Following up on my previous post, some typical and not-so-typical arguments appeared at the Third South African AIDS Conference earlier this week. First, the typical in describing the apparent risk-reduction from the recent HIV studies:
“The effect was long-lasting, there wasn’t disinhibition [increased sexual risk-taking], they didn’t screw around more, they didn’t use condoms less,” said Neil Martinson¹.
Remember that both circumcised and intact groups in the studies saw a more significant drop in their rate of HIV infection over their national HIV infection rate than the effect presumably provided by circumcision. But it’s easier to keep focusing on circumcision, because that (allegedly) removes the human factor from HIV prevention. Sure.
“There’s no question that we need a male circumcision programme, but a mass programme is more debateable. Operationalising it is going to be complicated,” said Professor Alan Whiteside of the University of KwaZulu Natal.
He advocated routine opt-out male circumcision at birth. “Thirty years from now we’ll be so glad we did it.” He believes that “if we’d started 25 years ago we wouldn’t be in this godawful mess.”
An audience member suggested that op-out circumcision should also become standard practice for adult males who attend sexually transmitted infection clinics.
…routine opt-out male circumcision at birth. When talking about saving for retirement, opt-out programs make sense. It involves only the person whose money will be siphoned off into a separate, presently untouchable account. There is a (mostly) objective rationale behind the requirement. It’s a form of “we know better what you should do”. But he can easily reject this. He can also reverse his decision later.
Routine opt-out male circumcision at birth requires a specific action from one group (parents) to avoid violating another’s (their male child) right to not have part of his genitals cut off without medical need. There is an entirely subjective reasoning behind the requirement. Parents could reject this, although they’d likely receive information with overblown, fear-based hysteria. The experts are counting on the well-intentioned parental desire to protect children, with a bit of residual goodwill toward the procedure if the father’s chosen it for himself. But the male child can never reverse this decision. This is little more than social engineering with children and their genitals as pawns for the public health nannys.
If African nations had started routine infant male circumcision 25 years ago, they might not be in this “godawful mess, but they’d also have a generation of cut males to demonstrate that HIV infection is still possible and that more effective, less invasive methods of prevention already exist. But don’t bother to learn from the United States the lessons that are inconvenient to learning what you want to learn from the United States.
Now, for a moment of respite from insanity, something non-typical:
However Professor Timothy Quinlan of the Health Economics and HIV/AIDS Research Division at the University of KwaZulu Natal was sceptical about the need for a mass programme, arguing that the evidence doesn’t justify it.
… he said, prevention needs to focus on the two factors known to have the biggest effect on HIV transmission rates: concurrent partnerships and high viral load during primary infection.
There’s a need for clearer messages to communicate these facts,” he said. “We need to promote serial monogamy.”
I know, that’s unworkable because it assumes some sense of personal responsibility and ability to learn among African men.
And now a return to the typical:
Audience members raised some of the practical issues that are likely to arise in the implementation of any sort of circumcision programme. Traditional healers in particular will need to be brought on board, said numerous speakers.
“Don’t talk about circumcision in isolation from the initiation processes going on in all the different cultures in South Africa,” said one male audience member.
But there was general agreement that traditional healers who carried out circumcision during the initiation of young males into adulthood had a captive audience for passing on important prevention messages, and that this potential wasn’t being exploited.
Yes, what about those traditional healers? Ahem:
A 22-year-old unregistered traditional surgeon was arrested for illegally circumcising two boys in Libode, the Eastern Cape health department said on Saturday.
Meanwhile, police were searching for another unregistered traditional surgeon who allegedly circumcised 24 under age boys in Mthombe.
Kupelo said three of the boys were taken to hospital with serious complications.
2006 Eastern Cape summer-season circumcision deaths have declined markedly compared to 2005, Eastern Cape provincial health department spokesperson Sizwe Kupelo said, adding that only four would-be initiates had died so far this season, compared with 24 in 2005.
Of those four, only two were the result of complications of the circumcision operation. …
This reliance on traditional healers is an acceptance that, among several challenges, the public health community doesn’t have the resources to provide full, clinical circumcision in Africa. Yet it pushes the notion that it must be done both “mass” and “soon”. Why is it so difficult to see how this will end? How many deaths are acceptable? Are we really ready to rely solely on the utilitarian argument that more lives will (probably) be saved with mass circumcision than will be taken through mass circumcision? I’m not, since I’m capable of understanding individual rights.
¹ To another point by Dr. Neil Martinson:
“It’s all about cold steel – it’s more akin to sterilisation, it’s not like giving people clean water, it’s not like breastfeeding that we can all get warm and fuzzy about.”
Promoting mass circumcision is primarily about giving advocates warm and fuzzy feelings that they’re doing something monumental. Otherwise, why the rush to circumcise infants based on three studies of voluntarily circumcised adult males? It also reassures parents with a warm and fuzzy feeling that they’ve “protected” their sons from HIV rather than violated his rights.
There was confusion about who would be targeted with messages about circumcision. Would it be young men, or would it be their parents? Or must their future sexual partners be targeted, “so that they say `I won’t sleep with you unless you’re cut’,” asked Neil Martinson?
“I won’t sleep with you unless you’re cut.” Let’s promote such non-thinking. Maybe, if we work at it enough, we can convince African women that they prefer, and sh
ould prefer, the aesthetic look of the circumcised penis. It’s okay if that implies that men should change themselves to meet a woman’s expectation. The reverse is sexist and unacceptable, of course, but we all know that’s okay.