Potential barrier to male circumcision as HIV prevention strategy: ethnic division
I tweeted the other day that I was trying to finish up a co-authored paper with Michelle Poulin on ethnic identity and male circumcision. Joshua Busby pointed me to a blog post he wrote in March 2008 on male circumcision and HIV prevention that discussed an article in Future HIV Therapy: “Is male circumcision as good as the HIV vaccine we’ve been waiting for?” Josh’s post and the Future HIV Therapy editorial followed much-publicized results from three randomized controlled trials conducted in sub-Saharan Africa that established a causal link between circumcision and reduced risk of HIV transmission. The studies estimated a 50-60% reduction in risk of HIV acquisition among men who were circumcised.
In the wake of this evidence, the authors (and Josh) ask why hasn’t male circumcision been more aggressively pursued as an HIV prevention strategy. The first argument offered for the relative delay in a wide scale-up of the provision of medical male circumcision is that it may be “culturally inappropriate”:
Circumcision rituals, some have argued, are a practice that serves as a core rite of passage for young men among some ethnic groups and helps distinguish those groups from others… The use of circumcision as an identifier in targeting male victims for attack in the recent ethnic violence in Kenya, where Kikuyus generally practice circumcision and Luos do not, is a cautionary reminder.
But the authors of the Future HIV Therapy editorial counter that circumcision could be an “African solution to African problems,” citing the long history of circumcision on the continent, which predated the colonial period. Josh also points out the existing literature documenting widespread acceptability of male circumcision:
A dozen acceptability studies in different parts of Africa where circumcision is not traditionally practiced suggest that a majority of uncircumcised men want the procedure. Concerns about culture are not wrong, but if the acceptability surveys are an indication, culture may be more malleable than we think, particularly in the context of a crisis where millions have already died and millions more are at risk.
In my paper with Michelle, however, we find that circumcision is not nearly as “acceptable” as a previous study in Malawi would have suggested. In fact, among respondents who belong to ethnic groups that do not currently practice male circumcision, opinions of circumcision are generally negative. The data suggests the social significance of male circumcision is ethnically circumscribed and attitudes toward male circumcision follow ethnoregional patterns. From our working paper:
The social identities of Malawians are situated along ethnic divisions, which are critically bound with ideas of the “goodness” of male circumcision. Among the ethnic group that widely practices male circumcision in Malawi (the Yao), people are more likely to positively characterize circumcision and believe it decreases the chance of acquiring HIV. Respondents from typically non-circumcising ethnic groups who live among the Yao in the Southern Region are more likely to positively characterize male circumcision. Malawians outside of the South, however, generally have negative opinions of male circumcision, and believe it actually increases the risk of contracting HIV.
Josh concludes that the main roadblock to scaled up male circumcision is “supply, not demand.” And, I will relent that there is short supply, regardless of demand (and that in some cases, demand is rather great). Having said that, I don’t know that demand would ever outstrip supply in Malawi, where the Minister of Health continues to be skeptical of whether the findings from the randomized controlled trials on male circumcision were relevant in the Malawian context.
Our analysis suggests acceptance of circumcision as a tool for HIV prevention could be low in societies divided by ethnoregional identities that also shape the practice of male circumcision. This has not been the case in Kenya (an ethnically divided society with high demand for circumcision among previously non-circumcising groups), and that puzzle has led us to an extension of the project, which has yet to be written…