Monday, November 5, 2012

Mass Male Circumcision: Moral and Cultural Intolerance

The English Guardian's development section has an article on Arturo Escobar, a theorist cited as believing that development is little more than "the west's convenient "discovery" of poverty in the third world for the purposes of reasserting its moral and cultural superiority in supposedly post-colonial times". This could equally apply to the funder of the development section, Bill Gates. But also, it could be applied to the way HIV is viewed by big funders of programs to increase condom use, influence sexual behavior, (ostensibly) reduce family size, provide expensive birth control methods, some of which are deemed inappropriate for Westerners, and generally treat Africans as if they are a bunch of delinquents who are in need of a 'short sharp shock' from their otherwise benevolent, unelected, rich, intolerant (etc) benefactors.

Are those running voluntary medical male circumcision programs (VMMC; the word 'mass' is now deprecated, it seems) really in a position to play God? And what puts them in that position? Is it the fact that they have large amounts of funding? The support of political and even religious leaders? Or is it the fact that they really really want to carry out these programs and they will continue to find 'data' that appears to support what they fully intended to do anyway?

As a mere mortal, I realize I probably appear highly impertinent with my stupid questions. But I would still like to know, if circumcision reduces HIV transmission, why does it not work everywhere? In some countries HIV prevalence is indeed higher among uncircumcised men. Kenya and Uganda were chosen for randomized controlled trials for the very reason that they were two such countries. But there are also countries where HIV prevalence is higher among circumcised men, and countries where there is little or no difference in HIV prevalence between circumcised and uncircumcised men. Yet, the VMMC programs are planned for all (Africa) countries with sizable populations of uncircumcised men. [The full trial papers are available here for Kenya, here for Uganda and here for South Africa.]

It may be equally impertinent of me to ask why we are told that circumcision may possibly reduce HIV transmission (in some countries) because there are Langerhans cells in the foreskin, so removing it may give some protection against infection with HIV and other infections. But why does this not give protection to all circumcised men, rather than just some of them? And why is this not used to argue for female genital mutilation, or at least the removal of outer and inner labia, and any other part that is considered as unnecessary as the foreskin is in males? I'm glad it's not used, but is there justification for a war on male Langerans cells, only?

It is very basic science that there is no hypothesis about circumcision and protection against HIV transmission, unless you consider 'male circumcision may sometimes give some protection against HIV in some parts of some countries, although it often doesn't, and we don't really know why this is the case' to be a hypothesis. So it is perfectly legitimate to ask 'by what mechanism is circumcision thought to work'? So if the answer is still 'we don't know, and it fails just as often as it succeeds', there is nothing at all impertinent in asking why VMMC programs are going ahead, with billions of dollars at their disposal. Why are they going ahead?

I can understand why programs like VMMC concentrate on sexual transmission of HIV and completely ignore non-sexual transmission, through unsafe healthcare and various cosmetic and traditional practices. Circumcision itself is often unsafe, whether it is carried out in traditional settings or in clinics; it is often carried out because it is a traditional or religious rite, rather than because of claims about some kind of public health benefit. But the much hyped randomized controlled trials carried out in Kenya, Uganda and South Africa did not even exclude HIV transmission events that were not sexual. Circumcision, even according to partisans, could only protect against sexual transmission. It may even expose people to additional HIV risks that they would not normally face.

We can trade data about the pros and cons of circumcision forever. But why are we discussing a VMMC program that is already up and running, rather than still flailing about for a viable hypothesis? We don't use the argument about Langerhans cells in women possibly leaving them exposed to HIV in order to investigate the possibility of removing various parts of their genitalia, because we consider female genital mutilation of any kind to be horrific physical abuse. Granted, male circumcision is not the same as FGM, but why is it not considered to be abusive to insist that HIV is always transmitted sexually, that Africans have a lot of 'unsafe' sex and that therefore circumcising all uncircumcised men will result in a substantial reduction in HIV transmission? And even if we are convinced of all that, what makes us think we have the right to impose our program on people in African countries?

The important questions are not about how beneficial or how damaging VMMC may be; those questions are too late for many people, anyway. But we need to be asking if what we are doing is still based on notions, tacit or otherwise, of moral and cultural superiority? If HIV transmission is not mostly a result of unsafe sexual behavior, there is no justification for most HIV interventions in African countries. But nor will most of those interventions have much impact on HIV transmission. Bad science may be behind a lot of programs carried out in the name of public health and development, but it doesn't explain why we openly discuss dubious scientific claims and continue to ignore moral, cultural and perhaps other issues that may be the real drivers of programs such as voluntary medical male circumcision.

Why are we doing this? Do we suddenly love (uncircumcised male) Africans (in certain parts of certain countries) so much that we are reaching out to them, ready to stand between them and all harm? Or are we doing it because we can, because we have the money, because we love circumcision and what it stands for, because our reputation depends on it, and various other, not so laudable motives? What will it take for all these issues to be addressed, issues that should have been addressed before this ill-gotten program was ever dreamed up? VMMC is, as things stand, an intolerable imposition on people whom we clearly consider to be inferior to us.



HappyMommy said...

The war on intact boys and men as well as on Langerhan cells is such BS. The funders want to be right at any cost and want to pretend their penises have not been harmed by circumcision. Pride is more important to them than truth which is why so many funders became rich in the first place. " Looking closely at the interaction of HIV and Langerhans cells, they found that the cells "donotbecome infected by HIV-1, because the cells have the protein Langerin on their cell surface," Geijtenbeek said. "Langerin captures HIV-1 very efficiently, and this Langerin-bound HIV-1 is taken up (a bit like eating) by the Langerhans cells and destroyed."

In essence, Geijtenbeek said, "Langerhans cells act more like a virus vacuum cleaner."

Simon said...

Thank you for your comment and link. A viable explanation of how male circumcision could reduce transmission from females to males has been outstanding for too long now!