The myth of a naturalised male circumcision: Heuristic context and the production of scientific objects

ABSTRACT

In March, 2007, the WHO and UNAIDS established a joint recommendation at the Montreux technical consultation, making male circumcision the first surgery to be used as a preventative tool against an infectious disease. This recommendation was immediately followed by the publication of numerous articles denouncing its content, leading to two distinct controversies, one between epidemiologists, and a second between epidemiologists and social scientists. Interestingly, however, none of these works took male circumcision as an issue in itself, exploring neither that both epidemiologists and social scientists had taken the object ‘circumcision’ as a given, nor what each party was referring to when talking about circumcision. In this paper, taking a step back, and building on the notion of heuristic context, I show how the RCTs constructed this object in a very specific way, and how this construction was often lost in translation, leading not only to an illusion of universality, but also to misunderstandings between disciplines regarding what is at stake in global health issues.

KEYWORDS:

• Heuristic context
• clinical trials
• male circumcision
• evidence-based medicine
• biomedical packages

Acknowledgements

I would like to thank Frédéric Le Marcis for having accompanied me during the development of this project on Voluntary Medical Male Circumcision and for his always useful and fruitful support. I also want to thank the reviewers of the article who, by their very inspired and precise comments, helped me improve my arguments.

Disclosure statement

No potential conflict of interest was reported by the author.

ORCID

Charlotte Brives http://orcid.org/0000-0001-7459-0646

Notes

1. Circumcision has indeed taken place as part of an arsenal of prevention strategies initially focused on behavioural changes but which has increasingly become characterised by strong medicalisation in the last decade or so. Thus, alongside the ABC strategy (Abstinence, Be faithful, use a Condom), other techniques such as the use of microbicides or TasP (Treatment as Prevention) have developed. Circumcision is thus part of a desire not to focus prevention on behavioural changes, with the assumption increasingly displayed by Northern actors that people in the South are unable to change their behaviour due to conceptions of sexuality and African culture inherited in part from the colonial era (Packard & Epstein, 1991). The role of major funders such as the Bill and Melinda Gates Foundation is also very important, since these organisations actively support circumcision programs, although for different reasons (Birn, 2005). Finally, if the interest of some researchers in circumcision is based on personal views regarding the act itself, it is also dependent on the power relations between laboratories and between national research traditions. In this way, the choice of circumcision can be read within the more general context of a race to capture resources against the proponents of an HIV prevention strategy through microbicides.

2. For a summary of this controversy, please refer to Bell (2012) and de Camargo, de Oliveira Mendonça, Perrey, and Giami (2013).

3. For an analysis of the links between global health and neoliberalism, see Adams (2016).

4. For an extensive description of this point, see Bell (2012).

5. Directly linked to our purpose, we can cite the book of Timmermans and Berg (2003), The Gold Standard, and Timmermans and Berg (1997), Rationalizing medical work. On a different but exciting subject, see Levinson (2006), The Box: How the shipping container made the world smaller and the world economy bigger.

Additional information

Funding

This work was funded by the French Association SIDACTION.