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Circumcision – health and cultural imperialism?

Posted by Don McLenaghen on June 1, 2011

We received a letter from a loyal listener, thanks Aaron,  who was asking about whether circumcision was really a valid method of HIV infection prevention or just an attempt by ‘westerners’ to impose a religious tradition on a ‘vulnerable’ population. First things first, we will be discussing male circumcision and not female genital mutilation.

Long tradition

Okay, so the question we are asking … “Is the attempt to promote male circumcision in Africa a form of religious or cultural imperialism”?

Cultural Imperialism?

To answer this question we must decompose this big question and ask a few questions – “Does it help prevent HIV infection?”

The scientific evidence seems quite clear; circumcision reduces HIV transmission in male populations by over 60% and to women by almost 50%. This is based on a number of peer reviewed independent randomized studies, so the science seems clear that male circumcision does help in the prevention of the spread of aids. Now in their own research some of our listeners may find some studies that report to show circumcision in North American context shows no effect on HIV transmission raising questions as to the true effectiveness of procedure and perhaps a double standard between here and there. These studies, from what I can decipher are voluntary surveys which ask if men would volunteer for a study of circumcision and HIV transmissions and would be willing to be circumcised. This showed the impact on HIV transmission would be minimal at best because of a low number of men willing to participate or have the procedure done. However, this is not a study of the effectiveness of circumcision but a cultural willingness of men to be circumcised as adults. Also its target population was the gay community, where HIV transmission via anal intercourse has a different pathology than vaginal intercourse. Although, it is still my understanding that although less effective, HIV transmission is still reduced even in this category of sexual activity.

There is also a strong correlation between circumcision and the prevention of penile cancer. Although less understood, the vast majority of cases of penile cancer occur in uncircumcised men while incidence in those circumcised at birth is almost unheard of. That the odds of developing penile cancer is magnitudes less if one has been circumcised at birth…with less benefit for adult circumcision.

So, the first order question “Does circumcision help reduce the spread of aids?” seems overwhelming yes and as such, should be supported. The second question we could ask is “Should we, as good atheist, promote a religious practice and should not it overt association with Judaism and ‘the west’ make us unwilling to support widespread advocacy of circumcision especially in areas of western colonialism?”

Cultural ignorance in humour?

The simple answer I think is no, it is a historical accident that the practice is currently associated with Judaism. It is also a west attitude as well, as the vast majority of religiously circumcised men are Muslim and not Jewish. If one does a little research we find circumcision has a long history. It was practiced by the Pharaoh-nic Egyptians; it’s a common practice among Muslims as well as being a millenniums old rite of passage in western Africa.

That said, I do not like the attempt of some ‘missions’ who stress the religious nature of the procedure. I have heard of one such mission that is referred to as “operation Abraham”…where a team of ‘practiced’ Israeli doctors are doing mass circumcision of men in Africa. However, I do not like the fact that a number of churches have soup kitchens and yet, until suitable secular resource can be brought to bear, it seems in the interest of harm reduction we should hold our noses and allow these groups to do their thing until we can muster alternatives.

Rates of circumcision

It was also argued that while promoting the practice of circumcision in Africa for aids prevention, similar missions have not been done in other ‘low circumcised’ populations in ‘white’ countries. To understand this we must look at the existing prevalence of circumcision and the prevalence of HIV infection. Now the region of the world with some of the highest rates of circumcision are Saharan Africa and the Middle East; followed by North America. The regions with lowest rates of circumcision are Europe, South America and parts of Sub-Saharan Africa. On this information, one could jump to the conclusion that efforts to promote circumcision should be focused on Europe (with some of the lowest rates of circumcision) but we must contrast this cultural practice with the medical need. IF we now look at the prevalence of HIV infection and the deaths from aids we see that the highest rates are in sub-Saharan Africa while Europe has some of the lowest. Now, I am sure this discrepancy in HIV infections reflects an underling link between poverty and undeveloped medical infrastructure…as well as the concerted efforts of the Catholic church to demote the use of condoms in Africa (notable the church does not pursue this anti-condom policy as aggressively in ‘white’ countries’). The prevalence of HIV in Eastern Europe is about 0.8%, South America 0.5% and Western Europe 0.2%…while Sub-Saharan Africa is about 5%…for reference North America its about 0.5% but our highest source of infection is IV drug use…thanks to our war on drugs.

Rates of HIV transmission

So, in context, the promotion of circumcision of African men as a means to control HIV seems to be both effective (if the face of the high rates of HIV infection) and practical. It’s practical in the sense that the Catholic Church which has banned condoms has no issue with non-religious circumcision.

 

 

3 Responses to “Circumcision – health and cultural imperialism?”

  1. phalacrocorax said

    Are you sure the map labeled “rates of circumcision” is correct? It looks like another map of HIV infection.

  2. There is a lot of emotion and noise around this issue, but there are lots of things we don’t know, such how many intact (uncircumcised) men are comfortable with their condition and how many wish they’d been circumcised as infants, or how many circumcised men are resentful about the reduction of bodily integrity that was imposed on them, or how many circumcised men have had problems with their circumcision scar.
    Please participate in this survey, which is an attempt to answer these and many more questions. The survey is trying to remain neutral on the issue. Information is needed from both men and women.

    https://www.surveymonkey.com/s/6R2MTBF

    without any cynicism, I say, think of the children.

  3. Deniz said

    Pretty much any discussion of circumcision by anyone who has not been studying the issue for a long time ends up being really misguided and focuses on the wrong questions. Some of your facts or wrong or lack critical context.

    Firstly, religion is not an issue. Why should atheists care if this procedure has religious roots? The relevant questions are, is it valid medicine to circumcise an entire population, will such a campaign even work (http://ow.ly/6En4j – why a mass circ. campaign will fail), and what other issues are at stake (e.g. loss of sexual enjoyment, informed consent, forced circumcision of children, medical ethics generally, risks of the procedure, etc.)
    The science, while it may seem quite clear to you based on casual perusal of available evidence, is debated fiercely. See: http://www.circumstitions.com/HIV-SA.html . Long story short: even if circumcision reduced male-female transmission rates (it actually increases male-female transmission rates from HIV infected partners), mass circumcision campaigns will not do anything productive, for multiple reasons, will probably backfire, and at best are a dangerous distraction from solutions that would actually work.
    I think we should be cautious about accepting HIV findings too quickly. For one thing, the careers of researchers who do these studies consists of looking for correlations between circumcision and disease prevention, so they are biased. Secondly, if you look at the history of circumcision, it has been characterized by health claims which invariably get debunked a few decades later (e.g. the HPV claim was debunked less than a month ago http://ow.ly/6EmOd. The same goes for UTI studies done in the 80s, which were also done by a career circumcision advocate. The studies have been criticized increasingly for methodological flaws over time. If I were a betting man, I’d bet half my life savings that the HIV claims will be completely debunked or reduced to triviality within the next 20 years. Also, if you think about it, how many parents are actually expecting their newborn boy to be having unprotected sex with HIV+ women in the future? (studies only look at female-male transmission, and honestly what are the odds you will get vaginal fluids under your foreskin if you’re wearing a condom?). What’s even more absurd is that children don’t have sex, so why cut off a normal, healthy body part of a baby? If circumcision so important, it can still wait until they can decide for themselves when they’re older and sexually active. At any rate, only condoms really matter. A slightly reduced statistical risk isn’t protection. You will still get STIs just like everyone else.
    The only health claim that seems to have remained true is the penile cancer claim, but that is so rare that it affects 1 in 10,000 people. Hardly an argument for routine circumcision of everyone. The American Cancer Society states that circumcision should not be recommended to prevent it, since the real underlying causes are the usual, smoking and poor health. Sure, it stands to reason that if you amputate a good chunk of a body part, that body part is less likely to develop cancer, but is that an argument for, say, forced childhood mastectomies?. Also, circumcisions are not without complications and boys die every year from the United States from the procedure. If you added up all the deaths, accidental amputations, life-altering disfigurements and serious botches from circumcision in the USA, I am absolutely certain it would vastly exceed 1 in 10,000.
    Circumcision also affects sexual pleasure. This is often ignored by circumcising societies and people are in complete denial of this fact. But it’s pretty hard to deny. No part of the penis is non-erogenous, and the nerves at the tip are most sensitive and also specialized to stretching. Why cut them off? It’s quite absurd, really. Foreskin also provides mechanical lubrication, faciliating sex and enjoyment. Only a circumcising society could rationalize such a radical procedure.
    Circumcision also violates medical ethics. In the absence of a disease, non-therapeutic surgery without should not be performed on a non-consenting minor. (http://ow.ly/6En5b – brief discussion of bio-ethics; http://ow.ly/6EnaR – on doctors’ dilemmas and the reality of why circumcision is performed) Of course, it obviously violates the first principle of medicine, i.e. “First, do no harm”. Circumcision absolutely fails this test, in pain, loss of tissue and risk exposure.

    You have mostly ignored these key contextual issues, and sadly have focused on minor debates around statistics, whose information isn’t even very accurate. It’s not your fault that you grew up in a society where this was normalized and you were fed misinformation constantly, but the result is that this show is not terribly useful or productive.

    Oh, and don’t get me wrong: I’m not against circumcision. I’m against the forced circumcision of children.

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