Brian Earp answers the question,”Why aren’t Swazi men jumping at the chance to have their foreskins cut off?”
According to this article, “A multimillion-dollar drive to circumcise the majority of Swazi males between the age of 15 and 49 within a year has failed to reach its target.” Apparently, Swazi men are not exactly jumping at the chance to have their foreskins cut off. Why not?
First, some background. The original idea was to take some heavily-hyped clinical data showing that adult male circumcision may reduce female-to-male transmission of HIV (in populations with very high base-rates of heterosexually transmitted HIV), and turn this into a massive public health initiative. There are a number of problems with this approach.
First, the initial studies linking circumcision to a reduction in rates of HIV transmission have been heavily criticized, as I’ve summarized before. In other words, is it far from accurate to say that these preliminary findings have been “scientifically proven” as the article reports. Instead, there is an ongoing debate in the scientific community about the medical quality of the initial studies. This point was underlined in a recent commentary by 38 leading international medical experts, who added that the evidence for a protective effect of circumcision against HIV is contradicted by other data.
Second, the “60%” figure that is invariably trotted out as the magnitude of the supposed benefit of being circumcised refers to the relative reduction in HIV infections between the cut and un-cut groups in those famous “randomized control trials.” The absolute reduction was a mere 1.3%. Whether this is a clinically meaningful percentage, given the numerous sources of bias and other confounding factors in the original studies, remains unclear.
Third, clinical findings – even robust and uncontroversial ones – typically don’t flawlessly reproduce themselves in the complicated mess that is the real world. Lawrence Green and his colleagues published an article on this point in the American Journal of Preventative Medicine. “Effectiveness in real-world settings,” they write, “rarely achieves the efficacy levels found in controlled trials, making predictions of subsequent cost-effectiveness and population-health benefits less reliable.”
So it shouldn’t come as a huge surprise that things aren’t working out exactly as planned.
But why—specifically—should there be such resistance among Swazi males to the idea of having their foreskins removed as a form of preventative medicine? The article I’m responding to suggests that it might have to do with fears about witchcraft and other forms of magical or irrational thinking.
But maybe these Swazi males are simply using their common sense. After all—as Robert Van Howe and Michelle Storms point out in The Journal of Public Health in Africa—the basic logic of undergoing circumcision to ward off HIV is dubious in the extreme:
How rational is it to tell men that they must be circumcised to prevent HIV, but after circumcision they still need to use a condom to be protected from sexually transmitted HIV? Condoms provide near complete protection, so why would additional protection be needed? It is not hard to see that circumcision is either inadequate (otherwise there would be no need for the continued use of condoms) or redundant (as condoms provide nearly complete protection).
The editor of the South African Medical Journal, Dr. Daniel J. Ncayiyana, has raised a similar concern:
What man would want to accept circumcision and the associated risks, if he were made clearly to understand the need to continue to abstain [from unsafe sexual practices], be faithful and/or condomise? What then would be the benefit?
The implied answer, of course, is “none whatsoever.”
In other words, maybe it isn’t so much the case that the men of Swaziland are guilty of being dupes to superstition, or overly wary of Western influence, than it is that they are clear-headed enough to connect the logical dots. As Samkelo Mduli, a Swazi university student, is quoted as saying: “When I heard I would still have to wear a condom, I said, ‘What is the point?'”
Mduli has it right. The Australian Federation of Aids Organizations has stated unequivocally: “Correct and consistent condom use, not circumcision, is the most effective means of reducing female-to-male transmission, and vice-versa.” Or as Dr. Green and his colleagues memorably made the point in another important paper of theirs: “Circumcision is not the ‘HIV vaccine’ we have been waiting for.”
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Photo: AP/File
The reason they don’t want their foreskins chopped off is because the foreskin is where all the sexual pleasure comes from.
Circumcision destroys sexual pleasure.
The notion that circumcision is the answer to the HIV / AIDS epidemic is not only misguided, it is dangerous. Even the proponents know that if circumcision is effective at all, even at the 1.3% level, it endangers women. The very slight protective effect, if we believe it, only protects HIV negative men from HIV positive women, if it does that. It does absolutely nothing to protect HIV negative women from infected men. Unfortunately, some men, once circumcised, may believe they are immune, or insist to their female partners that they are immune. That situation, ‘risk compensation’ as it is… Read more »
Actually, failure is the wrong word to apply to Swaziland. Persuading men to undergo so personal a procedure as male circumcision takes time as it should. But contrary to (erroneous) references in the article and Petite Poulet’s inaccurate reading of data, the promise of this simple intervention for bringing about the end of a thirty year HIV scourge in eastern Africa makes the case for perseverance. Medical male circumcision is not the whole answer, but it is a big part of the answer. Thoughtful people will consider the benefits that can lift the next generation beyond a threat that has… Read more »
DCR: There exists a study which found that female circumcision reduces the risk for HIV. The authors expected to find the opposite results – that female circumcision would increase the risk of HIV and they even did a follo-up study to try to find other confounding factors which might explain the reduced risk for HIV in circumcised women. They failed – circumcision lead to a significant reduction of HIV infection.
What conclusion do you arrive at from that? Is female circumcision a matter of saving lives then in you opinion?
Actually, failure is the wrong word to apply to Swaziland. Persuading men to undergo so personal a procedure as male circumcision takes time as it should. But contrary to (erroneous) references in the article and Petite Poulet’s inaccurate reading of data, the promise of this simple intervention for bringing about the end of a thirty year HIV scourge in eastern Africa makes the case for perseverance. Medical male circumcision is not the whole answer, but it is a big part of the answer. Thoughtful people will consider the benefits that can lift the next generation beyond a theat that has… Read more »
Circumcision is not a “simple intervention”, nor is it “a big part of the answer” when women are at much more risk from infection by men than the reverse, and non-sexual infection (such as by “needle men” with an injection for ailment) a major, unmeasured factor. Those are reasons not to embrace circumcision even before we start to doubt its effectiveness, which we should do, strongly, if only because of its sorry history as a fanatically adopted panacea for everything from masturbation to epilepsy.
As the student quoted in the article says a condom does the job very well. Also a condom is more likely to stay on an intact penis, simple mechanics, condoms will move with the loose skin.
Good for them. The practice is barbaric.
seconded, seconded. completely agree with you
As Samkelo Mduli, a Swazi university student, is quoted as saying: “When I heard I would still have to wear a condom, I said, ‘What is the point?’”
indeed
There are at least eight countries in Africa where circumcised men have a higher prevalence of HIV infection than men who are not circumcised. What does this mean? Either circumcision hasn’t worked in the past (and unlikely to work in the future) or that is it is a very minor player. It would be a better use of resources to supply clean medical equipment and needles to prevent the 20% or so infections that are spread through medical treatments and to identify and treat those who are infected so they do not spread the infection further.
Might mean that circumcised males think the surgery negates the need for a condom.
That may also be true (in fact there are signs that it is true), but it does not explain the survey figures, which were taken before circumcision campaigns, or where there are no circumcision campaigns, or, as in Zimbabwe, both before and after circumcision campaigns, with the same ratio both times. (The rate was lower for both circumcised and non-circumcised men after the campaign, perhaps because the education aspect of the campaign, rather than circumcision, made people more safe-sex conscious.)