Male circumcision is the surgical removal of all or part of the foreskin of the penis. It is a practise that has existed for more than a thousand years throughout the world, mainly for religious and cultural reasons. In 2006, the World Health Organisation (WHO) estimated that 30 percent of men in the world had been circumcised. Male circumcision is commonly practised in Africa, but its prevalence is not as high in East and Southern Africa as it is in other African regions.(2) This CAI discussion paper appreciates the fact that male circumcision is a beneficial intervention in the fight against the HIV and AIDS pandemic plaguing particularly Southern Africa, but aims to point out some shortcomings of programmes in implementing it.
Male circumcision and HIV and AIDS
HIV and AIDS remains the leading cause of death and illness, especially in Africa. Consequently, attempts to curb the pandemic persist. Male circumcision is increasingly being cited as one of the ‘the’ HIV and AIDS prevention strategies. As a result, following the 2007 recommendation by WHO/ The Joint United Nations Programme on HIV/AIDS (UNAIDS) that male circumcision be included as an HIV prevention measure, Africa in particular is witnessing drives to promote male circumcision as a preventative measure against HIV infection. The recommendation pertains especially to Botswana, Kenya, Malawi, Mozambique, Lesotho, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe.(3) In most of these countries, campaigns advocate for the circumcision of males of all ages, including children. Research has indicated that male circumcision reduces the rate of male infection with HIV by approximately 60 percent.
However, it is important to note that male circumcision reduces the spread of female to male infection; not of male to female transmission. It is possible and worth stating that in Africa the risk of male to female infection is higher than that of female to male infection. This is due to the fact that sexual relations are largely shaped by the powers and desires of men and reflect the heightened sense of patriarchy in Africa. As a result, male circumcision is an intervention that protects men from contracting HIV from women but is not beneficial to women.
Points to ponder: male circumcision and its shortcomings
When considering the pros and cons of male circumcision, the most important point to ponder is that circumcision does not prevent HIV infection. Against the 60 percent that do not get infected are another 40 percent who do. Plus, the mentality of some circumcised men that they are immune to infection due to the fact that they have been circumcised has consequences for the spread of HIV, notably if and when they put themselves and others at risk. Additionally, circumcision is known to desensitise the penis. A man might therefore use force when having sexual intercourse, resulting in abrasions in the genitalia of his female partner, thereby increasing her chances of contracting HIV. Similarly, loss of sexual sensitivity due to circumcision can result in reduced use of condoms. Furthermore, men might also engage in sexual contact before their wounds are completely healed, increasing their chances of infection by an HIV-positive partner, or alternatively, in the case that they are already infected, resulting in them more easily infecting their partner.
Male circumcision, like any surgical procedure, has its complications. It can result in blood loss, infection, mutilation, penile amputation or, in severe cases, loss of life.(4) Some of these serious complications are caused by the lack of trained staff, poor or neglected follow-up procedures and the unavailability of appropriate and especially sterile equipment in already burdened health care systems in Africa.
Circumcision is also likely to encounter social and cultural opposition in places where it was not previously practised. Circumcision differentiates between cultural groups; it is an element of identity. Its prior association to culture and religion could in fact be a reason why some people might reject it. Additionally, fear of how circumcision might affect men’s sexual behaviour can be a contributing factor in opposing it. They might fear desensitisation of the penis resulting in lack of sexual pleasure and fulfilment.
Thus far the discussion here has related to adult male circumcision. However, as highlighted above, the drive for circumcision includes children. In some African countries, Zimbabwe for example, infant circumcision is being advocated based on the premise that when the male children become sexually active they will then have a lower chance of contracting HIV. This supposition is justifiable because it applies to the discussion above about the reduction of female to male transmission.
However, the shortcomings listed above also apply. Children like men also go through the risky medical procedure that can result in a number of complications or death. The cultural and social opposition to circumcision also applies to children in the event that their parents reject that their children be circumcised. In addition, circumcision of children is a human rights’ issue as children are not old enough to decide for themselves if they want to be circumcised or not so the decision lies with their parents. As a result, questions of the ethics of circumcision of its possible infringement on children’s rights arise here.(5) The viability of channelling resources on child circumcision is questioned considering that child circumcision will prevent HIV in the future when programmes exist that can address the present situation, taking into account how limited the resources are and how pertinent the issue is. On another note, children that are put through the programme might already be infected and may die even before they become sexually active.(6)
This discussion paper supports male circumcision as an intervention to curb the spread of HIV because it does help reduce 60 percent of female to male infection but it also emphasises its shortcomings. In some circles, male circumcision is being touted as ‘the silver bullet,’ almost as a cure for HIV. Campaigns should make it a point to clarify what male circumcision can do and the fact that it has its shortcomings. Campaigns should point out that male circumcision does not prevent HIV infection, that it only reduces the chance of male infection. Care should also be taken not to overshadow other preventative measures like condom use and abstinence. Furthermore, a lot more research should go into male circumcision as a preventative measure as well as delve into the consequences it has for females. Attention should be taken that the investments currently flowing into male circumcision are being well utilised.
It is understandable that male circumcision is generating attention because of the recent discovery and promotion of its benefits. However, caution should be taken on how it is promoted and implemented. The WHO (link to: www.who.org) could not have put it any better when it said: “Male circumcision provides only partial protection, and therefore should be only one element of a comprehensive HIV prevention package which includes the provision of HIV testing and counselling services; treatment for sexually transmitted infections; the promotion of safer sex practices; the provision of male and female condoms and promotion of their correct and consistent use.”(7) It is therefore clear for all to see that the peddling of male circumcision as 'a silver bullet' and not as an intervention that is part of a comprehensive plan is precarious.
- Elizabeth Zishiri, Consultancy Africa Intelligence’s HIV & AIDS Unit (firstname.lastname@example.org). The October edition of the CAI HIV/AIDS Issues Newsletter is republished here with permission from Consultancy Africa Intelligence (CAI), a South African-based research and strategy firm with a focus on social, health, political and economic trends and developments in Africa. For more information, see http://www.consultancyafrica.com or http://www.ngopulse.org/press-release/consultancy-africa-intelligence. Alternatively, click here to take advantage of CAI’s free, no obligation, 1-month trial to the company’s Standard Report Series.
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(1) Contact Elizabeth Zishiri through Consultancy Africa Intelligence’s HIV & AIDS Unit (email@example.com).
(2) 'Male circumcision information package', WHO, 2010, www.who.int.
(4) 'Male circumcision and its links to HIV prevention', South African Medical Research Council (MRC), 2010, www.mrc.ac.za.
(5) 'Doctors opposing circumcision HIV statement', www.doctorsopposingcircumcision.org.
(7) 'Male circumcision and its links to HIV prevention', South African Medical Research Council (MRC), 2010, www.mrc.ac.za.