Wednesday, December 15, 2010

"real men get circumcised"

i know my work can be a bit mysterious to those of you outside the development world, but suffice it to say there are some aspects of what i do that are pretty clear cut. take male circumcision (pardon the pun there ha): whereas in the states it's purely a cosmetic/religious/cultural preference, here in tanzania (where an estimated 1.5 million live with hiv), circumcision can be a matter of life or death.

male circumcision is thought to dramatically decrease the likelhood of hiv infection among men (i don't want to get too scientific-y here, so feel free to investigate my claim on your own), and one of the programs i support here is aimed at providing circumcision among at-risk populations. this week i had a chance to travel to a field site and see our project in action (well, um, all but the sensitive bits, of course). in a remote district in northern tanzania (where circumcision rates are about 25%), we started offering procedures (along with hiv testing and counseling) to any/all males over the age of 18 months.

now, i know what you're thinking: who in their right mind and of their own free will would sign up to get snipped? i thought the same thing. which is why i was shocked to learn that not only is there demand for circumcisions in this area, but men's desire to fling off their lil turtlenecks is so great that the tiny 4-bed surgical center we set up is filled to capacity every day. in less than one month, more than 300 brave volunteers have offered themselves up (so to speak), and the project is racing to scale-up. all this without so much as a community-based ad campaign.

so what's the deal? the very mention of circumcision makes most men wince and clutch at their jewels. so what is it that's driving the demand here? well, i got to talking to some of the boys milling around outside the health center one morning and, it turns out, the answer is very simple: "real men get circumcised".

from what i was able to learn, the process of male circumcision is seen by these boys as a masculine affair, only to be undertaken by the most courageous of souls. once the ball got rolling (sorry again, puns, terrible..), it seems the whole community was caught in a high-stakes game of chicken. the social pressure is particularly strong among the younger ones (conveniently, also our target group), with adolescent boys taunting, almost daring, one another to lay their manhood on the line (geez, seriously, i'm not doing this on purpose).

now this is all i could gather from my brief, non-scientific-y chat with folks at the health center, but i'd say the phenomenon lends itself to closer inspection, which i'll hopefully get to do soon (research i mean..not..inspecting penises...geez...). until then, i'll leave you with some shots of the brave little warriors i met that morning. in case you were wondering, this is what real men look like:


matthew said...

Wow- what a brilliant marketing campaign someone must have thought up to instill this view of circumcision. Thanks, Ghaz. Really fascinating

matthew said...
This comment has been removed by the author.
ghazaleh said...

matt, it's amazing - we haven't even started campaigning yet! this is completely self-generated behavior/mentality. we don't know how/where it got started, but we're eager to find out! thanks for reading :)

ghazaleh said...


Sorry, I accidentaly rejected your post, so I'm reposting your comment here, with my own reponse:

[HUGH 7's POST]:
In Tanzania, 6.5% of the circumcised men have HIV, compared to 5.6% of the non-circumcied men, according to the National Health and Demographic Surveys. So where does anyone get off on saying circumcision prevents HIV in Tanzania? The WHO and UNAIDS have been captured by some circumcision enthusiasts, victims of the same circumcision memeplex that is driving these boys. It's going to be years before those boys are at any risk of sexually transmiitted HIV. Is anyone teaching them about condoms between now and then? Or do they think that real men don't get HIV too?

Hi Hugh, Thanks for reading the blog and for livening up the conversation. While I agree with you that there is no current evidence of male circumcision benefits specific to Tanzania, there have been several randomized-control trials of male circumcision conducted in similar settings that have proven hugely effective in reducing the infection rate of HIV among heterosexual men. In particular, I point you to the work done in Rakai, Uganda, Kisumu, Kenya and South Africa (see citations below).

These studies (using the gold standard for biomedical research) showed that male circumcision can reduce HIV infection by between 50-60%. In fact, the findings of the original of the three studies (Orange Farm Trial in South Africa) was so alarming that the UN and WHO issued an immediate statement about the effectiveness of this procedure for HIV prevention. So, I would hardly say that the campaign for male circumcision is being driven by a band of wild cutting fanatics, just looking to impose their own cultural values on others (for the record, Tanzanians themselves have a wide diversity of circumcision practices, with 95% of those in the northern Masai regions practicing traditional male circumcision).

To your second point (about condom use, etc), all of the male circumcision efforts currently being led by the development community require HIV counseling and testing as a pre-requisite for the procedure. Meaning that every client receives private, individualized testing and education about the HIV prevention package - they are specifically instructed that male circumcision is but one tiny factor in a constellation of prevention efforts, most of which rely on the person's own conduct. For those that test positive at the outset, they are immediately referred to continued counseling and treatment care. Is the state of this care where we would like it to be in Tanzania? Surely not. But as a result of these efforts, many who would otherwise never get tested/educated for HIV are doing so.

Furthermore, male circumcision is a quick and relatively low-risk procedure. Even so, each client in our program is given free follow-up care at 2 days, 7 days and 4-6 weeks after the procedure. In a recent campaign here in Tanzania, of 2,000 people who got circumcised only 8 experienced any post-operative adverse events and all of these were treated in a timely and effective manner.

Given the evidence we currently have, I would say that the motivation behind the male circumcision campaign is hardly the machinations of some "memeplex", but rather the effort of concerned care providers trying to put a dent in the armor of a formidable opponent.

Thanks again for your post!

Auvert B, Puren A, Taljaard D, Lagarde E, Sitta R, Tambekou J. Impact of male circumcision on the female-to-male transmission of HIV. 3rd IAS Conference on HIV Pathogenesis and Treatment; Rio de Janeiro; July 24–27, 2005. Abstract TuOa0402.

RH Gray, G Kigozi and D Serwadda et al., Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial, Lancet 369 (2007), pp. 657–666.

RC Bailey, S Moses and CB Parker et al., Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial, Lancet 369 (2007), pp. 643–656.