First things first. I like circumcised men. They smell and taste better, and have longer erections. Circumcision is cleaner and protects from some nasty infections. I also like uncircumcised men. Each to his own.
There. Done. Nobody can accuse me of having an anti-circumcision agenda. Let’s move on into this unfolding juggernaut, this mounting hype about snipping foreskins to prevent Aids — in United Nations/NGO jargon-speak, the roll-out and scaling-up of mass male circumcision programmes across Africa.
Last year I attended a colloquium on male circumcision at the perinatal HIV research unit at Johannesburg’s Chris Hani Baragwanath Hospital in Soweto. More than a debate, it was a barrage of propaganda. The zeal was missionary and seemed to be led by desperation: if nothing else works, maybe this will.
I will not go into the relative benefits of the relative protection — at 60% male circumcision still requires safe sex — but into other disturbing aspects.
The marketing
How will this sensitive issue be packaged? Two variations of a slogan were tossed around:
Real men are circumcised.
Real men are circumcised and use condoms.
This one is a no-brainer, two messages cancelling each other.
Real men? Interventions that separate and polarise people worry me. Who defines a real man? Whose hegemonic model of masculinity will be endorsed? Is a man who chooses to keep his foreskin less of a man? He could be faithful. He could practise safe sex. He could just like his foreskin. His partner could like it.
Circumcision as a test of manhood. That’s dangerous, crafting messages that endorse discrimination and exclusion in a country where speaking some words of isiZulu means the difference between being burnt alive or not. Where a joke about the size of an Indian penis gets three men shot and killed at a bar in Durban.
Remember the hate emails against the uncircumcised Luo, pitted against the circumcised Gikuyu during Kenya’s post-election violence a year ago. In South Africa, one hears more hostile, ethnically based remarks about the uncircumcised Zulu and the initiated Xhosa, the ANC boys (uncut) versus the ANC men (cut). The Fikile Mbalula initiation saga played right into this tension. To market a slogan like “real men are circumcised” is to stoke the bonfires of prejudice.
The emphasis on speed
A pilot project in Orange Farm is streamlining the procedure, whittling every movement to make it easier, faster, more efficient. Only five minutes of the doctor’s time per patient. Wow. Would you choose the doctor who advertises the fastest tooth implant or the fastest hysterectomy? I wouldn’t. I like to kid myself that my doctor spends a bit of time because I am paying through the nose for it.
But the poor don’t have that choice: rows of narrow beds separated by blue curtains; rows of penises emerging from sterile sheets. The doctor moves quickly down the row spending less than five minutes with each penis. The team does the rest. The slideshow reminded me of a factory assembly line of cattle-dipping.
Counselling takes longer than the operation and a three-day interval allows for rethinking. The French fund this project, and this is the rule in France and in French-funded projects. Forty percent of counselled men in Orange Farm decide not to do it. It would be good to hear their reasons, but the project does not know. In any case the dropouts are a sign of good counselling that gives the pros and cons: the operation does not grant full and permanent protection, they still must have safe sex and no sex during the first six weeks after the operation. And it hurts.
The drain on resources A team of 13 (one doctor, nurses, suture technicians and assistants) can do 80 circumcisions a day. If they worked 300 days a year, that is 24 000 operations. Problem is, just to circumcise all the 14-year-olds in Soweto alone requires 80 000 operations a year, we heard.
Meanwhile those health workers are not attending births or trauma victims. To hear this at Chris Hani hospital — scene of horror stories about patients bleeding unattended for hours in the emergency ward — was disturbing. Project this to poorer countries. Can African public health systems afford to divert precious human resources? Will the pots of donor money for male circumcision drive health staff to the well-funded snip programmes? Are we robbing Peter to pay Paul?
Circumcising babies is faster, cheaper and presents fewer complications. One way of raising an Aids-free generation might be to offer it routinely to new parents, along with HIV testing. This lands us in another bonfire: is male circumcision a form of genital mutilation. Does it violate a baby’s right to his foreskin? Yes or no; people feel very strongly about this.
Mass male circumcision treads on cultural and ethical minefields. Every step must be carefully thought through.