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 ,. VMMC is a highly cost-effective HIV prevention strategy for both generalized and high-prevalence HIV epidemics . 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 .[...] (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4011573/)
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"?
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
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 –, 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 , 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.
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)  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. 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.