Report on Male Circumcision: an Arguable Method of Reducing the Risks of HIV Transmission

 II The dangers of an affirmed policy of male circumcision

Promoting male circumcision may confuse existing prevention messages.

In March 2007, the WHO and UNAIDS published the findings of an international technical consultation and reiterated the fact that «male circumcision does not provide complete protection against HIV» [20], but is a supplementary means of reducing the risk of infection. It must only be used within the framework of a wider strategy aimed at preventing HIV. Even though no studies demonstrate this at the moment, there is a serious risk that people will mistakenly believe themselves completely protected from the virus and will use fewer condoms. How can it be explained clearly to people that they must be circumcised in order to reduce the risk of transmission, but the use of other forms of prevention (abstinence, fidelity, condoms, etc.) remains essential despite this?

Male circumcision may increase the number of infections

Various authors have highlighted the importance of ritual male circumcision in certain African populations and the inherent risks of infection [21]. In certain communities, it forms part of a rite of passage to adulthood, or it is a ritual associated with marriage that leads to rapid and repeated sexual activity after the act of circumcision itself [22]. In the first month, while scar tissue is forming, men are much more vulnerable to the transmission of HIV and increase their risk of infecting or being infected by their partners. Similarly, a study in Uganda that was part of a trial showed that around 10% of serodifferent couples, where the man was infected with the HIV virus, resumed sexual activity before the doctor had declared the man’s scarring process to be complete – ultimately leading to infection of his partner [23]. The few studies on the links between male circumcision and sexual activity may lead us to believe that the beliefs held by the population concerning male circumcision could give rise to paradoxical effects. It is primarily the symbolic aspect that the population has in mind; it is also chiefly ritual practitioners who carry out the circumcision [24] and in terms of hygiene and safety the results are far from ideal [25]. There have even been incidences where people have died [26]. Circumcision is therefore linked to socio-cultural concerns that set in competition hospital workers, who use it as a means of supplementing their salary, and the ritual practitioners who occupy a central role as the «cutter» in their traditional society [27]. The wider use of male circumcision therefore calls for an examination of the place of ritual practitioners, «cutters», compared to hospital workers at the core of this public health policy [28]. This examination also needs to be carried out on the risks of virus transmission during the surgical procedure itself. A study performed in Kenya, Lesotho and Tanzania has demonstrated that a significant proportion of children who were infected with HIV and who had not had prior sexual relations were probably infected through the act of circumcision as a result of poor hygiene [29].

Circumcision can lead to unethical practices

The act of circumcision brings with it numerous ethical risks. Circumcision must not be carried out without the informed consent of the individual or his parents [30]. The recommendations of the WHO indicate that circumcision is not advisable for men infected with HIV, which implies that a screening test needs to be offered with the circumcision [31]. As the issue of mandatory screening is becoming increasingly prevalent in the countries of Africa, the risk that male circumcision could serve as a pretext for enforcing testing in a coercive manner must not be underestimated. This would merely lead to screening being rejected by the population – even though it is one of the key pillars of prevention policy. The issue of stigmatisation must be carefully watched for, as the painful memories of the Second World War must not be forgotten. Non-circumcision could equally be a reason for stigmatisation. Indeed, twenty Kenyan pupils have already been sent home from school for not being circumcised, as the headmaster wanted these pupils to be circumcised in order to reduce the risks of HIV transmission [32].

Ritual male circumcision and medical circumcision

In many countries in Africa, male circumcision and excision are linked in people’s minds. It is impossible to consider circumcision independently of other forms of physical mutilation, such as excision in Central and Western Africa. The same word, meaning «to cut», is used for the two procedures in a great number of African languages, while in English the terms used are male and female circumcision, or excision in the latter case. There is therefore a risk of confusion. Circumcision and excision are part of the individual’s personal and physical development, allowing the man or woman to identify him or herself within their society. This ritual act of circumcision or excision reinforces the separation of the sexes and their hierarchy within their society, and both acts are hard to dissociate in people’s minds [33]. Physical mutilation is often a rite of passage and inscribes a personal and collective memory on the body. Circumcision often represents a symbolic death and rebirth. Circumcision is a significant ideological and religious issue. In Gabon, for example, circumcision is carried out a second time when the individual reaches adulthood. In societies where women must have children before they are officially married, excision only takes place after the children are born [34]. The encouragement of male circumcision for medical reasons and not for traditional reasons could also destabilise the policy aimed at eliminating female circumcision, especially at a time when certain traditional practices which had fallen into disuse are being revived. This is reflected in considerable identity movements. Moreover, in order to discourage ritual circumcision, some countries are planning to forbid the act before the age of sixteen [35], whereas one of the WHO’s recommendations is to encourage circumcision of newborns, since this is simpler and less risky [36].

Table of contents

• I The relationship between male circumcision and HIV prevalence [page 2]
• II The dangers of an affirmed policy of male circumcision [page 3]
• III The place of male circumcision in strategies aimed at fighting AIDS [page 4]
• List of individuals interviewed [page 5]