The Unethicality and Ineffectiveness of “Voluntary Medical Male Circumcision” in Africa — Misguided Groupthink or a Form of Cultural Imperialism in the HIV crisis?
By Andrew Little
This post is part of a series of opinion pieces in diverse mediums focusing on the theme “What makes you mad about global health?” These submissions are by McGill students who were part of the course PPHS 511 Fundamentals of Global Health in Fall 2021.
It is well-known that male circumcision is neither the least invasive nor the most effective method of achieving HIV prevention and control (1-3), yet the CDC and WHO continue to spout misleading relative risk reduction statistics and conclusions from flawed studies as proposed justifications for VMMC (“Voluntary Medical Male Circumcision”) in Africa (3-5). Condom usage and antiretroviral treatment for HIV-positive individuals have been demonstrated to be the most effective preventative measures (3, 4, 6, 7). Additionally, these methods do not require invasive surgery—the irreversible amputation of a healthy and functional body part (2, 8). The human prepuce has sensory, sexual, protective, and immunological functions (2, 8, 9), and these functions are permanently precluded by circumcision. To make matters worse, circumcision causes harm in that it is extremely painful (10, 11); provides opportunities for infections because it creates an open wound (especially in LMIC settings); most people who agree to VMMC are not fully informed about its harms, as well as its limited conclusiveness and dubious effectiveness regarding the prevention of disease (1, 3, 10); and lastly, it entails the permanent loss of the prepuce—a healthy and functional body part (2, 8-10).
Who is responsible for the push for VMMC? The VMMC campaign, which started in 2008, is largely driven by the Bill & Melinda Gates Foundation and the Joint United Nations Programme on HIV/AIDS (12). The persistence of the UNAIDS, WHO, and Bill & Melinda Gates Foundation in promoting VMMC has distracted from other HIV prevention and treatment methods which are actually helpful and sequesters money that would have otherwise been given to effective HIV prevention measures such as access to condoms, better public education, and antiretroviral therapy.
A deeper look into the implementation of the VMMC campaign reveals an even more upsetting reality—it has undoubtedly caused much more trouble than it has helped. The VMMC campaign in countries including Kenya and Uganda has manifested worrisome social consequences among the public. Some men engage in more risky behaviour because they believe that their genital status provides lower infection risk or immunity from HIV (13, 14). Even worse, among the public target nations, the campaign has resulted in coercion to circumcise, sexual shame, and forced circumcisions (15) due to the VMMC campaign’s pathologization of a healthy body part and its insensitivity to the limited of education among nations in which it has been implemented (12). In response to the growing number of African men who have wished to keep their genitals intact, coercive measures have been adopted by the UN and WHO: money and food vouchers as incentives aimed at pressuring impoverished Africans into circumcision, despite the fact that this money does not even cover the costs associated with postoperative care (12). Even more disturbing, UNAIDS gives aid and grants to governments on the basis of meeting circumcision quotas, inspiring these governments to deny services to intact (uncircumcised) men and even barring them from holding positions in public office (12). Stemming from the pressure and monetary incentive from UNAIDS—which is primarily funded by the United States and other developed countries—the Ugandan and South African governments have advertised circumcision through misleading and offensive campaigns, in which they depict men with intact 2 genitals as unhygienic and sexually-unappealing to women (12). Due to the combination of these social factors, the behaviour of UNAIDS has indirectly promoted the violent circumcision attacks targeting people, tribes, and minorities based on their intact genitals (12, 15). Therefore, the UN and WHO’s disregard for the lack of medical evidence and the social consequences associated with VMMC represents a gross violation of the right of both African adults and children to bodily autonomy.
If VMMC is recognized as ineffective and ethically problematic in the effort for HIV prevention, why does the UNAIDS and Gates Foundation insist on pumping so much money into this campaign? Perhaps they perceive VMMC as ‘low-hanging fruit’ in the effort to combat the spread of HIV among African populations. After all, VMMC is considered to be low-cost and has a high probability of success as portrayed by portfolio analyses for global health impact (16). This appears to be a case of ‘tunnel vision, in which measures are favoured based on easiness, production of quick numbers, and tangibility & quantifiability, regardless of whether the method in question is effective and ethical. In other words, global health investors can pat themselves on the back and celebrate a public health victory over the successful implementation of VMMC, while being oblivious to the logical inconsistencies, ineffectiveness, and negative consequences regarding the VMMC campaign as they are disconnected from the actual logistics of HIV prevention and the negative social impact of their campaign.
There is no question that the push for VMMC and its incessant advertisement by UNAIDS and WHO stem from a cultural bias among Western Countries such as the United States, where circumcision has been motivated by socio-cultural traditions and convictions originating in the 19th century (3, 10). It has been said that male circumcision is unique in that its rationale is logically backwards—it is a surgery that has always been in search of medical justification (3, 10). The export of circumcision from the United States to developing countries represents a form of cultural imperialism as it is motivated by an attempt to spread American tradition, culture, and influence to areas perceived as culturally inferior (17). Proponents of medical circumcision have always been largely based in the English-speaking world (18), and the medical authorities based in other developed countries (where circumcision was never adopted) have been much more critical of the practice (19-22). Thus, it follows that the WHO’s and UN’s tenacity of circumcision in the context of HIV prevention is mostly American-driven and based on culturally-biased recommendations.
As people involved in the global health discourse, we must be vocal about the problem of VMMC in Africa in the name of justice, equity, and the commitment to evidence-based health policy and disease prevention measures. The time has been long overdue for the UNAIDS, WHO, and the Gates Foundation to remediate the mistake of VMMC in the context of HIV prevention campaigns. The money is better spent elsewhere. It is needed for investments in evidence-based, effective, and ethical measures in the fight against HIV to best support the needs of the developing world.
References:
British Medical Association. (2004). The law and ethics of male circumcision — guidance for doctors. J Med Ethics., 30, 259-263.
Fleiss, P. M., Hodges, F. M., and Van Howe, R. S. (1998). Immunological functions of the human prepuce. Sex Transm Infect., 74(5), 364-367.
Van Howe, R. S. (2015). A CDC-requested, Evidence-based Critique of the Centers for Disease Control and Prevention 2014 Draft on Male Circumcision: How Ideology and Selective Science Lead to Superficial, Culturally-biased Recommendations by the CDC (pp. 1-208). Central Michigan University College of Medicine, Mount Pleasant, MI. Available at: https://www.researchgate.net/publication/271841897_A_CDC-requested_Evidence-based_Critique_of_the_Centers_for_Disease_Control_and_Prevention_2014_Draft_on_Male_Circumcision_How_Ideology_and_Selective_Science_Lead_to_Superficial_Culturally-biased_Recom. Acesssed November 28th, 2021.
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Svoboda, J. S. (2017). Non-therapeutic Circumcision of Minors as an Ethically Problematic Form of Iatrogenic Suffering. AMA J Ethics, 19(8), 815-824.
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The VMMC Experience Project. (2020) UN Report: African Opposition to mass circumcision. Available at: https://www.vmmcproject.org/wp-content/uploads/2020/09/VMMC-UN-Report.pdf Accessed November 28th, 2021.
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Lamont, M. (2017) Forced male circumcision and the politics of foreskin in Kenya. African Studies, 77(2), 293-311.
Mundel, T. (2016) Honing the Priorities and Making the Investment Case for Global Health. PLOS Biology, 14(3), e1002376.
Fish, M., Shahvisi, A., Gwaambuka, T., Tangwa, G. B., Ncayiyana, D., and Earp, B. D. (2020) A new Tuskegee? Unethical human experimentation and Western neocolonialism in the mass circumcision of African men. Dev World Bioeth., doi: 10.1111/dewb.12285.
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Royal Durch Medical Association (KNMG). (2010) The non-therapeutic circumcision of male minors (p. 5). Royal Dutch Medical Association, Urtrecht, The Netherlands. Available at: http://www.knmg.nl/circumcision Accessed November 28th, 2021.
German Association of Pediatricians. (2012) Statement by Dr. Wolfram Hartmann, President of the Professional Association of Pediatricians, at the hearing on November 26, 2012 on the German government's draft law on circumcision (in German). Available at: https://www.bvkj.de/bvkj-news/pressemitteilungen/news/article/stellungnahme-drmed-wolfram-hartmann-praesident-des-berufsverbands-der-kinder-und-jugendaerzte/. Accessed November 28th, 2021.
Danish Medical Association. (2020) Circumcision of boys without medical indication is ethically unacceptable (in Danish). Available at: https://www.laeger.dk/omskaering-af-drenge-uden-medicinsk-indikation-er-etisk-uacc eptabelt. Accessed November 28th, 2021.
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Acknowledgments:
We would like to thank Professor Madhukar Pai for setting and sharing this assignment results with us and the teaching assistants Alexandra Jaye Zimmer, Lavanya Huria and Angie Sassi for their support in coordinating the results.