Wednesday, 20 January 2010

Circumcision and HIV/AIDS 4

The king of the Zulus has issued an edict to bring back circumcision in KwaZulu-Natal, South Africa, two hundred years after it was abolished.

King Goodwill Zwelithini claims to be reintroducing the practice because it reduces HIV transmission but evidence for its effectiveness is contentious, as I have discussed here, here and here.

The Xhosa, South Africa's second largest tribe after the Zulus, never gave up traditional circumcision. Uncut men are considered inkwenkwe - boys - who are not allowed to mix with the men. Hospital circumcisions do not count.

Health workers tell of the serious problems it causes including 'rotting penises, septicaemia and inadvertent castrations'. Other boys die of dehydration or hypothermia and, far from preventing the spread of HIV, circumcision can increase it as the same knife is used on a large group of boys. In the last year, 80 boys have died, including two suicides.

Researchers into traditional circumcision 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'.

On top of the health risks, the rituals place a heavy financial burden on poor families who have to come up with goats, blankets, alcohol and new clothes for the boy.

There is often criticism of Zulu men by the Xhosa for not being circumcised. In 2008, ANC politician Fikile Mbalula (a Zulu) succumbed to pressure and, at the age of 37, entered an initiation school where he was circumcised the traditional way. He later became deputy minister of police. These two events may not be linked but they may also suggest why the Zulu king wants to bring back circumcision. Zulus make up 21% of the population and Xhosa 17%; the difference is small enough for the Xhosa to exert considerable influence.

As I wrote previously, the South African government recognizes the health risk. In 2001 it passed an act requiring a license from a medical officer for each male circumcision. The act seems to be having little effect.

Given that the Xhosa circumcise for purely cultural reasons and the ritual is what counts, it seems unlikely that the Zulus will accept hospital circumcision.

Even if circumcision did protect the men, there is no evidence that it helps prevent transmission from HIV positive men to women, a concern reiterated by the Secretary General of the Treatment Action Campaign, herself a Xhosa. She commented that 'most new incidences of HIV are among women'.

A trial in Uganda reported in The Lancet found that rates of transmission to women increased with circumcised men. The trial had to be abandoned for ethical reasons.

In America, recent research has found that circumcision does not reduce transmission rates among gay men. Dr. Peter Kilmarx, of the U.S. Centers for Disease Control and Prevention said that circumcision "is not considered beneficial" in stopping the spread of HIV through gay sex.

Previous research has suggested circumcision doesn't make a difference when anal sex is involved. The latest study, by CDC researchers, looked at nearly 4,900 men who had anal sex with an HIV-infected partner and found the infection rate, about 3.5 percent, was approximately the same whether the men were circumcised or not. Presumably the same applies to men having anal sex with women.

KwaZulu Natal Province has one of the highest HIV infection rates of any South African province. If circumcision does not reduce transmission rates then thousands of young men's lives and well-being will have been put at risk for nothing. Women's lives will also be at risk as these men become their sexual partners. There is still no conclusive evidence that circumcision works any better than good hygiene.

The trial in the Lancet reported above concluded that 'Condom use after male circumcision is essential for HIV prevention'.


  1. Circumcision is usually a personal/family choice, but in the case outlined above circumcision can be either forced or completely prohibited, there really isn't much personal choice for members of such tribes. However, it is important to remember that circumcision can actually help prevent HIV transmission and aid in male cleanliness; nonetheless, circumcision needs to be done in a more hygienic manner in these types of settings so more disease is not spread.

  2. "A trial in Uganda reported in the Lancet found that rates of transmission to women increased with circumcised men. The trial had to be abandoned for ethical reasons." Not quite. They called the trial off "for futility" after 18% of the circumcised HIV+ men's partners had HIV and only 12% of the non-circumcised HIV+ men's partners, but it was not yet statistically significant. There was no ethical reason to halt the trial, since circumcising the control group would not improve matters. The suspicion arises that they halted the trial in order not to confirm that circumcision increases the risk to women.

    @circumcision sunshine coast: "personal/family choice"? The two are mutually exclusive. As one man said (in more colourful language): "My family doesn't [urinate] with my [penis], they don't [masturbate] with my [penis], and they don't [have sexual intercourse] with my [penis], so what right do my family have to cut parts off my [penis]?"