The Herald.co.zw
March 5 2010
HIV infection: Positive benefits of male circumcision
By Dr Stamps
I must confess, at the outset, my initial reservations about the
enthusiastic, and sometimes irrational, adoption of adult male
circumcision as a strategy against the worldwide threat, especially
the threat in our country, Zimbabwe, posed by HIV infection.
For a start, it confuses some of the messages we have painfully and
intensely propagated over many years. The "ABC" of abstinence, being
faithful, and using a condom is somehow muddied, because young men, in
particular, go for circumcision in order to avoid the messy business
of having to use a condom.
Secondly, the widely publicised experiments at Orange Farm in Gauteng,
South Africa, Rakai in Uganda and Kisumu in Kenya were not, by any
ordinary definition, "gold standard" randomised controlled trials. In
fact, they were not random controlled trials at all, and even the
experiment was uncompleted.
The only thing which was randomised, and this was not fully blinded,
was the allocation of the volunteers to the two groups (circumcision
or delayed circumcision). It is obvious to anyone that both the
volunteer and the researcher knew immediately to which group the
volunteer belonged, raising the strong probability of the Hawthorne
effect, i.e. the bias introduced by multiple changes occurring at the
same time, only one of which is recorded as being responsible for the
effect seen. This, of course, was the effect that the funders of the
experiment wanted to see. A moment’s thought will impress the
objective observer that circumcision with enforced abstinence for 42
days is probably the most dramatic "behaviour change" a sexually
active young man can ever experience as an individual!
Thirdly, if money for health initiatives is available, there are many
more urgent and beneficial initiatives which cry out for funding in
this region, in particular. One has only to see the disastrous
effects, and, indeed, downstream consequences on both the family and
the health worker of the deteriorating statistics and causes of
maternal mortality and perinatal death and disability in our country.
This quantum of money could have been more profitably used in
preventing and treating cervical cancer, from which almost nobody now
dies in rich countries. And I’ve only touched on reproductive health.
Many initiatives in the broad spectrum of health could produce better
and more permanent improvements in our social setting.
Fourthly, the question of gender balance has to be raised. Even the
most ardent enthusiast will admit that this initiative will benefit
men, exclusively, in the initial phase at least, though I’ve seen some
fanciful medical modelling claiming that it will lead to benefits for
women (on the HIV incidence) eventually. It is, however, an initiative
totally targeted at benefiting young men.
Fifthly, there is the thorny problem of discrimination. Some can still
remember the fact that in the Nazi regime the mere fact of being
circumcised was likely to end you up in a death camp. Similar
discrimination, either for or against circumcision, has been with us
throughout the ages. It is not as well known that the British civil
service, especially those who were to serve in the East India Company,
were required to be circumcised, because the Moghul empire in the 16th
and 17th centuries would not negotiate with the uncircumcised heathen!
And the medical services of the 19th century on both sides of the
Atlantic advocated adult male circumcision as a "cure" for all kinds
of illnesses, including paralysis, hip-joint disease, and, more
frequently, psychiatric disease brought on by various environmental
conditions ‘ "exhausting climate, work, worry, tobacco and alcohol".
Some, such as Remondino, even associated the prepuce with "a malign
influence . . . striking the patient down unawares in the most
unaccountable manner ¦"
In 1894, Merrill Ricketts listed a whole series of illnesses that
could be cured by male circumcision, including eczema, elephantiasis
epilepsy, gangrene, TB, bed-wetting, convulsions, "hystero-epilepsy"
and impotence. If only the manufacturers of Viagra had known!
No wonder that the British Royal family circumcised all their male
heirs, and, by the start of the Second World War an estimated 80
percent of "upper class" males were circumcised in the UK.
Some civilisations, such as those in the earlier part of the Islamic
religion, made it a condition of rising in rank in the armed forces
that the number of trophies ‘ prepuces of unbelievers ‘ removed
personally counted in the superiority. I suppose that was analogous to
the scalps in a "Red Indian’s" pouch demonstrating him to be a mighty
warrior. And in the years leading up to the Turkish occupation of
Armenia in 1915, large numbers of male indigenous Armenians were
forcibly circumcised (and died, because circumcision was done in
primitive, unhygienic conditions, and without anaesthetics) although I
suppose it also helped in the process of annexing the land, because so
many fighting people were disabled.
Lastly, the scenario of the international debates was deeply divisive.
Both in Toronto, (which to some of us is more associated with a
charismatic event ‘ the "Toronto blessing") and in Montreux, (which
has staged some brilliant jazz festivals) both sides accused the other
of "irrationality", and created some curious alliances, which served
only to deepen the stigma associated with the disease when we have put
in so much to promote the normality of those affected by HIV. Some of
the claims of the effectiveness (against Aids) do need to be assessed
in the light of experience, rather than the enthusiasm demonstrated by
zealots that this procedure alone can replace appropriate behaviour
education and practice.
In Kenya, scene of one of the highly publicised experiments, Professor
P. Aggleton was told that it would be unthinkable for that nation to
have an uncircumcised President, and Dr. R. Darby reports that boys
have been excluded from some schools if they aren’t circumcised.
I’ve gone into some of the history of the procedure because, in some
circumstances male circumcision, especially adult male circumcision,
can be a deeply political activity. Its connexion with a whole range
of non-clinical beliefs, mores, and the process of colonising the
mindset of a nation such as Zimbabwe, is very broad and needs to
involve all aspects of our emerging society. The advocacy, and indeed
the policy, for upscaling adult male circumcision in Zimbabwe comes
largely from rich countries in the North, and the money for the
procedure almost exclusively from international organisations and NGOs
who call themselves "donors". The danger of attracting sexually
deviant persons and "voyeurs" who have a twisted pleasure in seeing
young, male, black penises has been underplayed, too.
So, we have to be careful on several points:
(a) That the policy shall be ours, and in particular, not compulsory
or enforced, even by monetary or other non-medical inducements, and
(b) That the policy we craft, or adopt, shall be unbiased and not
affect the already significant gains we have already achieved against
the disease, especially on the field of prevention.
(c) That the process shall accord with our culture (several
traditional groups already promote the concept) and, conversely, the
resons for adult male circumcision shall be purely a public health
initiative, not an imposed programme by well-wishers with hidden
agenda.
With all the opinions I’ve expressed, it will no doubt come as
surprise that I support the programme so far, and I believe readers
have a right to know the positive benefits of male circumcision.
They are not limited to the narrow prevention of HIV infection, but
they are, of course, related.
Firstly, Holy Scripture endorses it:
1. Abraham and his household were circumcised as a bodily sign of
God’s covenant (Genesis 16). In fact, he was 99 years old when he got
circumcised, and lived on a good few years after that. My
interpretation of that recorded fact is that age is no barrier, and it
doesn’t affect one’s future health. (Ishmael, by the way, was 13,and
his half-brother, Isaac was a baby.)
2. Our Lord, Jesus Christ, was circumcised, according to the customs
of that time, on the 8th day ‘ i.e. the 1st of January, A.D.1. Yes, I
mean, 01.01.0001. That was the first day of our present era.
3. My namesake, Timothy, was circumcised as a young adult by Paul
(Acts 15,3). Just in case the analogy is taken too far, I’m not
advocating that (Dr.) Paul (Chimedza) should repeat that procedure
now!
Secondly, male circumcision, done with optimal hygiene and expert
skill is a very different proposition than even 100 years ago in
civilised societies.
Modern surgical procedures, done in specially designated units in
Zimbabwe, are safe, and the surrounding physical and professional
environment ensures maximum security and success, and the counselling,
both before and after the procedure, is of a very high standard.
Especially the difficult 42-day period subsequently is handled with
great attention to personal needs.
Thirdly, and to me, most importantly, it can serve to reinforce the
"B" of our acronym ‘ ABC.
Being faithful to one’s faithful spouse (and I suppose it can apply to
traditional polygamy as well) has tended to be overshadowed in recent
advocacy promotions by the "A" (Abstinence) and the "C"(Condoms) parts
of prevention methods, both because they are simpler to propagate and,
especially in the case of condom use, quantifiable. But if the two
prevention policies succeed it takes little thought to see that
eventually we shall end up with a childless Zimbabwe, and we shall
have no posterity to thank us for our effort!
So, I was very impressed to see that over 25 percent of clients are
accompanied to the procedure, and we should strongly advocate that
adult male circumcision should involve women as well ‘ not as clients,
but as active participants in a life long decision.
That way we shall promote the "B" part of the fight against Aids, and
promote the development of our country and region. I recall one of my
patients telling me that her husband’s (circumcised) penis was the
"only lolly that got bigger when she sucked it". And the joy of
marital intimacy has been discounted for too long in our current
society where relationships that go wrong seem to be the target for
all sorts of publicity.
Confucius said the family is the most important part of any nation.
And we would do well to emulate his wise counsel by being active
contributors to the family.
Uxorial fidelity is not a well promoted concept. I hope that the
current programme of adult male circumcision can enhance this joint
adventure, and I anticipate a greater number of female partners being
involved in what should be an inclusive programme.
Dr. T. J. STAMPS
Health Advisor In the Office of the President and Cabinet
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