Any procedure which involves cutting off a healthy part of a human’s body, a part which functions normally, should raise ethical questions. Ethicists are still debating whether it is ethical to circumcise a boy child, as this will affect him for the rest of his life.
With evidence that circumcision can reduce HIV risks for men engaged in vaginal sex by up to 60%, the drive for voluntary medical male circumcision (VMMC) in adult men has taken on a new urgency. New ethical challenges are arising, beyond voluntarism and informed consent.
How do we respect the principle of beneficence, ensuring procedures and programmes are good, not just for the person, but for society as a whole?
Non-malificence – the commitment to “first do no harm” – is crucial, and we should avoid unintentional consequences. The principle of justice should also be observed, with a focus on equity and fairness, especially when we allocate scarce resources.
Circumcision is more than just a biomedical procedure – it is a personal, social and political marker. It connotes difference or similarity. It can signify belonging to a particular religion, ethnicity, cultural group or power bloc in a country or region.
History is full of examples of circumcision being used as a tool of inclusion, exclusion and even marking for killing in times of conflict. Have we anticipated the impact of changes in identity that circumcision can signify?
Not just a cut
Not long ago I accompanied a young friend to a VMMC site in a hospital west of Pretoria, South Africa. I noticed that all the supporters of the young men in the ward (fathers, uncles, and friends) as well as the nursing staff, imbued the changed (circumcised) status of the young men with meanings around sexual prowess, transformation and rites of passage into proper masculine adulthood, away from maternal influences. For me, this suggests that VMMC is not a neutral intervention.
Current VMMC drives have failed to adequately engage with masculinity, tradition and traditional circumcision, possibly blurring intentions and outcomes.
Take the case of Swaziland, not traditionally a circumcising country. It had set ambitious targets for VMMC for HIV prevention but, by 2011, the country had only met about 12% of its target.
Against this backdrop, researcher Alfred Khehla Adams explored meanings of circumcision for Swazi men in the Kwaluseni district of Manzini.
Men feared reduced sexual pleasure and possible adverse effects, like wounds and swelling, and said the procedure threatened their notions of manhood.
Where manhood was defined as “someone who has a wife and children” and therefore is “sexually functional”, medical circumcision introduced a threat to this.
In South Africa, traditional circumcision (with its rituals, messages and meanings) is regarded as a non-negotiable rite of passage into acceptable masculinity for some groups, perhaps precisely because there is some risk. Mutilation, amputation and death do occur.
Here, VMMC has been met with some suspicion, a reluctance to accept a clinic circumcision as an acceptable test of manhood, among concerns that “culture” is being diluted.
Given that a clinic circumcision would maximise the HIV benefits of the cutting, because sufficient foreskin is removed, VMMC campaigns have to manage this tension between a desirable health outcome (medical circumcision) and an acceptable social identity (traditional circumcision).
Objectification of black bodies
Is VMMC a form of social engineering? Because some men refuse to use a condom, believing they have sufficient HIV protection from circumcision, some women have reported more difficult condom negotiations.
On a large scale, VMMC could thus impact on gender relations, especially in contexts where gender violence and rigid masculinities dominate.
Does mass circumcision of men represent a form of biomedical pessimism, seeing men as subjects, not citizens, incapable of agency and autonomy? This pessimism says men can’t change and won’t change, and therefore we need to intervene on their behalf.
And finally, does mass circumcision of African men represent a revitalisation of the “colonial project” that views black bodies and black sexualities in a particular way?
In South Africa, the apartheid state and parastatals such as the mines constructed medical machinery which viewed male bodies as objects to be medically managed and controlled, while at the same time the reproductive rights of black South Africans were limited through contraceptive programmes.
It would be naive, I believe, to ignore this history of objectification, and broader ethical debates, as donor money is used to save African men from themselves.
Pierre Brouard, director of the Centre for the Study of AIDS at the University of Pretoria, South Africa, is a clinical psychologist interested in sexualities, gender, human rights, and finding just the right word to grace a sentence, convey empathy or complete a crossword.
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