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The US-funded (in)voluntary male medical circumcision program and its 20 million victims to date.

September 13, 2021
154 upvotes

VMMC stands for Voluntary Medical Male Circumcision.

It is a totally legitimate and totally medical procedure that is obviously done under informed consent.

According to research by researchers and governments who legitimately refer to themselves as the "VMMC community" in papers, more than 6 million of such totally consensual procedures had been carried out by 2013 with more than 20 millon planned by 2016 and more than 80% of the ones completed by 2013 having been payed for by:

the United States President's Emergency Plan for AIDS Relief [PEPFAR]

The VMMC program is an ambitious public health intervention. While it is estimated that close to 6 million circumcisions had been completed by the end of 2013, against a goal of 20.2 million by 2016, this progress should be viewed within the context of the recent and rapidly developing understanding of the importance of VMMC as an HIV prevention intervention (Figure 1). (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4011573/)

As you can see, the reason for what researches refer to as "the VMMC program" is the belief that circumcision could prevent 60% of female on male HIV contractions without having to provide education on safer sex practices or female and male condoms. Of course, such a program is claimed to be implemented to help the people, but the justification for choosing a method that, as I will show later on, inevitably lead to gruesome human rights violations was to save money. The estimated savings were more than 16 billion in treatment costs with the VMMC program wheighing in at only 2 billion without "demand creation" - obviously, the "created demand" will be totally voluntary, organic and gras fed:

Furthermore, the choice to be circumcised involves deep-seated values, beliefs, and motivational factors that vary with ethnic, religious, and cultural identities, and must be addressed effectively to generate demand for circumcision. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4011573/)

Of course, the surgeries are not the only, nor the most effective way to prevent HIV. But with almost 14 Billion in total savings, it is the way to make the most money as VMMC is a one-time procedure that provides "continuous benefits" without having to continuously invest into further adherence:

Modeling studies done in 2009–2011 showed that in these 14 priority countries, achieving 80% circumcision prevalence among males aged 15–49 within five years (“catch-up”), and maintaining this coverage rate in subsequent years (“sustainability”), could avert 3.4 million new HIV infections within 15 years and generate treatment and care savings of US$16.5 billion [7],[8]. VMMC is a highly cost-effective HIV prevention strategy for both generalized and high-prevalence HIV epidemics [7]. It differs from most other prevention methods (e.g., pre-exposure prophylaxis, sexual behavior change, or condom use) in that it only requires a one-time action in order to provide continuous benefits.[...]

A major limitation of the cost studies in this collection is that they do not include the costs of demand creation nor analyze how increased spending on demand creation might affect the actual demand for services.[...]

The program faces increasing competition for declining funding for HIV prevention and treatment. The funding need for VMMC remains significant, and continued evidence-based advocacy is necessary to secure funds for accelerated scale-up from a broad base of donors. One way to do this is to evaluate the population-level impact of those VMMC programs that have already been scaled up. Another is to continue to draw comparisons between VMMC and other HIV prevention programs, highlighting specifically that if VMMC coverage reaches the JSAF goal of 80%, it will prove the most cost-effective and cost-saving HIV prevention intervention in Eastern and Southern Africa. In addition, it does not require sustained adherence, and there is evidence that referrals made from the VMMC program increase HIV-positive males' access to treatment [32]....

Totally unfortunately though, they are struggling to reach their goals:

Despite the rapid implementation and scale-up of VMMC programs and the doubling of the cumulative total VMMC procedures in the past year (from 3.2 million by the end of 2012 to an estimated 5.8–6 million by the end of 2013), progress at the country level has varied widely (Figure 3) and the year-on-year rate of growth in the number of VMMCs performed is declining (Figures 2 and ​and 4). This is due to a combination of factors: the JSAF goal of reaching 80% of uncircumcised men by 2016 did not fully take into account country-specific constraints that have tempered the pace of scale-up, lack of sufficient demand, and insufficient funding from a broad base of international donors (the United States President's Emergency Plan for AIDS Relief [PEPFAR] has funded more than 80% of circumcisions to date). Modeling suggests that even if the current growth rate is maintained and adequate funds are forthcoming, the number of VMMCs completed by 2016 would fall about 3 million short of the JSAF goal of 20.2 million (Figure 4). (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4011573/)

So what do you do? What is this "demand creation"?

Let's see:

Demand creation: Messaging must be tailored to different age groups and to the cultural norms of different communities. Men aged 25 and above are less motivated to undergo VMMC. Studies suggest that we need to go beyond simple HIV messaging and present VMMC in terms of hygiene, appearance, attractiveness to partners, peer group norms, and modernity. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4011573/)

In other terms, stigmatize being uncurcumcized as ugly, dirty and unattractive, incite bullying, make them self-conscious and ultimately psychologically break them into totally voluntarily undergoing the assault surgery.

I mean, they totally look at the human and their needs as victims of coercion "users":

While a large portion of this collection focuses on surgical efficiency or quality [9]–[12], the bigger challenge is overall programmatic efficiency. The challenge of scale-up can be approached as a management challenge that requires addressing each element of the delivery value chain (the specific activities that deliver the end product to the user), using time and resources appropriately, and matching supply with demand for VMMC services while working to increase both.[...]

The cost of circumcision devices and other supply chain costs must be brought down considerably if devices are to reduce overall program costs. This will require advocacy as well as negotiation with manufacturers and suppliers in tandem with demand-creation activities. We recommend further study to ascertain whether devices make circumcision more attractive to men and to understand whether devices could assist with balancing supply and demand to help achieve needed programmatic efficiencies. It is also important to tailor demand-creation activities for devices in order to reach those who may already be aware of circumcision's benefits but who have avoided conventional surgical methods.[...]

To date little research has looked at the male population as a market of consumers of an intervention with multiple benefits. A market research approach, along with insights from diverse fields such as behavioral economics and anthropology, can provide new tools to inform the development of new approaches. More funding should be allocated to systematically evaluate the effectiveness of the many approaches to creating and mobilizing demand. Those that show positive results should be taken to scale. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4011573/)

By now, by the way, we are in the next stage and already target boys down to the age of 10 (and below, as I will show later on):

It is important to begin strategizing for the sustainability phase that should follow the present “catch-up” activities. It will take time to determine the best approach to sustaining high MC prevalence in each country, develop global and national frameworks, secure resources, and implement long-term programs. Since the cohorts prioritized in the sustainability phase will likely be some combination of uncircumcised boys (aged 10−14 years) and infants (aged 0−60 days), it will also be important to explore how best to reach young adolescents and parents of infants, taking into account impact, cost, the feasibility of scale-up, cultural acceptability, and other factors. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4011573/)

So let's look at some actual approaches for coercing promoting mutilation demand.

Voluntary medical male circumcision (VMMC) programs in Africa have significantly altered social norms related to male circumcision among previously non-circumcising groups and groups that have practiced traditional (non-medical) circumcision. One consequence of this change is the stigmatization of males who, for whatever reason, remain uncircumcised. This paper discusses the ethics of stigma with regard to uncircumcised adolescent males in global VMMC programs, particularly in certain recruitment, demand creation and social norm interventions. Grounded in our own experiences gained while conducting HIV-related ethics research with adolescents in Kenya, we argue that use of explicit or implicit stigma to increase the number of VMMC volunteers is unethical from a public health ethics perspective, particularly in campaigns that leverage social norms of masculinity. (https://academic.oup.com/phe/article-abstract/14/1/79/6134846)

The objective of this study was to explore norms of masculinity and the decision-making process among Luo young men to provide a better understanding of how circumcision and masculinity relate to cultural norms within this community. The methodology consisted of eight FGDs with male peer groups and 24 in-depth interviews to elicit young men's perceptions of masculinity and voluntary medical male circumcision. Findings from thematic analysis reveal that young men described several key characteristics of masculinity including responsibility, bravery and sexual attractiveness. For some young men, voluntary medical male circumcision has embedded itself into cultural norms of masculinity by being a step in the transition from boyhood to manhood and by being a marker of some of these masculine characteristics. In the case of voluntary medical male circumcision, there may be opportunities to integrate other programming that helps men transition into healthy adulthood.(https://www.researchgate.net/publication/345920045_Integration_of_voluntary_male_medical_circumcision_for_HIV_prevention_into_norms_of_masculinity_findings_from_Kisumu_Kenya)

There is a need to identify key barriers and facilitators to VMMC uptake in priority countries to improve uptake. In this paper, we report findings from a systematic review of the barriers and facilitators of VMMC uptake, comparing them across countries in order to provide programmers critical information to design effective VMMC uptake interventions. Our review followed PRISMA protocol. Twenty three articles from 10 of the 14 priority countries were included. The top three barriers cited were: MC negatively perceived as being practiced by other or foreign cultures and religions, fear of pain caused by the procedure, and perceptions of VMMC as not helpful/needed. The top four facilitators cited in most countries were: Belief that VMMC reduces health risks and improves hygiene, family and peer support of MC, and enhanced sexual performance and satisfaction.(https://www.researchgate.net/publication/324780087_Systematic_review_of_barriers_and_facilitators_to_voluntary_medical_male_circumcision_in_priority_countries_and_programmatic_implications_for_service_uptake)

Note that "peer support" and "peer educators" are very euphemistic terms, given what they actually describe:

Many circumcised respondents, especially the younger men, relayed stories of peer-influence in their decision to get circumcised: "There was a friend of mine who had decided to go for circumcision and told me, ‘Let’s go and circumcise. How can we continue like this and let other people ridicule us?’ The fear of ridicule from age-mates [already circumcised] influenced our decision." (Circumcised man, age 35) Similarly, some uncircumcised men in the more peri-urban areas, said they would be more likely to “go for the cut” if their peers had been circumcised. [...] Social network influences on VMMC uptake are relatively unexplored [28], although the use of peer educators is widespread in VMMC programming. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4011674/)

Studies with these populations have exposed numerous problems, for example the fact that the victims "clients" have to be turned in by certain groups of "mobilizers" and "peer educators" for them to collect money that was put on their heads:

For mobilizers especially, monthly remuneration (and their future employment) depends on referring enough clients to the clinic each week; failing means earning less, regardless of the amount of time and effort invested in mobilization. From our interviews we learned that while most mobilization supervisors receive a base salary from their IPs regardless of the targets, other lower-level, subcontracted “associate” mobilizers or “peer educators” only receive payment by providing clients and meeting targets. [...]. (This and following quotes without links are from here: https://www.researchgate.net/publication/337027391_Voluntary_medical_male_circumcision_for_HIV_prevention_among_adolescents_in_Kenya_Unintended_consequences_of_pursuing_service-delivery_targets)

One mobilization supervisor said:

And you know, when there are zero clients cut, all the pressure comes to the mobilization supervisor because the surgeons will be saying, ‘We are ready to cut, where are the clients?’ So the buck stops on me as the mobilizer; so it is not a very easy task.

Another:

Likewise, a 30-year-old, female mobilization supervisor offered, “We bank on schools so much. And now, when they are taking their exams, you can’t pick a child from school [. . ..] . . .when schools are so engaged, then definitely I will not meet that target” [Mobilizer 4].

The pressure to meet targets leads to numerous ways of coercing, pushing or otherwise making people undergo the procedure:

Data collected during interviews and observations suggest that the drive to meet targets may lead some VMMC mobilizers to use misleading or otherwise questionable mobilization practices to increase the number of adolescents they can refer for circumcision. As Mobilizer 1 explained: "Another thing is the peer mobilizers, yeah, someone wants to meet his or her targets and that is the time that they engage in what I called the uncouth methods, whereby the end justifies the means; whichever means that can make those clients come out. So you end up having the clients coming, but they are not coming for the VMMC the way we want it. They have been pushed; they have been coerced. . .yeah. This one is happening because of these targets. So that is the downside of the targets." These practices are sometimes blatant: during one door-to-door village mobilization, the mobilizer kept referring to himself as “doctor” although he had no medical training. Another mobilizer, a 38-year-old male who referred to himself as a “VMMC champion” explained how he pays boys to help him mobilize their friends: "For us we are calling it ‘broking [brokering] system’. So after the exercise, you tell him to go. . . and convince a friend and bring a friend. . . [. . .]. For me I am using my own system being that we are not even allowed to give children money. But for me, because I have a target, and if I get my target, I am expecting 10800 KES [108 USD]. So I do divide this 10800 KES; maybe if he brings me two boys, I can give him up to 50 KES. I can even give out 100 KES [1 USD]. The moment I give that money, 50 bob, to that boy, he is going to bring me more four boys. So the more he bring boys for instance if they are four, I give 100–150 KES. At the end of the day, I will hit my target" [Mobilizer 5].

They also perform skits in which they try to stigmatize foreskin:

Other times, these practices are subtle and easy to overlook. During a promotional skit in which mobilizers played the roles of a husband, wife, and brother all discussing VMMC, the message to the audience was one of strong female preference for circumcised men. The wife told her husband, “Go and cut your firimbi [whistle] . . . go and remove that sleeve of a sweater. That whistle is not going inside me. . .don’t blow the whistle inside me. I have refused. . .. I am not giving you [sex].” Later, when the husband’s brother arrived, he explained that his wife is refusing to have sex. In response, his brother said, “I was passing here to tell you to go for circumcision. Look at me, I have gone, and I am fine. I am now a clean person.” Explaining the benefits, his brother offered that MC reduces HIV risk by 60% and enhances cleanliness (“you avoid smelling”) and prevents cervical cancer.

That being said, I want to explicitly distance myself from the author's statements claiming this to be "subtle" and even framing it as merely "unbalanced humor" later on:

While we recognize that the promotional skits used during VMMC “roadshows” use humor and dramatize promotional messages to accentuate the positive, greater efforts should be made to ensure that this messaging is balanced so that benefits and risks are neither over- or understated. For similar reasons, the practice of public health workers persuading boys to become circumcised by claiming that their future female partners will definitely prefer them that way (and reject them if they are not) [45] should be questioned if not discouraged.

I strongly disagree. As long as uncircumcised men are in any way stigmatized, the resulting willingness to undergo such a prcedure may not actually be based on personal preferences rather than an attempt to avoid social sanctions. In fact, the abovementioned alterations of social norms may act as a coercive force even if these practices were completely abandoned, let alone only "balanced". It doesn't surprise me though, given that according to netflix, telling men with small dicks to go kill themselves already is "balanced humor". Outsourcing the coercion to peers does not change the inherent conflicts associated with not wanting to get circumcised whilst not wanting to get bullied or even attacked for being incorrectly held responsible for all HIV infections that will inevitably occur until education and supply of proper prevention methods is ensured. You can stop claiming to be a doctor, you can stop using material incentives to persuade those who are easy to manipulate - but you can't just revert the social changes and misinformation (as shown later: only uncircumcised men contract HIV; the only prevention method is circumcision) which induce the creation of pressure by people whom you have no control over. The damage is done and may be irreversible.

Another way of coercion is paying them with food and clothing:

According to interviewees, food, money, water, sanitation, clothing, and other basic needs are issues of concern for many adolescents’ households. During health talks, some mobilizers emphasized the incentives that boys will receive (e.g., sodas and/or new underwear) following circumcision—items that may be significant inducements among impoverished children. During a village mobilization effort, one mother explained her reluctance to let her son be circumcised: “. . .this one is small. Even his heart was there because those who have come from circumcision are ‘seducing’ their friends to go also. They are telling them, ‘go and it is not painful.’ [OP: Remember boys are paid to seduce their friends.] They are also giving people sodas. So that soda is what brings them nearer. I told this boy not to sneak, but to wait and I will take him there. . ..” Offering a similar analysis, Provider 3 told us: "Sometimes they also entice them for us; in the facility we give them a bottle of soda, Fanta to be specific because one, some of the boys come probably from poor families, they haven’t had a meal in the morning or breakfast and sometimes stay in the clinic for more than two hours, three hours and thus to maintain their sugars. [But] that one [soda] becomes a bait, especially for the young ones ‘We will give you a soda; we pick you with a vehicle’ . . .which is actually wrong because, it is like enticing a client which you are not supposed to, but that is how they [mobilizers] ply their trade." However, according to our interviewees and as we observed first hand, clinics sometimes lack sodas and/or underwear to give to clients.

A common theme here is the incitation of social stigma and peer pressure:

All six of the teachers we interviewed recognized social pressure as a primary motivator for MC among adolescents. During observations of mobilization activities, we saw firsthand how mobilizers sometimes make use of or encourage peer pressure to promote circumcision, including through the use of abusive and/or stigmatizing language. During a health talk in front of a large group of boys at a primary school, one male mobilizer referred to foreskins as the “sleeve of a sweater” and “cold matumbo” [boiled goat intestines]; at the end of the talk, he implored those who still had their “whistles” to have them removed. He also told them: “Those who are still having the foreskin, you are the ones who are going to spread the diseases. In the future, you are the ones who are going to spread the HIV virus.” Later that same day, the mobilizer asked a large group of older students,“How many of you wish to get the HIV virus? If you don’t want to get the HIV virus, the only option is to remove the foreskin.” Revealing his awareness of this type of language and messaging within VMMC mobilization, Provider 3 explained: "This is demeaning and they try to create some peer pressure. Like when you go to those mass cuts in high schools, probably they registered like 100 clients, you would likely get another probably 30 or so who, because of the peer pressure, just jump into it. But if it was like walking from home to hospital and demanding for the service, they are not likely to have gone. But now that it is here, and so and so has gone and is my friend, I have to be in it."

Unfortunately, the quality of the provided "surgery" is lacking as well:

Under pressure to meet targets, some Clinical Officers and other VMMC medical staff find ways to speed up the clinical process. For example, as we were told during interviews and observed firsthand at multiple VMMC facilities, providers may opt not to take patient medical histories or conduct preoperative examinations (e.g., blood pressure, weight, preexisting conditions, etc.) and/or 30-minute post-operative check-ins, and yet fill in the requisite forms as if these activities had been completed. Other avenues for time-saving include rushing circumcisions, inadequate stitching, splitting surgical utensil and bandage packs between patients, not following recommended protocols or procedures (e.g., the dorsal slit method for circumcision), and stacking patients one after another with little pause in between, which raises additional sanitary and privacy concerns. According to an experienced VMMC surgeon: "We cut a lot of corners and I will give you an example: [. . .] so because of speed, you find that while one client is dressing [after circumcision], the other one is [already] undressing. Ideally, it is supposed [to be] that you finish with this client, you give [them] instructions on how to take medication and all that, but because of the high volume, you find that some of us we are not the ones giving out the medication. We assign somebody randomly, you know, who will be giving out the medication and the refreshment and so [the] information [they provide to the client] may not be correct. [. . ..] Sometimes even the vitals of post-operation 30 minutes after [circumcision] are not done. It is skipped, or somebody else does [it]—probably a receptionist who is nonmedical, just to fulfill the requirements of the form. [This] is wrong because you are supposed to do the circumcision and the client rests for 30 minutes in a bed or a couch, then after that, you do the vitals then you discharge. Oh, even the wound care instructions, [that] information may not sink in for the client because it is presented so fast and there may not be [time] for questions. Yeah, there are so many corners we cut. [. . ..] . . .at a clinic last year, I saw them hold that yellow form [medical files] and going through [and just] check, check, check. . . adding blood pressure, adding all these things, just filling them in [without actually measuring blood pressure, etc.]". [Provider 3]. One assistant surgeon, a 25-year-old female nurse, claimed her record time for completing a circumcision was six minutes. She too associated VMMC targets with client overload, and with rushing surgeries and an increase in adverse events. She explained: "Sometimes you compete cutting clients and the clients are too much. The average time for a client’s [circumcision] is between 12 to 20 minutes. So when the clients are too much, and you want to meet your targets, you will perform the surgery a bit fast. So upon that you will have [an] adverse event and maybe a child will come back with a bleeder [an oozing artery or other blood vessel] you did not close [suture] well" [Provider 4].

And finally, the guidelines to not accept boys under the age of 10 are regularily ignored:

Current VMMC for HIV prevention guidelines and national protocols approved for use in Kenya require that adolescent clients must be at least ten years of age.[16] Despite this directive, interviews and observations confirmed that VMMC staff sometimes mobilize and circumcise boys who are under ten years of age in order to boost their numbers to meet targets. When asked about potential links between targets, mobilizer strategies, and underage circumcision, Provider 3 offered: "Yes, they bend the rules. . . because you know sometimes our current age according to WHO is 10 years and above. But when they [mobilizers] go to the field and get a nine-year-old for example, they coach this client and the parent, because we insist on seeing the con-sent. We always insist they put the ID and telephone number of the parent [on the consent form]. When they come to the facility, we [call to] confirm the age and whether the parent has consented for the child to be circumcised. And you know, they will tell you ‘yes I am 10 years old’, but when you look at the guy, he is probably 8 or. . ." . We observed evidence for the mobilization of underage boys at ten of the 14 VMMC facilities we visited for observation, including boys (and their mobilizers) who readily admitted that they were underage.

These findings are in line with other research, showing that consent is undervalued and that uncircumcised men report higher rates of depression and a lower quality of life - which you are free to attribute to anything but the incitation of stigma, if you like:

We identify gaps in the consent process and poor psychosocial outcomes among a key target group: male adolescents. We assessed compliance with consent and assent requirements for VMMC in western Kenya among males aged 15–19 (N = 1939). We also examined differences in quality of life, depression, and anticipated HIV stigma between uncircumcised and circumcised adolescents. A substantial proportion reported receiving VMMC services as minors without parent/guardian consent. In addition, uncircumcised males were significantly more likely than their circumcised peers to have poor quality of life and symptoms of depression. (https://www.researchgate.net/publication/334897740_Consent_Challenges_and_Psychosocial_Distress_in_the_Scale-up_of_Voluntary_Medical_Male_Circumcision_Among_Adolescents_in_Western_Kenya)

Others have questioned the way the 60% figure is used as well as understood by patients (https://www.researchgate.net/publication/261870976_The_ethics_of_claiming_a_60_reduction_in_HIV_acquisition_from_voluntary_medical_male_circumcision).

By december 2019, about 19 million boys and men had been victimized:

To date, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) has supported nearly 19 million VMMCs to protect men and boys in east and southern Africa. (https://www.researchgate.net/publication/338220761_Guide_on_High-Impact_Practices_to_Create_Demand_for_Voluntary_Medical_Male_Circumcision_Services)

With other sources claiming it to have been 23 million in 2018 already (https://www.researchgate.net/publication/344199074_A_New_Tuskegee_Unethical_Human_Experimentation_and_Western_Neocolonialism_in_the_Mass_Circumcision_of_African_Men).

Guides have stressed the importance of encouraging "peer-to-peer demand creation" (which is of course not bullying, nor mobilizers hiring hitboys to "bring them boys" for cash, as we know...), setting targets to boost performance (well...), recruiting exclusively satisfied patients to "dispell myths" (which unsatisfied patients can't, apparently) and to promote and integrate the program into highly misandristic traditions of mutilation as an initiation to becoming a "man" (https://www.researchgate.net/publication/338220761_Guide_on_High-Impact_Practices_to_Create_Demand_for_Voluntary_Medical_Male_Circumcision_Services) - beliefs akin to those that have resulted in some of the most barbaric traditions around public displayals of forced sexual torture (https://www.researchgate.net/publication/324477813_Forced_male_circumcision_and_the_politics_of_foreskin_in_Kenya).

In the end, it is undeniable that the "voluntary" in VMMC was a naive ideal at best, and a lie at worst. Other ways to address the issue were present: Education on safer sex practices and rarely known devices that are accessible to couples in which the man has penile (surgery) scars, lower erectile performance or other variations in shape and anatomy of their primary genitalia - such as female condoms, as well as the distribution of such devices are just one example. After all, if these misguided attempts wouldn't have changed societal norms and stigma to a state that makes it practically impossible to differentiate between choice and coercion, nobody would stop anyone from providing accurate information on (https://www.researchgate.net/publication/261870976_The_ethics_of_claiming_a_60_reduction_in_HIV_acquisition_from_voluntary_medical_male_circumcision) and a safe execution of voluntary circumcisions.

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Title The US-funded (in)voluntary male medical circumcision program and its 20 million victims to date.
Author DistrictAccurate
Upvotes 154
Comments 17
Date September 13, 2021 6:42 PM UTC (1 year ago)
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[–]DarthEquusleft-wing male advocate 24 points25 points  (0 children) | Copy Link

This gets even worse when we look at the studies. The frequent claim is that circumcision reduces the risk of men contracting HIV by 60%. This is based on the results of three randomized controlled trials done in Africa ([1], [2], [3]). The researchers found in their studies that  2.5% of intact men and 1.2% of circumcised men got HIV. The 60% figure is the relative risk (2.5%-1.2%/2.5%). Media outlets even take the liberty of dismissing basic mathematics and round up the relative reduction from 52% to 60%, making for an even more impressive (yet exaggerated) number.

If circumcision did reduce rates of HIV transmission, which it doesn't, it would be a small reduction. The Canadian Paediatric Society says this, using estimates from the CDC:

“The number needed to [circumcise] to prevent one HIV infection varied, from 1,231 in white males to 65 in black males, with an average in all males of 298. The model did not account for the cost of complications of circumcision. In addition, there is a risk that men may overestimate the protective effect of being circumcised and be less likely to adopt safe sex practices.”

These figures are relevant only if the trials were accurate in the first place. There were several methodological errors including,  but not limited to:

  • The circumcised experimental group got more medical care, including education on the proper use of condoms
  • In one study, circumcised men's infection rates were increasing faster than the intact men's until the study was terminated early
  • The circumcised group could not have sex for 4-6 weeks after the circumcision; this was excluded from the analysis and distorts the results
  • HIV was contracted through means other than sex (e.g. contaminated needles)
  • The trials were terminated early when statistical significance was reached. Though they did reach statistical significance, they never reached clinical significance
  • Significantly more men were lost to the studies than tested positive for HIV
  • Also, many of the researchers had cultural and religious biases

There is no histological evidence which supports the hypothesis that circumcision reduces the risk of HIV/AIDS infections. It is probable that circumcision doesn’t help at all, or potentially even makes things worse. For example, there are statistics showing that there was a 61% relative increase (6% absolute increase) in HIV infection among female partners of circumcised men. It appears that the number of circumcisions needed to infect a woman was 16.7, with one woman becoming infected for every 17 circumcisions performed.

Further criticism of the African RCTs:

Critique of African RCTs into Male Circumcision and HIV Sexual Transmission

On the basis of three seriously flawed sub-Saharan African randomized clinical trials into female-to-male (FTM) sexual transmission of HIV, in 2007 WHO/UNAIDS recommended circumcision (MC) of millions of African men as an HIV preventive measure, despite the trials being compromised by irrational motivated reasoning, inadequate equipoise, selection bias, inadequate blinding, problematic randomization, trials stopped early with exaggerated treatment effects, and failure to investigate non-sexual transmission. Several questions remain unanswered. Why were the trials carried out in countries where more intact men were HIV+ than in those where more circumcised men were HIV+? Why were men sampled from specific ethnic subgroups? Why were so many men lost to follow-up? Why did men in the intervention group receive additional counselling on safe sex practices? The absolute reduction in HIV transmission associated with MC was only 1.3 % (without even adjusting for known sources of error bias). Relative reduction was reported as 60 %, but after correction for lead-time bias alone averaged 49 %. In a related Ugandan RCT into male-to-female (MTF) transmission, there was a 61 % relative increase (6 % absolute increase) in HIV infection among female partners of circumcised men, some of whom were not informed that their male partners were HIV+ (also some of the men were not informed by the researchers that they were HIV+). It appears that the number of circumcisions needed to infect a woman (Number Needed to Harm) was 16.7, with one woman becoming infected for every 17 circumcisions performed. As the trial was stopped early for “futility,” the increase in HIV infections was not statistically significant, although clinically significant. In the Kenyan trial, MC was associated with at least four new incident infections. Since MC diverts resources from known preventive measures and increases risk-taking behaviors, any long-term benefit in reducing HIV transmission remains dubious.

Circumcision of male infants and children as a public health measure in developed countries: A critical assessment of recent evidence

Sexually Transmitted Infections and Male Circumcision: A Systematic Review and Meta-Analysis

A fatal irony: Why the “circumcision solution” to the AIDS epidemic in Africa may increase transmission of HIV

A comparison of condom use perceptions and behaviours between circumcised and intact men attending sexually transmitted disease clinics in the United States

This investigation compared circumcised and intact (uncircumcised) men attending sexually transmitted infection (STI) clinics on condom perceptions and frequencies of use. Men (N = 316) were recruited from public clinics in two US states. Circumcision status was self-reported through the aid of diagrams. Intact men were less likely to report unprotected vaginal sex (P < 0.001), infrequent condom use (P = 0.02) or lack of confidence to use condoms (P = 0.049). The bivariate association between circumcision status and unprotected sex was moderated by age (P < 0.001), recent STD acquisition (P < 0.001) and by confidence level for condom use (P < 0.001). The bivariate association between circumcision status and infrequent condom use was also moderated by age (P = 0.002), recent STI acquisition (P = 0.02) and confidence level (P = 0.01). Multivariate findings supported the conclusion that intact men may use condoms more frequently and that confidence predicts use, suggesting that intervention programmes should focus on building men's confidence to use condoms, especially for circumcised men.

The Fragility Index in HIV/AIDS Trials

The recent report by Wayant and colleagues on the fragility index did not include the African randomized clinical trials on HIV and adult male circumcision. Analysis of these trials may provide insight into the interaction between p values and fragility in overpowered studies. The three trials shared nearly identical methodologies, the same sources of differential bias (lead-time bias, attrition bias, selection bias, and confirmation bias), and nearly identical results. All three trials were powered to demonstrate an absolute risk reduction of 1%. All three were discontinued prematurely following interim analyses that satisfied pre-established early termination criteria.

The findings are also not in line with the fact that the United States combines a high prevalence of STDs and HIV infections with high circumcision rates. The situation in most European countries is the reverse: low circumcision rates combined with low HIV and STD rates. Therefore, other factors (mostly behavioral) play a more important role in the spread of HIV than circumcision status. This also shows that there are alternative, less intrusive, and more effective ways of preventing HIV than circumcision such as consistent use of condoms, safe-sex programs, proper sexual education, easy access to antiretroviral drugs, and clean needle programs.

r/Intactivism

[–]DarthEquusleft-wing male advocate 17 points18 points  (0 children) | Copy Link

Here is a partial list of research finding male genital surgery did not reduce HIV risk or even increased risk for heterosexual men and women:

Chao, 1994 - male circumcision significantly increased risk to women

Auvert, 2001 - 68% higher odds of HIV infection among men who were circumcised (just below statistical significance)

Thomas, 2004 - circumcision offered no protection to men in the Navy

Connelly, 2005 - circumcision offered no protection to black men, and only insignificant protection for white men

Shaffer, 2007 - traditional circumcision offered no protection

Turner, 2007 - male circumcision offered no protection to women

Baeten, 2009 - male circumcision offered no protection to women

Wawer, 2009 - the only RCT on M-to-F HIV transmission found male circumcision increased risk to women by 60%

Westercamp, 2010 - circumcision offered no protection to men in Kenya

Darby, 2011 - circumcision offered no benefit in Australia

Brewer, 2011 - youth who were circumcised were at greater risk of HIV in Mozambique

Rodriguez-Diaz, 2012 - circumcision correlated with 27% increased risk of HIV (P = 0.02) and higher risks for other STIs in men visiting STI clinics in Puerto Rico

And for gay men / men who have sex with men (MSM):

Millett, 2007 - no protection to US black and Latino men who have sex with men (including those practicing the active role exclusively)

Jameson, 2010 - higher risk to men who have sex with men (including 45% higher risk in those exclusively active role)

Gust, 2010 - statistically insignificant protection for unprotected active anal sex with an HIV+ partner (3.9% vs. 3.2% infection rate) in the US

McDaid, 2010 - no protection to Scottish men who have sex with men

Thornton, 2011 - no protection to men who have sex with men in London

Doerner, 2013 - no protection to men who have sex with men in Britain (including for those practicing the active role exclusively)

News about male circumcision curbing condom use, not actually helping with disease transmission or contributing to other diseases:

Nov. 2010: Zambia: Boys see circumcision as licence for unprotected sex

Dec. 2010: Swaziland: “Skoon sex” crisis looming after circumcision

Dec. 2011: Zimbabwe: Circumcision: a canal for new HIV infections

Jan. 2012: Kenya: Cut Men Have Many Mates [and believe they are immune to HIV]

Jan. 2012: Kenya: Circumcised men and partners more promiscuous, less likely use condoms

Jan. 2012: Zambia: Quarter of men resume sex before wounds from circumcision fully healed in Zambian study

July 2012: Zimbabwe: Circumcised men not spared from HIV infection

Oct. 2012: Malawi: Men more likely to practice unsafe sex after circumcision

Sept. 2013: Botswana: Botswana HIV infection among circumcised men rises

Sept. 2013: Kenya: Push for male circumcision in Nyanza fails to reduce infections

Sept. 2013: Kenya: Big Blow as circumcision of Luo Men fails to reduce HIV/AIDS infections in Nyanza

Oct. 2013: Israel: New cases of HIV in Israel hit record high in 2012

Nov. 2013: Zimbabwe: Circumcised men indulge in risky sexual behaviour

Nov. 2013: Zimbabwe: Circumcised men demand unprotected sex from HIV positive pregnant prostitute

Dec. 2013: Nigeria: 40 Million Have Hepatitis Virus and May Not Know

Aug. 2014: Nigeria: Circumcision, tattooing fuel spread of hepatitis

Sept. 2014: Uganda: Circumcision Promoting Risky Behaviour

July 2015: Malawi: Malawian circumcised men most likely to be infected by HIV, research shows

[–]daguix 10 points11 points  (2 children) | Copy Link

To add to the disgrace, the 20 million number of victims has been grossly inflated. The US taxpayer and Bill Gates got scammed in the process. https://www.standardmedia.co.ke/amp/counties/article/2001307681/exposed-mystery-of-kenyas-ghost-circumcisions

[–]RoastedPony 2 points3 points  (0 children) | Copy Link

Poor Casper.

[–]Algoresball 3 points4 points  (1 child) | Copy Link

I once brought up how opposed I am to circumcision to a group of friends (not randomly, I’m not that guy) and one of the females in the group talked about how she’d be grossed out if she got down their and saw a “turtleneck”.

I think a lot about how much (rightful) outrage there would be if anyone advocated for surgically altering baby girl’s gentles so that they’d be more aesthetically pleasing to men.

[–]Strikes001 4 points5 points  (0 children) | Copy Link

Complete 180 to what I dealt with. An expected mom was looking for opinions on it as her husband got it, told her the facts about it, explained how ot was done, and discouraged it. She decided she wasn't going to mutilate her kid, and when she was talking to the other women there, they agreed with her and I.

So it all depends on the crowd.

[–]DJWalnut 6 points7 points  (0 children) | Copy Link

We're gonna owe reparations for this shit

[–]sensuallyprimitive 4 points5 points  (1 child) | Copy Link

circumcision is fucking stupid and it blows my mind that anyone would ever do that to their son

[–]Oncefa2left-wing male advocate 5 points6 points  (0 children) | Copy Link

Lots of people don't know any better.

It's all about educating people at this point.

[–][deleted] -1 points0 points  (3 children) | Copy Link

Just a point in your mention of coercion.

It's only coercion if it's undue enticement that amounts to overbearing the individuals will where their consent is volitionally compromised.

However, all of us do things for rewards. Eg working rewards you with money, but that doesn't automatically make it coercion just because it gives you a reward.

Offering a reward is only unethical here if the size and nature of the reward exceeds normal resources available for a person in that position.

[–]DistrictAccurate[S] 15 points16 points  (2 children) | Copy Link

According to interviewees, food, money, water, sanitation, clothing, and other basic needs are issues of concern for many adolescents’ households. During health talks, some mobilizers emphasized the incentives that boys will receive (e.g., sodas and/or new underwear) following circumcision—items that may be significant inducements among impoverished children.

Not sure if you read the whole post, but there is a paragraph on that. The ones targeted by soda and underwear are children, at times 8 years old. Additionally, it is to be evaluated in the context of other methods like social pressure.

A bullied and anxious 8 year old trading his foreskin for a soda and underwear so he fits in is not just making a normal deal. U use soda as bait for visiting a dentist, not giving away parts of your primary genital - which most of these boys haven't or have just barely used to its full potential yet.

You can kill a man, but you can't kill an idea.

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