Penile transplants and ritual male circumcision in Africa

It should not be going to too far out on a limb to say that ritual male circumcision is not, and never has been meant to be, a medical intervention. Certainly in sub-Saharan Africa, where it has generally been understood as part of a larger rite of passage from boyhood to manhood, questions of safety, hygiene, pain relief or psychological trauma are typically not concerns central to the ritual. If they were, the use of unsterile instruments by non-surgeons on the un-anesthetized would have led to the disappearance of the practice long ago. The ritual is about risk, not safety; it is about testing an initiate's response to fear, not making the youth feel comfy. And what is more fearful that the threat of a sharp instrument being brought to bear on your private bits? One can be appalled by the practice, but you have to at least acknowledge that it is not an attempt to do the same thing as medical circumcision, except more primatively and with higher complication rates. It has unsafe practices partly because it serves a whole other purpose.

Nevertheless, it is hard to say that penile amputation or death are just the price you pay for ritual male circumcision, and those who think otherwise should just man up. Are you culturally ignorant if you care about and want to protect those who are harmed by traditional circumcision? Are you culturally insensitive if you want to change the practice to reduce harm to persons? One interesting development related to the issue has been the announcement of the first penis transplant. A nine-hour surgery by a South African surgical team late last year transplanted the penis of a dead donor to a young man who had lost his own member due to ritual circumcision complications. To barely-contained chuckles in news reports and the twitter-sphere, the patient enjoyed a rapid recovery, successfully putting his Johnson through its sexual paces only five weeks after surgery. Bad knifework corrected by better surgery, giving hope to all those harmed by ritual.

There are some puzzling and disquieting aspects to the story though. I suppose the first is that I never realized that you could donate your penis. Is this a checkbox on a form? The second is the question -- never answered in any news report that I saw -- whether the donated penis was itself circumcised. If it  wasn't, this could be a first: the first man to be circumcised twice. But most of all I wondered: how many of those who suffer from penile amputation via ritual circumcision are in a position to afford a nine-hour operation? And how will having another man's penis play itself out in their communities? Will it be considered more or less strange than not having one at all? And to what extent is this surgical achievement an adequate response to the deaths and dismemberments of ritual initiates occurring each year, rather than showcasing what powerful medical institutions are able to do?

Prevention rather than treatment is probably the only realistic way to cut down on the morbidity and mortality associated with ritual male circumcision. The problem is that it is unclear how to minimize the harm associated with the practice without significantly altering its meaning. Probably no headway will be made until the adherents themselves (and not just outsiders) regard the deaths and mutilations as matters of deep moral concern, rather than something that just comes with the ritual territory.

Ethics of implementing male circumcision in Swaziland

Dispatch from Maputo, Mozambique. As far as I know, the European Union has sent me here to discuss ethical issues in research with new ethics committee members. In the past, there was only one ethics committee in Mozambique, whose original mission was to review all health-related research. As requirements to get ethical approval (for funding, for publication, etc.) get more strict, and the number of local research studies involving human participants rises, having just a single committee is no longer workable or sustainable. So they are wisely decentralizing into a number of institutionalized ethics committees around the country. I am here to discuss the ins and outs of ethics committees, their ups and downs, their virtues and vices.

During downtime in the Hotel Cardoso, I noticed this piece about implementation of male circumcision initiatives in Swaziland. Apparently, these HIV prevention initiatives have not come close to reaching their targets, after millions of dollars have been spent, causing both soul-searching and finger-pointing. (The program spent almost 500 dollars per circumcised male in a country which has an average per capita annual income of roughly $5000). I've thought for a long time that much more bioethics attention -- to its detriment -- has been spent on research ethics than the ethics of implementing research results into practice. The latter has its own particular conundrums, such as: what do you do about a (less than) half-implemented program? Particularly when part of the reason why the implementation was partial is due to significant community reluctant/resistance towards the very idea of male circumcision for HIV prevention? Where should you go from here?

Community concerns about male circumcision and HIV prevention include: why do circumcised men still get counseling about using condoms? What happens with the foreskin? Is there any connection between these circumcision programs and witchcraft? Why must men need to refrain from sexual activity for some time afterward? Other forms of resistance or reluctance, in the Swazi case, reach up to the highest levels of policymaking. Local public health authorities may have been interested in gaining funds and collateral benefits from male circumcision initiatives, while being skeptical about the value of the intervention itself. Low community and governmental 'buy in' (as they call it) can derail any public health program. Add to this the work of the anti-circumcision groups and individuals worldwide, who can be found on the comments section of any news item on male circumcision and HIV, whipping up fears and debunking the science. For the latter, the ethics of implementing male circumcision programs is simple: just make it stop.  

Newborn circumcision for HIV prevention in Zimbabwe

It is fair to say that the connection between male circumcision and HIV prevention is known by now, i.e. the idea (supported by a number of research studies) that being circumcised reduces your chance of gaining the virus from an HIV-positive woman during sex. There are those who doubt the results of the studies, which is predictable when you are talking about a controversial surgical intervention to control a highly stigmatizing infectious disease in circumstances of poverty. And, perhaps less known, are the initiatives taking place throughout sub-Saharan Africa, backed by powerful donors like the Bill and Melinda Gates Foundation, to circumcise males for this purpose. If estimates are to be believed, hundreds of thousands of circumcisions prevent thousands of new HIV infections. HIV will not be circumcised out of existence, but in the face of a deadly epidemic you take what you can get.

Previous efforts have been focused on circumcisions among adolescent and adult males. These are men who are (just about to be) sexually active and likely to acquire HIV. These were also the populations for the studies showing that circumcision lowers HIV risk. This is why the new plan in Zimbabwe to promote circumcision among newborns is interesting and potentially explosive, for different reasons. Circumcising infants would only have an effect on HIV prevalence in the next generation. By the time that the infants become sexually active, the landscape of HIV/AIDS may have changed: perhaps there will be more effective means of prevention, perhaps there will be a cure, perhaps there will be a vaccine. Importantly, infants are in no position to give informed consent: there are strong arguments in favor of allowing persons to choose for themselves in such a case. It is also not clear how the public health approach in Zimbabwe relates to traditional male circumcision practices, nor how the intervention is going to be 'sold' to parents in communities who do not traditionally circumcise. Worries about circumcised men feeling more protected than they really are abound. And as for the newborn circumcision policy: recommended circumcision? Incentivized circumcision? Mandatory circumcision? So this is very much a work in progress, and we will see where it goes.

Foreskins, clamps, and stabbings

Part of the interest in getting Google Alerts, at least as far as I am concerned, is that they provide diverse (if not surreally clashing) news items about the same topic. This week, I received a couple of links about male circumcision as HIV prevention strategy in low-resource, high HIV prevalence countries. A few years ago, three randomized controlled trials in Africa indicated that being circumcised significantly reduced risk of female-to-male HIV transmission. Male circumcision was then all the rage for awhile, but soon slipped off the front pages as it passed from 'research innovation' to 'yet another intervention to be implemented.'

Some countries in Africa are making male circumcision part of their HIV prevention strategy, though informing/convincing men to have their foreskins removed for this purpose, and actually getting it done, has proven slow going. There is some movement to change this. The New York Times has an article about new methods to speed the process of circumcision, complete with pictures of what to the untrained eye look (predictably?) like cock rings of a fairly utilitarian sort. The most promising of these devices seems to be the PrePex, which basically involves putting a ring around your Johnson, and cutting off blood circulation to the foreskin, until the latter comes off 'like a fingernail' as one proponent so sensitively put it. Apparently the clinical trials on male circumcision and HIV gave birth to a growing industry in foreskin removing clamps, from China's somewhat sinister sounding Shang Ring to the exoticism of the Turkish Ali's Klamp, to the device that terrorized many a South African penis a few short years ago, the infamous Malaysian Tara KLamp. That is the new story: which plastic gadget most cost-effectively whips off the African foreskin?

The other story on my Google Alert really goes in another direction. The Citizen, a Tanzanian newspaper has an item entitled 'One Hacked to Death in Male Circumcision Confrontation'. Apparently traditionalists in Tanzania are (very) opposed to the idea of medicalizing male circumcision and treating it similarly to an appendectomy; after all, circumcision in Africa is commonly viewed as a rite of passage for males, where the pain of circumcision is part of its meaning, and the act is part of a ritual performed by traditional practitioners. A crowd of those who have this 'old school' view of male circumcision confronted someone who was treating it more as a medical, disease prevention intervention, and things got ugly. Modernity meets tradition. So the clinical trials on HIV and male circumcision have not only given rise to plastic gadgets, but also some measure of inter-tribal conflict.

Forced circumcision case in South Africa

The ancient practice of circumcision never fails to stir things up. Neonatal circumcision, whose popularity has steadily declined in Europe and is on the wane in the United States, is a reliable flashpoint for ethical debate. The debate over the costs and benefits of circumcision has been stimulated by research indicating that being circumcised significantly reduces a man's chances of getting HIV via hetrosexual intercourse. In South Africa, there has been much discussion about the state of traditional circumcision rituals, given that a significant number of young men die from circumcision-related causes each year.

An ongoing case in South Africa adds some new wrinkles to ethical and legal debates about circumcision in Africa. Bonani Yamani claims that when he was 19, he was abducted from his home, taken into the bush, circumcised against his will and forced to eat his own foreskin. His father apparently arranged or otherwise had knowledge that the abduction/circumcision was to take place, and it is his father that Yamani is suing. As it turns out, Yamani had undergone a (partial?) medical circumcision some months before. So Yamani is not against circumcision per se; he is opposed to traditional (Xhosa) circumcision, which he believes is contrary to his own Christian faith. And he is naturally opposed to having had it forced upon him.

The case brings out conflicts in a number of directions. There is the conflict between the father and son. The conflict between different views of circumcision: medical, traditional and (adopted) religion. But there is also a conflict between traditional leaders (in particular, the Congress of Traditional Leaders of South Africa or Contralesa) and the South African constitution: according to traditional norms, a male Xhosa who refuses to be circumcised is to be ostracised from his community. Traditional circumcision is not a matter of informed consent. It is just simply done, as part of being a Xhosa man, and refusal is not accepted. On this view, non-traditional circumcision and community membership are mutually exclusive. Yamani's legal defense will be arguing that not being able to live as a non-traditionally circumcised Xhosa should be regarded as discrimination under the South African constitution. Members of Contralesa have publicly stated that the constitution really has no grip on this area of South African life. This should be one to watch.

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.

A yellow light for male circumcision

In the past few years, a series of randomized controlled trials indicated that male circumcision reduced the risk of men acquiring HIV from women during hetrosexual intercourse. This finding seemed to confirm two decades of less rigorously controlled studies, and has turned out to be a rare success in the world of HIV prevention research, a world still reeling from failed HIV vaccine, diaphragm and microbicide trials. Male circumcision has always been a contested practice, so findings of the randomized controlled trials on male circumcision predictably sparked a great deal of debate. Some critics have argued that the findings were untrustworthy for a variety of reasons: because the trials were stopped prematurely or because not all possible confounders had been controlled for. Some of these criticisms were motivated by sincere concerns about scientific standards, but many times it seemed that criticisms of the trials were driven by a priori ethical views about the irrationality and harmfulness of male circumcision as such. In the meantime, emerging news items about male circumcision and HIV prevention are invariably accompanied by verbal battles among pro- and anti-circumcisionists in their comments sections.

The world has moved on. Or, at least, the biomedical research establishment in developed countries -- and in some developing ones -- seem to have moved on. The methods and findings from the randomized controlled trials are no longer the main event. The focus now is on how to implement male circumcision as an HIV prevention strategy in high HIV-prevalence countries with low-circumcision rates, mainly in sub-Saharan Africa. And the wallets are starting to open. To use a traffic metaphor, the strategy is getting a 'yellow light': proceed, but with caution. Caution for surgical risks in resource-poor clinics. Caution for diversion of scarce resources from other important health needs to circumcision initiatives. Caution for risky sex behavioral change among the recently circumcised. And a variety of other vexing and challenging hurdles. But there is the overwhelming sense of rolling up one's sleeves, that this is a fight worth fighting.

In the interests of full disclosure, my colleagues and I published a 'proceed with caution' piece about HIV and male circumcision last year in the Journal of Medical Ethics. But that piece does not have the same sort of authority or significance as last week's commentary article in Journal of the American Medical Association or the perspective piece in the New England Journal of Medicine: these are prestigious journals with a large and influential readership, and these are some well-known authors. Initiatives to promote male circumcision seem to have gotten the official yellow light, and join the increasingly crowded and messy world of HIV prevention.

Circumcision and HIV: If it can make it there, it can make it anywhere

I know that this blog has discussed male circumcision and HIV prevention before. But now that the World Health Organization has endorsed the use of male circumcision to reduce risk of HIV transmission, the issue has really gone global. News items are everywhere. And Americans can no longer think it is something that just Africans, living in high HIV prevalence countries, have to contend with. No, the debate has arrived, like many a new immigrant to these shores, in New York.

The Department of Health and Mental Hygiene in New York City is planning a promotion campaign for male circumcision among populations deemed to be at risk for acquiring HIV. The Department has started asking some community groups and gay rights organizations to discuss circumcision with their members. Health and Hospitals Corporation, a company that operates city hospitals and clinics, is being asked to perform the procedure at no charge for men without health insurance. As usual, New York is being avant guard, since the Centers for Disease Control and Prevention have not formulated national guidelines yet. The Department of Health and Mental Hygiene is so proactive that it seems to have even caught New York City Mayor Michael Bloomberg off-guard.

There are a lot of unknowns and issues raised by the use of male circumcision as HIV prevention strategy in a place like New York. One is that the African studies were about the reduction of HIV risk among circumcised men in hetrosexual relations. The high-risk groups in the US are mostly injection-drug users and men who have sex with men, and the studies say little to nothing about that. New York City's Health Commissioner, Thomas Frieden, claims that if a man's risk from penetrative anal sex with an HIV positive man is about the same as the risk from sex with an HIV positive woman, then the African studies should mean that gay men who are circumcised are at lower risk for HIV acquisition too. Of course, that is not how science works. You are supposed to run a study with the population in question. But apparently the city that doesn't sleep doesn't have time for that.

The comments (85 and counting) about this possible new initiative in one of the New York Times' articles are well worth reading. Besides interesting insights -- such as the possibility that uncircumcised men in the gay community could become stigmatized analogously to injection drug users -- you have the whole gamut: conspiracy theories, non sequiturs, accusations of distorting scientific facts, libertarians in favor of adult circumcision, human rights activists against infant circumcision as 'genital mutilation', as well as those who are absolutely convinced that the retention of a foreskin is a condition sine qua non of sexual joy.

New York City is apparently poised to undertake a massive social and epidemiological experiment; the rest of us will just have to watch and wonder.

HIV, male circumcision and India

This blog has dealt with ethical questions about male circumcision and HIV before, but somehow the assumption crept in that this is a distinctively African controversy. Maybe it was because of the high HIV prevalence in that part of the world. Maybe its was because of the longstanding interest -- especially among anthropologists -- with circumcision rituals in Africa. Let us make a confession here: the author of this post has co-authored an article in the Journal of Medical Ethics called Male Circumcision and HIV Infection: Ethical, Medical and Public Health Tradeoffs in Low-Income Countries. And it too is guilty of identifying the issue a bit too much with sub-Saharan Africa.

Whatever way this came about, the ethical questions concerning the promotion of male circumcision to lower risk of HIV transmission have to embrace India. For one thing, the number of new HIV infections has rising in India dramatically over the last years. For another thing, male circumcision is a highly charged matter, both politically and religiously, when Hindus do not traditionally circumcise and Muslims do.

An article in the Times of India today gives an indication of just how sensitive the question is. The National AIDS Control program in India will not even think of conducting randomized controlled trial to test whether being circumcised lowers a man's risk of getting HIV infected: not because three such studies have been done before, but the whole idea seems too hot to handle. When Richard Feachem, Director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, said that he expected that Hindus would increasingly have more HIV infections because their men do not get circumcised, his inbox was inundated by hate mail. An interesting post on the Olive Ridley Crawl shows some of the passion the debate raises, and the issue is inseparable from the larger relationship between mainly Hindu India and its Muslim neighbor and rival, Pakistan. The foreskin has geopolitical significance.

The question is: when circumcision acts as a religious/cultural marker from neighboring groups, will men still agree to do it, to reduce their chances of getting HIV? A World Health Organization/UNAIDS meeting in Switzerland on March 6 is set to tackle these tradeoffs between cultural identity and public health, among others. When HIV infections globally are increasing, vaccines are probably at least 10 years away, and the once-promising microbicides are crashing and burning, the ancient practice of male circumcision is strangely enough carrying the torch in the fight against HIV/AIDS.