Mandatory male circumcision in the Zambian police force

In the last couple of years, there have been a number of high-profile studies exploring the relationship between male circumcision and HIV acquisition. Three randomized clinical trials in Africa confirmed an association suggested by less rigorously designed studies, i.e. that men who are circumcised are significantly less likely to acquire HIV from infected women during vaginal intercourse. But what to do about these findings in terms of public health policy? The professional views and lay public opinions are highly diverse and sometimes highly emotive. Some in public health circles consider male circumcision as effective as a vaccine and the promotion of male circumcision in regions of high HIV prevalence as an ethical imperative. Others, who have ethical objections to (especially neo-natal) male circumcision in general, criticize the methodology of the clinical trials, question their conclusions, and view the promotion of male circumcision as deeply misguided and harmful.

Whatever side one takes on this issue, the approach of the Zambian police force is bound to raise eyebrows. According to the Lusaka Times, the national police force is planning to make male circumcision a requirement for all new recruits. The police force has apparently been losing male police officers to HIV/AIDS. Male circumcision is being strongly promoted in other professional contexts in sub-Saharan Africa, such as Rwanda, which has included it as part of an HIV prevention strategy within its army.

Of course, the Zambian approach is not 'mandatory male circumcision' in the strict sense: it is only mandatory among those who have chosen to join the police force. At the same time, the idea of mandatory irreversible preventative genital surgery on healthy males bound to be controversial. Making the practice obligatory, rather than a matter of choice, raises the ethical stakes: you need a very strong justification to move from voluntary to mandatory. Is the HIV incidence among policemen in Zambia very high? If so, what explains that incidence? Is male circumcision likely to counteract whatever forces are driving the high incidence? To pull off a utilitarian justification of the policy, you need to clearly show that the overall benefits of the policy will outweigh the overall costs. And even if you do, not everyone will be impressed: not everyone is a utilitarian.

For a flavor of the online debate this sort of story inspires, have a look over at the Universal Circumcision blog.

Hat tip: Daniel Westreich.