Medical Circumcision's Skeletons

Pick up the Fourth Volume of the 1894 National Popular Review and you will find Peter Charles Remondino's article, Questions of the day: Negro rapes and their social problems. In it, Remondino argues for "the wholesale circumcision of the Negro race as an efficient remedy in preventing the predisposition to" rape white women.

Not to be outdone, the Maryland Medical Journal staff also published an article they titled "Circumcision for the correction of sexual crimes among the Negro race." They made no secret of their intention: the black man's foreskin, which they affectedly referred to as a "prepuce", had to go. They wrote, "The brutal and uncontrollable passion of the Negro has been traced to a variety of causes, the chief of which has been referred to as a perversion of his sexual instincts and ungoverned sexual passion. An enlarged prepuce is assigned as the most frequent cause of irritation, and its removal ...will lead to the stopping of sexual crimes and to the moral improvement of the race."

This was not going to be the last time circumcision would be suggested as a quick fix to problems. So ridiculous did the exercise become that people believed Merrill Ricketts when he lied to the world that eczema, oedema, elephantiasis, gangrene, tuberculosis, hip-joint disease, enuresis, general nervousness, impotence, convulsions and hystero-epilepsy could be cured through circumcision.

The circumcision of the black man was specifically suggested as a solution to the crisis of hygiene among the Negros, masturbation and more recently, HIV/AIDS and cancer. There has always been a lot of enthusiasm to cut off men's foreskins, especially the African man's foreskin. Therefore, the 2007 Montreux decision to implement Medical Male Circumcision for HIV reduction in 14 priority countries did not come as a surprise. If anything, it was another predictable attempt to convince the world of circumcision's curative potency. By the end of 2018, 23 million African men had been medically circumcised with WHO estimating that this had prevented some 250,000 infections in fifteen Eastern and Southern African countries. Of the 23 million, the United States of America's PEPFAR had supported more than 18.9 million procedures exceeding targets by millions.

WHO met, WHO decided

From the 6th to the 8th of March 2007, the World Health Organisation, UNAIDS and other international organizations met in Switzerland's Montreux, did not deliberate but simply decided to push medical male circumcision. But there is nothing like a strictly medical circumcision; circumcisions are political. Peter Aggleton has argued, "...male circumcision - like its counterpart female genital mutilation - is nearly always a strongly political act, enacted upon others by those with power..." Those with power, therefore, sat and enacted.

Eighty people selected by the UNAIDS/WHO taskforce attended the meeting. Of the eighty, there were no non-technical people. Further, participants who came from Africa or had worked in Africa constituted only a third of attendance and even these participants were not decision-makers but merely policy-makers, there to assist in drafting. Giami et and colleagues say,

Nearly all the papers presented came from researchers or the representatives of institutions in the 'Global North'. This distribution is evidence of an imbalance: participants from research centers tended to come from and work in the USA or Europe, whereas the African participants tended to be involved in public health or policy-making."

The meeting was a reinforcement of the colonial hierarchies of knowledge with the Global North producing valid knowledge while the South is doomed to receiving it unquestioningly. It is epistemic violence, the systematic silencing of Africans because they are Africans and their knowledge systems are dismissed as inferior. If the stage had been opened to conversation rather than imposition, Montreux might have come up with a workable proposition that does not smack of colonial bullying. It is not a wonder that the medical male circumcision programme, without the initial buy-in of many ordinary Africans has had to use unethical means to achieve its targets. Advertising campaigns attempt to redefine African masculinity by conflating it with circumcision, misleading ads pretend sex is better when cut yet the opposite is probably true, programme mobilizers are paid on commission to meet their targets which are tied to continued funding while mobilization campaigns overestimate the efficacy of circumcision and at times target minors incapable of consenting. These immoral approaches stem directly from the failure to incorporate Africans in the decision making about their own bodies. It could have been so much easier!

Debatable Science

Debatable science has been used to justify the cutting of at least 23 million men in Sub-Saharan Africa. The current campaign rides on the three randomized clinical trials carried out in South Africa, Kenya and Uganda. The trials proved that circumcision provided a 60% relative risk reduction in female to male HIV transmission which, according to Auvert, a key proponent of medical male circumcision, was "equivalent to what a vaccine of high efficacy would have achieved". It has been said that circumcising 80% of all uncircumcised adult men in the countries with high HIV prevalence and low prevalence of male circumcision by 2015 would avert one in five new infections by 2025. According to research, delicate foreskin tissue is vulnerable to microscopic lesions which increase risk of infection. Further, the foreskin has Langerhans cells which HIV and other pathogens readily attach to.

However, Van Howe & Storms argue that claims that the foreskin is thinner and prone to tearing, and that it has Langerhans cells prone to attacks are just speculation that has been repeated so often in medical literature that many physicians and public health officials consider them factual. They conclusively state, "There is, however, no direct scientific evidence to support the hypothesis that the foreskin is a predisposing factor for infections."

In another article, Van Howe argues that there is a puzzling inconsistency between the epidemiological evidence of HIV prevalence and the protective effect of circumcision as claimed by the clinical trails. For example, while the trials suggested a 60% relative risk reduction of HIV infection, the national population based survey in South Africa found that the prevalence of HIV was 12.0% among intact men and 12.3% in circumcised men. This represented a 2.5% increase in relative risk for circumcised men. In 10 other African countries, circumcised men have a greater prevalence of HIV infection than uncircumcised men. Even assuming the science is correct, consistent condom use is said to cost 12.3 times less to prevent one case of HIV than circumcision. In any case, even circumcised men still have to use condoms. Then what is the point?

Ulrich Fegeler of the German Paediatric Society argued that, "You can achieve the effect of a moderate reduction in the rate of HIV with a 1 500% increase in the number of circumcisions, or with a 3% increase in the condom rate." Again, what then is the point? With so many apolitical and far more effective methods to fight HIV/AIDS - Anti Retro-viral Therapy, Post Exposure Prophylaxis and Condoms, why the fuss about a 60% relative risk reduction? In addition, even that 60% is subject to much debate about its scalability in Sub-Saharan Africa. The sad reality is, as pointed out by Van Howe: with every circumcision, 3 000 condoms will not be available making circumcision a relatively ineffective distraction. With its political baggage, scientific debates and problematic history, there is no reason for circumcision to be pushed in Africa. It represents Western hegemony over knowledge systems, projection of Western power in Sub Saharan Africa, epistemic violence against Africans and ultimately, disrespect for African bodies.

There are better and more effective ways to fight the HIV/AIDS epidemic which should be dominating airwaves and campaign efforts not this dubious chopping of skin. In a few years, the results will be clear to everyone and if they do not show real reduction in HIV prevalence, WHO should be held accountable for the unwarranted mutilations. Before then, WHO should explain why its decision making processes are not inclusive and respectful of African knowledge especially in decisions concerning African bodies. The status quo amounts to colonial condescension. Nothing about Africans without Africans!