12/04/08

Kenya gets out the scalpel, circumcising men to prevent HIV

Kenya plans to offer all men the snip, in an effort to reduce HIV transmission. It’s a brave move in a country when circumcision status is a badge of ethnicity and differences in ethnicity are reason enough for rioting, looting and murder.

According to a report in The Nation Kenya’s Ministry of Health has published a new policy on male circumcision (the policy hasn’t made it on to the MoH website yet.) The country aims to provide circumcision for any man who wants it. It’s not a radical decision in terms of public health. Although the anti-circumcision ring-masters continue to rail against the data, most public health professionals are convinced by studies suggesting that a man without a foreskin is 60% less likely to contract HIV than a man with a foreskin. Uganda and Rwanda have already decided to try and circumcise as many men as are willing. The controversy comes, rather, from people who are worried about two things: behaviour and culture.

The behavioural worry is this: if men think they can’t get infected if they are circumcised, they won’t bother with condoms. Possibly. But the reason a third of adults are infected with HIV in some parts of Kenya is that men aren’t bothering with condoms in any case. If you can reduce the likelihood that those men will contract the disease, how is that a bad thing?

The cultural worry comes from the “in some parts of Kenya” thing. HIV is much higher among some of Kenya’s tribes than among others. It is notably higher among the non-circumcising Luo, for example (22%), than among the circumcising Kikuyu (5%). Nationwide, HIV among non-circumcised men is 13%, compared with 3% among men who have had the snip. Current president Mwai Kibaki is Kikuyu. Raila Odinga, who believes he should be president following December’s disputed election, is Luo. There’s an uneasy truce between the two at the moment, but just a couple of months ago being a member of one group or the other was enough to get you burned out of your house or slaughtered. In these circumstances, markers of tribal identity such as a foreskin take on a significance that goes way beyond a concentration of HIV-susceptible cells. Circumcising everyone would remove that badge of identity. In my mind, that another reason for circumcision, not against it.

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This post was published on 12/04/08 in Science.

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  1. Comment by Lee Rudolph, 12/04/08, 09:09:

    Re: “a concentration of HIV-susceptible cells”. Is that now the consensus view of the underlying reason for the (statistically undeniable) relation between “foreskin status” and HIV-susceptibility?
    If this has been published in the popular press (and it may well have), I’ve missed it. Any good pointers? (The prospect of using Google to search for “HIV” and “circumcision” at the same time is too horrible to contemplate.)

    P.S. “Preputial status” would sound much classier than “foreskin status”, but I suppose “preputial” looks too much like “prenuptial”.–Though maybe Kenya might want to look into preputial prenuptial agreements, at that.

    P.P.S. “Kenya’s Ministry of Health has published a new policy on male circumcision (the policy hasn’t made it on to the MoH website yet.)” Pity there’s an “a” in Health, or it would be the MoHel website.

    EP replies: Interestingly, if you search for “HIV” and “circumcision”, you get different results from a search on “circumcision” and “HIV”. But the denialists don’t make it into the top 5 on either one. Search for “HIV” and “preputial”, on the other hand, and “mothersagainstcirc.org” comes up at number 2! For cell suscpetability, search “Langerhans” and “HIV”.

  2. Comment by Carter, 19/05/08, 09:52:

    “Circumcising everyone would remove that badge of identity. In my mind, that another reason for circumcision, not against it.”

    It is important to remember that circumcision is a surgery of limited efficacy, not a needle in the arm.

    Given that it is a non-medically necessary, and permanent removal of sexual tissue, it must be voluntary. The circumcision lobbyists might pay lip service to the word voluntary, but the meaning of the word seems to often escape them judging by some of the statements I have read.

    Making circumcision available for those who would choose it is one thing – and where is the harm in that? “Circumcising the Africans” is quite another. As in your above statement (“Circumcising everyone…), the language of those that would push for mass circumcision often reflects the latter.

    What should also be addressed, and echoed in a recent journal article http://www.futuremedicine.com/doi/full/10.2217/17469600.2.3.193 is the following:

    “…the results of studies performed on consenting adult African males should not be extrapolated to a health policy for newborns. It is unprecedented and unethical for an inadequately evaluated prophylactic surgery to be offered as a ‘health benefit’ to parents of newborns to reduce risks of an adult-acquired disease for which alternative preventatives, in addition to condoms, are likely to be available before today’s infants reach sexual maturity [25].

    Newborns are not sexually active and, therefore, not at risk for sexually contracted diseases. Ethically and according to human rights law, circumcising an unconsenting child is in many ways similar to forcing circumcision upon an unwilling adult. Children deserve special protection from practices that put them at unnecessary risk and abrogate their rights to self-determination in the future.”
    .
    The removal of any non-essential body part will be associated with some health benefits or another as it is one less body part that might be affected by disease. The fact that excision of male genital tissue is associated with a lowered risk of acquiring HIV (if more effective prevention methods are not employed) does not create ethical justification for performing it on a child.

    Administering a vaccine is one thing, a permanent body modification is quite another.

    Another problem is how to promote the surgery in a way that does not do so at the expense of stigmatizing men who are intact and prefer to stay that way. Mitigating HIV risk can be achieved in far more effective ways. Creating social conditions that exploit peoples vulnerability to group pressure – where people would submit to the procedure primarily to avoid being the odd man out, or being seen as an HIV risk to potential partners – runs contrary to medical ethics.

    “The country aims to provide circumcision for any man who wants it.”

    Of course this makes perfect sense. If that were truly the sole aim of circumcision promotion there would be no problem. Unfortunately, the policy also will have the effect of promoting circumcision in unconsenting children, and will likely, if successful, create social conditions that stigmatize intact males.

    Regarding circumcision to ‘remove’ a badge of identity. The intact penis is the natural anatomical state of the human male. It is, in fact, circumcision that is, and has always been, a cultural ‘badge of identity’. This whole idea of removing genital anatomy to reduce STD risk is largely cultural phenomenon. The age old custom is still around, so lets find reasons for it after the fact. I have yet to see decades of research devoted to finding potential benefits associated with removing ‘dispensable’ parts of the female genital anatomy. Something one might expect if finding ‘dispensable’ parts of the human genital anatomy in the name of STD prevention was purely a scientific endeavor.

    Langerhans cells are also found in high concentration in the external female genitalia, like the labia and clitoral hood. Surely, in a medical context, it could be done safely without any significant detriment to a woman’s sexual enjoyment. Apparently, most women report it actually improves. http://www.labiadoctor.com/labiaplasty.html, http://en.wikipedia.org/wiki/Labiaplasty. And less vulnerable anatomy equals less susceptible to disease, no?

    If there was analogous benefits associated with, say, clitoral hood removal in women, would anyone dare suggest that its removal in female infants and children would be appropriate? Would it be acceptable for a proponent of this strategy to suggest that men urge their female partners to undergo the surgery? and even go so far to say that men might refuse to have sex with women who have not submitted to the procedure? (as was said by a prominent male circumcision promoter regarding women’s role in the uptake of male circumcision).

    It is important for any circumcision campaigns to proceed cautiously and respect medical ethics and human rights.

  3. Comment by Dave, 09/01/11, 08:01:

    Circumcision does not prevent HIV and condoms and having safer sex to a better job of preventing HIV transmission than any sort of pointless genital mutilation does.

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