Circumcision is a physical event that always has cultural significance. Sometimes this culture is traditional and part of a ritual aimed at the wellbeing of society; sometimes it is medical and aimed at reducing health risks to individuals.
Often traditional and medical cultures meet, and circumcision is then performed as a ritual in which the health benefits are made explicit. Sometimes they clash and the one culture characterises the other as harmful.
Research has shown that the risk of a circumcised man contracting HIV during vaginal sex is reduced by up to 60%, compared with that of an uncircumcised man, although the risk to a female is not reduced. Since 2007, medical circumcision has been promoted as part of a comprehensive strategy to prevent HIV. In 2010, the South African government, in line with World Health Organisation (WHO) recommendations, began to target boys and men aged 15-49 for circumcision, purely for HIV risk reduction. There is little doubt that neonatal circumcision will soon be adopted as best practice.
Medical circumcision and the provision of antiretrovirals (ARVs) are now at the forefront of multilateral, international and national HIV prevention campaigns. Circumcision is aimed at reducing the risk of HIV infection across an entire group of people (men), whereas the roll-out of ARVs in this hyper-epidemic aims to reduce the viral load not only in individuals but in society as a whole.
But WHO policy-makers and health professionals are quick to warn that we should guard against viewing medical circumcision and ARVs as the new magic bullet. They are not the “terrific twins” that will save us, yet there is a real danger that we might focus so exclusively on these biomedical interventions that we neglect the broader sociocultural context that used to inform prevention campaigns.
Until recently, prevention was mainly about abstinence, safer sex and reducing the numbers of sexual partners in the context of broader social determinants of health. Thabo Mbeki’s attempt to have a national conversation about poverty as a key determinant of health became tragically lost in his own denialist folly — and heaven knows, we don’t want to go there again.
‘Cultural lessons’
Maybe our failure as a society to heed the systemic cultural lessons of Aids begat this new era in which medical circumcision has become an exemplar of medical triumphalism. This has happened to the exclusion of either traditional circumcision or serious introspection about sexual culture. Consequently, as a society, in spite of the increasing efforts of gender-focused civil society organisations, we remain reluctant to confront existing notions among men and women of what it means to be a man. Men’s perception of sexual risk and responsibility for preventing HIV remain largely unchallenged.
By shying away from culture and constructing it as a single (traditional) thing (and thus essentially backward and harmful), and by privileging the biomedical in this way, we are denying ourselves the opportunity to use Aids to learn more about ourselves and to allow our culture to adapt and respond to new circumstances and challenges, as they do and should. The reality is that neither the traditional nor the biomedical culture can solve the problem alone: neglecting one culture in favour of the other will come at a cost to all of us over the longer term.
It would be much more constructive to cast aside spurious notions of superiority and to focus on the common values that underlie both medical and traditional cultures: values geared to the survival, wellbeing and improvement of society.
A recent workshop in Durban that brought together traditional and medical circumcision practitioners from several provinces revealed remarkable areas of consensus. There is broad support for the practice of circumcision, with a real emphasis on respect for individuals as well as for the context in which they live. Most gratifyingly, neither the traditional nor the medical culture claimed a monopoly on wisdom. The traditional practitioners were open to medical training to improve health and safety, whereas the biomedics recognised the value of incorporating into initiation cultural instruction on sexually responsible behaviour.
This is the moment for learning, at a societal level, to expand this consensus and nascent goodwill and address those areas about which there is still disagreement. These areas include the age of circumcision, the partial or full removal of the foreskin, the role of women, the surveillance of the practice within traditional contexts, working with government and, significantly, the need for the biomedical approach to incorporate a greater emphasis on sustained sexual behaviour change after circumcision.
We still have a chance to use Aids as a lens through which to interrogate what it means for men truly to respect themselves and their sexual partners and to counter the deeper drivers of gender-based violence. If we do not, we may eventually defeat HIV/Aids using circumcision, drugs, condoms, microbicides and possibly a vaccine, but we will remain ill-equipped to respond with courage and compassion when the next crisis comes along.
Deborah Ewing is manager of the culture and health programme and Pieter Fourie is a specialist technical advisor with the Aids Foundation of South Africa. The foundation recently hosted a workshop in which medical and traditional circumcision practitioners could engage on issues of mutual interest.