Circumcision and HIV/AIDS: 2

Ritual circumcision is a different area but its practice in South Africa, for example, has important ramifications for the promotion of circumcision as an HIV/AIDS prophylactic.

 This story was in the news this week:

 Eight boys have died and three are in hospital after botched circumcisions in the South African province of Mpumalanga, officials say. The teenagers were at an initiation school in the town of Kwamhlanga. One of the initiates died in hospital and the seven others were found by health officials dead at the school.

These circumcisions were done as part of a widespread traditional rite of passage for boys before they can be considered men and play a full adult role in their community.

 There are two separate issues here, the ethical/moral and the medical.

Commenting on another culture’s traditions has become taboo in some circles thanks to Post Modernism and cultural relativity where one culture may not be judgmental of another, especially if it’s a Western culture commenting on a Third World one. This is seen as a kind of cultural imperialist invasion or at best patronizing and ignorant. Just because something is considered wrong in one culture doesn’t mean it’s wrong for another. Everyone’s traditions and beliefs should be respected because there are no absolutes.

 The question of whether it is a cultural crime to raise ethical and Human Rights objections to children being mutilated without their consent, putting their health and sometimes their lives at risk is not the subject of this current post. But the serious implications for HIV/AIDS prevention is germane.

 The South African Government recognizes the health risk of ritual cutting; in 2001 it passed an act (The Application of Health Standards in Traditional Circumcision Act) requiring a license from a medical officer for each (male) circumcision. But the act seems to be having little effect. In July last year, 15 boys died and 90 were taken to hospital after botched circumcisions. The main causes of death and hospitalisation are blood loss and dehydration.

 Despite the Government’s attempts, community leaders are resisting medical supervision and licensing because, as they said, this ‘infringed community rights’.  Protecting children’s lives is apparently less important than protecting beliefs.

Researchers found that ‘in general, communities considered morbidity and mortality as par for the course. Interviewers were told that "deaths and injury were seen as a way of separating out those boys who were not fit to play the role of men in society." Compounding this 'natural selection' technique, another popular belief is that if an initiate suffers medical complications, he has brought it upon himself through some form of wrong doing, and is therefore being punished.

 There may be cultural resistance to condom use – albeit a different kind of resistance, based on male preference rather than ancient tradition – but overcoming entrenched beliefs about who has the right to cut boys and in what context (ritual rather than clinical) makes it difficult to see how an initiative to encourage it as a preventive will work in areas where it is seen as belonging to cultural practice, a ritual based on a belief that may not be invaded by science – even in the minimal form of sterile conditions and instruments.

 Moreover, some research has found that ritual cutting can increase infection rates:

Traditionally an assegaai is used. Implements may be blunt or reused. This practice has been implicated in the spread of blood-borne infections, such as Tetanus, Hepatitis B and STDs, including HIV/AIDS (source as above).

 In addition, one researcher has revealed a further problem:

 Of late, the practice has degenerated into a money-making operation. People pay as much as R400 per boy for the attendance of (circumcision) schools. The schools are launched annually at some localities (as opposed to the old tradition of every five years) (as above).

 Illegal procedures will prove even harder to monitor and medicalise.

 Even if it were possible to tap into an existing culture of circumcision to use it as a preventive, research done in South Africa and published in the South African Medical Journal states that:

 It is, however, questionable how circumcision, and particularly neonatal circumcision, could achieve such a goal. A rational and critical analysis of the scientific evidence ought to conclude that non-therapeutic infant circumcision is merely the medicalisation of an old ritual that should not, in the 21st century, be advocated as prevention strategy for HIV/AIDS. (my underlining)

 This whole article is worth reading.

 The evidence against circumcision is stacking up. The statistics do not show that it is an effective protection. Ritual circumcision is likely to prove an obstacle to (the alleged benefits of) medical prophylaxis and may also worsen the problem.

Finally, some further information from this article to add to last week’s post about the situation in America, the country behind PEPFAR, a major partnership initiative to promote preventive circumcision in America.

 Teens 15 years and older in the USA have the highest rate of STDs in any industrialised country and half will contract a sexually transmitted disease by age 25, despite two-thirds of young males having been circumcised. Such reports suggest that the social experiment of circumcision to prevent STDs, including HIV, has already failed in the USA, which has the highest rate of non-therapeutic infant circumcision in industrialised countries and the highest rate of HIV in the developed world.

 The call for neonatal non-therapeutic circumcision for prevention of HIV by some members of the Catholic Church suggests misunderstanding of the local context, and supporting genital surgery on newborn boys but discouraging the more effective preventive measure of condom use lacks logic.

 Of course, it is not just the Catholic Church and Catholic organisations that are anti-condom (and often pro-abstinence), there are other religiously-inspired organizations promoting circumcision as the list of PEPFAR partners discussed in the previous post shows.