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Dr Edward C. Green

Senior Research Scientist in the School of Public Health, Center for Population and Development Studies, Harvard University

African Men, Circumcision, HIV/AIDS and Anthropology

Paper presented at the American Anthropological Association Annual Meeting, 11/18/00, San Francisco, 2000

Background

Epidemiological data suggests that male circumcision provides some degree of protection against STD and HIV infection, especially in developing countries with predominantly heterosexual transmission of HIV (Halperin and Bailey 1999; Bailey, Neema and Othieno 1999; Moses S, Plummer FA, Bradley 1998; Moses et al 1994; Bongaarts et al 1989). Public health programs have not promoted male circumcision as a means of risk reduction, for a number of reasons. These are worth mentioning.

1. In less-developed countries, circumcision is often performed under in non-medical settings, under conditions conducive to sepsis. If men in societies that traditionally do not circumcise men were to opt for circumcision, this might increase the chances of health problems resulting from dangerous surgical practices by poorly trained or untrained practitioners.

1. In less-developed countries, circumcision is often performed under in non-medical settings, under conditions conducive to sepsis. If men in societies that traditionally do not circumcise men were to opt for circumcision, this might increase the chances of health problems resulting from dangerous surgical practices by poorly trained or untrained practitioners.
   
2. Men--and perhaps their partners--might develop a false sense of security if they become circumcised in order to avoid HIV/AIDS. They may as a result engage in riskier behavior (cf. Richens et al 2000).
   
3. There is insufficient evidence that becoming circumcised as adults would protect men from STDs including HIV infection. In fact, the evidence suggests that the earlier the age of circumcision, the greater degree of protection against STDs and HIV (Kelly et al 1999).
   
4. There is a movement in the United States to discourage circumcision of boys, using the argument that this amounts to useless genital mutilation, and linking this at least indirectly with the female genital mutilation issue in Africa.
   
5. Finally, some who work in AIDS mitigation are simply unfamiliar with epidemiological findings related to AIDS and MC, or they are familiar with the evidence but they don’t believe it.

This topic generated heated discussion among anthropologists at the 1999 AAA meetings in Chicago. Some critics seemed to believe that only condoms are effective in HIV/AIDS prevention. Others seemed committed to political and economic interpretations of the spread of HIV/AIDS, and have little sympathy for biological factors, let alone foreskins. Others have been involved in the worldwide struggle against female circumcision, or female genital mutilation, and seem uncomfortable about the prospect of promoting circumcision for men but condemning it in women. Further, anthropologists may not be comfortable with the prospect of promoting circumcision in societies where it is not traditionally practiced.

Whatever the reasons, the evidence that lack of male circumcision (MC) is an HIV risk factor "has been met with resistance or silence," as Bailey noted in a Boston Globe interview. Last year, Halperin and Bailey (1999) brought renewed attention to the issue by suggesting that public health promotion of MC could potentially save millions of men and their partners from HIV infection. These authors also suggested, with Marck (1997), that a number of Bantu speaking peoples of sub-equatorial Africa formerly practiced MC but then abandoned the practice, along with initiation schools and age-grades. Therefore promotion of MC among these groups would arguably amount to reviving traditions only recently abandoned.

The present paper takes the position that events on the ground, so to speak, may be overtaking this debate (a point Halperin and Bailey acknowledge). Men in traditional societies in countries such as South Africa, Uganda, and Papua New Guinea--from societies within those countries that do not circumcise traditionally--have started to seek circumcision in the belief that this will provide them some degree of protection against HIV infection. Let us consider some preliminary evidence.

South Africa: Adults found to opt for Circumcision to Avoid AIDS

During a workshop for South African traditional healers in 1992, the presenter discovered to his surprise that some healers were advising their STD patients to become circumcised as a way to prevent STDs and AIDS. The healers giving such advice were those from societies that traditionally circumcise males, mainly Xhosa, Tsonga ("Shangaan") and Sotho.

These healers claimed that a number of their STD clients were following this advice and were visiting hospitals or traditional healers (mostly the former) in order to become circumcised. In other words, traditional healers as early as 1992 were addressing an AIDS risk factor--namely lack of male circumcision that at the time was seldom if ever discussed let alone advocated in AIDS intervention programs (Green 1993, Green, Zokwe and Dupree 1993).

I was given a pamphlet mass-produced by a local traditional healers' organization called TRADAP, a representative of which had participated in the workshop. The pamphlet advised: "TO CIRCUMCISE IS THE BEST REMEDY TO REDUCE SEXUALLY TRANSMITTED DISEASES." I was told that TRADAP had been advising uncircumcised men to become circumcised as a way to prevent STDS since September 1991. As I was unaware of any African or international AIDS or STD education or intervention program that promoted male circumcision, I asked how TRADAP came to learn about a relationship between lack of male circumcision and STDs, including possibly AIDS. The president of this organization claimed that TRADAP healers had discovered this connection by themselves, through their own clinical experience, that is, from seeing patients from a variety of groups that presented with STD symptoms.

Note: There is no circumcision of women in this part of Africa.

Specifically they noticed that male patients who repeatedly become infected with STDs tended to be uncircumcised. Such patients were said to have rashes, "dirt," or infections under their foreskins. When I pressed further, one informant told me many rural men bathe infrequently and may not wash their penis after intercourse. She said that "stale sperm" and the blood or fluids of the woman remain under the foreskin and fester over the days into a foul-smelling "dirty something." She has seen many a penis crown with a rash due to what she called unhygienic practices (some Swazi healers call this condition luhlanga (1). This "dirty something" was said to be passed to the next sexual partner of the uncircumcised man, thereby spreading disease (2).

In 1993 my colleagues and I conducted an evaluation of the impact of training traditional healers in HIV/AIDS. We interviewed a sample of 70 healers, or 11% of the total number trained at that time. [Sample: 14 in Northern Transvaal (Gazankulu), 13 in Qwa-Qwa, 10 in Eastern Transvaal (KaNgwane), 10 in Alexandra (Johannesburg), 10 in Durban and environs, 7 in Capetown environs, and 6 in Soweto/Orlando townships. The plan to interview 10 from each area had to be modified somewhat in the field...]

We asked the sample of healers, "Do you believe that if a man is circumcised, it can help him avoid STDs?" This was of course a follow up to our earlier findings. Fully 65 (93%) said yes to the question. This is perhaps not a surprising answer among healers from circumcising societies, but it is for the 31 Swazi and Zulu respondents. For those healers affirming a circumcision/STD connection, we asked what the connection is. The responses are seen in the following table.

FOLLOW-UP QUESTION:
WHY DOES CIRCUMCISION OF MEN HELP
PREVENT STD INFECTION?
(Multiple responses possible)

Healers from a circumcising tradition tended to have more to say on the subject and to give culturally patterned reasons, such as the Sotho who commented, "The foreskin is something that was meant to be removed like a child's first teeth, otherwise it causes sickness." Another Sotho said, "the wife of an uncircumcised man will die of pelvic inflammatory disease before the age of 45." Swazi and Zulu healers tended to state simply that the foreskin stores or retains germs and/or that STD treatment outcomes are poorer among uncircumcised men.

I wondered at the time if Swazi and Zulu healers--healers from non-circumcising societies--btheir answers to this question, or were they just trying to give what they thought from their training to be a correct answer? I posed this to a Swazi healer who helped train fellow healers in KaNkwane, where ethnic Swazis predominate. She said she thought Swazi healers do believe in the causal connection because many healers may have noticed differences in STD treatment outcomes between uncircumcised Swazis, circumcised Tsongas and others in kaNkwane (where Swazis predominate), but they had never had an opportunity to discuss this openly until the issue was raised as a topic in her AIDS workshop. She felt that what she taught Swazi healers helped them confirm their own experience with their patients; and when one healer related his or her experience, this prompted others to reveal similar experience.

Some healers claimed they had convinced parents from non-circumcising societies to have their children circumcised in order to "protect them in later life." When I asked about cultural resistance to circumcision in non-circumcising societies, the TRADAP president observed, "When tradition and the health of our people are in conflict, it is tradition we must sacrifice."

(I recommended follow-up of these important findings, specifically, more research to determine whether at least adult men were in fact opting for circumcision to avoid STDs and HIV. But there was no follow-up at all)

Uganda and Beyond Africa

More recently (Nov.-Dec. 1998), I evaluated the impact of IEC programs on sexual behavior and on HIV infection rates in Uganda. A colleague and I had a meeting at Kibuli Muslim Hospital (11/23/98), where both Muslims and non-Muslims are treated for STDs as well as AIDS, and where AIDS preventive education is also promoted. I asked the Matron if she had noticed any difference between Muslims and non-Muslims in the incidence of STD or HIV. She rather quickly and defensively that she "had no evidence." But later when I brought up the topic of circumcision, she volunteered the information that "many non-Muslim adults are coming to this hospital to become circumcised in order to prevent AIDS." Surgeons and regular medical officers are in fact performing "many such operations." This anecdotal evidence obviously needs to be followed up systematically, through examination of hospital records and through population-based surveys [which Bob Bailey, has in fact done in both Uganda and Kenya].

To cite further anecdotal evidence, an anthropologist working in Papua New Guinea recently wrote to me that many young men in the highlands, where men are not usually circumcised, are now opting to become circumcised (Mundhenk 2000):

“There seem to be a variety of motivations given when I ask people why they are getting circumcised. Apparently boys from the areas where circumcision is practiced have been boasting about the values of circumcision, mentioning two in particular. First, they claim that women get a lot more pleasure sleeping with a circumcised person than with an uncircumcised one. Second, they say that being circumcised helps to prevent you from getting various diseases, including venereal diseases and AIDS, so that after being circumcised one can sleep around with confidence.

Other reasons given are that it is easier to keep clean and that it looks good [“it” referring presumably to the penis].

The AIDS prevention people in PNG give me the impression of being totally unaware of this phenomenon. Certainly I have never heard any of them mentioning circumcision in connection with AIDS.”

Finally, less than a year ago, during the design of a national AIDS program in Indonesia, I came upon a US-supported private health organization in Indonesia suggesting in one of its brochures that male circumcision is protective against HIV/AIDS infection, and that if men are not circumcised, they at least ought to carefully wash their genital area after coitus. There was also the implicit message: It would be better of men were circumcised.

It should be stressed that the preliminary findings just reviewed were serendipitous rather than a result of a systematic search for this kind of evidence.

In sum, whatever public health officials chose to say or not say, the reality on the ground in parts of the world where MC has been shown to make the most difference in HIV infection rates is that some people seem to be opting for MC, whatever local traditions might be in this regard. Anthropologists are the logical candidates to establish and document such behavior, and understand associated related beliefs and attitudes. Further, there needs to be follow-up research (involving epidemiologists and anthropologists) on men who opt for MC as adults, such as a prospective study with a control group for comparison purposes to see whether MC makes a significant difference in STD and HIV infection rates after X number of years.

Discussion

Participants in the MC debate have already begun to call upon anthropologists to provide accurate information on contemporary MC practices. Questions that have arisen include:

• Does society X practice MC? At what age is it normally done? (the main epidemiologic factor here is whether circumcision is done before or after sexual debut. Another is that secondary infections can result from unsafe circumcision practices);
  
• Who performs the circumcision and how are they trained? (the main epidemiologic factor here is sterilization of instruments and prevention of sepsis);
  
• Is the foreskin completely removed?
  
• Do all males nowadays become circumcised? (if not, what percent do?);
  
• When MC is part of rites of passage for males beyond the age of puberty, are there practices of ‘celebrating’ one's newly established manhood by seeking many sexual partners? (I found evidence of this in eastern Uganda, and Halperin also found this among the Xhosas)
  
• Is there a trend away from MC, due to urbanization and the abandonment of rites de passage—or even to government policy? (3)

Yet contemporary anthropological paradigms may make asking about circumcision seem old-fashioned, indeed pre-modern. It seems that fewer anthropologists these days are researching these practices, therefore those who are consulted on MC might not have contemporary and accurate information to bring to the discussion. Some may rely on the Human Relations Area Files, the ethnographic sources of which may date back to the 1940s, 1930s or earlier. Practices might have changed or been abandoned since then.

Where MC is practiced in Asia, e.g. Indonesia, the Philippines, Bangladesh, Pakistan, national seroprevalence is well under 1%, much lower than most sub-Saharan countries where MC is practiced. Why? Many epidemiologists attribute this difference to variations in patterns of "sexual networking." This is another area where anthropologists are called upon to shed light yet where they often feel uncomfortable as either researchers or discussants. Researching sexual behavior seems intrusive, prurient, Malinowskian. It harkens back to the Sexual Life of Savages type of ethnography that has long been superceded.

Yet anthropologists connected to public health programs will continue to be asked to provide information to shed light on these issues. If they cannot or will not, health agencies will commission “quick and dirty” sample surveys, which may not provide valid data or capture the complexities of dynamic culture change.

Research related to MC may pull anthropologists into the public health argument over whether such practices should be encouraged, discouraged or ignored. Whatever our position on this, we may at least need to help develop a harm reduction response to what people in some parts of the world are apparently electing to do themselves (Green 2000). We may, for example, need to develop a response that advises men who have decided to be circumcised as adults to have the operation done in a safe clinical setting under local anesthesia. We also need to advise (as Halperin and Bailey emphasize in their Lancet article) that one can still become infected with HIV-1 even if one’s chances of such infection might be decreased.

Finally, even apart from the sensitive policy issue over the possible promotion of MC, there are MC-related issues of significant potential public health consequence. Two come to mind that, if translated into “interventions,” would involve modifying “traditional” or at least existing practices in order to impact HIV infection rates positively. One involves lowering the age of MC, to have this done when boys are babies rather than teenagers or older. Another is having MC performed by a trained medical person rather than an indigenous circumciser, at least in societies where such circumcisers are found to be ill-trained and causing infections (4). Rites of passage would remain the same, it has been proposed, but the actual circumcision would be performed by someone medical trained, under sanitary conditions. There seems to be support among at least elements of local societies, including traditional healers whose views tend to be influential, to consider such modifications of practices. Again, I would like to quote the Xhosa healer who said, "When tradition and the health of our people are in conflict, it is tradition we must sacrifice."

If indigenous healers are willing to consider the issues raised in this paper, anthropologists ought to be able to as well.

References

Bailey RC; Neema S; Othieno R, “Sexual behaviors and other HIV risk factors in circumcised and uncircumcised men in Uganda.” J Acquir Immune Defic Syndr. 1999 Nov 1;22(3):294-301.

Barton, Tom, Seboka Thamae, and Maseabata Ntoanyane, 1997, “AIDS in Lesotho - A community based response: a summative evaluation of the CHAL-DCA AIDS Project. Maseru: Christian Health Association of Lesotho (CHAL) and DanChurchAid.

Bongaarts, J., P. Reining, P. Way and F. Conant. 1989n "The Relationship between Male Circumcision and HIV Infection in African Populations.'' AIDS, 3(6):373--377.

Green, E.C., 1993 "Ethnomedical Practices of Significance to the Spread and Prevention of HIV in Southern Africa. (2)" XIV International Conference on AIDS and IV STD World Congress. Berlin, June 9, 1993. abstract no. PO-C03-2611.

Green, E.C., B. Zokwe and J.D. Dupree, "Indigenous African Healers Promote Male Circumcision for Prevention of STDs." Tropical Doctor Oct. 1993, pp. 182-3.

Green, E.C., AIDS and STDs in Africa. Boulder, Co. and Oxford, U.K.: Westview Press, 1994.

Green, E.C., 2000a “The Male Circumcision and AIDS Issue.” Anthropology News Vol.41(1) Jan. 2000, p.22.

Green, E.C., 2000b “Male Circumcision and HIV Infection. Lancet 2000; 35 (9207) 3/11/00, p.927.

Halperin, DT., RC Bailey, " Male circumcision and HIV infection: 10 years and counting." Lancet 1999; 354: 1813-15.

Kelly R; Kiwanuka N; Wawer MJ; Serwadda D; Sewankambo NK; Wabwire-Mangen F; Li C; Konde-Lule JK; Lutalo T; Makumbi F; Gray RH, "Age of male circumcision and risk of prevalent HIV infection in rural Uganda." AIDS 1999 Feb 25;13(3):399-405.

Marck J, "Aspects of male circumcision in sub-equatorial African culture
history." Health Transition Review 1997;7 Suppl:337-60.

Moses S, Plummer FA, Bradley JE, Ndinya-Achola JO, Nagelkerke NJD, Ronald AR. "The association between lack of male circumcision and risk for HIV infection: a review of the epidemiological data." Sexually Transmitted Infections 1994; 21: 201-10.

Moses S, Bailey RC, Ronald AR. "Male circumcision: assessment of health risks and benefits." Sexually Transmitted Infections 1998; 74: 368-73.

Mundhenk, Norm, e-mail to author, 26 May 2000.

Richens J, Imrie J, Copas A. Condoms and seat belts: the parallels and the lessons. Lancet 2000;29:400

Notes:

1. Green 1994:64-5

2. Epidemiologists like Plummer, Moses and Ndinya-Achola (1991), make similar observations about genital and coital hygiene practices, smegma, the prevalence of infections under the forekin, and the like, pointing to interesting parallels between ethnomedical observations and etiologic theories, and biomedical counterparts.

3. In order to prevent opportunities for transmission of hepatitis and tetanus, indigenous circumcision practices involving blood-to-blood contact should be identified.

4. Judging by a recent documentary film made by a Xhosa filmmaker in Cape Province, South Africa, fear of infection and related negative outcomes of traditional MC may be keeping some Xhosa youth from becoming circumcised at all.

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