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Sources and Debates on

Excision / Female Genital Cutting (FGC) / Female Genital Mutilation (FGM)



For further information consult:

- the November/ December 2001 email thread on <H-AFRICA@H-NET.MSU.EDU> about "Female Circumcision in Africa", at:
http://www.h-net.org/~africa/threads/#Circumcision

- Three contributions on clitoridectomy, available on H-Africa's website, at:
http://www.h-net.org/~africa/sources/clitorodectomy.html

- A selection of emails about "Circumcision and FGM" from the H-Net List on the History of Sexuality <H-HISTSEX@H-NET.MSU.EDU> from February/March 2004 (see below)



(thread listed in inverted order of posting: please consult the end first)

Selected Postings collected by Charles BECKER <beckerleschar(a)sentoo.sn>

Co-Editor of <H-West-Africa@h-net.msu.edu>

Edited by Patrick F.A. WURSTER <wurster(a)mail.h-net.msu.edu>

Co-Editor of <H-Africa@h-net.msu.edu>

Wed, 10 Mar 2004 19:57:53 -0000

From: "Dustin M. Wax" <dwax@gmx.net>

Sent: 10 March 2004 17:50

Subject: Re: circumcision again

Hera writes:

The lengthy debate on FGM on this list has shown quite clearly that there are many people of your imagined women's faith who believe FGM is wrong and unnecessary.

Which is all fine and well, but useless. A Native American (an Omaha, to be exact) worked with Alice Fletcher on the plans for Indian "civilization" that became the Dawes Act, which allocated Indian land held in common to individual Indians, probably the single most disastrous policy ever imposed on Native Americans. Some Jewish people in Germany formed "Jews for Hitler" groups to support what they saw as a necessary step in the "civilization" of Europe's minorities; others fought in the Luftwaffe in Scandinavia. My point is not so much that they were wrong, but that just becuase an "insider" feels something to be right is no guide to my own role. Which is why I advocated the kind of understanding that you take me to task for denying...

I feel that the kind of cultural relativism you are espousing has little to do with respect - which necessitates finding out about other cultures - and a lot to do with the fun of turning ideas upside down etc to see how they look.

First of all, you're criticizing me for *moral* relativism, *not* cultural relativism, which is a theoretical/methodological position which hardly precludes the making of judgments but which does privilege the ability of a society to meet the physical and psychological needs of its members over the personal distaste of the observer in making such judgments. Second of all, I'm not making this up out of whole cloth, here -- I'm drawing on what I know of FGA practices from the ethnographic record. Yes, as I've said several times, there are women who oppose their communities' FGA practices -- but there are also women who fight tooth and nail to make sure their daughters are cut in whatever fashion necessary. When women are willing to a) break the law, and b) defy their husbands by having secret initiation ceremonies, I have to ask what's going on, what makes this practice so essential to this woman. I have to believe that simply asserting that the basis of her faith is incorrect is not going to do much.

For a real "cultural relativist" look at one form of FGA, I suggest you have a look at "Facing Mt. Kenya" by Jomo Kenyatta, who wrote what I feel is one of the most beautiful and complex descriptions of both male and female cutting rituals (which take place at puberty in Kikuyu society) -- and went on to oppose the practice throughout his political life (for those who don't know the name, Kenyatta was the first president of independent Kenya; he studied anthropology in England).

This can be a valuable process but I think the time has long since passed when it is an appropriate response to FGM.

And what is an "appropriate response"? "Exterminate the brutes"? "Educate women to show them how oh-so-very-wrong they are? Explain to me what *my* "appropriate response" should be, something that doesn't assume that men and women in FGA-practicing societies are either simply evil, too stupid to understand what they are doing, blinded by "false consciousness", or otherwise deficient in some sort of understanding that we "moderns" have to bring to them. Please be sure to base it on actual practices in specific societies -- I am sure we all agree that the argument against and response to FGA in one society must be vastly different than the arguments and response to every other.

--Dustin

Wed, 10 Mar 2004 09:35:35 +1100

From: hercooka@arts.usyd.edu.au

Subject: Re: circumcision again

Date: Wed, 10 Mar 2004 09:35:35 +1100

«it might pay to imagine this debate from the point of view of a woman who is insistent on having her child cut in whatever fashion. How do you tell her that it is not "necessary" when God/god/the gods tell her it is? And how is she going to be swayed by the arguments of people who clearly know and believe nothing of her faith?

--Dustin M. Wax

dwax@gmx.net

The lengthy debate on FGM on this list has shown quite clearly that there are many people of your imagined women's faith who believe FGM is wrong and unnecessary. I feel that the kind of cultural relativism you are espousing has little to do with respect - which necessitates finding out about other cultures - and a lot to do with the fun of turning ideas upside down etc to see how they look. This can be a valuable process but I think the time has long since passed when it is an appropriate response to FGM.

Hera

Sun, 7 Mar 2004 12:21:38 -0000

From: "Dustin M. Wax" <dwax@gmx.net>

Sent: 07 March 2004 06:04

Subject: Re: the role of God, or gods, in our discourse (was: circumcision again)

Michel Faber writes:

However, arguing that God made the stars and the flowers, or that the gods are responsible for fertility or birth defects, is not the same as arguing that God issued a specific edict, in the language of the relevant tribe, promoting or banning a specific practice.

We cannot prove conclusively that God or gods don't exist, but we can demonstrate that the specific opinions attributed to them were in fact issued by a motley collection of mullahs, tribal elders, kings and so forth. Whatever God may possibly be, He, She, or It does not manifest in the afternoon sky, point down at an individual human, and shout "Get your hair cut!" "Grow your beard!" "Put a skull-cap on!" "Don't masturbate!" "Sacrifice a goat!"

"Cut your daughter's clitoris off!" and so on.

And Stephen Morris writes:

It seems almost impossible to argue against this or any other practice that is rooted in a particular religious/symbolic system....

In my Intro to Anthropology class this week, in which we covered sex, marriage, family, and household, I took the liberty of using the "Biblical Definition of Marriage" e-mail that someone posted here a couple of days ago, explaining that my pointwas not so much to mock Mr. Bush and his cohort (which was, I explained, only a pleasant side-effect of the reading...) but rather to show how religious practices can change, citing everything from national-level debate to local gossip as arenas for such change. So I definitely agree with Michel F's overall argument -- I don't think it's "impossible", as Stephen M. writes (ok, "*almost* impossible"), simply because it is "rooted in a particular religious/symbolic system".

What I do think, though, is that the appeals that make up the bulk of anti-FGA activism that I've encountered are going to remain ineffective without the application of coercion, because they are embedded in medical, human rights, and/or progressive frameworks that simply do not address the reasons that people employ these practices. "Don't do that, you'll get an infection and might even die" seems rather slim placed against, say, favor in the eyes of Allah, or never achieveing full womanhood. Look at the tale of Abraham and Isaac: God ordered Abraham to *kill* his son -- his favorite and onliest son, given the casting out of Ishmael. Is a good Jew to have said "Oh, I'm sorry, Mr. Lord, terribly sorry but doing that might irreperably harm the boy"? No, the good Jew follows the will of the Lord without question, even when, as in the case of Job, the Lord turns the poor fellow over to the Source of Evil on Earth to be scourged and robbed of every shred of human comfort.

In this light, I'm not so sure I can agree with Michel F's argument about the attribution of such edicts to particular human agents. For one thing, I don't think people typically approach their religious belief with that degree of reflection -- religious dogma, however demonstrably the word of human actors, still *feels* like the will of God/god/whoever/Shirley the Great. For another, even if one could convince someone that a particular practice comes from a human's interpretation of the Divine Will, who are they likely to believe? The Mullah or whomever who has devoted his life to devining the will of God or the clearly politically-motivated activist who is challenging what is taken as a foundation of religious faith?

I don't know the answers to these questions. Clearly there are people who are refusing to undergo or have their children undergo FGA practices, so this isn't an unstoppable force -- few beliefs are. What I do know is that I'd feel a lot more comfortable about arguments against FGA and circumcision if I had ever detected even a minimal appreciation for the religious faith that their activism must necessarily call into question. This is not a call to "give them something to replace FGA" -- how f&*#ing arrogant are we that we think we can give anyone religious meaning in their lives?! In fact, I do n't know what this is a call for, other than a scholar's desire to see understanding as the basis for one's actions rather than disgust.

--Dustin

Sun, 7 Mar 2004 06:23:40 -0000

From: "Salwa Ghaly" <complit01@yahoo.ca>

Sent: 07 March 2004 06:23

Subject: Re: circumcision again

The pediatrician I spoke with suggested one: which is that in some cases not being circumcised can cause complications which are serious.

The "value" of male circumcision appears to be entrenched in the minds of a lot of American medical practitioners. This has an impact not only on what advice they give parents at the birth of a son, but also how they treat medical problems when they arise. My nephew (born in New Jersey in 1994 to an American [circumcised] father) escaped routine neonatal circumcision, the parents having taken to heart the message that circumcision was injurious and unnecessary. However, at age 3, and at the first sign of inflammation, his pediatrician strongly recommended circumcision, which the boy then had to undergo. I am in no position to pass judgment on that doctor, but I do have a hunch that she responded in a heavy handed manner...

Salwa Ghaly

complit01@yahoo.ca

Sat, 6 Mar 2004 23:03:45 -0000

From: "Michel Faber" <michel@ablach.co.uk>

Sent: 06 March 2004 17:28

Subject: the role of God, or gods, in our discourse (was: circumcision again)

Dustin M. Wax wrote:

I wonder where religion is in this debate. What I mean is, certainly many of these practices are considered necessary because God, god, or the gods demand them? [...]

This is an epistemological sort of problem I have had in anthropology for a while, the fact that most social scientists, no matter how hard they work to eliminate ethnocentrisms from their perception of their subjects, believe that religion is not really real, a sham, a cover-up for other things. You can find any number of works about how religion is used by the so-and-so people of wherever to effect political or economic control, as a coping mechanism in an often chaotic and oppressive world, as a template for social and political movements, and so on -- but rarely will you come across a work that describes political control in terms of playing out God's will, or whatever. Religion always seems to mean something else.

Thought-provoking post. There are two issues here which we need to take care not to conflate. First is the question of whether there is a God or gods. Second is the question of religious laws & customs, how they come about & evolve, and what evidence there is that they reflect the values & opinions of deities.

I agree that Western scientists, and academics generally, tend to be an atheistic or agnostic lot. When looking for explanations of how the universe works, they tend to discount the notion that there may exist a God or gods who created everyone & everything. This may, as Dustin M. Wax goes on to suggest, form part of the dynamic between non-Western or so-called "primitive" cultures and the educated Westerners who comment upon, or attempt to intervene in, those cultures. As such, this dynamic warrants some scrutiny.

However, arguing that God made the stars and the flowers, or that the gods are responsible for fertility or birth defects, is not the same as arguing that God issued a specific edict, in the language of the relevant tribe, promoting or banning a specific practice. This is where religion crumbles under even the most rudimentary scrutiny, and is safe only in cultures where such scrutiny is discouraged or absent.

Dustin Wax gives the following example:

Clearly various female genital operations are "necessary" for young women in many societies, though not *medically* -- who do we trust to make that distinction? And if [we are] wrong, and we are condemning the poor girl to eternal damnation, who is to take responsibility for it?

I don't bring this up *solely* to throw a wrench in the works (though that's fun, too!) but because it might pay to imagine this debate from the point of view of a woman who is insistent on having her child cut in whatever fashion. How do you tell her that it is not "necessary" when God/god/the gods tell her it is? And how is she going to be swayed by the arguments of people who clearly know and believe nothing of her faith?

This is a perceptive analysis of the way a religious person might feel when challenged by a stranger "who know[s] and believes nothing of her faith".

But it is a very shaky point about religious ideology itself. The edicts promoting or banning various behaviours can be traced back to texts that were demonstrably written by human beings. Equally notable and demonstrable is that purportedly God-dictated laws & customs change over the centuries (or even over the decades) as the religion struggles to keep pace with social evolution. Given half an hour it would be possible to cite several dozen examples of religious dogmas that had once been described as the express will of God which are now repudiated by exponents of that same religion -- in favour of updated dogmas that are calibrated to fit in with prevailing norms, the influence of other cultures, and government legislation.

We cannot prove conclusively that God or gods don't exist, but we can demonstrate that the specific opinions attributed to them were in fact issued by a motley collection of mullahs, tribal elders, kings and so forth. Whatever God may possibly be, He, She, or It does not manifest in the afternoon sky, point down at an individual human, and shout "Get your hair cut!" "Grow your beard!" "Put a skull-cap on!" "Don't masturbate!" "Sacrifice a goat!" "Cut your daughter's clitoris off!" and so on.

Best wishes,

Michel Faber

michel@ablach.co.uk

Sat, 6 Mar 2004 23:03:44 -0000

From: "Stephen Morris" <smmorris58@yahoo.com>

Sent: 06 March 2004 17:05

Subject: Re: circumcision again

Dustin raises an excellent point. Most Americans simply do not think of circumcision as a religious act but in my experience of European travel, circumcision is most often considered the sign of membership is a particular religious community.

It seems almost impossible to argue against this or any other practice that is rooted in a particular religious/symbolic system....

Stephen

Sat, 6 Mar 2004 14:41:29 -0000

From: "Dustin M. Wax" <dwax@gmx.net>

Sent: 06 March 2004 00:31

Subject: Re: circumcision again

Michel Faber writes:

I would've thought that a basic principle of a responsible surgeon is to decline to perform operations that are unnecessary.

Can I just throw in a thought, here? I'm finding this debate to be really interesting, and I'm not intending this as a cut against any particular post -- I've been thinking about it for a few days now and Michel F's post just gave me the chance to try and express it more fully. So:

I wonder where religion is in this debate. What I mean is, certainly many of these practices are considered necessary because God, god, or the gods demand them? Certainly He was very insistent with Abraham (whose initial response was "You want me to cut of my WHAT?!").

This is an epistemological sort of problem I have had in anthropology for a while, the fact that most social scientists, no matter how hard they work to eliminate ethnocentrisms fromn their perception of their subjects, believe that religion is not really real, a sham, a cover-up for other things. You can find any number of works about how religion is used by the so-and-so people of wherever to effect political or economic control, as a coping mechanism in an often chaotic and oppressive world, as a template for social and political movements, and so on -- but rarely will you come across a work that describes political control in terms of playing out God's will, or whatever. Religion always seems to mean something else.

Clearly circumcision is "necessary" for most Jewish male infants. It is not *medically* necessary, but still necessary. Is that a distinction physicians should make? Clearly various female genital operations are "necessary" for young women in many societies, though not *medically* -- who do we trust to make that distinction? And if you or I or whoever is wrong, and we are condemning the poor girl to eternal damnation, who is to take responsibility for it?

I don't bring this up *solely* to throw a wrench in the works (though that's fun, too!) but because it might pay to imagine this debate from the point of view of a woman who is insistent on having her child cut in whatever fashion. How do you tell her that it is not "necessary" when God/god/the gods tell her it is? And how is she going to be swayed by the arguments of people who clearly know and believe nothing of her faith?

--Dustin M. Wax

dwax@gmx.net

Sat, 6 Mar 2004 23:03:42 -0000

From: Vanesa Casanova-Fernandez casanov@GEORGETOWN.EDU

Sent: 06 March 2004 16:05

Subject: Re: FGM in the Arab world

Salwa Ghaly wrote:

"Now that's interesting: have a look at the following link for a much less certain endorsment made by the same man: what does it tell you? It suggests to me that Qaradawi probably realizes that the endorsment he can get away with among Egyptians will not sit well with some of his other audiences."

Vey interesting and, if I may add, very "Qaradawi-like:" have as many discourses as different audiences you have. It depends on who is listening, and for what purpose.... It comes to show you that these things cannot be read in a vacuum.

Cheers,

vanesa

Fri, 5 Mar 2004 22:12:52 -0000

From: "Salwa Ghaly" <complit01@yahoo.ca>

Sent: 05 March 2004 20:12

Subject: Re: FGM in the Arab world

Another example (sorry for the multiple postings) Sheikh Yusuf al-Qardawi - another Egyptian-born TV-super-star sheikh based in Qatar - also defended the practice: "In any case, whoever thinks that this [practice] will safeguard his daughters better, then do it; I endorse this, particularly in our present age. And whoever doesn't do it, there is no sin in that [fa-la junah alayhi]."

Source: http://www.almansiuon.com/women/serry/038.htm

Now that's interesting: have a look at the following link for a much less certain endorsment made by the same man: what does it tell you? It suggests to me that Qaradawi probably realizes that the endorsment he can get away with among Egyptians will not sit well with some of his other audiences.

http://www.islam-online.net/English/News/2004-02/07/article06.shtml

Salwa Ghaly

Fri, 5 Mar 2004 19:48:53 -0000

From: "Michel Faber" <michelfaber@ablach.freeserve.co.uk>

Sent: 05 March 2004 18:01

Subject: Re: circumcision again

Ethan Miller wrote:

it is fairly clear that, at least in "modernized" nations like the US, Canada, etc there is no reason for the medical establishment to come down on either side of the issue.

I would've thought that a basic principle of a responsible surgeon is to decline to perform operations that are unnecessary. This principle has been much undermined in recent years as more & more surgeons are getting into the highly lucrative field of cosmetic surgery. It has also endured a fascinating legal challenge in the notorious recent case of a mentally disturbed man who was convinced that his perfectly healthy legs were diseased, and who managed to find a surgeon willing to amputate them.

(Or was it just *one* of his legs? I can't recall.) Anyway, these lapses aside, I still think that the principle of reserving surgical intervention for cases of necessity is a sound one.

Now, you can go ahead and call this relativism gone out of control, but what I think is clear is that there is little to suggest that this practice is either inherently good or bad

While I take Ethan's point about relativism, I think the desire to avoid pain and trauma is about as "inherently good" as human impulses get.

--unless, you, again for cultural reasons, have some strong objection to it, say because you sympathize with hippy notions of the purity of the body, you have a problem with the over-medicalization of the body, you object to the intrusion of a what you see as a practice of some "other" whether they be Jews or Arabs, etc. If you want to say that this is relativism gone out of control, then you must define the absolute principle that you want to privilege as truth and convince us why that principle is right.

I don't know that it's necessary to define what we "want to privilege as truth", nor to use faintly disparaging terminology like "hippy notions of the purity of the body". People who have a choice in the matter generally don't like to be hurt & injured, and injuries can lead to infections & other complications. Those are uncontroversial, basic generalisations that most of us live by. Of course it could be objected that some people enjoy pain and seek out injury, etc. True. But when we talk about (-- to give a different example --) violent crime, we have no difficulty generalising about it as being undesirable, because we know that most people don't wish to be victims of violent crime. And please NB -- I am *not* linking circumcision with violent crime to score some sort of emotive point, only citing an example of a phenomenon which we generally & undemurringy agree is "bad" without needing to get into a debate about "relativism gone wild".

The medical profession is neither forcing this practice on people nor making any recommmendation one way or another.

This is a problematic assertion. If a parent with a newborn baby asks a doctor whether or not the baby should be circumcised, does the doctor hum a tune, stare out of the window and pretend not to have heard? No, he or she will either advise for or against the procedure.

circumcision, when done on adults is extremely painful. Pain can in fact last long after the procedure. This does not occur when the procedure is done on newly born infants.

Given the inability of infants to describe their pain (except by weeping until they are too tired to continue), this seems an unwarrantably confident claim.

Finally, in terms of the objection to circumcision that seems most convincing, the lack of choice given the child: Are not the parents also exercising a choice when they choose not to circumcise?

"Choose not to circumcise" implies that, either way, the parents have to do something to the baby. Whereas in fact, the parents of an uncircumcised baby need do nothing except leave the baby's flesh intact. They are exercising choice in the same way that they are exercising the choice not to tattoo the infant or feed it LSD or pierce its nose or any number of things that the child might conceivably choose to do when it grows up.

As I have pointed out, due to the painfulness of the procedure when performed later in life, it is not necessarily something that they can choose later in life.

This implies that a significant proportion of men will be obliged, for health reasons, to consider circumcision later in life, but will be hampered in that decision by the fear of pain which (supposedly) babies don't experience. How many adult men have ever wished they'd been circumcised and regretted that the best time for doing it had been missed? Such men no doubt exist (everything exists) but the percentage would surely be statistically minuscule.

Best wishes,

Michel Faber

michelfaber@ablach.freeserve.co.uk

Fri, 5 Mar 2004 22:12:50 -0000

From: "Salwa Ghaly" <complit01@yahoo.ca>

Sent: 05 March 2004 20:00

Subject: Re: FGM in the Arab world

Vanesa Casanova-Fernandez wrote:

Just to clarify, the first thing I said in my previous posting was that these are just hypotheses that would need to be researched thoroughly and further, I was simply calling for a more nuanced view of how research would need to be conducted.

Yes, agreed. They are hypotheses, ones that I feel do not speak to the realities on the ground in the Arabian peninsula where I have been living for the past 6 years. I am not about to pass myself off as a "native informant," but I am an eager culture observer, and I have not seen any signs indicating that FGM is becoming an "issue" here. It is totally absent from the media and from the discourses I am familiar with, which is why I asked you for concrete sources that might explain to me why you think FGM is being legitimized there where it previously was not.

My concerns

were methodological, and I think some of the questions I was asking are still legitimate, such as: when is a certain practice "legitimized" in discourse, by whom, and why? What is the relationship between discourse and practice? Is it possible that a practice that is foreign to a particular society becomes "traditionalized" within it at certain point and legitimized in legal/religious discourse?

Yes, excellent concerns and questions. My response to you is that it is too early to formulate hypotheses predicting the legitimization then the adoption (?) of FGM. Ideas, beliefs, practices travel faster than before, it is true, but that does not mean that the worst case scenario will become an actuality. The opposite might be the case: seeing that FGM is not a universal Muslim practice might spur Egyptians and others to abandon the practice or call it into question. In the domain of cultural traffic, we cannot predict outcomes. Hypothesizing using flimsy or anecdotal evidence (not that I am suggesting that this is what you are doing, rather a general comment) might take us in the direction of more homogenizing: I am far from being an apologist for Islam or any other religious belief system, but I do feel that the cause of intercultural communication is not well served by blanket statements that make a group look worse than it already does. If I were to forward your post to Syrian colleagues, they would be absolutely mortified to see FGM associated with their country, and they're likely to fall back on the familiar charge/mantra that the West misunderstands/vilifies this region, etc. This is all deja vu for me (ostensible charges, defensive reactions...), and I am simply cautioning against leaps of faith that complicate the picture more than is necessary: to reiterate, the "transfer of legitimacy" from FGM-practicing Egypt/Sudan to neighboring Arab countries is not something you have convinced me should be a cause for concern.

I would rather we discussed FGM where it actually exists than hypothesize that at some point in the future it might become a problem beyond its present boundaries in the Arab world.

pan-Arab TV channels is perhaps the most paradigmatic example of how certain ideas "travel" now faster than before, but the truth is, the exchange of ideas has always occurred: students from Iraq, Syria, Palestine, or wherev er may choose to study in Al-Azhar, then go back to their home countries.

Yes, this has been the case for centuries, and FGM was not taken back in the Azhar-trained students' bags of tools. Why would it now? Because of the ubiquity of satelite media? All the more reason to assume that 30+ channels on the TV dial would add to the social discourses and break the monopoly Egyptians had for a good half century. In fact, Sat TV has become the "new satan," as clerics decry from mosque pulpits the secularist messages being sent out, not to speak of the scantily clad women on music and dance shows beamed from Lebanon and Syria.

True: FGM was not debated in

Syria in the 1970s,

but it is debated today. And the point is, why?

Debated by whom? By clerics? It probably always was, as there is the aporetic insnad (attribution), some posters have referred to. Since it exists "in the books," it is highly unlikely that Muslim clerics from Syria would not have come across it. But did/do they "debate" it in the sense of "wow, that sounds like a good idea"?! In a society where FGM is considered "a barbaric practice"?

Because at some point, the issue has been introduced somewhere, for certain reasons that ought to be studied.

Yes, since we're in the realm of hypotheses, let me venture one of my own: so long as the religious scriptures are considered holy and untouchable, Muslim clerics will find themselves having to "reconcile" themselves with all kinds of unpalatable (to them) texts. What religion does not have downright embarrassing statements and edicts? The Hadith assumed to be pro-FGM can be tagged "weak," but that won't make it go away. If a cleric believes the body of Hadith is the "truth," he (almost always a he!) will have to come up with an explanation for why the line about "cut but do not obliterate" is there. I am sure that across the ages, clerics from non FGM-practicing societies have had to contend with that line. The difference now may well be that, due to better communication, we, the lay people, have better access to some of the bedeviling questions clerics like to pass their time contemplating. To destabilize pro-FGM, anti-gay, anti-Semitic messages (etc.), you need to de-pedestalize the scriptures. You need to break out of the theocratic episteme, which clashes at so many points with many social beliefs and practices. This is not about to happen in Islam. No Reformation is in the offing. Ergo, weak or not, this line will continue to dog clerics and pose problems for them.

[...]

"Do you have any references on this "process of legitimization"? I'm surprised by your argument, because though fatwas [edicts] and religious pontificating are rife in the media here, I have yet to come across any references legitimizing FGM or even referring to it."

>

Sheikh Sharawi - whom I am sure you are familiar with - worked in the Kign Abd al-Aziz University during the 1970s before returning to Egypt.

But that is precisely my point: those who have spoken in support of FGM have almost consistently been Egyptian. Sharawi, whom you mention (incidentally, one of the "spiritual guides" behind the assassination of Anwar Sadat) is long dead and buried. And his sojourn in SA ended several decades ago. That Saudi Arabia remains free of FGM today means that Sharawi and his ilk did not succeed in propagating FGM there. At the time he was in Saudi Arabia, he was your run-of-the-mill cleric, no more illustrious than some of my Egyptian colleagues who teach with me in the UAE... But this is neither here nor there.

At the same time, many Muslims have equally been open advocates of the "Islamicity" of the practice. The denial of the existence of these currents is dangerous.

Yes, but a much closer reading of the facts on the ground is in order. FGM is not a phenomenon in the countries you are hypothesizing about. So, to assess potential dangers, we have to look not merely at what some over-zealous Azharite lecturer might have imbibed in Egypt and is blurting out, but equally at telling social data and statistics: we need to read the global picture, adopting at once a bird's and a worm's eyeview. I know I am not breaking any news to you by saying that it takes more than a religious trend of some specious provenance for FGM to be adopted in areas that never knew it.

It is

also paradoxical that those same voices that say "FGM is an un-Islamic practice" are the same voices that call for the killing of homosexuals in their discourse (but that is a different matter).

Yes, homophobia is rife, as are anti-Others discourses in general... But that's a different matter. :)

From the very beginning, I clearly indicated that what I was proposing is to look into things, and I stated a couple of hypotheses that I said should be tested through research! It would be naïve - to say the least - to assume that people read a fatwa and go out there doing what the fatwa says. But it would also be naïve to assume that the legitimacy offered by certain prominent scholars to certain practices do not have an impact in daily life, even if the impact is very long-term.

Well, as I said, Vanesa, I am not about to predict doom and gloom in the short or long term. I have, however, enjoyed our exchange and have learnt from it. You ask valid questions. Between the questions and the hypotheses and conclusions, however, is a yawning gap. That's all I wanted to say. I'll leave things at that.

Cheers,

Salwa Ghaly

complit01@yahoo.ca

Fri, 5 Mar 2004 18:11:25 -0000

From: Vanesa Casanova-Fernandez casanov@GEORGETOWN.EDU

Sent: 05 March 2004 15:42

Subject: Re: circumcision again

Ethan Miller wrote:

"But what seems clear to me--as somebody who, at least when it comes to medical issues, wants to assess things in a utilitarian way, which includes allowing people to decide whether they want or do not want a procedure such as circumcision based on their cultural tendencies as long as those cultural tendencies do not involve something decidedly dangerous--is that there is really nothing to be upset about surrounding the present state of this issue. The medical profession is neither forcing this practice on people nor making any recommmendation one way or another."

Exactly. Because the people who decide are not deciding for themselves (i.e. whether to circumcise themselves) but are deciding and playing with the lives of others (namely their children). And what makes circumcision unacceptable to many (myself included) is that is a non-reversable process in which the person it is performed on has no saying whatsoever. It's very difficult to know whether you want to be circumcised when you're 8. This is, effectively, relativism gone wild and does not solve the very serious problems raised by the practice of FGM.

Thank you.

vanesa

Fri, 5 Mar 2004 13:14:21 -0500

From: "Ethan Miller" <ezmiller77@yahoo.com>

Sent: 05 March 2004 13:01

Subject: circumcision again

Below I've attached an article which summarizes medical research into the advantages and disadvantages of circumcision. I think its conclusion is pretty much that there are a few advantages (decreased in likelihood of urinary tract infection, decrease in the transmission of HIV), but on the other hand it is fairly clear that, at least in "modernized" nations like the US, Canada, etc there is no reason for the medical establishment to come down on either side of the issue. That is, according to a pediatrician who I spoke with, in fact the current practice in the US that doctors follow: they inform the parents to the possible risks and the possible advantages, then let them decide. Often, as the article testifies as well, they decide whether they want the procedure based on issues that might be termed "cultural": how it looks, whether the father is circumcised, etc.

Now, you can go ahead and call this relativism gone out of control, but what I think is clear is that there is little to suggest that this practice is either inherently good or bad--unless, you, again for cultural reasons, have some strong objection to it, say because you sympathize with hippy notions of the purity of the body, you have a problem with the over-medicalization of the body, you object to the intrusion of a what you see as a practice of some "other" whether they be Jews or Arabs, etc. If you want to say that this is relativism gone out of control, then you must define the absolute principle that you want to privilege as truth and convince us why that principle is right. From a certain perspective, an attempt to inveigh against this practice also seems like relativism gone wild. But what seems clear to me--as somebody who, at least when it comes to medical issues, wants to assess things in a utilitarian way, which includes allowing people to decide whether they want or do not want a procedure such as circumcision based on their cultural tendencies as long as those cultural tendencies do not involve something decidedly dangerous--is that there is really nothing to be upset about surrounding the present state of this issue. The medical profession is neither forcing this practice on people nor making any recommmendation one way or another.

If you want, then, to rage against the medical profession as it was in the 40s or 50s when the practice began in the US, that is a different matter. Certainly the question of why the practice began is an interesting one. As one post suggested it is possible that there was a sort of crude Freudianism behind the decision, in the sense that the idea of mothers touching the penis of their child might have been felt to be psychologically unhealthy. That would be an interesting thing to examine, if only because it would show how the medical profession may or may not have become victim to cultural influences, and perhaps reveal something about the flash-points at which science becomes most clearly a cultural discourse. Yet, if we were to examine how the science of medicine had at moments become a cultural discourse, it would require also recognizing the rational, scientific arguments that might have been used. The pediatrician I spoke with suggested one: which is that in some cases not being circumcised can cause complications which are serious. For instance, after birth the foreskin is connected to the head of the penis by small fibers. In some cases, these fibers do not go away, and this can require correction later in life. The problem with this, is that circumcision, when done on adults is extremely painful. Pain can in fact last long after the procedure. This does not occur when the procedure is done on newly born infants. So, one can see that when a complication such as this was added to the connection that had been postulated but not researched (I think) between the uncircumcised and urinary tract infection, it could seem to a public health official a good idea to suggest the circumcision of all male children. After all, they might have thought, the practice had existed in other communities such as the Jews, and without problem. If this sort of argument is true, then at best you can accuse the medical profession of not doing sufficient research, and of taking liberties with people's bodies (albeit in a way that did not seem nor does it now to have any consequences). But it does not seem to me to be part of an evil plot, but simply a medical profession that over zealously supported a procedure with out doing enough research. To their credit, once the back to nature movement in the US started to raise questions in the 70s, the medical establishment responded quite quickly it seems. But all this would need to be researched. Has it been?

There's another interesting question too. As also evidenced in the article below, even after the American Pediatrics Association stopped recommending circumcision, people continued to request circumcision, such that the rate of circumcision only dropped from 80% to 60%, and it has subsequently risen back to around 80%. What's going on here? I think this would be very interesting to explore, both in terms of the way people responded to the introduction of this practice originally, and then how and why it has become part of people's cultural practice. Again, one could claim this to be a result of the power of medical discourse, but at the point where the medical discourse is no longer making any recommendation one way or another, something else seems to be going on. Finally, in terms of the objection to circumcision that seems most convincing, the lack of choice given the child: Are not the parents also exercising a choice when they choose not to circumcise? As I have pointed out, due to the painfulness of the procedure when performed later in life, it is not necessarily something that they can choose later in life.

Ethan

Ovid Technologies, Inc. Email Service

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Full Text of: Moses: Sex Transm Infect, Volume 74(5).October

1998.368-373

Sexually Transmitted Infections

Copyright (C) 1998 by Sexually Transmitted Infections

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Volume 74(5) October 1998 pp 368-373

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Male circumcision: assessment of health benefits and risks [For Debate]

Moses, Stephen; Bailey, Robert C; Ronald, Allan R Departments of Medical Microbiology, Community Health Sciences and Medicine, University of Manitoba, Winnipeg, Manitoba, Canada

S Moses A R Ronald

Division of Epidemiology and Department of Anthropology, School of Public Health, University of Illinois at Chicago, Chicago, Illinois, USA

R C Bailey

Correspondence to: Stephen Moses, MD, Departments of Medical Microbiology, Community Health Sciences and Medicine, University of Manitoba, Basic Medical Sciences Building, Room 543, 730 William Avenue, Winnipeg, Manitoba R3E 0W3, Canada.

Accepted for publication 7 May 1998

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Outline

Abstract

Introduction

Human immunodeficiency virus infection

Sexually transmitted diseases

Penile carcinoma

Cervical carcinoma

Urinary tract infections

Pain during circumcision

Complications of the circumcision procedure

Sexual and psychological issues

Conclusion

REFERENCES

Graphics

Table 1

Table 2

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Abstract

Objectives: Globally approximately 25% of men are circumcised for religious, cultural, medical, or parental choice reasons. However, controversy surrounds the procedure, and its benefits and risks to health. We review current knowledge of the health benefits and risks associated with male circumcision.

Methods: We have used, where available, previously conducted reviews of the relation between male circumcision and specific outcomes as "benchmarks" , and updated them by searching the Medline database for more recent information.

Results: There is substantial evidence that circumcision protects males from HIV infection, penile carcinoma, urinary tract infections, and ulcerative sexually transmitted diseases. We could find little scientific evidence of adverse effects on sexual, psychological, or emotional health. Surgical risks associated with circumcision, particularly bleeding, penile injury, and local infection, as well as the consequences of the pain experienced with neonatal circumcision, are valid concerns that require appropriate responses.

: Further analyses of the utility and cost effectiveness of male circumcision as a preventive health measure should, in the light of this information, be research and policy priorities. A decision as to whether to recommend male circumcision in a given society should be based upon an assessment of the risk for and occurrence of the diseases which are associated with the presence of the foreskin, versus the risk of the complications of the procedure. In order for individuals and their families to make an informed decision, they should be provided with the best available evidence regarding the known benefits and risks.

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Keywords: circumcision; HIV; STDs; penile carcinoma; urinary tract infection; sexual health

Introduction

Ritualistic circumcision has been carried out in west Africa for over 5000 years, and in the Middle East for at least 3000 years. [1] In the United States and Canada, circumcision appeared as part of the medical culture during the late 19th and early part of the 20th century, and by the early 1970s, about 40% of Canadian and 80% of American newborns were being circumcised. [2] In 1971, because of insufficient evidence as to health benefit, the American Academy of Pediatrics adopted a position against routine neonatal circumcision, and the rate of the procedure in the United States declined to about 60% by the mid 1980s. [3] In 1989, in the light of new evidence regarding associations between lack of circumcision and various health risks, the American Academy of Pediatrics modified its position to one of neither supporting nor discouraging the practice, [4] and there is some evidence that the circumcision rate in the United States has increased again (for example, to over 80% among infants delivered in US army hospitals in 1990). [5] Currently, about one quarter of men in the world are circumcised, largely concentrated in the United States, Canada, countries in the Middle East and Asia with Muslim populations, and large portions of Africa. We review here the current state of knowledge on the association between male circumcision and important health benefits and risks, as well as on the foreskin and sexual health. We have used, where available, previously conducted reviews of the relation between male circumcision and specific outcomes as "benchmarks", and updated them by searching the Medline database for more recent information.

Human immunodeficiency virus infection

In 1994, we conducted a review of epidemiological studies investigating the association between male circumcision and risk for human immunodeficiency virus (HIV) infection. [6] Of 30 studies that were identified at that time, 26 were cross sectional, of which 18 from six countries reported a statistically significant association, four from four countries found a trend towards an association, and four from two countries found no association. There were also two prospective and two ecological studies identified which reported significant associations. Since that time, we have identified reports from an additional 11 cross sectional and five prospective studies. Of the 11 cross sectional studies, one was from Cote d'Ivoire, [7] two from India, [8,9] three from Kenya, [10-12] one from Rwanda, [13] three from Tanzania, [14-16] and one from Uganda. [17] Eight reported a statistically significant association between presence of the foreskin and HIV infection, [7-12,15,17] one reported a trend towards an association, [16] one reported no association, [14] and one reported an increased risk with circumcision. [13] To our knowledge, the latter report is the only one in the literature in which, after controlling for potential confounding factors, male circumcision has been associated with an increased risk for HIV infection.

The two prospective studies reviewed in 1994 were both from Kenya. [18,19] The additional five prospective studies which have been identified since then are from India, [8,20] Kenya, [21] Tanzania, [22] and two from the United States. [23,24] The results of all seven are summarised in Table 1. Four have been published as papers and three as conference abstracts. For one of them, [24] additional information was provided from the authors that was not included in the conference abstract. In five of the studies, statistically significant associations were found between lack of circumcision and risk for HIV acquisition. In the two remaining ones, multivariate risk ratios were three or above, but did not attain statistical significance. Each of these latter studies was limited by lack of statistical power, one because of a low proportion of circumcised men in the sample, [8] and the other because of a small number of HIV seroconversions observed. [23]

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Table 1. Summary of results of prospective studies investigating the association between lack of male circumcision and risk for HIV infection

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It has been pointed out that different sexual practices or hygienic behaviours can confound the association between circumcision status and HIV infection. [25,26] For example, ethnic groups which perform ritual circumcision may have different sexual behaviours from those which do not circumcise. Thus, different risks of becoming infected may be due to behavioural factors, not circumcision status. Recently, this has been found not to be the case in eastern Uganda and Rwanda, where circumcised men were found in fact to engage in higher risk behaviours than uncircumcised men. [27,28] In addition, non-circumcising groups in Africa are suggested to have their distribution largely because of outward diffusion over time of loss of the circumcision ritual. [29] There is little reason to expect sexual behaviours to diffuse in parallel with lack of circumcision. In a Ugandan study, although no differences were found in various self reported hygienic practices between circumcised and uncircumcised men, [30] both men and women felt that it was more difficult to maintain genital cleanliness in uncircumcised men. Further research is required to clarify the relation between genital hygiene and risk for HIV and other genital infections.

The effect of circumcision in reducing the rate of increase of HIV infection at the population level may be greater than suggested by the two to threefold reduction in prevalence observed in most epidemiological studies. As Koopman and Longini have shown, with infectious diseases, where a disease outcome in a given individual influences exposures and outcomes in other individuals, risk measured at the individual level underestimates effects at the population level. [31] They argue that disease transmission models should be used to analyse the relation between risk factors for transmission and outcomes. When such modelling is conducted to analyse the population level effect of a potential risk factor such as male circumcision on HIV prevalence, dramatic effects can be demonstrated over time between populations where circumcision is practised and not practised. [32] The effect on populations can also be observed in ecological studies. Male circumcision is generally not practised in virtually all populations in which HIV seroprevalence exceeds 10% in "low risk" urban adult populations. [33,34]

Sexually transmitted diseases

The relation between the presence of the foreskin and sexually transmitted diseases (STDs) other than HIV is complex and varies with the individual STD. There is strong evidence for an association between ulcerative STDs (particularly chancroid and syphilis) and lack of circumcision in at least 11 studies. [12,18,35-43] We were unable to identify any studies with sufficient statistical power which reported increased risk with circumcision or no association.

For genital herpes, two studies have reported statistically significant associations with lack of circumcision, [37,44] and four have reported no association. [43,45-47] For gonorrhoea, five studies have reported significant associations with lack of circumcision, [35,37,43,48,49] and two have reported no association. [47,50] For chlamydial, non-gonococcal, or other types of urethritis, two studies have reported a significant association with lack of circumcision, [34,48] three have reported increased risk with circumcision, [42,47,50] and three have reported no association. [43,45,47] For genital warts, one study has reported a significant association with lack of circumcision, [34] one increased risk with circumcision, [43] and one no association. [45] In addition, associations have been reported between the uncircumcised foreskin and the presence of anaerobes, [51,52] as well as Gram negative rods, streptococci, and mycoplasmas. [52] These may potentially be transmitted to women, contributing to the bacterial vaginosis syndrome. The above findings are summarised in Table 2. Although there is some inconsistency among studies, there is good concordance for an association between lack of circumcision with chancroid, syphilis, genital herpes, and gonorrhoea. Only for urethritis other than gonorrhoea and genital warts is the evidence for an effect of circumcision inconclusive.

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Table 2. Summary of studies investigating the association between lack of male circumcision and risk for the "conventional" sexually transmitted diseases

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Penile carcinoma

In the 1989 review of the American Academy of Pediatrics' Task Force on Circumcision, [4] five major published studies of penile carcinoma in North America were identified, in which essentially all men with penile carcinoma had not been circumcised neonatally (circumcision later in life may not offer as much protection against penile carcinoma). [53] Similar observations have been reported from Africa. [54] Increased susceptibility to penile carcinoma among uncircumcised men may be mediated by the human papillomavirus. [55,56] A more recent case-control study from North America found a strong association between penile carcinoma and not being circumcised neonatally. [53] A cross sectional study from France found that penile intraepithelial neoplasia (PIN), which may be a precursor to penile carcinoma in some men, was also associated with lack of circumcision. [57] Although arguments have been advanced that improved hygiene will reduce the risk for penile carcinoma, there is no scientific evidence that this intervention is effective. It is estimated that about 750-1000 cases of penile carcinoma occur per year in the United States, virtually all among men who have not been circumcised at birth, [3] and mortality may be as high as 25%. [4] Neonatal circumcision reduces the risk for penile carcinoma by at least 10-fold, and probably by much more. It has been argued, however, that as most cases of disease occur in men over the age of 50, and as the disease is relatively rare (annual incidence of about 2 per 100 000 among uncircumcised men in North America), [3] neonatal circumcision is not a cost effective intervention with respect to the prevention of penile carcinoma alone. [58]

Cervical carcinoma

Cervical cancer is almost certainly a sexually transmitted disease, caused by oncogenic strains of the human papillomavirus. [4] Evidence linking risk for cervical cancer with uncircumcised male partners is largely ecological, drawing on the observation that cervical carcinoma is relatively uncommon in certain populations where men are generally circumcised. [59-61] In addition, a case-control study from India has reported that among women with one lifetime sexual partner, cervical cancer is significantly associated with having a husband who was not circumcised during the first year of life (risk ratio 4.1). [62] Although cervical and penile carcinoma are likely caused by the same agent, and penile carcinoma is strongly linked to the presence of the foreskin, a protective effect of circumcision of male partners with respect to the occurrence of cervical carcinoma remains to be demonstrated. Urinary tract infections In 1993, Wiswell and Hachey conducted a meta-analysis of studies reported in the literature which had investigated the association between lack of male circumcision and risk for urinary tract infection among male infants. [5] Nine studies were identified, six retrospective and three prospective. In all of the studies, uncircumcised infants were more likely to develop urinary tract infections than circumcised ones, with risk ratios ranging from 5 to 89. The meta-analysis yielded a pooled risk ratio of 12.0 (95% confidence interval 10.6-13.6, p

Pain during circumcision

The 1989 review of the American Academy of Pediatrics' Task Force on Circumcision noted that infants undergoing circumcision without anaesthesia demonstrate physiological responses suggesting that they are experiencing pain and behavioural changes. [4] More recently, it has been reported that circumcised infants exhibit a stronger pain response to subsequent routine vaccination than uncircumcised infants. [69] Local anaesthesia should be applied in all cases of neonatal circumcision, [70] either through dorsal penile nerve block, [71] the application of topical lignocaine-prilocaine cream, [72] or both.

Complications of the circumcision procedure

The 1989 review of the American Academy of Pediatrics' Task Force on Circumcision reported that the rate of postoperative complications of male circumcision was approximately 0.2% to 0.6%. The majority of complications are minor, the most common being local infection and bleeding, although two deaths from the procedure did occur in the United States over a 25 year period. [4] Another review has indicated that the complication rate may be somewhat higher, in the order of 0.2% to 2%. [73]

Sexual and psychological issues

Long term psychological, emotional, and sexual adverse effects from male circumcision have been claimed by some, but we were able to find only anecdotal accounts, [74] and scientific evidence is lacking. A longitudinal study which began in 1946 in Britain and followed more than 5000 individuals from birth to age 27 found no difference between uncircumcised and circumcised males in relation to a number of developmental and behavioural indices. [75] Although some maintain that male circumcision interferes with sexual satisfaction, [74] few studies have addressed this issue. In an American study examining female attitudes to male circumcision, 87% of college aged women expressed preference for pictures of circumcised penises over uncircumcised ones, [76] and when asked why they preferred to have sex with a circumcised man, 90% of a sample of predominantly white US women responded that it "looked sexier". Among women whose partners were uncircumcised, over 50% expressed preference for vaginal sex with a circumcised man, and this proportion was much higher if oral sex was considered. Among Ugandan tribes that do not generally practise male circumcision, women have indicated that they derive greater sexual pleasure from circumcised men. [30]

Laumann et al, [47] in a survey of more than 1400 American men, found that circumcised men reported a more highly elaborated set of sexual practices, and were slightly less likely than uncircumcised men to experience various sexual difficulties. There is indirect evidence suggesting that the foreskin may have an important sensory function, [77] although aside from anecdotal reports, it has not been demonstrated that this is associated with increased male sexual pleasure. Some loss of sensory function may not be an important consideration, or may not even be felt to be disadvantageous by men and women more troubled by premature ejaculation than concerned with increased penile sensitivity. [78] However, few studies have investigated the relation between male circumcision and sexual pleasure or satisfaction; more research is needed to clarify the role of the foreskin in sexual health.

Conclusion

In summary, substantive evidence supports the premise that circumcision protects males from HIV infection, penile carcinoma, urinary tract infections and ulcerative sexually transmitted diseases. Although we could find little scientific evidence of significant adverse effects on sexual, psychological, or emotional health, there are surgical risks associated with circumcision. A decision as to whether to recommend male circumcision in a given society should be based upon an assessment of the risk for and occurrence of the diseases which are associated with the presence of the foreskin, versus the risk of the complications of the procedure. Further analyses of the utility and cost effectiveness of male circumcision should be made in the light of currently available information. Although it may be debatable to recommend circumcision to reduce the risk of acquiring any one of the diseases noted above in isolation, taken together reduction in their overall risk appears compelling.

While the decision to circumcise or not is often made more on the basis of sociocultural values than medical knowledge, [79] people's preferences can be changed by information provided by health professionals, as indicated previously in relation to neonatal circumcision in the United States and the changing recommendations of the American Academy of Pediatrics. Experience from Africa may be similar. In eastern Uganda, 27% of uncircumcised men have indicated that they would opt for circumcision if the procedure could be performed at minimal cost, and 33% have indicated that they would choose to have their sons circumcised. [27] In South Africa, some indigenous healers have advised their uncircumcised male clients to be circumcised to avoid STDs and HIV infection. [80] It has also been observed in east Africa that, with the widespread publicity given to studies finding an association between lack of circumcision and HIV infection, clinics specialising in male circumcision have opened, and men now come to hospitals and clinics in increasing numbers to request circumcision for themselves and their sons. [81] While some argue against performing neonatal circumcision without the affected newborn male's consent, many men who later elect or require circumcision to treat phimosis or recurrent balanitis face a significant surgical procedure that would have been relatively minor if performed as an infant. It has been estimated that 10-15% of males not circumcised at birth will require the procedure later in life because of such problems. [82] Removal of the foreskin could be viewed as preventive care, analogous to other procedures, such as immunisation, which are administered to children without their consent. If male circumcision is to be promoted in any region, it should be in conjunction with the range of effective interventions with the range of effective interventions available (for example, condom promotion, behavioural change, and STD prevention and treatment to prevent HIV infection). In addition, adequate safety measures should be in place, and operational requirements must be met. [6,25] Since cultural traditions and social values are often paramount in the decision whether to circumcise or not, [76,79] there is need not only for clear explanations of the health risks and benefits of circumcision, but also for the ability by health professionals to act as cultural brokers, honouring clients' perceptions of health and optimal sexual function.

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69. Taddio A, Katz J, Ilersich AL, et al. Effect of neonatal circumcision on pain response during subsequent routine vaccination. Lancet 1997;349:599-603. Ovid Full Text Bibliographic Links

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71. Snellman LW, Stang HJ. Prospective evaluation of complications of dorsal penile nerve block for neonatal circumcision. Pediatrics 1995;95:705-8. Ovid Full Text Bibliographic Links

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73. Canadian Pediatric Society, Fetus and Newborn Committee. Neonatal circumcision revisited. Can Med Assoc J 1996;154:769-80. Ovid Full Text Bibliographic Links

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Fri, 5 Mar 2004 15:09:28 -0000

From: Vanesa Casanova-Fernandez casanov@GEORGETOWN.EDU

Sent: 05 March 2004 14:54

Subject: Re: FGM in the Arab world

Salwa,

Just to clarify, the first thing I said in my previous posting was that these are just hypotheses that would need to be researched thoroughly and further, I was simply calling for a more nuanced view of how research would need to be conducted. My concerns were methodological, and I think some of the questions I was asking are still legitimate, such as: when is a certain practice „legitimized‰ in discourse, by whom, and why? What is the relationship between discourse and practice? Is it possible that a practice that is foreign to a particular society becomes „traditionalized‰ within it at certain point and legitimized in legal/religious discourse?

You also said: „"Colony" may be a misleading word. There is a large Egyptian community in the UAE as well, but, as in Saudi Arabia, Kuwait and elsewhere in the Gulf, many Egyptian men come without their families on short contracts; their job security is nil and their living conditions are abysmal. I can't see how the practices of a disempowered, marginalized subaltern group can ever gain wider currency even if some Saudi Wahabis [Wahabism is an insular religious movement in SA] were to accept then confer value on FGM. The power and social dynamics in the Gulf/Arabian Peninsula region are such that locals and guest workers (even educated and skilled ones) live in two completely separate worlds.‰

Yes and no. While it is true that isolation plays a role in limiting the type of interactions that can take place amongst communities, this by no means signifies that communities are totally isolated from one another. Even if „isolated,‰ Egyptians in the Gulf watch television and read scholarly/religious literature mostly produced in the Gulf (not to mention attendance to mosques, meetings, study circles, etc.) At the same time, migrants contribute to the societies wherein they reside by bringing literature from their home country (religious publications, etc.). It goes both ways, and my point was: we cannot study these developments in isolation, but taking into consideration the dynamics of exchange of ideas in the societies we‚re studying. The advent of pan-Arab TV channels is perhaps the most paradigmatic example of how certain ideas „travel‰ now faster than before, but the truth is, the exchange of ideas has always occurred: students from Iraq, Syria, Palestine, or wherev er may choose to study in Al-Azhar, then go back to their home countries. True: FGM was not debated in Syria in the 1970s, but it is debated today. And the point is, why? Because at some point, the issue has been introduced somewhere, for certain reasons that ought to be studied.

You say: „There are no "emigres" or "immigrants" in SA. Those Egyptians can/could never gain immigrant status and are/were never integrated in any way into Saudi society. No guest worker goes there with the expectation to stay.

My question: does being in legal/non-legal status imply that people do not think, ask, and find a need to respond to their questions? When talking about immigration, I don't refer to whether one has legal or illegal status as an immigrant. I don‚t think the status of an immigrant deters him/her from the kind of interaction I am talking about.

Do you have any references on this "process of legitimization"? I'm surprised by your argument, because though fatwas [edicts] and religious pontificating are rife in the media here, I have yet to come across any references legitimizing FGM or even referring to it.‰

Sheikh Sharawi ˆ whom I am sure you are familiar with ˆ worked in the Kign Abd al-Aziz University during the 1970s before returning to Egypt. Although I don‚t have specific references here, I recall reading several fatawa by him justifying female circumcision and advocating it as a „preferable, although not necessary‰ practice that should be performed in its "minor" manner. Although I have abandoned researching the issue a long time ago, I recall reading other sheikhs from Syria justifying the practice. Moreover, while I attended Arabic lessons at a local mosque in Madrid during the mid-1990s, the issue was discussed by the instructor, a Spanish-Moroccan lady married to a Syrian man who had immigrated to Spain for political reasons, him being a member of the Muslim Brotherhood. The kind of literature they read was printed mainly in Egypt and the Gulf, and yes: it justified „limited‰ FGM for reasons that I remember well. FGM, they said, „protects‰ the woman from masturbating and even from ˆ heaven forbid! ˆ becoming a lesbian. It is done ˆ they said ˆ for „health reasons‰ because in hot climates vaginal discharges can have a terrible odor and provoke infections, arouse women sexually, etc. etc. etc. Were they going to undertake the practice themselves? Honestly, I don‚t know, but both of them came from two traditions where FGM was a foreign practice and here they were, justifying it with the backing of scholarly texts, in Spain!! I am not saying everybody who reads a fatwa goes out and decides to mutilate their daughter, but the mere fact that the literature legitimizing the practice as „Islamic‰ exists certainly opens the door for this to happen. I believe also Sheikh al-Munajjid (from Dahran province) legitimized the practice, and although I would have to go back to the sources and check, I think Sheikh Ibn Baz had also something to say about it.

This discourse is based on "Ijtihad," as I'm sure you are aware, meaning that clerics are forever involved in scholastic-type exegetical pursuits. Consensus is hard to reach (as attested by the current debates on Jihad or "crusades" against "infidels" etc). Since there is nothing in the Quran to support FGM, I can't see how Muslim Sunni clerics in the Arabian peninsula might one day decide en masse to advocate FGM.‰

Scholars do not need to en masse advocate a certain practice for it to exist or to receive some degree of legitimacy. This is the case in Egypt , where the scholarly (religious) community is clearly divided on this particular issue. Also, the fact that it is not in the Quran, as you very well know, means very little to certain people. Male circumcision is also not in the Quran, but is sunnah confirmed through both practice of the community and numerous ahadith. I believe there are differences with regards to male circumcision between schools: Hanafis state obligatory circumcision for males, whereas Shafiis establish both male and female circumcision as nearly obligatory. With regards to Hanbali and Maliki I am not certain.

Another point: while some may well be for more oppression of women through importation of FGM, many Muslims, even Islamists, have gone online to shatter the impression many have that Islam condones FGM.‰ At the same time, many Muslims have equally been open advocates of the „Islamicity‰ of the practice. The denial of the existence of these currents is dangerous. It‚s kind of what happened in September 11th, when everybody went out of their way to say that these acts where „against Islam.‰ ***Whose*** Islam??? It‚s very easy to delegitimize the discourse of sectors that we consider „radical‰ and unacceptable, but it certainly doesn‚t solve the problems posed by their existence. It is also paradoxical that those same voices that say „FGM is an un-Islamic practice‰ are the same voices that call for the killing of homosexuals in their discourse (but that is a different matter).

A cursory look at a few online Muslim sites supports the impression I have that Muslims are trying hard to dissociate Islam and FGM.‰

What Muslims, and where? This is exactly what I was trying to say: the Muslims that go online are not the only Muslims in the world, and I would dare say, they are a minuscule percentage of Muslims worldwide. Just because a certain discourse is online, it does not become the only truth, nor does it become the only view. I am not devaluing the internet as a source (I‚m working right now on a very related topic myself!) but what I am saying is: we must study ***all*** discursive spaces where interaction can take place. In this regard, James C. Scott‚s notion of the „hidden transcript‰ is very pertinent. We need to study both the public transcript and the hidden transcript. It is important to study what is going on the Internet (and how do we measure and quantify the effects of a certain site?), but it is also important to study when certain fatwas begin to appear, who wrote them, where this person was educated, what impact this person has in other areas (and Sharawi is a good e xample). We need to look at alternative spaces where discourses are being shaped and transmitted: official mosques, „illegal‰ mosques run by organizations deemed „illegal‰ by the State, meetings, Quran reading classes for men and women (are they different? Do they ask different questions? Why?), etc. etc. etc. Unless we look at all these spaces of interaction and exchange, I don‚t think we‚ll be able to understand the topics we‚re studying.

Some go as far as to suggest that those Westerners who maintain that a connection exists are willfully giving Islam bad press. In other words, there are many Muslim "activists" [I hesitate to call them outright clerics] out there who are vociferously anti-FGM. A good sign, to say the least.‰

Yes, and I have never denied that. But this is not the discourse that concerns me. In 1997, you will remember the terrible blow dealt by the Egyptian government to these anti-FGM activists. In 1996, the Egyptian Minister of Health issued a ban prohibiting female circumcision (khitan al-inath or khitan al-banat) in state hospitals. A year later, the order was challenged in court by a group of doctors (with the support of prominent scholars). Finally in 1997, the court in charge of the decision overturned the initial prohibition. In between, however, an unprecedented debate took place in the media ˆ a debate that spilt to other parts of the Arab world ˆ in which everybody had something to say. The sheikh of Al-Azhar (sheikh Tantawi) supported the state ban on female circumcision, but he also said that if performed, the practiced should be carried out by „expert doctors,‰ thus partially legitimizing the practice (?); numerous other activists and scholars came out in favor of it.

Why assume that people might slavishly follow a new edict on FGM if one were to come into existence?‰

Who is assuming that? From the very beginning, I clearly indicated that what I was proposing is to look into things, and I stated a couple of hypotheses that I said should be tested through research! It would be naïve ˆ to say the least ˆ to assume that people read a fatwa and go out there doing what the fatwa says. But it would also be naïve to assume that the legitimacy offered by certain prominent scholars to certain practices do not have an impact in daily life, even if the impact is very long-term. And it would certainly be naïve not to look into how certain ideas come into place and how they may ˆ or may not ˆ impact local practices.

Why not Lebanon and Turkey as well?! They, too, have large Sunni populations. No, I think Syria is a tall order. I can't imagine Syrian families becoming so brainwashed by alien and suspect religious views as to even contemplate importing FGM. Unlike most other Arab countries, even the return-to-the-veil phenomenon hasn't taken root there. The Muslim Brotherhood movement has not exactly received government sanction in secular Syria.‰

I do not know Lebanon or Turkey and thus have not commented on them. We could also talk about Indonesia or Malaysia , where there seems to be evidence that the practice of FGM is surfacing now among certain sectors of the population. But also, Turkey and other non-Arab speaking countries are a different matter from what I was talking about: in that case, ideas not only need to travel: they need to be ***translated*** (and I‚m not just speaking of linguistic translation), with all that it implies.

With regards to Syria: the reason why the return-to-the-veil phenomenon has not taken place en masse (and I partially disagree: there are more veiled women in Syria, Jordan and Palestine ˆ including women who wear full-face veil or niqab - today that there ever were in the past) has less to do with what people want to do than with Syria being a police state where wearing certain clothes can still land you in jail because of its association with membership in the Brotherhood. It‚s also interesting that you argue that people who defend FGM as Islamic practices must be „brainwashed.‰ Why? What makes you say so?

ŒAlso, for FGM to spread to a new area where it is unknown and where it is not tied to rituals or rites of passage, there has to be, not just an audience with an unequivocal pro-FGM position, but also a whole infrastructure, including physicians and hospitals ready to perform FGM.‰

Granted, but I don‚t think that there needs to be „an audience with an unequivocal pro-FGM position.‰ Take some immigrant communities in Europe. They don‚t have hospitals; it‚s illegal, and they‚re risking going to jail. And they still do it.

Thanks for reading,

Vanesa Casanova

Fri, 5 Mar 2004 18:11:27 -0000

From: Vanesa Casanova-Fernandez casanov@GEORGETOWN.EDU

Sent: 05 March 2004 15:52

Subject: Re: FGM in the Arab world

Another example (sorry for the multiple postings)

Sheikh Yusuf al-Qardawi - another Egyptian-born TV-super-star sheikh based in Qatar - also defended the practice: "In any case, whoever thinks that this [practice] will safeguard his daughters better, then do it; I endorse this, particularly in our present age. And whoever doesn't do it, there is no sin in that [fa-la junah alayhi]." Source: http://www.almansiuon.com/women/serry/038.htm Thank you.

vanesa

Fri, 5 Mar 2004 18:11:29 -0000

From: "Salwa Ghaly" <complit01@yahoo.ca>

Sent: 05 March 2004 16:09

Subject: Re: FGM in the Arab world

Robert Darby wrote:

There is nothing in the

Koran authorising male

circumcision either (no mention of it at all), yet

most Moslems regard

this

as an indispensable part of their religious

obligation.

True, unfortunately.

The practice is

based on a brief remark attributed to the prophet,

but he said the same

thing about the value of circumcision for both men

and women: that it

was

equally meritorious for both, but obligatory for

neither.

Attribution is one of the Islamic "sciences".

Interestingly, the quotation attributed to Muhammad reagarding FGM is considered "weak", i.e. unreliable, by clerics in countries where FGM is not practiced, and is brandished as proof of the importance of the practice in countries that do. "Quotations," or _Hadiths_ were speeches made by the Muslim prophet: each hadith is supposed to have been heard by one of Muhammad's companions and was then passed on through a chain of disciples of varying reliability until it was textualized. This, of course, was in the pre-Derrida days when people, lost souls that they were, believed in origins and authentic texts!

The supposed reliability of all the hadiths was later evaulated and determined by schools of Islamic interpretation. Needless to say, in any exegetical endeavor, clerics empowered to undertake the process of interpretation find what they expect/hope to find. The supposedly pro-FGM hadith has, thus, lent itself to two diametrically opposed usages. Now, does it prove or disprove that FGM was practiced in pre-Islamic/ early Islamic Arabia? Who knows. Hadith scholarship developed in several Muslim cities, including Cairo, around the same time, and a pro-FGM line might have been expedient for those looking for renewed legitimation of a pre-Islamic practice in places where FGM was accepted.

Dr Sami Aldeeb, "To mutilate in the name of Allah or

Jehovah: The

legitimation of male and female circumcision"

Medicine and Law, Vol 13, No 7-8, 1994, pp. 575-622

http://www.cirp.org/library/cultural/aldeeb1/

Aldeeb's work is very useful for researchers working on FGM in Egypt/Sudan. It is a scathing critique of the discourse of the Egyptian clerical establishment on the issue. The sheikhs Aldeeb takes to task are all products of that ossified body they call the oldest university in the world: the Egyptian al-Azhar.

A Moslem site explaining why women should be

circumcised and listing

the hygienic and medical benefits

http://www.themuslimwoman.com/hygiene

The identity of that site is unclear. My guess is that it is maintained by people who issue from a pro-FGM society. Here is one example of the sites that take the opposite view. The "authority" arguing against FGM in the site below is a Saudi university professor in Islamic jurisprudence.

http://www.islamset.com/hip/health5/forewor5.html

Salwa Ghaly

complit01@yahoo.ca

Tue, 2 Mar 2004 19:46:14 -0000

From: "vern bullough" <vbullough@adelphia.net>

Sent: 02 March 2004 19:28

Subject: female circumcision

I am reluctant to enter the debate on female circumcision but the the recent issue of Population Brief has an article on potential data bias in studies of female circumcision. In 1994 the government of Ghana passed a law banning female genital cutting and in 1996 a circumciser was jailed . Since then there has been a notable decrease in the stigma attached to women who are not circumcised. The Navrongo Health Research Center began recording demographic evens in 1993. In 1995 almost 2,400 of the 5, 275 women surveyed answered the question are you circumcised, and the other surveys has since been conducted.. They could compare the answers of women in 1995 with those in 2000 and the respondents were placed into four categories. In the first two categories were women whose survey answers in the two years agreed. In both surveys they reported either that they had or had not undergone circumcision. In the other two categories were women whose two survey answers disagreed.One group were those women who had reported being circumcised in the first study but said they had not been in the second, an impossible sequence of events. a much smaller group included those who said they had not been circumcised in the first and had in the second.The explanation offered to explain the impossible contradiction of those reporting they had in the first and not the second is that the stigma of not being circumcised was so great that they felt pressured to give what they thought was a socially appropriate response. Because being uncircumcised had become less stigmatized by the second sample, those women may have felt more comfortable reporting their true status. Whether women were simply not telling the truth can only be determined by having a physical exam, but this is almost impossible because of cost and reluctance of women to participate. Interestingly also the more education a woman had, the less likely she was to be circumcised. The only lesson to e drawn from this is that caution has to be used in interpreting data on female genital cutting, and there is a lot of false reporting of circumcision status. The study if you want to trace it down is Jackson, E.F., P. Akweongo, E. Sakeah, A. Hodgson, R. Asuru, and J. Phillips, 2003. Inconsistent reporting of female genital cutting status in northern Ghana: Explanatory factors and analytical consequences, Studies in Family Planning, 34 (3) 200-210.

Vern L.Bullough

Mon, 01 Mar 2004 18:08:28 +1100

From: RobD <robjld@webone.com.au>

Subject: Re: Pure quackery (was Health evidence for

circumcision)

I really don?t want to strain people's patience with any more ranting and raving on this subject. I am sure I have said too much already. I think that the Washington Times article makes the intentions of the US Agency for International Development perfectly clear: if they can't force circumcision on black adults, they will try to persuade them to circumcise a class who lack the power to object - their children.

Recent messages from Oscar W and Margaret Robinson have highlighted the dubious science, medicine and ethics of such a program with great clarity.

Since Andrew asks about cost/benefit analyses, I happen to know that a researcher at the Marshfield Clinic did do a very detailed cost/benefit analysis of circumcision as a strategy against AIDS, using the assumption that the connection between foreskin and HIV infection promoted by Bailey, Short, Halperin, Moses etc was correct (which it is probably not). Even then he found that it was grossly inefficient, with far higher costs, more adverse outcomes and less effect per dollar than educational campaigns to promote safe sex and cleanliness. No American medical journal would publish the analysis because their editors are already wedded to the idea that circumcision is the quick fix, and because American medicine is still in the grip of the Victorian delusion that the penis (and more especially a certain part of it which shall remain nameless) is somehow the root of all sexual evil.

With respect to Andrew's last point, health arguments for circumcision do not apply regardless of culture, because culture is a major determinant of sexual behaviour, and that is the decisive factor in whether a person contracts STDs, as Oscar so eloquently explained.

Now it is my turn to apologise for ranting at such length. If anybody would like further references, please contact me off-list.

Robert Darby

Canberra

Australia

Mon, 1 Mar 2004 09:01:57 -0500 (EST)

From: "Ken Mondschein" <editor@corporatemofo.com>

Subject: Re: Fwd: Re: health evidence for circumcision

Bev Smith asked:

What is a "higher standard of sexual conduct"?

One in which persons are expected to follow certain community values, say monogamy, no premarital sex, abstinence from homosexual relations, etc. I don't mean to imply a value judgment int this, but rather an idea of discipline - an idea that is certainly consonant with circumcision.

--

Ken Mondschein

editor@corporatemofo.com

Sun, 29 Feb 2004 21:12:14 -0500

From: "Bev Smith" <Bev.Smith@mail.wvu.edu>

Sent: 27 February 2004 14:16

Subject: Re: health evidence for circumcision

Rosemary Ryan wrote:

>HIV rates are demonstrably lower among peoples where circumcision is normative, and marked higher where it is not practiced.

Ken Mondschein responded

>Could this be due to behavioral factors? Say, a higher standard of sexual conduct amongst Muslims?

What is a "higher standard of sexual conduct"?

Bev Smith, West Virginia University

29 February 2004 21:43

From: "Margaret Robinson" <margaret.robinson@utoronto.ca>

Sent: 29 February 2004 21:43

Subject: Re: health evidence for circumcision

Circumcision might be correlated to lower HIV transmission, but it doesn't necessarily follow that it ought to be promoted.

For example, I bet castration would have an even higher correlation to lowered rates of infection, but I wouldn't want to promote that. Plus, it would be difficult to get volunteers for such a study.

Margaret Robinson

Toronto

http://www3.sympatico.ca/moogie.robinson/index.html

27 February 2004 23:29

From: "RobD" <robjld@webone.com.au>

Sent: 27 February 2004 23:29

Subject: Pure quackery (was Health evidence for circumcision)

I am pleased that Oscar and I have found ground on which we can agree.

What he says about HIV transmission is absolutely right, and the simple fact that it is sexual behaviour, not anatomy, which is the main factor determining whether a person will become infected with STDs seems to elude those naive but brutal researchers who think they have found a miracle solution to the AIDS crisis in penile surgery. They might as well advocate the pre-emptive excision of a lung so as to reduce the danger of SARS, or cauterisation of the nasal and throat passages so as to block the many common infections which get in that way. To say nothing of what might be done to women to reduce the area of their susceptible ("treacherous") genital mucosa.

I'm surprised, though, that the argument from culture does not seem to carry much weight here. It seems to work only one way. Judging from many of the posts in this discussion, which tend to be romantically anti-western and anti-modern in their tenderness for the exotic and the primitive, we are not allowed to discourage circumcising cultures from dropping the practice, but it’s fine and commendable for USAID and US medical bodies to try to foist circumcision on non-circumcising cultures in Africa, and even India, as a supposedly valuable tactic in the fight against AIDS. I should have thought that such a blatant example of medico-cultural imperialism, and from the USA at that, would have sent those who value the specificity of other cultures up in arms. Isn't it an example of racist stereotyping for Americans to assume that sex-crazed black men will never be able to direct their sex drive into safe channels?

The idea that pre-emptive surgery is the miracle-working answer to the AIDS crisis should be treated very sceptically by historians. The evidence for it is on a par with the abundant evidence in nineteenth century medical journals that masturbation caused tuberculosis, madness, pimples and premature decay (et tutti quanti), and the equally promoted delusion that circumcision provided immunity to syphilis. Whenever an incurable illness turns up, desperate people try to find scapegoats: in the Black Death it was witches and Jews. In the nineteenth century, when sexuality was seen as the root of most evil, doctors blamed "sexual excess" for many diseases, the foreskin for premature sexual arousal, masturbation, epilepsy and a host of other illnesses, and the clitoris for hysteria, catalepsy and other nervous complaints. American medicine has a particularly fine record in this area. In 1896 the Medical Record listed the following indications for male circumcision:

Hygienic indications: phimosis, paraphimosis, redundancy (where the prepuce more than covers the glans), adhesions, papillomata, eczema, oedema, chancre, chancroid, cicatrices, inflammatory thickening, elephantiasis, naevus, epithelioma, gangrene, tuberculosis, preputial calculi, hip-joint disease, hernia. Systemic indications: onanism, seminal emissions, enuresis, dysuria, retention [of urine], general nervousness, impotence, convulsions, hystero-epilepsy. (Medical record, Vol. 49, 1896, p. 430).

The logical flaws in and ethical bankruptcy of the case for mass circumcision in Africa are examined in in Robert Darby, "Been there, done that: Thoughts on the proposition that yet more circumcision can save the world from AIDS", Australian Quarterly, Vol. 74, Sept-Oct 2002. Since this journal may not be readily available overseas, I am happy to send a copy of the article to anybody who would like one.

Since this was published we have learned from research by David Gisselquist that a major cause of HIV transmission in Africa is unsafe surgical practices, including circumcision. In fact, some tribes are abandoning circumcision because they have realised that it is doing a lot more harm than good. In South Africa it is indisputable that more boys under 20 die as a direct result of circumcision than contract HIV through their supposedly viro-tropic foreskins. (See Editorial, "Astonishing indifference to deaths from ritual circumcision", South African Medical Journal, Vol. 93, August 2003). The very fact that Africa has poor medical resources, as Rosemary points out, is a reason why circumcision - a complex surgical procedure which has a serious rate of nasty complications even in western hospitals - should NOT be introduced.

Gisselquist's research is summarised, with references, at http://www.circinfo.org/news.html

For those who wish to read further than hysterical and misleading media beat-ups (the main source of the delusion that forcible mass circumcision is the answer to the AIDS crisis), the following thoughts by Greg Boyle may be of interest.

Issues associated with the introduction of circumcision into a non-circumcising society

G J Boyle

Bond University, Gold Coast, Qld 4229, Australia

gregb@bond.edu.au

Sexually Transmitted Infections, Vol.79, 2003, pp. 427-428

A team lead by Kebaabetswe propose the introduction of infant circumcision in Botswana, based on:

* a survey of its acceptability to Batswana (people of Botswana)

* its practice in certain Western nations, and

* its alleged value in preventing HIV infection.1

There are several medical, psychological, sexual, social, ethical, and legal problems with this proposal.

Medical effects

Male neonatal circumcision is not an innocuous procedure. There are many complications ranging from trivial to life threatening. Complications generally include bleeding, infection, and surgical accident, including penile necrosis and penile amputations.2 Bleeding or infection can progress to death.3,4 It is difficult to control complications with mass circumcisions.5 Circumcision excises significant amounts of nerve bearing penile skin and mucosa, especially the ridged band structure near the mucocutaneous boundary.6 The protective effects of circumcision against HIV remain controversial.7 UNAIDS has not accepted circumcision as a useful public health measure.

In neighbouring South Africa, many children are infected with HIV.8 This is attributed to unsafe health care.

Circumcision creates an open wound through which infection may proceed.9 It is not clear that safe aseptic circumcisions can be delivered in Botswana. It is possible that mass circumcision may worsen the epidemic.

Psychological effects

Psychological manifestations of circumcision have been an area of study at Bond University. Neonatal circumcision is an intensely painful, traumatic, and stressful operation.10 General anaesthesia is unsafe in the newborn. Available methods of anaesthesia are only partially effective.10 Circumcised infants show hypersensitivity to pain suggestive of post-traumatic stress disorder (PTSD).11 Our study of the incidence of PTSD in the Philippines found extensive PTSD in circumcised boys.12 PTSD secondary to neonatal circumcision has been documented in adult males.13 Victims of trauma tend to re-enact their trauma either on themselves or others in a cycle of violence.14 Circumcised males may rely on psychological defence mechanisms such as rationalisation and denial, and strongly avoid thoughts, feelings, or conversations about circumcision.15

There are additional concerns. The state of the phallus is closely related to a man’s sense of wellbeing.16 Men who were circumcised neonatally may feel unhappy about being circumcised, experience significant anger, sadness, feeling incomplete, cheated, hurt, concerned, frustrated, abnormal, and violated. In addition, circumcised men may suffer from resultant low self esteem,16 which frequently can result in a host of disordered behaviours.

Circumcision may be difficult to eradicate from a society once it is introduced. In addition, to the re-enactment described above,16 Goldman reports that circumcised men tend to defend the practice.16 Circumcised doctors tend to develop intellectual arguments to support genital cutting.17 Fathers who are circumcised may adamantly insist on a son’s circumcision in an emotional defence against their own painful feelings of grief for a lost body part and reduced sexual function.18 Kebaabetswe et al (page 217) reported that, "Being circumcised was the only significant predictor for a man who would definitely or probably circumcise a male child."

Sexual effects

As noted above, circumcision excises large amounts of skin and mucosa from the penis. The removal of the prepuce tightens the remaining skin and makes it relatively immobile. Since stimulation of the sex nerves normally occurs by movement of the mobile skin, this further desensitises the penis,17 perhaps even more than the removal of the ridged band of erogenous nerves noted by Taylor.6 Excision of sexual nerve endings necessarily reduces sensory input. A decrease in sensation may therefore decrease the sexual response.19,20

Male circumcision also may adversely affect female sexual response. A survey of women found that they were markedly less likely to have an orgasm with a circumcised partner.21

Social effects

There has been little study of social problems that may occur when entire cohorts of males are circumcised and consequently most of the men in a society bear physical and psychological wounds associated with circumcision.

We might expect more dependence on alcohol to relieve the symptoms of PTSD. Low self esteem may generate a feeling of shame. Shame may generate problems with relationship dissatisfaction, poorer health, depression, drug use, and loneliness. Increased sexual incompatibility and marital problems in circumcised societies might be expected as a result of reduced penile sensory input, increased sexual dysfunction, PTSD, and low self esteem among circumcised men.22 Increased antisocial behaviour may also be expected. Thus, we might expect to see higher levels of domestic violence, rape, child sexual abuse, suicide, and theft.22

Human rights

The fight against HIV-AIDS requires the careful protection of human rights.23 Among these human rights one finds the rights to security of the person and protection from degrading treatment. The unnecessary excision of normal human tissue6 from unconsenting minor children is an obvious violation of the security of the person.

Through amputation of erogenous tissue, circumcision necessarily diminishes sexual sensation and function as described above and may constitute degrading treatment.

Ethics

Doctors have a duty of care to behave in an ethical fashion. Among other requirements, they are expected to respect the human rights of their child patients.24 Circumcision has been shown to be a violation of the child’s human rights and, clearly, many ethical doctors are unwilling to carry out destructive circumcisions on normal, healthy boys. The British Medical Association recognises the right to conscientious objection to the performance of circumcision.24

Law

Male circumcision is not unlawful, but valid consent must be obtained. This may be a problem in the case of circumcision performed on unconsenting minors, in the absence of any medical indication.

Cases involving the right of parents to consent to the non-therapeutic surgical sterilisation of a child have been heard in several nations.25,26 The cases agree that, in the absence of any medical indication, parents are not empowered to consent to the non-therapeutic, irreversible, surgical alteration of their child’s genitals.

In the absence of a valid consent, a circumcision may constitute an assault.27

Conclusion

The value of male circumcision in preventing HIV infection remains unclear. Non-sterile circumcisions may increase the risk.

The proposal by Kebaabetswe and colleagues for the introduction of circumcision into Botswana is seriously flawed, and is irresponsible in failing to place the emphasis on safe sex practices. As described here, there are many medical, sexual, psychological, social, human rights, ethical, and legal aspects that must be considered.

Reliance on circumcision to prevent HIV transmission is wishful fantasy, and can only result in a calamitous worsening of the HIV-AIDS epidemic.

Once started, circumcision tends to persist even when the need is over. Circumcision was introduced more than 100 years ago in Western nations on the grounds than it would prevent masturbation, which would prevent mental and emotional illness. That, of course, is no longer believed, but the practice of circumcision persists and has proved difficult to eradicate although progress is being made. The incidence of circumcision is declining in Western nations. The Department of Health of the Philippines is trying to discourage circumcision (called "tule") in that nation where it has persisted.28 The practice of neonatal circumcision in certain Western countries such as the United States does not constitute a valid reason for introducing neonatal circumcision in Botswana.

Extreme care must be taken in a decision to introduce circumcision into a society.

References

1. Kebaabetswe P, Lockman S, Mogwe S, et al. Male circumcision: an acceptable strategy for HIV prevention in Botswana. Sex Transm Infect 2003;79:214–19.[Abstract/Free Full Text]

2. Williams N, Kapila L. Complications of Circumcision. Br J Surg 1993;80:1231–6.[Medline]

3. Scurlock JM, Pemberton PJ. Neonatal meningitis and circumcision. Med J Aust 1977;1:332–4.[Medline]

4. Proctor P. Totally unexpected death of baby probed. The Province. Thursday, 29 August 2002. Vancouver: British Columbia.

5. Ozdemir E. Significantly increased complication risks with mass circumcisions. Br J Urol 1997;80:136–9.[Medline]

6. Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996;77:291–5.[Medline]

7. Van Howe RS, Cold C, Storms MR. Some science would not have gone amiss. BMJ 2000;321:1467.[Free Full Text]

8. Brody S, Gisselquist D, Potterat JJ, et al. Evidence of iatrogenic HIV transmission in children in South Africa. Br J Obstet Gynaecol 2003;110:450–2.

9. Committee on Fetus and Newborn. Standards and recommendations for hospital care of newborn infants. 6th ed. Evanston, IL: American Academy of Pediatrics, 1977:121.

10. Lander J, Brady-Freyer B, Metcalfe JB, et al. Comparison of ring block, dorsal penile nerve block, and topical anesthesia for neonatal circumcision. JAMA 1997;278:2158–62.

11. Taddio A, Katz J, Ilersich AL, et al. Effect of neonatal circumcision on pain response during subsequent routine vaccination. Lancet 1997;349:599–603.[CrossRef][Medline]

12. Ramos S, Boyle GJ. Ritual and medical circumcision among Filipino boys: evidence of post-traumatic stress disorder. In: Denniston GC, Hodges FM, Milos MF, eds.Understanding circumcision: a multi-disciplinary approach to a multi-dimensional problem. New York: Kluwer/Plenum, 2001.

13. Rhinehart J. Neonatal circumcision reconsidered. Trans Analysis J 1999;29:215–21.

14. Van der Kolk BA. The compulsion to repeat the trauma: re-enactment, revictimization, and masochism. Psychiatr Clin N Am 1989;12:389–411.

15. 309.81 Posttraumatic Stress Disorder. In: Diagnostic and statistical manual of mental disorders. 4th ed. Washington: American Psychiatric Association, 1994:424–9.

16. Goldman R. The psychological impact of circumcision. BJU Int 1999;83(Suppl 1): 93–103.[CrossRef][Medline]

17. Gemmell T, Boyle GJ. Neonatal circumcision its long-term sexual effects. In: Denniston GC, Hodges FM, Milos MF, eds. Understanding circumcision: a multi-disciplinary approach to a multi-dimensional problem. New York: Kluwer Academic/Plenum, 2001.

18. Boyle GJ, Goldman R, Svoboda JS, et al. Male circumcision: pain, trauma and psychosexual sequelae. J Health Psychol 2002;7:329–43.[CrossRef]

19. Winkelmann RK. The erogenous zones: their nerve supply and significance. Proc Staff Meetings Mayo Clinic 1959;34:39–47.

20. Halata Z, Spaethe A. Sensory innervation of the human penis. Adv Exp Med Biol 1997;424:265–6.[Medline]

21. O’Hara K, O’Hara J. The effect of male circumcision on the sexual enjoyment of the female partner. BJU Int 1999;83(Suppl 1): 79–84.[CrossRef][Medline]

22. Goldman R. Circumcision: the hidden trauma. Boston: Vanguard Publications, 1997:139–75.

23. United Nations High Commissioner for Human Rights. HIV/AIDS and human rights. Geneva: Office of the United Nations High Commissioner for Human Rights, 2002(available at www.unhchr.ch/hiv/index1.htm#approach ).

24. Committee on Medical Ethics. The law and ethics of male circumcision www.bma.org.uk/ap.nsf/Content/malecircumcision2003 ).

25. E (Mrs) v Eve, 2 SCR 388 (1986), Supreme Court of Canada.

26. Secretary, Department of Health and Community Services v JWB and SMB. Marion’s Case 1992:175 CLR 218 F.C 92/010, High Court of Australia.

27. Boyle GJ, Svoboda JS, Price CP, et al. Circumcision of healthy boys: criminal assault? J Law Med 2000:301–10.

28. Ramos GAS. Circumcision: the uncut version. Healthbeat (Manilla) 2003(available at www.doh.gov.ph/mmc/issue01/tule.htm ).

Sun, 29 Feb 2004 17:56:51 -0000

From: <oscarw@yorku.ca>

Sent: 29 February 2004 14:55

Subject: Re: health evidence for circumcision

The literature from which the report on circumcision and HIV transmition was based came from 27 studies in Africa. Science is not my field, but from what I remember, for a scientific study to support a hypothesis such as foreskins affect the rate of HIV transmission, then the study needs to be replicated elsewhere, or are African foreskins different than other foreskins? Considering all the research done on gay men in North America, isn't it strange that, after 20 years, no one has found that, say, more gay Muslims and gay Jews don't/do contract the virus than, say, gay Catholics? (Maybe the transmission has nothing to do with the foreskin, but that the HIV virus has a strong religious bias.)

Does this type of research truely stop the transmission of HIV, or is it just a means to start/stop circumcisions? You cannot transmit the virus, with or without a foreskin, unless you have the virus. You can not get the virus, with or without a foreskin, unless you are involved in unsafe practices with someone who has the virus. More skin, whether penile or vaginal, creates a higher probability, but the salient word in the study was "unprotected" sex. You have a higher probability to be bit by playing with two rabid pitbulls than with one, but you won't get bit at all if you put muzzles on them beforehand.

How will information such as the one on foreskins and HIV be perceived by the general public? Anyone who has been involved in the HIV community since the beginning will remember all the crazy beliefs people had to protect themselves from the virus, many based on "scientific research," instead of just not sharing blood or sperm. Why won't this study be used the same way, as the author of the USAIDS study worries? When I was a teenager, I heard guys saying that they couldn't get v.d. because they had a hood. I heard men saying their wifes couldn't get ovarian cancer because they were Jewish [read:circumcised]. I can see straight teenagers (the group with the largest increase of HIV transmission) now having sex without condoms because they are un/circumcised.

(And let's not forget about all those who share uncircumcised needles.)

It is easier to find something/someone to blame ("Patient Zero," gays, loss of religious beliefs, the media's constant promotion of sex, the West, Democrats, foreskins) than to work hard at changing one's activities, regardless of countries or traditions. Education has been shown to be the best way to prevent HIV transmission. With such a small amount of money going into HIV/AIDS research--particularly on women and HIV--and money for medication for people living with HIV/AIDS, isn't focusing on the [uncondomed] penis (the favorite activity for all men) side-stepping the real issues of HIV transmission?

Sorry for the rant, but as someone who has been working in the area for 20 years, not just intellectually, but with real people, I am very concerned about how an epidemic affecting the whole world has been reduced to a debate on circumcision. I had to say this; now I'll go back to lurking.

oscar wolfman

(For the record, I couldn't care less if a guy is circumcised or not.)

Sat, 28 Feb 2004 15:40:45 -0000

From: "Terrence Lockyer" <lockyert@mweb.co.za>

Sent: 28 February 2004 05:47

Subject: Circumcision

Speaking not as a specialist, but as someone from a country in which HIV / AIDS, deaths from adolescent circumcision (which reported studies suggest may or may not precede first genital sexual experience) during initiation rituals, and expenditure on medical services are all major issues, I wish to raise one point. It may well be that circumcision is correlated to significantly lower rates of HIV infection, but this is certainly not a universal prophylactic. This being so, as a question of policy, is it a good idea, especially in relatively poorer societies, to encourage extra- medical practices that have a record of causing death or serious injury, or alternatively to encourage expenditure of public monies on a medical procedure, when the practice or procedure is only, at best, a partial retardant, *and* the financial choice would seem to be between paying for the procedure (and for the care of those in whose cases the procedure or practice goes wrong) or paying for other prevention strategies, including ones aimed at encouraging behavioural changes that offer far more reliable protection from infection and that have the potential, at least, to cost less in reaching far more people?

I would not, incidentally, describe myself either as a proponent or an opponent of circumcision per se (although I will confess to a bias against body-modifications in which the body modified has no choice), and raise this merely as a point that might need to be considered in practice, whatever one's conclusions in principle or in research.

Terrence Lockyer

Johannesburg, South Africa

e-mail: lockyert@mweb.co.za

Sat, 28 Feb 2004 15:40:45 -0000

From: "vern bullough" <vbullough@adelphia.net>

Sent: 28 February 2004 16:48

Subject: RE: health evidence for circumcision

incidentally it was the problem of dealing with the mucosal cells which led to the medical practice of circumcision in the U.S. To clean the penis of the infant, the mother had to pull back the foreskin, and do a good cleansing job. The argument was that this practice led inevitably to an erection, and the infant learned to associate this with pleasure. This early recognition of the sensitivity of the infant, led the developing boy child to more likely to touch and feel his penis and masturbate. The solution was to remove the foreskin and the mother no longer had to arouse her son, and masturbation would be less likely to occur. Whether this was true or not (in terms of preventing masturbation), but it was sold as such, and soon became institutionalized in the U.S. In the days of home delivery and midwives, it also gave the burgeoning field of ob-gyn specialists a source of income, since the circumcision was not done by a midwife. Obviously the issue is more complicated than that, but this in the U.S. was at the heart of the circumcision movement.

Vern L. Bullough

Sent: 28 February 2004 16:26

From: "Andrew Hobbs" <andhobbs@hotmail.com>

Sent: 28 February 2004 16:26

Subject: Re: Pure quackery (was Health evidence for circumcision)

Rob D wrote about:

"the delusion that forcible mass

circumcision is

the answer to the AIDS crisis."

Rob, do you have a reference for recommendation of mass forced adult circumcision of black Africans? It sounds outrageous.

As an uncircumcised man, I would like to see a public health cost-benefit analysis of infant male circumcision, on which parents could base a decision in the interests of their child. If there were fewer health risks for circumcision, I would probably have a (theoretical) infant son circumcised.

If there are health arguments in favour of circumcision, these could apply regardless of the cultural group/colour of the children involved.

Andrew Hobbs

UK

Sent: 28 February 2004 23:22

From: "RobD" <robjld@webone.com.au>

Sent: 28 February 2004 23:22

Subject: HIV and circumcision

Rosemary did not circulate the full text of the Washington Times article. Omitted were the rather embarrassing comments from Mr Green, from USAID, about the value of traditional African medicine: "herbalists, faith healers ad witchdoctors" - that is, the very people promoting the sort of harmful practices condemned by the South African Medical Association in the editorial I previously cited. Strange company for American scientists.

The full article is provided here, with brief comments from me in square brackets.

Circumcision shown to deter HIV spread

April 25, 2003

Section: WORLD

Page: A16

Tom Carter, THE WASHINGTON TIMES

Circumcised men are at least 50 percent less likely to contract the virus that causes AIDS during unprotected sex than uncircumcised men, according to a soon-to-be released report by the U.S. Agency for International Development (USAID).

Based on a systematic review of 28 scientific studies published by the London School of Hygiene and Tropical Medicine, the USAID report "found that circumcised males are less than half as likely to be infected by HIV as uncircumcised men."

"A sub analysis of 10 African studies found a 71 percent reduction among higher risk men," said the report obtained by The Washington Times.

[These studies have since been rejected as inconclusive by the Cochrane Review.]

"There is really an incredible preponderance of evidence. There is really a strong association," between circumcision and HIV protection, Dr. Anne Peterson, assistant administrator for global health at USAID, said yesterday in an interview.

[All that has been found is a correlation: the studies reveal nothing about causation. Since they have a narrow focus on tying to prove the connection between the foreskin and HIV infection, they simply ignore dozens of behavioural and biological factors which may be relevant.]

According to the scientific studies, the skin on the inside of the male foreskin is "mucosal," similar to the skin found on the inside of the mouth or nose. This mucosal skin has a high number of Langerhan cells, which are HIV target cells, or doorway cells for HIV.

[The female genitals are full of Langerhans cells as well: that's what the body is made of in mucosal areas. Presumably something will also have to be done about the vulnerable mucosal tissue in the mouth, urethra and all other areas where it is found. If the tissue of the foreskin is like that of the mouth, how come there are no reports of oral infection with HIV? It is well known that oral sex is safe (or at least safer) sex.]

The rest of the skin on the penis is more like the outer skin on the rest of the body, a barrier that protects against germs.

[How many germs get into the body through the mucosa of the mouth? Very few, I should have thought, unless there is a cut.]

"HIV looks for target cells, like the Langerhans; it's a lock and key," said Edward G. Green, senior researcher at Harvard University, who has been looking at circumcision and HIV in Africa for 10 years. "The rest of the skin on the penis is armorlike."

[I am not sure that anybody would want the skin of his or her genitals to be like armour. This rather proves the point about circumcision reducing sexual responsiveness. Doctors used to cauterise tissue to destroy the nerves and make it impervious - but that was nineteenth century medicine.]

He said that it is better to be circumcised as a baby, rather than as a teenager in "rite-of-passage" ceremony, because many teenage boys in Africa are already sexually active.

[American scientist want to change traditional African cultural practices so that they are uniform with hospital American practice. The claim about "already sexually active is untrue": where circumcision is prevalent, women shun intact men as "boys" who are not yet allowed to have sex with women. What he really means is, "We have to get them before they've enjoyed sex with a whole penis, or they'll never submit to it."]

Mr. Green said that if all males in Africa were circumcised, the HIV/AIDS prevalence rate could be reduced from 20 percent in some regions to below 5 percent.

[Wild speculation.]

In addition, circumcision reduces the transmission of other sexually transmitted diseases, is more hygienic, reduces infections associated with poor hygiene and makes it easier to use a condom, Mr. Green said.

[Too many advantages make this sound like the claims of a nineteenth century quack like Dr P.C. Remondino. Studies in Australia by Donovan et al have shown that circumcised men find it harder to use a condom and have fewer options for safe sex owing to the reduced capabilities of their penis.]

"This is something the tribal healers, the herbalists, faith healers and witch doctors have known for years," he said.

[Interesting to see the convergence of American scientific gurus and tribal witchdoctors.]

The 60-page USAID report is based on presentations given at a USAID conference in September, and will be available on the USAID Web site "soon," Dr. Peterson said.

She said that while the information "looks profound and wonderful," she cautioned there may be other factors that reduce HIV transmission in circumcised men.

[Desperate times induce unrealistic hopes: it's the ancient idea that if you sacrifice something to the gods, they will spare you from affliction. The claim that a surgical operation which still causes deaths and serious infections in American hospitals could be done safely in the primitive and unhygienic conditions of poverty-stricken African villages is absurd. USAID's efforts would be better directed at securing supplies of clean running water so that people could wash.]

She said clinical trials in Kenya and Uganda, under the auspices of the National Institutes of Health (NIH), Johns Hopkins University and the Gates Foundation, would give a clearer picture. Until then, she said USAID would move cautiously to educate and promote male circumcision.

Dr. Peterson said there is no evidence the female circumcision, sometimes called genital mutilation, offers any benefit whatsoever.

In fact, the scarring produced in the procedure may enhance the transmission of disease, she said. "We are adamantly opposed to female circumcision."

[Notice the culturally determined sexual double standard. It is logically impossible that female circumcision would not have exactly the same effects in reducing the vulnerability of women to HIV infection as circumcision in men. If the genital mucosa is the trojan horse, then it should be removed equally from both males and females. Why should it be only men who get the benefit of armour-plated genitals? It may well be that the lower rates of HIV in regions of Africa where circumcision is common is due to female circumcision, not male, and that this is what USAID should be promoting. Western culture finds that idea abhorrent, however, and would not even investigate the possibility. Also, if female circumcision transmits AIDS, as western anti-FGM activists insist (and I am sure they are right), it follows that male circumcision will do likewise; no doubt the same instruments are frequently used for both surgeries.]

Another concern is that by promoting circumcision, circumcised men may mistakenly believe they are invulnerable to HIV. They are not, said Dr. Peterson.

"It reduces your risk. It does not protect you outright," said Dr. Peterson. "People who are circumcised still get HIV. It is still better to abstain, be faithful in marriage," or use condoms, she said.

[In that case, why circumcise at all?]

27 February 2004 21:48

From: "Andrew Hobbs" <andhobbs@hotmail.com>

Sent: 27 February 2004 21:48

Subject: health evidence for circumcision

The theory is that the foreskin makes for a greater surface area through which the HIV virus can enter the bloodstream. It's the same thinking which is used to explain why a woman is more likely to contract HIV than a man from the same amount of unprotected sex -- more surface area of mucous membrane. So perhaps it is what you have, as well as what you do with it.

Andrew Hobbs

andhobbs@hotmail.com

27 February 2004 21:26

From: "Rosemary Ryan" <r2@u.washington.edu>

Sent: 27 February 2004 21:26

Subject: Re: health evidence for circumcision

Paul Snijders writes:

I wonder what's the physical reason a foreskin should increase the risk to get STD or HIV. Do you have a theory? It can't be difficult to compare samples of circumcised and uncircumcised men as to their percentage of getting STD or HIV.

Below is a news report that summarizes the science on this.

Also, Ken Mondschein suggested that geographic differences in HIV seroprevalence might be due to cultural differences that drive both circumcision and sexual risk practices. I suspect there is something to this but, as the article below indicates, after controlling for behavioral differences the absence of a foreskin reduces the risk of acquiring and transmitting STDs, including HIV. There are also studies underway to see whether circumcision reduces transmission of HPV, the virus that causes genital warts and most cases of cervical cancer.

Rosemary

_____________________

"Circumcision Shown to Deter HIV Spread"

Washington Times (04.25.03)::Tom Carter

Circumcised men are at least 50 percent less likely to contract HIV during unprotected sex than uncircumcised men, according to a soon-to-be released report by the US Agency for International Development.

Based on a systematic review of 28 scientific studies

published by the London School of Hygiene and Tropical Medicine, the USAID report "found that circumcised males are less than half as likely to be infected by HIV as uncircumcised men." "A sub analysis of 10 African studies found a 71 percent reduction among higher risk men," said the report obtained by the Washington Times.

According to the scientific studies, the skin on the inside of the male foreskin is "mucosal," similar to the skin found on the inside of the mouth or nose. This mucosal skin has a high number of Langerhan cells, which are HIV target cells, or doorway cells for HIV. "HIV looks for target cells, like the Langerhans; it's a lock and key," said Edward G. Green, senior researcher at Harvard University. "The rest of the skin on the penis is armorlike."

Green said that if all males in Africa were circumcised, the HIV/AIDS prevalence rate could be reduced from 20 percent in some regions to below 5 percent. In addition, circumcision reduces the transmission of other STDs, reduces infections associated with poor hygiene, and makes it easier to use a condom, Green said.

The 60-page USAID report is based on presentations given at a conference in September, and will be available on the USAID Web site "soon," said Dr. Anne Peterson, assistant administrator for global health at USAID. She said that while the information "looks profound and wonderful," she cautioned there may be other factors that reduce HIV transmission in circumcised men.

If circumcision is promoted, another concern is that circumcised men may mistakenly believe they are invulnerable to HIV. They are not, said Peterson. "It reduces your risk. It does not protect you outright," she said. "People who are circumcised still get HIV. It is still better to abstain, be faithful in marriage," or use condoms.

27 February 2004 19:53

From: "Paul Snijders" <paulsn@wanadoo.nl>

Sent: 27 February 2004 19:53

Subject: Re: Re: health evidence for circumcision

Rosemary Ryan writes:

In Sub-Saharan African, there is strong evidence that the presence of a foreskin increases the likelihood of STD and subsequent HIV infection.

I wonder what's the physical reason a foreskin should increase the risk to get STD or HIV. Do you have a theory? It can't be difficult to compare samples of circumcised and uncircumcised men as to their percentage of getting STD or HIV.

Paul Snijders

27 February 2004 14:16

From: "Ken Mondschein" <editor@corporatemofo.com>

Sent: 27 February 2004 14:16

Subject: Re: health evidence for circumcision

Rosemary Ryan wrote: HIV rates are demonstrably lower among peoples where circumcision is normative, and marked higher where it is not practiced.

Could this be due to behavioral factors? Say, a higher standard of sexual conduct amongst Muslims?

--

Ken Mondschein

editor@corporatemofo.com

Wed, 25 Feb 2004 00:06:28 -0500

From: Rosemary Ryan <r2@u.washington.edu>

Subject: Re: health evidence for circumcision

Date: Thu, 26 Feb 2004 14:42:57 -0800

oscar wolfmnan writes:

Thank you, Andrew, for all the references, even theones that have beendismissed by more recent medical reviews. But here isa simple rebuttal: HIV transmission derives from what you do(unsafely), not what you have.

Ah, I must come out of lurk mode. I do HIV behavioral prevention research in Seattle, and not an expert of the African pandemic, but I do follow the news from there and I do take exception to Oscar's post.

In Sub-Saharan African, there is strong evidence that the presence of a foreskin increases the likelihood of STD and subsequent HIV infection. With HIV rates reaching 20-30% in the general population, non-monogamous sexual customs perpetuate the spread of the virus. HIV rates are demonstrably lower among peoples where circumcision is normative, and marked higher where it is not practiced. On a continent plagued by war, poverty, malnutrion, TB, malaria, several other infectious tropical diseases, and where medical care is in critically short supply, it seems that circumcision has the potential to save millions of lives.

Rosemary Ryan

University of Washington - Social Work

Seattle

25 February 2004 12:05

From: "Andrew Hobbs" <andhobbs@hotmail.com>

Sent: 25 February 2004 12:05

Subject: health evidence for circumcision

Most recent studies of male circumcision and risk of HIV transmission seem to favour circumcision.

Here's a few references:

Jan 2004: USAID and Population Services International's AIDSMark project published the report "Male Circumcision: Current Epidemiological and Field Evidence; Program and Policy Implications for HIV Pre- vention and Reproductive Health" which examines the relationship between male circumcision (MC) and HIV transmission, and other health concerns. The comprehensive report summarizes the proceedings of a two-day conference attended by hundreds of experts who discussed current epidemiological and biological evidence, clinical trials and field studies and offers their findings and conclusions. For more information, visit

http://www.psi.org/resources/male-circ.html

Feb 2001: Review of Male Circumcision and HIV The London School of Hygiene and Tropical Medicine has recently reviewed the published studies on male circumcision and its relation to HIV. Their results were published in 'AIDS' last year.

Readers interested in male circumcision and HIV can now access basic information on this subject from the following web page:

http://www.geocities.com/robertdavis71/CIRCUMCISIONANDHIV.html

"Uncircumcised men are at a much greater risk of becoming infected with HIV than circumcised men" Robert Szabo, Roger V Short, How does male circumcision protect against HIV infection? (British Medical Journal 2000;320:1592-1594 (10 June), full text :

http://bmj.com/cgi/content/full/320/7249/1592

Bob Huff: Male Circumcision: Cutting the Risk? (American Foundation for AIDS Research, July 2000 )

<http://ww2.aegis.org/pubs/amfar/2000/AM000802.html>

"More Data Needed before Male Circumcision is Advocated"

Van Dam, Johannes and Marie-Christine Anastasi: "Male circumcision and HIV prevention: Directions for future research", Horizons Project Re- port; Washington, DC, Population Council, 2000.

http://www.popcouncil.org/horizons/reports/circumcision/default.html

Andrew Hobbs

University of Central Lancashire

12 Feb 2003

Cross-posted from H-Africa — Peter Limb <plimb@MAIL.H-NET.MSU.EDU

Date: 12 Feb 2003

From: Marian Douglas

Nairobi, Kenya

<dasha@clubinternetk.com>

[The report below is reproduced with permission--ed.]

On a visit to the town of Eldoret in December 2002, I was invited to speak to a group of about 20 girls taking part in an education and awareness workshop given to them as an "alternative rite of passage", in place of FGM.

At the time I was unaware that Eldoret - in the Rift Valley- is one of the key locations of female circumcision in Kenya.

-------KENYA: Increased public awareness of FGM

Integrated Regional Information Network (IRIN)

UN Office for the Coordination of Humanitarian Affairs (OCHA)

[This report does not necessarily reflect the views of the United Nations]

NAIROBI, 11 February (IRIN) - For many years, efforts by human rights groups fighting female circumcision, also referred to as female genital mutilation (FGM), were frustrated by cultural taboos and lack of political commitment. Now, however, those efforts are paying off and have resulted in increased levels of public awareness.

But with this, a new problem has emerged. Media reports revealed last week that hundreds of primary schoolgirls were running away from home in the country's vast Rift Valley Province and "holing up" in churches to avert forcible FGM.

HUMANITARIAN CRISIS

NGOs say the numbers of girls now running away are overwhelming them, and they can no longer accommodate them without humanitarian supplies. They complain that they have received no response from the government on how to deal with the crisis.

According to Anne Gathumbi, who works for the Coalition on Violence Against Women (COVAW), the numbers of girls running away and seeking shelter are "getting out of hand". "There is no official communication from the government so far. We feel this is a lost opportunity on the part of the government to get involved and offer a sustainable solution," Gathumbi told IRIN. "It is humanitarian crisis. Their fears are very real. They need shelter. Someone has to take care of them. It is not right for their parents to just comfortably sit at home," she added.

Kenyan authorities, however, said they were not in an immediate position to respond. Anna Mbwere, the commissioner of social services, told IRIN that she needed time to establish the facts about the issues raised by the NGOs, and would forward them to the appropriate authorities. "We just can't respond to reports over the media. I'll find out what is happening and, depending on what information is there, then we will be in a position to comment," she told IRIN.

SECRECY

FGM was formally banned by the Children's Act, passed by parliament in 2001, but it is still widely practised in secret by a number of communities, particularly in Rift Valley Province, but also in the central, eastern and the northeastern parts of the country.

Communities still practising it claim that it is an important traditional cultural rite of passage, which prepares girls for their future roles as wives and mothers. Circumcised girls are showered with gifts and praises as part of an incentive to encourage others also to undergo the rite. Moreover, bride price, a deeply entrenched practice in many communities, is higher for circumcised brides.

Up to 53 percent of Kenyan women are said to have undergone FGM. In some districts, the proportion of girls circumcised, usually between the ages of eight and 14, can be as high as 95 percent.

According to the Kenyan umbrella women's group, Maendeleo ya Wanawake (Kiswahili for women in development), which is involved in anti-FGM campaigns, the Rift Valley region has the highest incidence of FGM in the country.

The most common form of FGM in Kenya, clitoridectomy, involves the excision of part or the whole of the clitoris, according to local experts. However, the most harmful form of FGM, infibulation, or excision of the labia minorae and majorae as well as the clitoris, is practised in the northeast.

In some parts, such as Meru, in the east and Kisii in the south, where FGM has been even been "medicalised" and is illegally performed in hospitals, civic education targets hospital matrons and nurses to discourage it. "It is not that some of them don't know, but they make cash out of it," Gathumbi said.

In the course of circumcision ceremonies, girls are first taken into seclusion for up to two weeks, during which they are taught about their future responsibilities as married women, before undergoing the operation. A colourful ceremony follows, in which the community celebrates with feasts and dancing.

Human rights activists opposed to the practice argue that the cut adversely affects the reproductive aspects of the lives of girls and women. Severe forms of FGM, in particular, cause complications during childbirth.

The increasing body of opinion against FGM has been attributed largely to the application of the Children's Act, as well as to public education.

ALTERNATIVE FGM

One of the most successful education programmes aimed at eradicating FGM in Kenya involves an "alternative rite of passage", in which girls are taken through all the ceremonies attending FGM, but without undergoing the actual cut.

The programme's success is credited to years of research undertaken by Maendeleo ya Wanawake and the US-based Program for Appropriate Technology in Health (PATH), which ended in 1996 in a culturally acceptable substitute for FGM. The girls also receive reproductive health training and instruction on social and cultural norms, after which they "graduate" in a big ceremony.

Samson Radeny, PATH's senior programme officer in Kenya, told IRIN that 5,500 girls had participated in this alternative rite under his programme by December last year. "We are at last getting the message across. Initially it was so difficult. They are now paying attention," Radeny said. "What we have seen in the last decade is a progression of protectiveness of this culture to the point where people are beginning to talk to us," he added.

An impressive number of former circumcisers are now condemning FGM and engaging in community education against the practice, according to PATH. Moreover, girls have started writing to NGOs, seeking assistance against family pressure to undergo the operation.

The use of slang among young men also reveals a change in attitude, says PATH: an uncircumcised girl has come to be referred to as a manyanga [Kiswahili for young, new], while a circumcised one is described as mitumba [second-hand, or used]. Moreover, for the first time in churches, clergymen have taken to talking about FGM during baptisms of girls, according to PATH.

A high-profile case in which two girls took their father to court to avert forcible circumcision further brought the issue of FGM into sharp focus. The sisters won the case, which was the first of its kind in the country.

Radeny, however, admitted that anti-FGM efforts were still facing considerable resistance in some areas, such as in Kisii District. "The history of fighting FGM started early in Kisii, but we are still having a bit of a problem there. A lot of things are still out of question there," he told IRIN.

[ENDS]

[This Item is Delivered to the "Africa-English" Service of the UN's IRIN humanitarian information unit, but may not necessarily reflect the views of the United Nations. For further information, free subscriptions, or to change your keywords, contact e-mail: Irin@ocha.unon.org or Web: http://www.irinnews.org . If you re-print, copy, archive or re-post this item, please retain this credit and disclaimer. Reposting by commercial sites requires written IRIN permission.]

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