We received a letter from a loyal listener, thanks Aaron,  who was asking about whether circumcision was really a valid method of HIV infection prevention or just an attempt by ‘westerners’ to impose a religious tradition on a ‘vulnerable’ population. First things first, we will be discussing male circumcision and not female genital mutilation.

Long tradition

Okay, so the question we are asking … “Is the attempt to promote male circumcision in Africa a form of religious or cultural imperialism”?

Cultural Imperialism?

To answer this question we must decompose this big question and ask a few questions – “Does it help prevent HIV infection?”

The scientific evidence seems quite clear; circumcision reduces HIV transmission in male populations by over 60% and to women by almost 50%. This is based on a number of peer reviewed independent randomized studies, so the science seems clear that male circumcision does help in the prevention of the spread of aids. Now in their own research some of our listeners may find some studies that report to show circumcision in North American context shows no effect on HIV transmission raising questions as to the true effectiveness of procedure and perhaps a double standard between here and there. These studies, from what I can decipher are voluntary surveys which ask if men would volunteer for a study of circumcision and HIV transmissions and would be willing to be circumcised. This showed the impact on HIV transmission would be minimal at best because of a low number of men willing to participate or have the procedure done. However, this is not a study of the effectiveness of circumcision but a cultural willingness of men to be circumcised as adults. Also its target population was the gay community, where HIV transmission via anal intercourse has a different pathology than vaginal intercourse. Although, it is still my understanding that although less effective, HIV transmission is still reduced even in this category of sexual activity.

There is also a strong correlation between circumcision and the prevention of penile cancer. Although less understood, the vast majority of cases of penile cancer occur in uncircumcised men while incidence in those circumcised at birth is almost unheard of. That the odds of developing penile cancer is magnitudes less if one has been circumcised at birth…with less benefit for adult circumcision.

So, the first order question “Does circumcision help reduce the spread of aids?” seems overwhelming yes and as such, should be supported. The second question we could ask is “Should we, as good atheist, promote a religious practice and should not it overt association with Judaism and ‘the west’ make us unwilling to support widespread advocacy of circumcision especially in areas of western colonialism?”

Cultural ignorance in humour?

The simple answer I think is no, it is a historical accident that the practice is currently associated with Judaism. It is also a west attitude as well, as the vast majority of religiously circumcised men are Muslim and not Jewish. If one does a little research we find circumcision has a long history. It was practiced by the Pharaoh-nic Egyptians; it’s a common practice among Muslims as well as being a millenniums old rite of passage in western Africa.

That said, I do not like the attempt of some ‘missions’ who stress the religious nature of the procedure. I have heard of one such mission that is referred to as “operation Abraham”…where a team of ‘practiced’ Israeli doctors are doing mass circumcision of men in Africa. However, I do not like the fact that a number of churches have soup kitchens and yet, until suitable secular resource can be brought to bear, it seems in the interest of harm reduction we should hold our noses and allow these groups to do their thing until we can muster alternatives.

Rates of circumcision

It was also argued that while promoting the practice of circumcision in Africa for aids prevention, similar missions have not been done in other ‘low circumcised’ populations in ‘white’ countries. To understand this we must look at the existing prevalence of circumcision and the prevalence of HIV infection. Now the region of the world with some of the highest rates of circumcision are Saharan Africa and the Middle East; followed by North America. The regions with lowest rates of circumcision are Europe, South America and parts of Sub-Saharan Africa. On this information, one could jump to the conclusion that efforts to promote circumcision should be focused on Europe (with some of the lowest rates of circumcision) but we must contrast this cultural practice with the medical need. IF we now look at the prevalence of HIV infection and the deaths from aids we see that the highest rates are in sub-Saharan Africa while Europe has some of the lowest. Now, I am sure this discrepancy in HIV infections reflects an underling link between poverty and undeveloped medical infrastructure…as well as the concerted efforts of the Catholic church to demote the use of condoms in Africa (notable the church does not pursue this anti-condom policy as aggressively in ‘white’ countries’). The prevalence of HIV in Eastern Europe is about 0.8%, South America 0.5% and Western Europe 0.2%…while Sub-Saharan Africa is about 5%…for reference North America its about 0.5% but our highest source of infection is IV drug use…thanks to our war on drugs.

Rates of HIV transmission

So, in context, the promotion of circumcision of African men as a means to control HIV seems to be both effective (if the face of the high rates of HIV infection) and practical. It’s practical in the sense that the Catholic Church which has banned condoms has no issue with non-religious circumcision.