Monday, December 31, 2012

Circumcision: a Case of Retributive Healthcare?

There are many objections to mass male circumcision, but only a few of them should be required to convince someone that the vast majority of operations should never have been carried out, and that infant circumcision should not be routine anywhere. I would attach most weight to the argument that infant circumcision is a denial of the right to bodily integrity and follow that up with the consideration that it is done without consent, and can easily be postponed until the infant grows up. Where consent can truly be claimed to be informed, adult circumcision should not be so problematic. Current mass male circumcision programs in African countries are demonstrating clearly that most adult men do not choose to be circumcised; whether those who have consented are appropriately informed is open to question.

But the most important objection against mass male circumcision as a HIV transmission reduction intervention is, in my view, that not all HIV transmission is a result of sexual intercourse. Circumcision does not reduce non-sexual HIV transmission, for example, that which is a result of unsafe healthcare, cosmetic or traditional practices. The majority of circumcisions in Africa are carried out in traditional, non-sterile conditions. But even conditions in hospitals and clinics are well known to be unsafe. The UN are very clear on this point, issuing its employees with their own injecting equipment when they are in developing countries because "there is no guarantee of the proper sterilization of such materials." UN employees are also reassured that "We in the UN system are unlikely to become infected this way since the UN-system medical services take all the necessary precautions and use only new or sterilized equipment."

The US Centers for Disease Control (CDC) states that "Injection safety is part of the minimum expectation for safe care anywhere healthcare is delivered; yet, CDC has had to investigate outbreak after outbreak of life-threatening infections caused by injection errors.  How can this completely preventable problem continue to go unchecked?  Lack of initial and continued infection control training, denial of the problem, reimbursement pressures, drug shortages, and lack of appreciation for the consequences have all been used as excuses; but in 2012 there is no acceptable excuse for an unsafe injection in the United States."

But what about safe healthcare in developing countries? The Safepoint Trust finds that each and every year due to unsafe injections there are:

  • 230,000 HIV Infections
  • 1,000,000 Hepatitis C Infections
  • 21,000,000 Hepatitis B Infections
  • The above resulting in 1,300,000 deaths each year (WHO figures)
  • Syringe re-use kills more people than Malaria a year which the WHO estimate kills 1,000,000 a year (WHO)
  • At least 50% of injections given were unsafe (WHO)

Safepoint only reports on injections. What about other healthcare procedures that may spread diseases, especially deadly ones? Many health facilities lack basic infection control capabilities and supplies, such as clean water, soap, gloves, disinfectant and much else. There are also the risks people face as a result of cosmetic procedures, such as pedicures and tattoos, and traditional procedures, such as scarification, male and female genital mutilation and traditional medicine.

Why are we even talking about something as invasive as circumcision, involving tens of millions of men and possibly hundreds of millions of infants? So many medical procedures are already carried out in unsterile conditions and can expose patients to risks of infection with HIV, hepatitis and perhaps other diseases. The circumcision operation itself is a risk for HIV and unless the risk of hospital transmitted HIV infection is acknowledged, it is not acceptable to carry out these mass male circumcision programs. It is not possible to claim that people can give their informed consent where they are unaware of the risk of infection through non-sexual routes.

A third important objection to mass male circumcision is that people in developing countries, particularly the high HIV prevalence African countries where all these mass male circumcision programs are taking place, are denied many of the most basic types of treatment. How can we propose universal infant circumcision where half of all infant deaths and a massive percentage of serious infant sickness is a result of systematic denial of basic human rights, such as access to clean water and sanitation, adequate levels of nutrition, decent living conditions, basic health services, an acceptable level of literacy and education, employment, infrastructure and a lot more?

To force 'healthcare' in the form of mass male circumcision programs on people who are lacking so many more important things is extremely patronizing, at best. But to force unsafe healthcare on people who have little access to the kind of information they need to be sure that they are protecting themselves against infection with HIV and other diseases, and against all the threats of unsafe healthcare, would be criminal behavior in western countries. Why are western countries silent about this treatment of people in developing countries? Are we punishing Africans for their poverty and lack of development, or just for their perceived sexual behavior? Mass male circumcision programs do seem very much like a form of 'retributive healthcare'.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]



Anonymous said...

Interesting piece. I've been particularly concerned about the informed consent issue in the African mass circumcision campaigns - a number of surveys have shown a lack of understanding of what is meant by decreased risk, and it seems that every study comes up with a figure of around 20 - 25 % of participants believing that the use of condoms is not required in circumcised men (for HIV prevention at least).

Clearly, there's two aspects - one is the knowledge of people out in society as a whole, especially women, to understand the need to continue with condoms, and that's not necessarily 'informed consent' as of course they're not the ones undergoing the procedure. But the informed consent aspect comes in of surveys of men who have undergone voluntary circumcision as a means of HIV prevention - and still around 20 % of those believe that they no longer need to use a condom, i.e. that circumcision is 100 % effective at preventing HIV transmission. This should be cause for grave concern over the pre-operation information, and really calls into question the informed consent process. Ironically, it's probably the heavy marketing and publicity of male circumcision and its protective effect on HIV that has resulted in such widespread misinformation.

Simon said...

There's a lot of misunderstanding all around. Many people think circumcision protects for hygiene reasons, that uncircumcised men in some way are less hygienic. But this is not the case; appropriate hygiene is more effective than circumcision, but there's been little information about what constitutes appropriate hygiene.

Similarly, many women believe they should take various measures to be more hygienic through vaginal douching and the like, but this is also incorrect.

The emphasis at present is to persuade men (and boys) to be circumcised, to persuade women to persuade their partners and to persuade parents to have their babies circumcised. It is well known that people have been systematically misinformed but the incentive is to get as many people circumcised as possible, not to ensure that people are well informed. So misinformation pays if you're in the business of circumcising.