HIV prevention: Making male circumcision the ‘right’ tool for the job

Abstract

In recent years, HIV/AIDS programming has been transformed by an ostensibly ‘new’ procedure: male circumcision. This article examines the rise of male circumcision as the ‘right’ HIV prevention tool. Treating this controversial topic as a ‘matter of concern’ rather than a ‘matter of fact’, I examine the reasons why male circumcision came to be seen as a partial solution to the problem of HIV transmission in the twenty-first century and to what effect. Grounded in a close reading of the primary literature, I suggest that the embrace of male circumcision in HIV prevention must be understood in relation to three factors: (1) the rise of evidence-based medicine as the dominant paradigm for conceptualising medical knowledge, (2) the fraught politics of HIV/AIDS research and funding, which made the possibility of a biomedical intervention attractive and (3) underlying assumptions about the nature of African ‘culture’ and ‘sexuality’. I conclude by stressing the need to expand the parameters of the debate beyond the current polarised landscape, which presents us with a problematic either/or scenario regarding the efficacy of male circumcision.

Keywords:

• male circumcision
• HIV prevention
• scientific facts
• social studies of science
• controversy

Acknowledgements

First and foremost, I would like to acknowledge the research assistance of Maggie Woo. Maggie's consummate skill in conducting literature searches, preparing literature summaries, hunting down obscure references and generally acting as an enthusiastic sounding board has been invaluable and I acknowledge my debt to her here (needless to say, she is not responsible for the arguments presented herein and any ire should be directed to me alone). It will probably come as little surprise that this paper has been reviewed many times by many people, relatively evenly divided between those who supported its central arguments and those who categorically rejected them. Their comments have fundamentally shaped the final paper and while I cannot thank them in person (given that all reviews were anonymous), I acknowledge their contributions here. I am also grateful to Darlene McNaughton and Vinay Kamat, both of whom provided constructive critical feedback on earlier versions of the manuscript, and Richard Parker, whose invitation to submit a manuscript on this topic came at just the right moment.

Notes

1. Fink's primary purpose in writing the letter seems to have been to push for the continued health care coverage of neonatal circumcision as opposed to any particular interest in HIV/AIDS.

2. One such example is CircLeaks (www.circleaks.org), a website styled along the lines of WikiLeaks which describes itself as ‘A place to learn about those who fund, promote, and profit from circumcision’. A conspiratorialist tone pervades the website and profiles focus on elucidating the ways in individuals, institutions and organisations are secretly (or not-so-secretly) ‘circumcision promoters’. For example, Stephen Lewis, a former head of UNAIDS, is denounced as Jewish and an ‘outspoken feminist’.

3. Although proponents of male circumcision tend to downplay the effectiveness of condom promotion, it is often cited as an important component of successful HIV prevention initiatives in countries such as Uganda (e.g., Kirby, 2008; Parkhurst & Lush, 2004).

4. This embrace of biomedical responses also speaks to broader processes of ‘biomedicalization’ (Clarke, Mamo, Fosket, Fishman, & Shim, 2010), with interventions progressively more reliant on science and technology and focusing on transforming bodies for the purposes of both treatment and enhancement.

5. Although Chin berates others for their carelessness with numbers, he provides no citations for these figures, although at their higher levels they stretch the bounds of credulity.

6. I have not discussed the role of gender in the acceptance of male circumcision as a HIV prevention tool, although this is a topic worthy of analysis in its own right (see Berer, 2007).