All it’s cut out to be…
By Wilson Johwa
21 April 2010 | | |Fellows Blogs | Men and HIV | Circumcision
It is now too late for my 14-year-old son to be circumcised - at least that's what he thinks.
The procedure should have been done when he was younger and less aware of the pain. “It’s embarrassing,” he says, refusing to buy into the argument that in 1995 when he was born, the impact of HIV was only just unfolding and there would have been no need for him to be circumcised.
Within medical circles in much of Africa there is now a strong recognition that male circumcision lowers the risk of HIV transmission. The sooner the procedure is performed on a male, the better.
But infant circumcision still has its fair share of skeptics such as a team of Australian researchers whose work was published in a recent issue of the Annals of Family Medicine.
They argue that not enough work has been done on the psychological impact of male circumcision, especially the fact that it could potentially cause anger, feelings of incompleteness, hurt, or being violated.
The review’s lead author, Dr Caryn Perera of the Australasian College of Surgeons, said the risk of major complications ranged from 2% to 10%. “These may be considered unacceptable for an elective procedure,” she told HealthDay News.
However, in a country like South Africa where HIV-related complications are the major cause of death, these figures are likely to be seen as an unavoidable consequence of a potentially life-saving procedure.
Yet the psychological and social effects of medical male circumcision are no idle consideration, especially for communities that traditionally do not circumcise either for religious or cultural reasons.
Such unchartered waters may account for the delay in the government rolling out a male circumcision strategy, despite talk that circumcision is the next frontier in the fight against the AIDS pandemic.
However, earlier this month Professor Gary Dowsett, the deputy director of Australia’s La Trobe University’s Research Centre in Sex, Health and Society, made a strong case against male circumcision when, at a seminar in Pretoria. He argued that the scientific evidence is weak, just as the procedure was unjustifiable since condoms would still need to be used. Under such circumstances it would be a violation of a boy’s sexual and human rights if his parents opt for the procedure, Dowsett argued.
But not everyone was taken in. Pierre Brouard, deputy director at the University of Pretoria’s Centre for the Study of AIDS concedes that male circumcision as an HIV prevention strategy comes with a number of challenges. For instance, gender activists have noted the lack of immediate benefits for women.
Furthermore, the messaging around circumcision needs to complex since the procedure only offers partial protection and condoms still need to be worn while sexually transmitted infection and pregnancy remain a concern.
“Communities need to be advised and prepared for circumcision and there are concerns that in a highly gendered epidemic male circumcision could play into patriarchal attitudes towards women,” Brouard says.
In no way does he believe psychological issues discourage its adoption on a mass scale. Instead, Brouard says male circumcision is already well established in many communities in SA hence should there be a need to scale up as a strategy against HIV, physical and emotional stress would most likely be accepted as something to be endured and overcome.
However, he advises caution as male circumcision can also play into traditional ideas of what it means to be a man – or a certain kind of man who needs to “prove” his masculinity, and complete his journey to full male adulthood.
But Brouard, a clinical psychologist, feels that the psychological issues are not to be taken lightly. For most men sexual functioning and prowess defines who they are in their personal and social relationships and the fear of losing this may not be openly acknowledged but exists.
All this makes male circumcision as a prevention strategy a work in progress, amid concern that biomedical interventions of this nature rarely accompany research on the wider social impact of the proposed action.
The World Health Organisation, together with UNAIDS acknowledge that male circumcision does provide some protection against HIV. In March 2007, they finalised recommendations encouraging countries with high prevalence HIV and low levels of male circumcision to scale up on the procedure.
But so far there are no governmental guidelines on medical male circumcision, which is still a matter of individual choice and a sector exploited mainly by NGO-type projects like Zuzimpilo, which operates in downtown Johannesburg.
Last month, health minister Aaron Motsoaledi announced the country’s largest ever testing and counselling campaign with a price tag of R1,4 billion. It will consume some 2.5 billion male condoms over the next year and will see 15 million tested for HIV and Aids by 2011.
While one can never provide too much information, a cynic would be forgiven to conclude that a deluge of information is favoured because for the government it is the easiest thing to do.
At the official level male circumcision is a strategy that will come with much preparation. “Gearing up health systems to address the demand will take time, resources and planning,” says Brouard.
The area of traditional circumcision is complex as in some cases these circumcisions are incomplete – where the whole foreskin may not have been completely removed as required.
“Cultural guardians may be reluctant to have their traditions in any way interfered with, and it is not always possible to be clear about messages towards women which are conveyed in traditional circumcision rites,” says Brouard.
Other concerns are that if men are denied a circumcision because they are already HIV positive communities are likely stigmatise those who are turned away from initiation ceremonies.
The upshot is that as a mass prevention strategy male circumcision may be far off in SA. So for now my son may yet keep his foreskin.
Wilson Johwa is a fellow with the HIV/AIDS and the Media Project
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