(AVfM News) AVfM recently published a story about the United Nations and World Health Organization’s plan to circumcise twenty eight million men, boys and infants in Sub Saharan Africa over the next five years. Since then, our ongoing research on the issue has produced more information.
Adding to what is becoming a furor in the medical community over the ethics and efficacy of circumcision as a tool in the war against AIDS, the Journal of Public Health in Africa published an article written by Dr. Robert S. Van Howe and Dr. Michelle R. Storms of Michigan State University in December of last year. The article was just short of an excoriation of the Orange Farm study and WHO policy concerning the massive drive to circumcise an immense portion of the male population in Southern Africa. Using very strong language for a medical journal piece the authors in the article entitled “How the circumcision solution in Africa will increase HIV infections” stated in the abstract:
Based on our analysis it is concluded that the circumcision solution is a wasteful distraction that takes resources away from more effective, less expensive, less invasive alternatives. By diverting attention away from more effective interventions, circumcision programs will likely increase the number of HIV infections.
The article goes on to point out the problems with the Orange Farm study and its failure to provide any real scientific evidence that circumcision reduces the risk of HIV infection for heterosexual males. Also covered are the lack of biological plausibility, compensation behavior and lack of consistent epidemiological evidence in much larger populations around the world. Also discussed in the article was a survey of men who had undergone the procedure in which it was reported that a substantial number of them were given promotional material telling them circumcision was an effective method to prevent HIV infection. The authors flatly stated that the policy was misguided -a strong term in medical circles- and meticulously draws a cost-benefit analysis of other methods such as condoms (the most effective method) for deterring the spread of AIDS.
This article and others like it came out on the heels of a much publicized speech given by U.S. Secretary of State Hillary Clinton on November 8, 2011, at the National Institute of Heath in Bethesda Maryland where she announced Helen DeGeneres as the new Special Envoy for Global AIDS Awareness. During the speech Clinton repeatedly mentioned a combination prevention strategy winch involved preventing mother to newborn infections, male circumcision, and antiretroviral drugs. Condom use was only mentioned as an afterthought in her speech. In fact circumcision was one of the key themes of her speech being mentioned often and it was also pointed out that of the one million circumcisions performed in Africa since 2007, three quarters of them were funded by PEPFAR- the Presidents Emergency Plan for AIDS Relief. The word “condoms” was used only once in the entire speech.
Another key theme in Clinton’s speech was gender equality. She states the need for “institutional changes” including “reducing discrimination against women and girls; stopping gender-based violence and exploitation, which continue to put women and girls at higher risk of HIV infection,” was a major tone setter for her speech. She stated that 60% of all people in Sub Saharan Africa infected with HIV are women and girls. In fact, epidemiological data published by UNIAIDS reports that this is true only in Sub Equatorial Africa and in no other region. Virtually everywhere else in the world it is men who comprise the majority of those infected with HIV.
The most implied explination for the discrepancy between southern Africa and other areas of the world is that there is something particularly anti female about the region and that it is a gender equality issue. However, there is no discernible difference between the economic and legal condition of women in Africa compared to other under developed areas in the world and no particular factor other than gender has been identified. There is, however, a discernible difference between the legal and social condition of homosexuals, particularly gay men, in Africa and the rest of the world. In most every country in Sub Equatorial Africa homosexuality is punishable by a prison sentence. In some cases the sentence is life long and spent in a labor camp. Yet again, in several countries like Uganda and Somalia either public flogging or the death sentence is prescribed. Many activists and epidemiologists have noted that this may be a major cause in the reluctance of men to get tested in Africa and leads to a skewing of the data. Critics of the Orange Farm study point out the reluctance of participants to divulge their sexual behavior as a factor in the studies fallibility.
The habit of linking rates of HIV infection with perceived gender inequality is ubiquitous throughout the army of people implementing the WHO’s initiative. In fact Dr. Katherine Hankins, Chief Scientific Advisor for UNIAIDS and only medical doctor present at the UNAIDS–PEPFAR Southern & Eastern Africa Region Male Circumcision Communication Meeting, where the plan for “scale up” was put together, is a ardent believer in this rather unscientific notion.
Dr. Hankins’ career has been characterized more by AIDS activism in non governmental organizations than clinical or research work. After finishing her medical degree in Canada, she spent a short time practicing with her father and then joined the Calgary Board of Public Health in Calgary, Alberta, where she eventually served for several years as Deputy Medical Officer of Health. When the AIDS crisis became acute in the mid 80′s she re-located to Montreal where there were a large number of cases present.
She focused her efforts on women with AIDS during that time period. In a 1989 address to the Fifth annual International Conference on AIDS in Montreal she stated: “Until we are economically equal, with pay equity and equal distribution of care giving responsibilities whether for the sick, the elderly, for children or the dependent women will not be in a position where they can fully protect themselves from HIV infection.” She presented no evidence to support this claim during this address and to this day there has been no scientific research that shows any link whatsoever with pay equity, and or gender roles with the incidence of HIV infection.
Since becoming the Chief Scientific Advisor for UNIAIDS Dr. Hankins has focused primarily on the needs of women affected with AIDS, strongly promoting antiviral drugs to reduce the rate of transfer of HIV from mother to child. There has never been any program or policy initiated or overseen by her that focuses solely on the needs of men affected with AIDS or prevention for men aside from the current drive for mass circumcision.
Not only has the AIDS epidemic and HIV infection been touted as a gender equality issue, but circumcision itself has become a symbol of gender equality and social change, as purported by the operatives on the ground in Africa. Ayanda Nqeketo , mentioned in the previous article on the subject, has been very busy in Swaziland in promoting male circumcision as an “entry point” for a gender based ideology that will supposedly change social norms and somehow benefit women and promote reproductive health. She states in an opinion piece, “Public attitudes on sexual, reproductive issues,” featured in the Swazi Observer on December 31 of last year:
Public opinion and attitude is often the yardstick against which interventions are made. Perhaps this is due to conventional gender roles ascribed to both sexes by educational programs focusing on sexuality. Male roles are often stereotypically understood as that of being breadwinners who work outside the home and thus not fundamentally relevant to reproduction as much as production. Females, on the other hand, were supposed to be responsible for domestic issues, which include reproduction and raising children. These gender based understandings of male and female roles nevertheless tended to assume that women acted as independent decision makers on matters related to their reproductive health, e.g. the number of children to have, use of contraceptives, etc. Yet a number of studies done among males in African countries show that some men exert profound influence on the contraceptive choices their partners could make and on the number of children they have. If men play such an important role in reproductive health it is imperative for me to focus my discussion today on male circumcision and respect for women in the context of male circumcision intervention as the entry point.
She continues later in the piece:
Male Circumcision intervention should be used to change sexual attitudes, practices and expand masculinity work with men and boys. There is now a body of international and national evidence pointing to the efficacy of gender-based work with men and boys in shaping attitudes and practices around gender and sexuality. Investment is required to scale up these efforts, and in particular to fund the training of an increased number of male peer educators who can lead this work. As this work is scaled up, it will be important to put training, support and monitoring systems in place to ensure the quality of work done, and to maintain a focus on male power and privilege, and their impact on women’s lives, as well as notions and practices of masculinity, and their impact on men’s lives. Individually-targeted and small, peer group interventions aiming to support self-defined behavioral change and shift social norms may be appropriate for this population. Health care institutions identified for MC must be utilized for these HIV preventive messaging. There is still much that is unknown or poorly understood about the complexities of men’s sexualities and vulnerabilities, and how these relate to women’s sexualities and vulnerabilities, that requires more ethnographically sophisticated research.
Also mentioned in her article are references to male violence and rape.
As with the argument that HIV infection rates are somehow linked to gender inequality, the argument that circumcision can be used as a tool to rectify the percieved and or imagined errors in social norms caries with it absolutely no proof and virtually nothing is done to convince target audiences that there is any link whatsoever. No links to reproductive health, no links to male privilege no links to gender violence….nothing. There is nothing more than an assertion, and in response to it comes millions upon millions of dollars and an incalculable amount of international political support.