis acts as a washer on the end of a piston in the same way as the piston and washer in a hand water pump. The circumcised penis draws lubrication from within the woman on each outstroke in the same way that a hand water pump draws water out of the well with each stroke. The foreskin is also packed with erogenous nerves which provide the wide range of sensations in the penis leading up to orgasm. Furthermore, if the strawberry like glans on the end of penis doesnât have a foreskin to cover it, it becomes dry and toughened thus reducing sensation. The combination of the lack of nerves and the toughened dried out glans means that a man feels much reduced pleasure in the build up to orgasm and that he has to ! thrust for a much longer time than he would if had foreskin. If the length of time a man can have sex before orgasming is considered to be an advantage then it is true that the lack of a foreskin might achieve this, but will result in considerably reduced feeling while doing so. Surely it is better for sex to last for the normal amount of time and for it to feel good from beginning to end rather than it lasting for hours with much reduced feeling? What is more, women donât want to be thrusted for hours on end; that is a myth. If the reason for cutting the foreskin off in the first place is to prevent HIV/AIDS then the protection a man gets from doing this is really very slight compared with the protection gained from using condoms, so why not just use condoms and keep all the good feelings that nature meant men to have during sex ? Finally, a natural penis is better for women too. Laurie Milner (UK).
17 Jul 2008 09:06:30 GMT
The studies which allegedly show a reduction in HIV among circumcised men are highly questionable. Not one of them was finished, despite the protective affect appearing to decline well below the oft-reported 65%, and several of the subjects disappeared. The fact that one study described circumcision as "comparable to a vaccine of high efficacy" seems to show clear bias. They appear to have been seeking a certain result. One has to wonder how many of the people promoting circumcision in Africa are themselves circumcised. Daniel Halperin is the grandson of a mohel, and seems to think that "maybe in some small way (he's) destined to help pass along (circumcision)" so his objectivity is questionable.
Other epidemiological studies have shown no correlation between HIV and circumcision, but rather with the numbers of sex workers, or the prevalence of "dry sex". The two continents with the highest rates of AIDS are the same two continents with the highest rates of male circumcision. Rwanda has almost double the rate of HIV in circed men than intact men, yet they've just started a nationwide circumcision campaign. Other countries where circumcised men are *more* likely to be HIV+ are Cameroon, Ghana, Lesotho, Malawi, and Tanzania. That's six countries where men are more likely to be HIV+ if they've been circumcised. Something is very wrong here. These people aren't interested in fighting HIV, but in promoting circumcision (or sometimes anything-but-condoms), and their actions will cost lives. Circumcised male virgins are more likely to be HIV+ than intact male virgins, as the operation sometimes infects men. The latest news is that circumcised HIV+ men appear more likely to transmit the virus to women than intact HIV+ men (even after the healing period is over). Eight additional women appear to have been infected during that study, solely because their husbands were circumcised. Female circumcision seems to protect against HIV too btw, but we wouldn't investigate cutting off women's labia, and then start promoting that. For a good summary of the case against promoting circumcision in Africa, see this link: http://www.17 Jul 2008 10:34:55 GMT
"Will the newly circumcised feel they have a permanent condom ... and ignore the 40 percent risk?" Probably, but the widely-touted claim of "60% reduction in HIV" actually boils down to 73 circumcised men in three countries who didn't get HIV while 64 did. They had to circumcise 5,400 men to achieve that, and of those, 327 lost interest in the studies and we don't know if they got HIV or not. (They were encouraged to get tested elsewhere, because it wasn't considered "ethical" to tell them if they were HIV+, and if you found you had HIV after a painful and marking operation to prevent it, would you go back?) It's quite possible that circumcision confers no protection at all.
17 Jul 2008 14:17:46 GMT
Guess the arguments presented mean that we journalists, especially, have a lot to do now more than ever. First of all, we need to lay all the facts on the table before someone devised some myth and attracted a cult-like following.
18 Jul 2008 07:19:04 GMT
In my opinion, the most important element raised in this article is that of the link between development science and local culture. All the good intentions, trendy data and Western money thrust into a campaign of circumcision will have little to no positive or sustainable results if it does not connect with local customs and cultural paradigms. The recent (60 yr) history of development efforts clearly reveal that apart from the true adoption by the local community, efforts to improve peoples' standard of living will fall short or even fall backward. Development must not continue to ignore the reality and strength of local customs for determining community improvements.
07 Aug 2008 16:41:37 GMT
I was never circumcised. My mother taught me to wash instead. The benefits of not being circumcised are rather obvious especially to any one who is not. In our family we regard it as male mutilation. Both my sons were not circumcised. It's not like it is a huge subject, but when it was brought up they both thanked my for not circumcising them. In a city close to us a baby was circumcised and was taken home and later died from blood loss. The were upset, of course, but said they would have another and circumcise that one too. Can you believe it?