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CIRCUMCISION – The unanswered questions
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The government of Swaziland with the help of benevolent sponsors that includes the United States government wants to embark on a massive male circumcision campaign beginning January next year.
Their target is to circumcise close to 200 000 men. Prince Masitsela, a traditionalist and senior citizen, has been one of the few leaders that have undergone the process.
At this stage we are avoiding to call it a custom, because it is not part of our initiation exercise, but a process that we are made to respond to in an attempt to curb the spiralling figures of HIV positive people in the country.
Readers will recall that this is not a new subject in this column. I have addressed it before, sceptical as I was. I have my own reasons for being sceptical, which I want whosoever is responsible for the programme to come forward and try to address.
I know that the minister of health, Benedict Xaba, met with Manzini region chiefs over two days this week at Tum’s George Hotel, where he tried to sell them the Male Circumcision Accelerated Saturated Initiative (ASI) project.
The mathematics has been done and concluded, but what I find strange is that no one seems to be concerned about addressing the whole MC concept, what it means to Swazi men and what impact it would have socially and politically.
war
That there are willing partners, well and good, but we must not rush where the dollars are, but really win the psychological and physical war of what this whole MC means.
To say that it will help reduce the HIV spread by making men more resistant to sexually transmitted infections and protecting women against cervical cancer, is not sufficient.
What we need to do is explain how this MC will impact on the social strata, if at all it would have such an impact. But surely, you cannot have close to 200 000 men circumcised in a 12 month period and have no social impact.
Already I read some comments from the Chiefs which suggest that the ministry of health needs to persuade the country’s authorities to buy into the idea before rolling out their programme, which may have serious social effects.
They suggest with strong traditional undertone that if this exercise goes on as planned, certain national cultural events would be impacted negatively.
In Swaziland, we know that, anything that threatens the existence of the institution of the Monarch is viewed with suspicion and its chances of survival are minimal.
So, let the proponents of MC not leave us with the scientific explanation, which also is not 100% guarantee for safety, when going about their project. They need to touch the core of Swazi culture and way of life.
circumcision
Yes, it is true that we are seriously affected by HIV and AIDS in the Kingdom, but MC alone is no panacea. In fact, I read that even the United States, where circumcision is done from infancy stage, has higher HIV infection rate than any developed country. What does that tell us?
It is stated that two American-sponsored studies in Africa claim that adult male circumcision significantly reduces the risk of acquiring HIV. Researchers then take the leap of recommending adult male circumcision as an HIV prevention strategy.
It is said that publishing such a report in the United States appears to support the American cultural practice of circumcision. Such judgments are dangerous.
The Kenya report spotlighted a 53% reduction of HIV acquisition in circumcised men relative to genitally intact men. However, only 47 of the 1 391 (one in 30) genitally intact men in the study contracted HIV, compared to 22 of the 1 393 (one in 63) circumcised men. These figures showed that about 56 circumcisions were needed to prevent one HIV infection, and 55 out of 56 circumcised men received no benefit.
In the Uganda study, investigators estimated that 67 circumcisions were needed to prevent one HIV infection while the rate of moderate and severe circumcision complications was about 4%.
Therefore, the chance of such a complication was more than 2.5 times greater than the chance of protection from an HIV infection, not including complications that would appear years later.
In addition, an association between circumcision and HIV infection does not prove a cause and effect relationship.
The studies failed to avoid selection bias and expectation bias. The studies were stopped early, and duration of the trials were short. No long-term follow-up can be done. The effects of commercial sex workers, female circumcision, genital ulcers, unsafe medical practices, non-sexual HIV infection, and condom use were not included. Furthermore, the HIV status of the female partners in the studies was not determined.
The studies do not account for cultural bias on the part of researchers. The Cochrane Collaboration is an international independent source of reliable evidence-based reviews of healthcare information.
It reports, “Circumcision practices are largely culturally determined and as a result there are strong beliefs and opinions surrounding its practice. It is important to acknowledge that researchers’ personal biases and the dominant circumcision practices of their respective countries may influence their interpretation of findings.”
infection
The lead researchers of the African studies are known American circumcision advocates.
Claims that circumcision reduces the risk of acquiring HIV infection have been made for 20 years. Other studies have found no significant effect of circumcision status on HIV acquisition.
Publication bias in favour of positive results makes it more difficult to bring attention to studies with negative outcomes. The fact is that the United States has a high circumcision rate and the highest prevalence of HIV infection in the developed world. Other countries have lower rates of HIV infection than the United States and do not practice circumcision.
The African adult studies cannot be applied to American infants because of the difference between the two groups. Because sexually transmitted infections obviously cannot be transmitted until an individual engages in sexual activity, a male may make a decision to be circumcised when he is older without losing this claimed “benefit.”
If you were an adult male and had the option of using a condom and getting virtually assured protection or having part of your penis cut off to get a one in 56 chance of protection, the choice is clear.
American researchers tend to avoid studying or acknowledging the sexual and psychological harm associated with circumcision. This pro-circumcision bias in American medicine reflects the pro-circumcision bias in American culture.
The United States is the only country in the world that circumcises most (56%) of its male infants for non-religious reasons.
Knowledge of studies on circumcision harm is important to properly evaluating advisability. There is strong evidence that circumcision is overwhelmingly painful and traumatic. Some infants do not cry because they go into shock. Infants exhibit behavioural changes after circumcision. Changes in pain response have been demonstrated at six months of age, evidence of lasting neurological effects and a symptom of post-traumatic stress disorder. Anesthetics, if used, do not eliminate circumcision pain.
The common American belief is that the foreskin has no value. That’s because most American circumcised men (and doctors) do not know what they are missing. Based on recent reports, circumcision removes up to one-half of the erogenous tissue on the penile shaft, equivalent to approximately 12 square inches on an adult.
foreskin
Medical studies have shown that the foreskin protects the head of the penis, enhances sexual pleasure, and facilitates intercourse. Cutting off the foreskin removes several kinds of specialised nerves and results in thickening and progressive desensitisation of the outer layer of the tip of the penis, particularly in older men.
In a survey of men who were circumcised after they became sexually active, there was a reported decrease in sexual enjoyment after circumcision. One described it as like seeing in black and white compared to seeing in colour. If you have less, you feel less. Circumcision removes the five most sensitive parts of the penis. (For this reason, many circumcised men are reluctant to use condoms because it contributes to further decreased sensation. Reduced condom usage adversely affects the HIV infection rate.)
In a survey of those with comparative sexual experience, women preferred the natural penis over the circumcised penis by 6 to 1.
Surveys of circumcised men and clinical reports show that when men recognise their loss due to circumcision and experience associated decreased sexual sensitivity, they report wide-ranging psychological consequences.
Most circumcised men seem satisfied because they may not understand what circumcision is and the benefits of the foreskin, they may not be aware of certain feelings and their connection to circumcision, or they may be afraid of disclosing these feelings. For American society, circumcision is a solution in search of a problem, a social custom disguised as a medical issue. Beware of culturally-biased studies on circumcision posing as science, and take your whole baby home.
NB: Additional information sourced from Circumcision Resource Centre. The Resource Centre is a nonprofit educational organisation with the purpose of informing the public and professionals about the practice of male circumcision
For feedback: email: weekendeditor@observer.org.sz , aleclushaba@yahoo.com or go to aleclush@twitter.com for personal engagement.
Their target is to circumcise close to 200 000 men. Prince Masitsela, a traditionalist and senior citizen, has been one of the few leaders that have undergone the process.
At this stage we are avoiding to call it a custom, because it is not part of our initiation exercise, but a process that we are made to respond to in an attempt to curb the spiralling figures of HIV positive people in the country.
Readers will recall that this is not a new subject in this column. I have addressed it before, sceptical as I was. I have my own reasons for being sceptical, which I want whosoever is responsible for the programme to come forward and try to address.
I know that the minister of health, Benedict Xaba, met with Manzini region chiefs over two days this week at Tum’s George Hotel, where he tried to sell them the Male Circumcision Accelerated Saturated Initiative (ASI) project.
The mathematics has been done and concluded, but what I find strange is that no one seems to be concerned about addressing the whole MC concept, what it means to Swazi men and what impact it would have socially and politically.
war
That there are willing partners, well and good, but we must not rush where the dollars are, but really win the psychological and physical war of what this whole MC means.
To say that it will help reduce the HIV spread by making men more resistant to sexually transmitted infections and protecting women against cervical cancer, is not sufficient.
What we need to do is explain how this MC will impact on the social strata, if at all it would have such an impact. But surely, you cannot have close to 200 000 men circumcised in a 12 month period and have no social impact.
Already I read some comments from the Chiefs which suggest that the ministry of health needs to persuade the country’s authorities to buy into the idea before rolling out their programme, which may have serious social effects.
They suggest with strong traditional undertone that if this exercise goes on as planned, certain national cultural events would be impacted negatively.
In Swaziland, we know that, anything that threatens the existence of the institution of the Monarch is viewed with suspicion and its chances of survival are minimal.
So, let the proponents of MC not leave us with the scientific explanation, which also is not 100% guarantee for safety, when going about their project. They need to touch the core of Swazi culture and way of life.
circumcision
Yes, it is true that we are seriously affected by HIV and AIDS in the Kingdom, but MC alone is no panacea. In fact, I read that even the United States, where circumcision is done from infancy stage, has higher HIV infection rate than any developed country. What does that tell us?
It is stated that two American-sponsored studies in Africa claim that adult male circumcision significantly reduces the risk of acquiring HIV. Researchers then take the leap of recommending adult male circumcision as an HIV prevention strategy.
It is said that publishing such a report in the United States appears to support the American cultural practice of circumcision. Such judgments are dangerous.
The Kenya report spotlighted a 53% reduction of HIV acquisition in circumcised men relative to genitally intact men. However, only 47 of the 1 391 (one in 30) genitally intact men in the study contracted HIV, compared to 22 of the 1 393 (one in 63) circumcised men. These figures showed that about 56 circumcisions were needed to prevent one HIV infection, and 55 out of 56 circumcised men received no benefit.
In the Uganda study, investigators estimated that 67 circumcisions were needed to prevent one HIV infection while the rate of moderate and severe circumcision complications was about 4%.
Therefore, the chance of such a complication was more than 2.5 times greater than the chance of protection from an HIV infection, not including complications that would appear years later.
In addition, an association between circumcision and HIV infection does not prove a cause and effect relationship.
The studies failed to avoid selection bias and expectation bias. The studies were stopped early, and duration of the trials were short. No long-term follow-up can be done. The effects of commercial sex workers, female circumcision, genital ulcers, unsafe medical practices, non-sexual HIV infection, and condom use were not included. Furthermore, the HIV status of the female partners in the studies was not determined.
The studies do not account for cultural bias on the part of researchers. The Cochrane Collaboration is an international independent source of reliable evidence-based reviews of healthcare information.
It reports, “Circumcision practices are largely culturally determined and as a result there are strong beliefs and opinions surrounding its practice. It is important to acknowledge that researchers’ personal biases and the dominant circumcision practices of their respective countries may influence their interpretation of findings.”
infection
The lead researchers of the African studies are known American circumcision advocates.
Claims that circumcision reduces the risk of acquiring HIV infection have been made for 20 years. Other studies have found no significant effect of circumcision status on HIV acquisition.
Publication bias in favour of positive results makes it more difficult to bring attention to studies with negative outcomes. The fact is that the United States has a high circumcision rate and the highest prevalence of HIV infection in the developed world. Other countries have lower rates of HIV infection than the United States and do not practice circumcision.
The African adult studies cannot be applied to American infants because of the difference between the two groups. Because sexually transmitted infections obviously cannot be transmitted until an individual engages in sexual activity, a male may make a decision to be circumcised when he is older without losing this claimed “benefit.”
If you were an adult male and had the option of using a condom and getting virtually assured protection or having part of your penis cut off to get a one in 56 chance of protection, the choice is clear.
American researchers tend to avoid studying or acknowledging the sexual and psychological harm associated with circumcision. This pro-circumcision bias in American medicine reflects the pro-circumcision bias in American culture.
The United States is the only country in the world that circumcises most (56%) of its male infants for non-religious reasons.
Knowledge of studies on circumcision harm is important to properly evaluating advisability. There is strong evidence that circumcision is overwhelmingly painful and traumatic. Some infants do not cry because they go into shock. Infants exhibit behavioural changes after circumcision. Changes in pain response have been demonstrated at six months of age, evidence of lasting neurological effects and a symptom of post-traumatic stress disorder. Anesthetics, if used, do not eliminate circumcision pain.
The common American belief is that the foreskin has no value. That’s because most American circumcised men (and doctors) do not know what they are missing. Based on recent reports, circumcision removes up to one-half of the erogenous tissue on the penile shaft, equivalent to approximately 12 square inches on an adult.
foreskin
Medical studies have shown that the foreskin protects the head of the penis, enhances sexual pleasure, and facilitates intercourse. Cutting off the foreskin removes several kinds of specialised nerves and results in thickening and progressive desensitisation of the outer layer of the tip of the penis, particularly in older men.
In a survey of men who were circumcised after they became sexually active, there was a reported decrease in sexual enjoyment after circumcision. One described it as like seeing in black and white compared to seeing in colour. If you have less, you feel less. Circumcision removes the five most sensitive parts of the penis. (For this reason, many circumcised men are reluctant to use condoms because it contributes to further decreased sensation. Reduced condom usage adversely affects the HIV infection rate.)
In a survey of those with comparative sexual experience, women preferred the natural penis over the circumcised penis by 6 to 1.
Surveys of circumcised men and clinical reports show that when men recognise their loss due to circumcision and experience associated decreased sexual sensitivity, they report wide-ranging psychological consequences.
Most circumcised men seem satisfied because they may not understand what circumcision is and the benefits of the foreskin, they may not be aware of certain feelings and their connection to circumcision, or they may be afraid of disclosing these feelings. For American society, circumcision is a solution in search of a problem, a social custom disguised as a medical issue. Beware of culturally-biased studies on circumcision posing as science, and take your whole baby home.
NB: Additional information sourced from Circumcision Resource Centre. The Resource Centre is a nonprofit educational organisation with the purpose of informing the public and professionals about the practice of male circumcision
For feedback: email: weekendeditor@observer.org.sz , aleclushaba@yahoo.com or go to aleclush@twitter.com for personal engagement.
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