Cultural, ethical and other concerns

Cultural, ethical and other concerns
In addition to the medical and
epidemiological aspects of male
circumcision, a number of cultural,
behavioural, ethical and other issues
and concerns have been raised. Some
have alleged that circumcision is a form
of “male genital mutilation”21 , and south
Africa has recently passed a child
protection law that would ban
circumcision for those under age 16, in
the absence of religious or medical
reasons22 . Certainly, circumcision of
neonates and young children raises the
greatest ethical concerns, with critics
asserting that the baby or young child
is deprived of his ability to give informed
consent for a permanent procedure23 .
Others argue that, as in the case of
childhood vaccinations, parents should
be supplied with the most accurate
information in order to decide what is in
the best interests of the child. In addition
to conferring potential future health
benefits such as reducing the risk of HIV
and other sexually transmitted infections,
some cancers, and balanitis (painfully
infected foreskin/glans), there are some
more immediate benefits for the neonate,
particularly the approximately 12-fold
reduced risk of urinary tract infections
during the first year of life24 . In most of
Africa, the main programmatic issues
revolve more around circumcision for
men and teens, who would be able to
provide informed consent.
Safety issues
As with all surgical procedures,
circumcision carries it with some risks,
particularly of pain, bleeding and
infection. While the rate of complications
in most clinical settings is generally fairly
low, and the vast majority of such
complications are minor and quickly
resolved25 , circumcision as practiced in
some traditional settings can be quite
risky26 . Each year in South Africa, for
example, dozens of boys and young
men are seriously injured or die due to
infections, exposure and other problems
resulting from unsafe practices27 . The
main reason for the decline in popularity
of circumcision in Britain in the 1940s
was that a number of male infants died
each year, nearly all of them from the
use of general anaesthesia. Local
anaesthesia, which is now recommended
for infants, teen and adult circumcision,
results in no deaths and few serious
complications28 .
Are African men (and women)
interested in male circumcision?
Of considerable importance is
ascertaining the acceptability of adult
male circumcision, especially in the high
HIV prevalence regions of Africa. Over
a dozen studies from nine African
countries have been conducted; across
these, the median proportion of
uncircumcised men wanting to become
circumcised, if the procedure was safe
and affordable, was 65% (range 29-
87%)29 . In the studies which surveyed
women (in areas where circumcision is
not traditionally practiced), a majority
also reported preferring a circumcised
male partner. The most common reason
across all studies given by both men
and women for preferring circumcision
is the belief that it results in improved
penile hygieneAnother very common reason reported
is perceived protection against sexually
transmitted infections. For example, in
an unpublished study by Sane Tsela of
400 Swazi men in January 2006, 81%
believed that circumcision reduces the
risk of sexually transmitted infections,
while only 18% said that it reduces the
risk of HIV infection. Furthermore, 54%
34 contact No.182 - August 2006
HIV PREVENTION: Current issues and new technologies
of the non-circumcised men said they
would want to be circumcised, and when
asked, “if circumcision reduces the
spread of HIV, would you like to do it?,”
87% said yes, suggesting, as in other
studies, that if information that
circumcision definitely reduces HIV risk
is circulated, an even greater increase
in demand for circumcision is likely.
In fact, men in some parts of Africa have
recently been “voting with their feet,” with
some public and private facilities in
southern Africa reporting being
inundated with men seeking clinical
circumcision services30 . Wait lists for
elective circumcision at public hospitals
in several countries, including Lesotho,
Swaziland and Zambia, now run to 6
months or longer. One important
concern, similar to the introduction of a
future HIV vaccine, microbicide, etc. is
that people who opt for circumcision
may engage in “risk compensation” i.e.
may increase their level of risk-taking
behaviour (have more sexual partners,
use condoms less, etc.) resulting from
a false sense of security31 . Clearly, it
will be very important to ensure that
scale-up of circumcision services is
carried out within the overall rubric of
comprehensive HIV prevention and
male reproductive health efforts, and the
message must be disseminated widely
and continually that it certainly does not
offer 100% protection