tag:theconversation.com,2011:/au/topics/male-circumcision-3453/articlesMale circumcision – The Conversation2022-10-06T13:44:24Ztag:theconversation.com,2011:article/1890922022-10-06T13:44:24Z2022-10-06T13:44:24ZUganda: an ancient circumcision ritual is key to imparting communal knowledge<figure><img src="https://images.theconversation.com/files/482802/original/file-20220905-18-etse8a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Amirr (centre) parades though his village ahead of the imbalu circumcision ritual. Imbalu begins with dance and music, as initiates visit relatives and friends to receive gifts.</span> <span class="attribution"><span class="source">Luke Drey/Getty Images</span></span></figcaption></figure><p>Music, dance, drama and poetry are important elements of ritual in African societies. Imbalu, the centuries-old circumcision ritual of Uganda’s <a href="https://www.insidemountelgonnationalpark.com/bagishu-bamasaba-people-culture.html">Bagisu people</a>, is no different. When Bagisu boys between the ages of 16 and 22 undergo this initiation into manhood, they learn the ancient meaning of the practice through music and dance.</p>
<p>Imbalu takes place every even year in August in the remote districts of eastern Uganda close to the border with Kenya. Imbalu ceremonies are not only staged in homes, but also in public spaces. Here, a broader audience witnesses the special dance and music performances.</p>
<p>In <a href="http://www.101lasttribes.com/tribes/Bagisu.pdf">previous</a> <a href="https://books.google.co.za/books?hl=en&lr=&id=MZJMlaisYmwC&oi=fnd&pg=PA71&dq=Dominic+Makwa&ots=optoAgyHI6&sig=XPwA4-uosT3jegD6CRqAhA3xFTc&redir_esc=y#v=onepage&q=Dominic%20Makwa&f=false">studies</a>, I have examined these performances. Music and dance are integral from the moment a boy declares he is ready to be initiated until he performs inemba, a final dance marking his return to society.</p>
<p>My most recent <a href="https://www.cambridge.org/core/journals/yearbook-for-traditional-music/article/abs/musicking-and-dancing-imbalu-at-namasho-enacting-indigenous-education-among-the-bagisu-uganda/47BBFBE5A253EC18B97BA2EA0113B864">study</a> looks at how imbalu music and dance performances act as platforms where boys are tutored about their society’s gender ideology, history and ritual practise. The public performance of these rituals at a sacred place called the Namasho Cultural Site is like a communal classroom where community members attending also share what they know of their history, identity and values.</p>
<p>But imbalu, like other cultural performances among the Bagisu, has been affected by fewer and fewer boys undergoing initiation. Hospital circumcision has become more common, and Christianity, Islam and western education have negatively impacted uptake. Many Bagisu who have adopted western religious practices look at imbalu performances as something of a cult and consider these rituals to be “backward” and “primitive”. </p>
<p>As a result, there is a risk that the music and dance created, performed and transmitted through cultural sites like Namasho at ceremonies like those staged for imbalu will be lost to future generations. However, they are valuable to the community since they transmit social histories, help form identity and teach social values. They should be documented and archived without delay to preserve traditional knowledge for use by future generations.</p>
<h2>Imbalu at Namasho</h2>
<p>The initiate and his family and community members all take on different roles during imbalu performances at Namasho.</p>
<p>The site, in Bududa District, stretches from the local school to the confluence of the Manafwa and Uha rivers. It is known as a place where wars were fought, and where fetishes of medicine men and women were dumped during the precolonial period. (Fetishes, in the form of calabashes or gourds, are objects kept by diviners or traditional healers to give them supernatural power. When they didn’t have successors, such objects were disposed of.) These histories are part of what is taught in the rituals performed at this sacred site.</p>
<p>Different forms of music are played during imbalu. Khukhubulula is one form. The boy, surrounded by friends and relatives, sings songs praising himself, his family and his clan. These are usually composed by him some months earlier. Some songs will praise his girlfriends, as marriage is the phase that follows imbalu among traditional Bagisu.</p>
<p>Then there are bibiwoyo, coaxing songs usually led by men. They use titles like umwami (chief), umukoosi (the one with respect) or umusani (man) to encourage the boy to go through with the circumcision. The community demonstrates to the boy that he will become a “powerful” person in society if he gets circumcised.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/483203/original/file-20220907-12-ap277n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Four people against a backdrop of dark pink sheet. They are colourfully dressed in traditional attire, a man holding a guitar." src="https://images.theconversation.com/files/483203/original/file-20220907-12-ap277n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/483203/original/file-20220907-12-ap277n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/483203/original/file-20220907-12-ap277n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/483203/original/file-20220907-12-ap277n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/483203/original/file-20220907-12-ap277n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/483203/original/file-20220907-12-ap277n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/483203/original/file-20220907-12-ap277n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Members of Yoyo Toto Wambale music group pose for a photo before performing at an imbalu ceremony.</span>
<span class="attribution"><span class="source">Badru Katumba/AFP via Getty Images</span></span>
</figcaption>
</figure>
<p>Then there is kadodi music and dance. Accompanied by five drums, kadodi is performed to accompany initiates as they visit cultural sites and relatives. At Namasho, it entertains initiates and visitors besides also enabling some initiates to meet and interact with girls who may be future marriage partners. Kadodi is so popular at Namasho that bands come to play just to advertise themselves. Moreover, although the isonja dance is displayed earlier in the year, it is sometimes brought to this sacred site to give expert singers an opportunity to advertise themselves to future candidates who hire them to learn how to compose and sing songs. </p>
<p>Lastly, groups congregating at Namasho play prerecorded imbalu songs, produced in a studio or recorded live at the event in previous years. This is meant to entertain candidates but also remind circumcised men about the vows about manhood they made during their own ceremonies, including the need to defend and provide for themselves, their families and the broader community.</p>
<h2>Communal classroom</h2>
<p>Music and dance turn Namasho into a communal classroom for imparting indigenous knowledge and history. Some performances, for example, tell the story of <a href="https://thisisafrica.me/lifestyle/nabarwa-marking-200-years-circumcision-uganda/">Nabarwa and Masaaba</a>, the woman and man who are believed to have introduced imbalu among the Bagisu. Mythical narrative has it that Masaaba, who met Nabarwa and asked for her hand in marriage, was asked by her to be circumcised before they could marry since she came from a circumcising community. When the Bagisu refer to themselves as Bamasaaba, they explicitly mean that they are children of Masaaba. The relationship between Nabarwa and Masaaba is used as testimony that women and men in this community should play complementary roles.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-sacred-sites-act-as-living-archives-in-a-ugandan-community-140571">How sacred sites act as living archives in a Ugandan community</a>
</strong>
</em>
</p>
<hr>
<p>Another song is about Lutseshe, a famous forefather. In singing this song, the community reminds the initiates about the need to produce children to fill Lutseshe’s land. As boys sing, some spectators will advise them to be assertive and objective if they are to manage their households well. </p>
<p>Through the interaction between women and men as they perform these rituals, their mutual roles in society are underscored. For example, as an initiate sings, his sisters and other female relatives are at the centre of responding to the songs, symbolising the need for women and men to work together on daily activities.</p>
<p>Acts like being smeared with clay from the sacred swamp are a reminder of the history of those who came before. </p>
<h2>Preserving cultural identity</h2>
<p>In the face of the threats to traditions like imbalu from social change, it is crucial that this knowledge be preserved for use by future generations. </p>
<p>Stakeholders like the Uganda Tourism Board, Bududa District local government and academic archives, like Makerere University’s <a href="http://musicarchive.mak.ac.ug">Klaus Wachsmann Audio-visual Archive</a>, need to work together to record and preserve these musical and dance materials. </p>
<p>Imbalu will then continue to offer its lessons to the Bagisu and help maintain their rich cultural identity.</p><img src="https://counter.theconversation.com/content/189092/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dominic D.B. Makwa does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The ritual site becomes a communal classroom where songs and dances teach history, impart values and preserve cultural identity.Dominic D.B. Makwa, Lecturer, Makerere UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1405712021-03-17T15:07:14Z2021-03-17T15:07:14ZHow sacred sites act as living archives in a Ugandan community<figure><img src="https://images.theconversation.com/files/389617/original/file-20210315-21-5q6hks.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">An initiate parades through his village in Mbale, Uganda.</span> <span class="attribution"><span class="source">Luke Dray/Getty Images</span></span></figcaption></figure><p>The <a href="http://www.country-data.com/cgi-bin/query/r-14050.html">Bagisu</a> people of eastern Uganda boast of special places where they gather to perform cultural rites, among them <a href="https://www.afro.who.int/news/who-guides-bagisu-community-carrying-out-cultural-norm-while-observing-covid-19-guidelines">imbalu</a>, a male circumcision ritual.</p>
<p>These sacred spaces can exist in the form of groves, rivers, thickets or even playgrounds. Namasho in Bududa District, for example, is at the confluence of the Manafwa and Uha rivers and has a sacred swamp where imbalu candidates are smeared with clay. Bumutoto in Mbale District, another important site, is a simple expanse of land designated for ritual purposes. </p>
<p>Although some of these places were made sacred through the consensus of elders, their existence is also attributed to supernatural beings. These sites participate in showcasing and transmitting these ceremonies and their music and dances to those who come to witness events. The sites thus act as archives for the community. </p>
<p>As an ethnomusicologist, I have <a href="http://2015.iasa-web.org/fr/node/99.html">carried out</a> <a href="https://catalogue.leidenuniv.nl/primo-explore/search?vid=UBL_V1&search_scope=lib_asc&query=any,contains,9939581229402711">research</a> in Bududa and Mbale over seven years <a href="https://scholar.sun.ac.za/handle/10019.1/100427">focusing</a> on how these sites are safeguarded by the community to become places where ritual performances are archived.</p>
<h2>Rethinking the archive</h2>
<p>For over three decades now, ethnomusicologists have called for rethinking the meaning of the archive and of <a href="https://www.researchgate.net/publication/263373004_Postcolonial_archival_fever_and_the_musical_archiving_of_African_identity_in_selected_paintings_by_Elias_Jengo">archiving</a>. They <a href="https://www.jstor.org/stable/852717?origin=JSTOR-pdf&seq=1">argue</a> that an archive should not only be seen as a physical building or digital vault. Instead the meaning of the archive should be extended to include cultural mechanisms through which material can be safeguarded for access and use in future.</p>
<p>This demands that we even consider songs or paintings as mechanisms through which artists put their ideas for retrieval and use in future; an archive. </p>
<p>The idea that archiving can only be done by societies with technologies of repetition such as audio recorders or cameras is shallow. People who rely on oral tradition have ways of ensuring that what they have is safeguarded and kept for others in future. </p>
<p>My <a href="http://www.101lasttribes.com/tribes/Bagisu.pdf">studies</a> focused on a recreational space – a playground called Bumutoto – as a living archive among the Bagisu. In this context, to safeguard such a place is to archive the rituals, musics and dances staged there. </p>
<h2>The imbalu tree</h2>
<p>The <a href="http://196.43.133.120/handle/20.500.12281/7702">Bumutoto Cultural Grounds</a> are situated in Bumutoto village near the town of Mbale. Despite serving as a playground where people relax as they drink in the nearby trading centre, this site is known for activities geared towards the inauguration of imbalu circumcision rituals. </p>
<p><a href="https://books.google.co.za/books?hl=en&lr=&id=MZJMlaisYmwC&oi=fnd&pg=PA63&dq=imbalu+circumcision+ritual&ots=oporGjzIGb&sig=7ypGDg4HW85c6fA8EKFtpr82UUo&redir_esc=y#v=onepage&q=imbalu%20circumcision%20ritual&f=false">Imbalu</a> initiates adolescent boys into manhood. Although many accounts exist, the history and act of imbalu remain largely a mystery. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/389625/original/file-20210315-17-1kyaofq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="An elderly man is bent over, using white chalk to form a spiral shape on the dirt ground." src="https://images.theconversation.com/files/389625/original/file-20210315-17-1kyaofq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/389625/original/file-20210315-17-1kyaofq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/389625/original/file-20210315-17-1kyaofq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/389625/original/file-20210315-17-1kyaofq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/389625/original/file-20210315-17-1kyaofq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/389625/original/file-20210315-17-1kyaofq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/389625/original/file-20210315-17-1kyaofq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">An elder prepares the ground for a ritual.</span>
<span class="attribution"><span class="source">Luke Dray/Getty Images</span></span>
</figcaption>
</figure>
<p>The most common <a href="https://search.proquest.com/openview/882b9050ab062da1f592bb5b05aef6e3/1?pq-%20origsite=gscholar&cbl=24212">account</a> is that imbalu was brought to the region by Nabarwa, a <a href="https://www.britannica.com/topic/Kalenjin">Kalenjin</a> woman from Kenya who married Masaaba from Bugisu. Despite the Bagisu abandoning this ritual eventually, one Fuuya, believed to have lived in the present day Bumutoto, revived imbalu as a healing remedy for his sick sons. </p>
<p>Other Bagisu followed suit because they saw that imbalu was associated with supernatural powers. Interview subjects told me that Fuuya planted a sycamore (kumutoto) tree in his compound to mark where other people should be circumcised in future. As Fuuya’s clan multiplied, they became known as Bamutoto and the place, Bumutoto. </p>
<h2>Performances at Bumutoto</h2>
<p>In homage, no other Mugisu may be circumcised until the initiates from Bamutoto are. Every early August during even-numbered years, the Bagisu from all the districts congregate at Bumutoto to witness the imbalu ceremonies. </p>
<p>Initiates put on distinctive regalia – thigh bells, head gear, skins covered in cowrie shells – to perform imbalu music and dances. There are speeches by cultural enthusiasts and guests. People play music by local pop musicians on CDs or memory sticks, or there are live musicians. The three dances that guests, and particularly initiates, perform during the festivities are called isonja, tsinyimba and kadodi.</p>
<p>Isonja, also staged between January and March in initiates’ villages, provides a platform for boys to be tutored in dancing and composing imbalu songs. They bend their backs and stamp the ground, form a circle and dance in a clockwise direction imitating the movement of the sun.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-music-helps-us-understand-displaced-communities-in-uganda-129390">How music helps us understand displaced communities in Uganda</a>
</strong>
</em>
</p>
<hr>
<p>During the tsinyimba dance the dancer ties a metal bracelet at the wrist and knocks it with a bell (liyimba) to provide a rhythm. This dance is common among the Bagisu living in Namisindwa District, close to the Bakusu of western Kenya where it is believed to have originated. A set of five drums provides the throbbing beats for the kadodi dance, which accompanies imbalu dancing parties as they visit cultural sites and relatives. </p>
<h2>Bumutoto as a living archive</h2>
<p>As these performances are staged, they turn Bumutoto into a living archive that opens its doors to people who want to access and learn from what is kept there. These are materials related to the origin of imbalu circumcision rituals as well as the music, dance and costume associated with this ritual. Through speeches and songs, the history of imbalu is further brought to the fore. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/389783/original/file-20210316-17-l95qxa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A crowd of men, in the centre a young man holding two cow's tail whisks in the air, white clay covering his face and a shiny blue piece of headgear." src="https://images.theconversation.com/files/389783/original/file-20210316-17-l95qxa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/389783/original/file-20210316-17-l95qxa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/389783/original/file-20210316-17-l95qxa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/389783/original/file-20210316-17-l95qxa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/389783/original/file-20210316-17-l95qxa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/389783/original/file-20210316-17-l95qxa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/389783/original/file-20210316-17-l95qxa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Andrew, a 17-year-old initiate from Mbale, performing the kadodi dance.</span>
<span class="attribution"><span class="source">Luke Dray/Getty Images</span></span>
</figcaption>
</figure>
<p>As candidates perform, they showcase the music and dances they learned during the earlier stages of imbalu, as well as the costumes they created or received from elders. Guests can easily tell what district a group of candidates comes from by looking at what costume they wear. Additionally, Bumutoto becomes an archive which showcases the power structures among the different clans of the Bagisu. </p>
<p>Like modern Western archives, there are special people in charge of the different performances at this site. Assisted by security personnel to control the mammoth crowds, they are the ritual experts who direct the public on where to pass and which rituals to witness. These ritual experts open and close the door of this archive to users. </p>
<p>In spite of debates calling for unlimited access to material in archives, it is a common custom for archivists to regulate the access to and use of material in the custody of archival institutions. </p>
<h2>Why this matters</h2>
<p>From these discussions, it becomes plausible to argue that a cultural site can act as an archive for a community. </p>
<p>Although one may see ‘nothing’ stored in such archives on ordinary days, these places are full of materials that articulate the socio-cultural, political and historical context of the community. </p>
<p>Preserving such areas is tantamount to archiving the rituals, musics and dances performed there. Governments and conservation experts should establish ways of working with local communities to safeguard these sites for future generations.</p><img src="https://counter.theconversation.com/content/140571/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dominic D.B. Makwa does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Sacred sites where rituals are performed by the community should be protected as living archives that house local heritage.Dominic D.B. Makwa, Lecturer, Makerere UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1251352019-12-09T01:11:07Z2019-12-09T01:11:07Z‘How do I clean my penis?’<figure><img src="https://images.theconversation.com/files/305101/original/file-20191204-70167-1dlj45h.png?ixlib=rb-1.1.0&rect=538%2C0%2C2958%2C2000&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Wes Mountain/The Conversation</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span></figcaption></figure><blockquote>
<p>Growing up, no one ever gave me the rundown on how or what I should do to keep my penis clean […] I’ve never read any reliable answer beyond washing it with water. Do I use soap? Any soap? How normal is smegma? If my penis gets itchy from smegma should I go see a doctor? If so, my GP or a urologist? — Anonymous</p>
</blockquote>
<h2>Key points</h2>
<ul>
<li>clean under the foreskin, using soap, but not too much</li>
<li>smegma is normal</li>
<li>if you have any concerns, see your GP.</li>
</ul>
<p><a href="https://theconversation.com/au/topics/i-need-to-know-66587"><img src="https://images.theconversation.com/files/290837/original/file-20190904-175686-polw3q.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=90&fit=crop&dpr=2" width="100%"></a></p>
<p>It’s a shame some people think talking about cleaning and caring for our genitals is embarrassing or taboo. We probably know more about hair care than penis care.</p>
<p>The penis is simply another part of our anatomy, so cleaning should be relatively straight forward.</p>
<p>If you’ve been circumcised, where your foreskin was removed soon after birth, your penis will look something like the one in the diagram (below, right), with the head (or glans) always exposed.</p>
<p>But if you have a foreskin (below left and centre), there are some extra things to think about when washing, which we’ll get to soon.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/305077/original/file-20191204-70116-1vv28db.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/305077/original/file-20191204-70116-1vv28db.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=390&fit=crop&dpr=1 600w, https://images.theconversation.com/files/305077/original/file-20191204-70116-1vv28db.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=390&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/305077/original/file-20191204-70116-1vv28db.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=390&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/305077/original/file-20191204-70116-1vv28db.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=490&fit=crop&dpr=1 754w, https://images.theconversation.com/files/305077/original/file-20191204-70116-1vv28db.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=490&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/305077/original/file-20191204-70116-1vv28db.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=490&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">The Conversation</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<h2>Foreskin facts</h2>
<p>But first, some foreskin facts. From around the time you turn five, your foreskin <a href="http://www.cirp.org/library/hygiene/camille1/">separates</a> from the head of your penis, bit by bit. This allows you to pull back your foreskin (retract it). In some boys, the foreskin can stay partially stuck to the head of the penis until puberty.</p>
<p>You should <a href="https://www.berghahnjournals.com/view/journals/boyhood-studies/1/2/bhs010206.xml">never forcibly pull back</a> your foreskin. That’ll be painful, you could bleed, you could scar, or have other complications.</p>
<h2>OK, now for the washing part</h2>
<p><a href="http://www.cirp.org/library/hygiene/camille1/">Once your foreskin separates easily from the glans</a>, gently retract and clean underneath the foreskin with each bath or shower. Then, after washing, pull the foreskin forward to its normal position.</p>
<p>When it’s time to dry off, retract the foreskin again so you can dry the head of the penis with a towel. Then, you guessed it, pull the foreskin forward to its normal position.</p>
<p>It’s OK to clean with soap whether you have a foreskin or not. But generally, too much soap is worse than none at all. Excessive cleaning removes essential body oils that would normally keep our skin moist and reduce friction. If you have sensitive skin, you can use a soap-free wash from the chemist.</p>
<h2>What about smegma?</h2>
<p><a href="https://www.healthline.com/health/smegma">Smegma</a> is a thick, whitish discharge consisting of a build-up of dead skin cells, oil and other fluids under the foreskin. And it’s very useful. It protects and lubricates the penis. </p>
<p>Some people have oilier skin than others and <a href="https://onlinelibrary.wiley.com/doi/abs/10.1046/j.1464-410x.1999.0830s1034.x">tend to have more smegma</a>.
So some smegma is normal, but if you have too much or it becomes smelly, you may need to clean more.</p>
<h2>Things to watch out for (and when to see your GP)</h2>
<p>If the head of your penis becomes painful, red, itchy and has a discharge, you may have a treatable condition called <a href="https://www.mshc.org.au/SexualHealthInformation/SexualHealthFactSheets/BALANITIS/tabid/134/Default.aspx#.XcJiPfZuKUk">balanitis</a>.</p>
<p>It’s more common if you have a foreskin. And the bacteria and fungus that cause it like the warm and moist conditions under there.</p>
<p>Skin disorders, infection, poor hygiene, friction from sexual activity, and using too much soap all <a href="https://www.dermnetnz.org/topics/balanitis/">cause the condition</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-to-make-your-next-sexual-health-check-less-erm-awkward-72498">How to make your next sexual health check less, erm ... awkward</a>
</strong>
</em>
</p>
<hr>
<p>You can clear a mild case with good hygiene and simple treatments, such as an antiseptic or antifungal cream. You can buy these from any pharmacy. In addition to the medication, the cream itself helps protect and moisturise the inflammed skin. </p>
<p>If you have balanitis you may need to be more careful than usual to avoid urine irritating your inflamed skin. Retract your foreskin when you urinate. Dry the head of the penis gently after you finish.</p>
<p>If your penis is still inflamed after a week of these simple measures it’s <a href="https://www.aafp.org/afp/2018/0115/p102.html">best to see your GP</a>. They can then investigate other causes, such as <a href="https://www.ncbi.nlm.nih.gov/books/NBK537143/">psoriasis or an allergy</a>.</p><img src="https://counter.theconversation.com/content/125135/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David King does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>It’s a surprisingly common question. Here’s what you need to know.David King, Senior Lecturer in General Practice, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1093112019-01-11T10:35:14Z2019-01-11T10:35:14ZNeonatal circumcision could increase the risk of sudden infant death syndrome in babies – new research<figure><img src="https://images.theconversation.com/files/252385/original/file-20190103-32145-kmeu2u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">shutterstock</span></span></figcaption></figure><p><a href="https://www.nhs.uk/conditions/sudden-infant-death-syndrome-sids/">Sudden Infant Death Syndrome</a> (SIDS) or cot death remains the leading cause of infant death in many developed countries. There are around 2,700 babies <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5083856/">who die from cot death every year</a> in the US – and around 300 in the UK. </p>
<p>Cot death occurs when a seemingly healthy infant – under 12 months of age – dies in their sleep with no cause of death established in a post-mortem investigation. Although many risk factors are known to increase the risk of cot death – such as <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1586150/">maternal smoking</a> and <a href="https://www.ncbi.nlm.nih.gov/pubmed/24080961">bed sharing</a> – nobody is exactly sure why it happens. </p>
<p>Research, for example, indicates that cot death is more common in boys than girls – at a ratio of <a href="https://www.ncbi.nlm.nih.gov/pubmed/2926568">3:2</a>. <a href="https://www.cdc.gov/sids/data.htm">Studies</a> also show it is 39% lower among US Hispanic communities compared to non-Hispanic people. There is also a <a href="https://jamanetwork.com/journals/jama/article-abstract/348269">seasonal variation</a> – most cases occurring in winter. And 50% of cases occur between seven and 17 weeks after birth – with only 10% of cot deaths occurring after 24 weeks.</p>
<p><a href="http://journal.frontiersin.org/article/10.3389/fneur.2016.00180/full">My research from 2016</a>, suggested that exposure to chronic stress, such as that caused by maternal smoking, can put a baby at higher risk of cot death – and that early circumcision may also be one of the major risk factors in sudden infant death syndrome (SIDS) or cot death in boys. </p>
<p>In my <a href="https://www.jctres.com/en/04.201802.005/">latest study</a>, I analysed the data on SIDS and male neonatal circumcision across 15 countries – where post-mortem examination of infants is mandatory – which included 40 US states. The results show a strong correlation between early circumcision and cot death. So where male neonatal circumcision rates are high, higher rates of cot death occur. </p>
<h2>Bleeding, shock and sepsis</h2>
<p>Until the 19th century, neonatal circumcision was practised almost exclusively by Jews, some Muslims, and certain African cultures for religious or ritual reasons. <a href="https://books.google.co.uk/books/about/Circumcision.html?id=_tXfAAAAMAAJ&redir_esc=y">During this time</a>, British and US physicians increasingly came to see masturbation and the foreskin as disease inducing – and circumcision as a potential cure. </p>
<p>By 1940, <a href="https://www.press.uchicago.edu/ucp/books/book/chicago/S/bo3534612.html">40% of British boys</a> and <a href="https://jamanetwork.com/journals/jama/article-abstract/414922">80% of US boys</a> were circumcised as a preventive health measure. But after World War II, circumcision rapidly fell out of favour in Britain. In the US however, unnecessary surgery was promoted as “preventative” and “healthy” and reached a rate of about 95% in the late 1960s before declining to about 65% by 1999. Today in Europe, rates of circumcision are low – and mostly confined to the Jewish and Muslim communities – but in the US, circumcision is still the <a href="https://www.hcup-us.ahrq.gov/reports/statbriefs/sb187-Hospital-Stays-Children-2012.pdf">most common elective surgery</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/252373/original/file-20190103-32145-1oieokt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/252373/original/file-20190103-32145-1oieokt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/252373/original/file-20190103-32145-1oieokt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/252373/original/file-20190103-32145-1oieokt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/252373/original/file-20190103-32145-1oieokt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/252373/original/file-20190103-32145-1oieokt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/252373/original/file-20190103-32145-1oieokt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Circumcision is one of oldest surgical operations, dating back more than 4,000 years.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>Male neonatal circumcision is usually performed in the first few days days after birth and is associated with many <a href="https://www.biorxiv.org/content/early/2018/06/07/339465">health risks</a>. These risks include bleeding, shock, sepsis, circulatory shock, haemorrhage, pain, and other long-term consequences – such as post traumatic stress disorder. </p>
<p><a href="https://europepmc.org/abstract/med/3627593">During circumcision</a> there is an increase in blood pressure, breathing rate and heart rate of the baby. And even with the most advanced techniques, bleeding occurs in <a href="https://www.ncbi.nlm.nih.gov/pubmed/25794628">more than 15% of cases</a>. Babies born early experience more than <a href="https://www.ncbi.nlm.nih.gov/pubmed/28412847">twice the rate of bleeding complications</a> than full-term babies.</p>
<p>With blood loss, there is also a danger that a lower blood volume could result in low blood pressure – reducing the amount of oxygen that reaches the tissues. Reduced blood pressure has also been associated with <a href="https://www.ncbi.nlm.nih.gov/pubmed/23768837">obstructive sleep apnea</a> – a condition where the walls of the throat relax and narrow during sleep, interrupting normal breathing. <a href="https://www.ncbi.nlm.nih.gov/pubmed/11704597">Research shows</a> babies who have died from cot death are more likely to have experienced obstructive sleep apnea. </p>
<h2>What the data show</h2>
<p>My findings also show a correlation between the proportion of Hispanics in a US state and the SIDS rates. In other words, Hispanics lower the state’s SIDS rate. This is despite the fact Hispanics in the US tend to belong to a lower socioeconomic status – which is strongly associated with SIDS. </p>
<p>Not only that, but in US states with high proportions of Hispanics, the SIDS gender bias was closer to one – that is males and females died in even numbers. This could indicate neonatal circumcision accounts for the gender bias in SIDS. Babies born early were also found to be more at risk – circumcised boys born prematurely were at the highest risk.</p>
<p>Of course, male neonatal circumcision does not explain why all cot deaths occur, but it could go some way to explain why in the 16th century, Jews in Israel, where circumcision is prevalent, blamed the deaths on a <a href="https://www.jstor.org/stable/3651935">beautiful demoness</a>. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/253043/original/file-20190109-32130-1x5e2bb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/253043/original/file-20190109-32130-1x5e2bb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/253043/original/file-20190109-32130-1x5e2bb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=1144&fit=crop&dpr=1 600w, https://images.theconversation.com/files/253043/original/file-20190109-32130-1x5e2bb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=1144&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/253043/original/file-20190109-32130-1x5e2bb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=1144&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/253043/original/file-20190109-32130-1x5e2bb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1438&fit=crop&dpr=1 754w, https://images.theconversation.com/files/253043/original/file-20190109-32130-1x5e2bb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1438&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/253043/original/file-20190109-32130-1x5e2bb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1438&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A painting of Lilith from 1887.</span>
<span class="attribution"><span class="source">John Collier in Southport Atkinson Art Gallery</span></span>
</figcaption>
</figure>
<p>Lilith, a controversial figure within Jewish mythology, was said to rob children of life and was responsible for the deaths of still-born infants and cot deaths. Male children were said to be at risk of Lilith’s wrath for eight days after birth (until circumcision) and girls for 20 days. </p>
<p>Deceiving Lilith into believing newborn babies were a girl – letting the boy’s hair grow and even dressing him in girl clothes – were said to be the most effective means to avoid her harm – tricks that were also practiced by <a href="https://www.jstor.org/stable/3651935">some Muslims</a>. The Jewish practice is called “Halake” (haircut in Arabic). </p>
<p>The traditions that tie Lilith to the fear of death during the circumcision period could suggest ancient Jews had also drawn a link between cot death and early circumcision, so religious elders created the story of Lilith to explain away the deaths, and keep the practice alive for centuries to come.</p><img src="https://counter.theconversation.com/content/109311/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Eran Elhaik consults the DNA Diagnostic Center (DDC), DNA Consultants, and MonDevices.
He receives funding from MRC and DDC. </span></em></p>Circumcising newborn boys could increase their risk of cot death, here’s why.Eran Elhaik, Lecturer in population, medical and evolutionary genomics, University of SheffieldLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/980152018-06-18T13:36:13Z2018-06-18T13:36:13ZWhy women should have more of a say in male rites of passage<figure><img src="https://images.theconversation.com/files/222743/original/file-20180612-112596-mi5wj8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">AmaXhosa women want to play a bigger role in cultural rituals.</span> <span class="attribution"><span class="source">South African Tourism/Flickr</span></span></figcaption></figure><p>Each year scores of boys from the <a href="http://www.sahistory.org.za/article/xhosa">amaXhosa</a> nation take part in <a href="http://vital.seals.ac.za:8080/vital/access/manager/Repository/vital:3271">ulwaluko</a> in South Africa’s Eastern Cape province. This involves the boys living in secluded areas away from their homes. They undergo circumcision and take part in a number of rituals. All of this entails the boy’s <a href="https://core.ac.uk/download/pdf/145051396.pdf">journey to manhood</a>.</p>
<p>Unfortunately the process can be problematic. More than 1000 initiates <a href="https://ulwaluko.co.za/Problems.html">have died</a> in the province between 1995 and 2017. Complications from <a href="http://www.samj.org.za/index.php/samj/article/view/2271">botched circumcision procedures</a> – including penile amputations – are common. There are also frequent reports of dehydration and physical violence in initiation schools. </p>
<p>These negative stories tend to make headlines. But for the most part, ulwaluko is shrouded in secrecy. And amaXhosa women tend to be among those who are the most excluded from this secretive set of rituals.</p>
<p>The participation of women in ulwaluko is <a href="http://www.koersjournal.org.za/index.php/koers/article/view/42">considered taboo</a> among amaXhosa. The Congress of Traditional Leaders of South Africa has in the past <a href="https://www.tandfonline.com/doi/abs/10.1080/13691050701861447">rejected</a> any suggestion of women’s involvement. </p>
<p>When the Department of Cooperative Governance and Traditional Affairs tried in 2016 to legislate for some involvement by women in ulwaluko, it was labelled “<a href="http://www.dispatchlive.co.za/news/2016/03/19/ribal-chiefs-reject-draft-bill-on-circumcision-rite/">a serious mistake</a>” by men opposed to the idea. The department retracted the controversial clause.</p>
<h2>Men and women’s roles</h2>
<p>Traditionally there’s a <a href="http://theconversation.com/changes-in-gender-norms-are-making-initiation-safer-for-south-african-boys-46488">significant split</a> in gender roles during ulwaluko. Women cook and prepare for the related ceremonies while men are responsible for the customary practices and the decisions required in the process.</p>
<p>I wanted to understand women’s feelings and perceptions about ulwaluko. I also wanted to establish whether their rights to gender equality, as outlined in the <a href="http://www.justice.gov.za/legislation/constitution/SAConstitution-web-eng.pdf">Constitution</a> and <a href="http://www.hrcr.org/docs/CEDAW/cedaw.html">other pieces</a> of South African and international <a href="http://www.justice.gov.za/legislation/acts/2000-004.pdf">legislation</a>, were being compromised in the name of protecting cultural norms.</p>
<p>I explored these issues in <a href="http://vital.seals.ac.za:8080/vital/access/manager/Repository/vital:28059">my PhD thesis</a>. The study found that although women embrace and celebrate ulwaluko as a rite of passage, they also view it as a practice that perpetuates patriarchy. </p>
<p>The findings suggest there’s a need for relevant government structures and traditional leadership to give women a voice in discussions around ulwaluko. Women believe that certain things can be done differently to help make initiation safer. They also want to be part of the discussions and decision-making process around ulwaluko.</p>
<h2>Women feel excluded</h2>
<p>I conducted eight focus group discussions and 10 in-depth interviews in the Eastern Cape towns of Mdantsane, Flagstaff and Grahamstown with women aged between 31 and 82. Most had sent at least one son to initiation school.</p>
<p>Women told me their role in ulwaluko merely involved labour intensive tasks such as preparing food and traditional beer for the initiation ceremonies. They were barred from decision making processes. </p>
<p>One of the interviewees, Mavuyi*, expressed frustration with this exclusion:</p>
<blockquote>
<p>We are not even allowed to speak about it! This is why some things fail, because sometimes this woman has good advice but is scared she will be asked why she is getting involved in this business.</p>
</blockquote>
<p>Another participant, Lulu*, complained that “nobody tells you anything, because you are a woman”.</p>
<p>A few women told me, however, that there was nothing untoward about the exclusion of women from the initiation process. They argued that the tradition should be respected and accepted as men’s territory in the same way that child birth was historically considered women’s terrain by amaXhosa. It is worth noting that there have been some shifts here, in that modern amaXhosa men observe their children’s birth in hospital and give their wives support.</p>
<h2>Harmful cultural practice</h2>
<p>However, my research and others’ suggests that on the whole ulwaluko can be viewed as a <a href="https://www.tandfonline.com/doi/abs/10.1080/09720073.2011.11891187">harmful cultural practice</a> because it puts women in harm’s way and causes them great distress. For instance, women who are seen in close proximity to an initiation school are accused of <a href="https://scholar.sun.ac.za/bitstream/handle/10019.1/86595/ncaca_yithi_2014.pdf">practising witchcraft</a> – and <a href="https://www.dispatchlive.co.za/news/2017-12-28-three-initiates-up-for-murder/">even killed</a> as a result.</p>
<p>Women are also vulnerable to a practice called <a href="http://vital.seals.ac.za:8080/vital/access/manager/Repository/vital:3271">ukukhupha ifutha or ukosula</a>. This encourages newly-initiated men to have sex with any woman who is not their girlfriend; they believe this will cleanse them of any bad luck they may have acquired during the initiation. The result is frequently coercive or non-consensual sex.</p>
<p>Initiates’ mothers also suffer tremendous distress and worry, particularly in the Eastern Cape’s Mpondoland region. They are denied information about their sons’ health. In some instances, boys died during the initiation period and their mothers were not told. Women weren’t even told where their children were buried. This weighed heavily on them.</p>
<p>Despite these issues, women don’t want ulwaluko to be scrapped. They understand its <a href="https://core.ac.uk/download/pdf/145051396.pdf">significance as a cultural practice</a>. </p>
<p>It is a deeply entrenched, age-old practice that has stood the test of time among amaXhosa. Initiates undergo this rite in the belief that it will transform even the most wayward boy into a dignified, self-respecting, and socially responsible man. </p>
<p>However, while respecting this history and culture, it’s also important to implement new ways of addressing the evident clash between ulwaluko and gender equality. </p>
<p>This is happening slowly in some areas. In parts of the Eastern Cape, mothers and female relatives who were traditionally denied information about initiates’ deaths are <a href="http://theconversation.com/changes-in-gender-norms-are-making-initiation-safer-for-south-african-boys-46488">no longer kept in the dark</a>. This allows them to grieve properly.</p>
<h2>Room for change</h2>
<p>Ulwaluko, like all other traditional practices, must be allowed to exist. However, custodians of the culture should be willing to part with the harmful aspects identified in this study. </p>
<p>Awareness must be created around initiation legislation and existing tensions. Awareness campaigns can also be used to modify the norms and values of the custom that are outdated. </p>
<p>At the heart of this is the need to incorporate the voice of women in ulwaluko processes. Gender equality programmes should be established at community level. But these initiatives will work only if they are grounded in law and involve all stakeholders.</p>
<p>Lastly, initiation practices that have been successful in other Xhosa regions need to be documented and shared with communities that continue to experience persistent problems and fatalities during the initiation season. </p>
<p><em>*Not their real names.</em></p><img src="https://counter.theconversation.com/content/98015/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mmampho KB Gogela received a small research grant from Walter Sisulu University for her PhD study. She is affiliated with the Democratic Alliance. </span></em></p>Women don’t want to be reduced to ceremonial roles; they believe they can add value in making decisions.Mmampho Gogela, Manager: Centre for Learning and Teaching Development, Walter Sisulu UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/769522017-07-04T20:09:18Z2017-07-04T20:09:18ZSurgery to make intersex children ‘normal’ should be banned<figure><img src="https://images.theconversation.com/files/175546/original/file-20170626-32724-121ds44.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1497%2C992&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Intersex people are born with sexual anatomy that doesn't fit binary notions of male or female bodies. </span> <span class="attribution"><span class="source">Boston Public Library/flickr</span></span></figcaption></figure><p>Questions in the proposed new citizenship test that address family violence, <a href="http://www.smh.com.au/federal-politics/political-news/malcolm-turnbull-targets-labor-over-australian-values-citizenship-quiz-20170419-gvo9jn.html">child marriage and female genital mutilation</a> imply opposition to these is an Australian value.</p>
<p>Indeed most Australians would agree female genital mutilation is an appalling breach of a girl’s right to bodily integrity, and that safeguarding children from violence is a vital goal in modern society. But protection from genital cutting should not only be granted to girls, but to all children. </p>
<p>While condemning female genital mutilation, Australian society appears to broadly accept routine circumcision of young boys, and genital modification surgeries on intersex children where the child’s genitals are reconstructed to resemble those typical of either a male or female. These procedures are legal and supported by Medicare.</p>
<p>In most cases, circumcisions and intersex surgeries occur without medical necessity or urgency: the children are healthy and no adverse medical consequences will arise if the surgery is not carried out immediately. Importantly, children undergoing such surgeries are often too young to understand what is happening to them and are legally too young to provide their consent. </p>
<p>Human rights concerns about underage male circumcision <a href="https://theconversation.com/infant-male-circumcision-stop-violating-boys-human-rights-8517">have been discussed in the past</a>, yet infringements suffered by intersex children are an emerging area of controversy. Medically unnecessary, non-consensual intersex genital modification should be made <a href="http://www.legislation.nsw.gov.au/#/view/act/1900/40/part3/div6/sec45">illegal in Australia in the same way</a> as female genital mutilation.</p>
<h2>Children with intersex variations</h2>
<p>Intersex children are <a href="https://unfe.org/system/unfe-65-Intersex_Factsheet_ENGLISH.pdf">born with sex characteristics</a>, including genitals, gonads (testes and ovaries) and chromosome patterns, that do not fit typical binary notions of male or female bodies. </p>
<p>Nearly 2% of Australia’s population have <a href="https://oii.org.au/16601/intersex-numbers/">intersex variations</a>, which may not always be apparent at birth and may reveal themselves at puberty or later in life. While some intersex people may have atypical external genitalia, others may not. </p>
<p>Intersex variations describe physical or bodily traits – they do not describe gender or sexuality. Like non-intersex folks, intersex people may identify with any number of gender or sexual identities.</p>
<hr>
<p><strong><em>Read more: <a href="https://theconversation.com/boy-girl-or-dilemmas-when-sex-development-goes-awry-49359?sr=7">Boy, girl or …? Dilemmas when sex development goes awry</a></em></strong></p>
<hr>
<h2>Genital “normalising” surgery</h2>
<p>Many intersex children undergo what proponents call genital “normalising” procedures, which implies these children’s bodies are abnormal. The procedures, intended to make the children conform to social norms of male or female bodies, often include irreversible surgical modification of sexual organs. These may result in sterilisation by removal of their gonads (testes or ovaries), and life-long hormone treatments. </p>
<p>Those who advocate for these procedures to be carried out when children are still young often argue the chances of medical success are higher and the children will be able to grow up with a consistent gender identity. However, this ignores the human rights of these children to independently develop a gender identity and decide for themselves whether they want their bodies to be altered irreversibly. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/175550/original/file-20170626-32724-1tot11t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/175550/original/file-20170626-32724-1tot11t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/175550/original/file-20170626-32724-1tot11t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/175550/original/file-20170626-32724-1tot11t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/175550/original/file-20170626-32724-1tot11t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/175550/original/file-20170626-32724-1tot11t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/175550/original/file-20170626-32724-1tot11t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Safeguarding children from violence is a vital goal in modern society.</span>
<span class="attribution"><span class="source">Man-wise/flickr</span></span>
</figcaption>
</figure>
<p>There are many examples of intersex people who, as children, were subjected to “normalising” procedures without their consent. In the 1970s, intersex advocate <a href="http://www.abc.net.au/local/stories/2014/12/01/4135509.htm">Georgie Yovanovic</a> went through forced medical examinations, hormone treatments, surgery to descend her testicles, and ultimately a unilateral mastectomy without her consent or any explanation from doctors when she was a child and teenager.</p>
<p>Alice Springs-based musician <a href="http://www.abc.net.au/local/stories/2014/12/01/4140196.htm">Shon Klose</a> was born without internal female organs. As a teenager in the 1980s, she was pressured into having medical treatment to create a vagina to have a more typical female body capable of heterosexual penetration. She did not receive any medical counselling, support or information.</p>
<p>Genital “normalising” procedures on young children still occur in Australia today. The recent <a href="http://www.theaustralian.com.au/national-affairs/health/carlas-case-ignites-firestorm-among-intersex-community-on-need-for-surgery/news-story/7b1d478b8c606eaa611471f70c458df0">Family Court of Australia</a> case of five-year-old Carla is an example. Carla was born genetically male but with the external appearance of a female child and had undergone early childhood surgery to enhance the appearance of her genitalia. </p>
<p>In 1992, the High Court of Australia had established a precedent in <a href="http://www.austlii.edu.au/au/cases/cth/high_ct/175clr218.html">Marion’s Case</a>, that parents cannot consent on behalf of their children to have certain types of medical procedures, which therefore require court authorisation. Consequently, in 2015 Carla’s parents, who were raising her as a girl, sought permission to have her gonads surgically removed, which the Family Court granted. </p>
<h2>Human rights violation</h2>
<p>Greater visibility of intersex people is driving increasing resistance to these procedures. There is now growing global criticism of genital modification procedures on intersex children as a violation of human rights. </p>
<p>In 2013, Europe’s leading human rights organisation, the Council of Europe, <a href="http://semantic-pace.net/tools/pdf.aspx?doc=aHR0cDovL2Fzc2VtYmx5LmNvZS5pbnQvbncveG1sL1hSZWYvWDJILURXLWV4dHIuYXNwP2ZpbGVpZD0yMDE3NCZsYW5nPUVO&xsl=aHR0cDovL3NlbWFudGljcGFjZS5uZXQvWHNsdC9QZGYvWFJlZi1XRC1BVC1YTUwyUERGLnhzbA==&xsltparams=ZmlsZWlkPTIwMTc0">identified intersex genital modification</a> as a non-medically justified violation of children’s right to physical integrity. The Council encouraged states to “guarantee bodily integrity, autonomy and self-determination” to intersex people. </p>
<p>In 2015, <a href="https://rm.coe.int/168045b1e6">Malta became the first country</a> to explicitly outlaw the practice. No other country has done so at the time of writing. In the same year, the United Nations Office of the High Commissioner for Human Rights (OHCHR) <a href="http://www.ohchr.org/EN/NewsEvents/Pages/Astepforwardforintersexvisibility.aspx">held a conference</a> to address what it called the human rights violations faced by intersex people. As the first of its kind, the meeting broadened global awareness of intersex issues and genital modification specifically. </p>
<p>Shortly after this, twelve UN entities including the OHCHR, UNICEF and the World Health Organisation, <a href="http://www.ohchr.org/Documents/Issues/Discrimination/Joint_LGBTI_Statement_ENG.PDF">released a joint statement</a> condemning anti-LGBTI discrimination and violence. They specifically pointed out that LGBTI persons may face </p>
<blockquote>
<p>abuse in medical settings, including unethical and harmful so-called “therapies” to change sexual orientation, forced or coercive sterilization, forced genital and anal examinations, and unnecessary surgery and treatment on intersex children without their consent.</p>
</blockquote>
<h2>So, what about Australia?</h2>
<p>There is growing awareness in Australia of the potential human rights abuses on intersex children. </p>
<p>A 2013 federal senate inquiry into the <a href="http://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/Involuntary_Sterilisation/Sec_Report/index">involuntary or coerced sterilisation</a> of intersex people found there is no medical consensus regarding how and when genital “normalising” surgery should be conducted. </p>
<p>Among the <a href="http://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/Involuntary_Sterilisation/Sec_Report/b01">committee’s recommendations</a> was that all intersex medical procedures be managed by multidisciplinary teams in a human rights framework, and require authorisation by a court or tribunal. These recommendations did not lead to policy changes or legislative reform. </p>
<p>In 2016, Australian Human Rights Commissioner Ed Santow <a href="https://www.humanrights.gov.au/news/stories/intersex-rights-are-human-rights">endorsed international calls</a> to end medically unnecessary procedures to safeguard the human rights of intersex children. </p>
<p>In February 2017, the Rationalist Society of Australia – a secular free thought organisation – published its <a href="https://www.rationalist.com.au/campaigns/genital-autonomy-2/">white paper on genital autonomy</a>. This condemns all forms of medically unnecessary, non-consensual genital modification as violations of human rights. The white paper calls for the criminalisation of these procedures on equal footing with the prohibition of female genital mutilation.</p>
<p>Despite increasing international and national awareness of the human rights violations caused by genital modification procedures, Australia has not reformed its laws. Yet rights to bodily integrity and autonomy should be protected for all children. Until we safeguard every child from all forms of violence, opposition to genital cutting will not be an Australian value.</p><img src="https://counter.theconversation.com/content/76952/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Cornelia Koch is on the Advisory Board of the Australasian Institute for Genital Autonomy. </span></em></p><p class="fine-print"><em><span>Travis Wisdom is an associate member of Organisation Intersex International Australia Limited (OII-Australia) and is the co-author of the Rationalist Society of Australia white paper, 'Genital Autonomy.' </span></em></p>Until we safeguard every child from all forms of violence, opposition to genital cutting will not be an Australian value.Cornelia Koch, Senior Lecturer in Law, University of AdelaideTravis Wisdom, PhD Candidate, International Human Rights Law, University of AdelaideLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/775692017-05-15T09:56:12Z2017-05-15T09:56:12ZHow different are female, male and intersex genital cutting?<figure><img src="https://images.theconversation.com/files/169144/original/file-20170512-3689-5q8xv0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Model Hanne Gaby Odiele (in white) has been outspoken about experiencing life as intersex.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Three members of the Dawoodi Bohra sect of Islam <a href="https://www.justice.gov/usao-edmi/pr/three-indicted-female-genital-mutilation">were recently indicted</a> on charges of “female genital mutilation” (FGM) in the US state of Michigan. In Norway, meanwhile, one of the major political parties <a href="http://www.independent.co.uk/news/world/europe/norwegian-ruling-progress-party-ban-circumcision-men-under-16-years-old-vote-annual-conference-a7723746.html">has backed</a> a measure to ban childhood male circumcision.</p>
<p>Fearing that objections to female forms of genital cutting will be applied to male forms, some <a href="http://www.eurasiareview.com/01052017-female-genital-mutilation-crime-not-circumcision-oped/">commentators</a> have rushed to draw a “clear distinction” between them. Others, however, have <a href="http://www.startribune.com/we-re-appalled-at-genital-mutilation-of-girls-what-about-boys-and-circumcision/422052673/">highlighted the similarities</a>. </p>
<p>In fact, childhood genital cutting is usually divided not just into two, but three separate categories: “FGM” for females; “circumcision” for males; and “genital normalisation” surgery for <a href="http://www.isna.org/articles/ambivalent_medicine">intersex children</a> – those born with ambiguous genitals or mixed sex characteristics.</p>
<p>In Western countries, popular attitudes towards these procedures <a href="https://www.dovepress.com/female-genital-mutilation-and-male-circumcision-toward-an-autonomy-bas-peer-reviewed-article-MB">differ sharply</a> depending on the child’s sex. In females, any medically unnecessary genital cutting, <a href="https://www.researchgate.net/publication/280238965_Female_Genital_Alteration_-_A_Compromise_Solution">no matter how minor or sterilised</a>, is seen as an intolerable violation of her bodily integrity and human rights. Most Westerners believe that such cutting must be <a href="http://www.npwj.org/FGM/UN-General-Assembly-Adopts-Worldwide-Ban-Female-Genital-Mutilation.html">legally prohibited</a>. </p>
<p>In intersex children, while it is still common for doctors to surgically modify their genitals without a strict medical justification, there is <a href="http://digitalcommons.law.yale.edu/cgi/viewcontent.cgi?article=1423&context=ylpr">growing opposition</a> to non-essential “<a href="https://www.researchgate.net/publication/279180849_Should_surgery_for_hypospadias_be_performed_before_an_age_of_consent">cosmetic</a>” surgeries, designed to mould ambiguous genitalia into a “binary” male or female appearance. </p>
<p>Belgian model Hanne Gaby Odiele, for example, has <a href="https://www.washingtonpost.com/news/arts-and-entertainment/wp/2017/01/25/a-supermodel-reveals-she-is-intersex-was-subjected-to-traumatizing-and-unnecessary-surgeries/">spoken openly</a> about the negative impact of the “irreversible, unconsented and unnecessary” intersex surgeries she was subjected to growing up.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/169300/original/file-20170515-7019-z7n00z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/169300/original/file-20170515-7019-z7n00z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=475&fit=crop&dpr=1 600w, https://images.theconversation.com/files/169300/original/file-20170515-7019-z7n00z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=475&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/169300/original/file-20170515-7019-z7n00z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=475&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/169300/original/file-20170515-7019-z7n00z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=597&fit=crop&dpr=1 754w, https://images.theconversation.com/files/169300/original/file-20170515-7019-z7n00z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=597&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/169300/original/file-20170515-7019-z7n00z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=597&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Sensitive issues.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/cropped-image-man-jeans-closeup-on-368677379?src=KpG5FfP8iW_h4PN3sU6O6g-1-20">Shutterstock</a></span>
</figcaption>
</figure>
<p>In male children, by contrast, the dominant view is that boys are not significantly harmed by being circumcised, despite the loss of <a href="http://onlinelibrary.wiley.com/doi/10.1002/tre.531/abstract">sensitive tissue</a>. Some even point to potential health benefits, although <a href="https://www.researchgate.net/publication/316527603_Cultural_bias_in_American_medicine_The_case_of_infant_male_circumcision">most doctors agree</a> that these benefits are not enough to <a href="http://pediatrics.aappublications.org/content/early/2013/03/12/peds.2012-2896">outweigh</a> the risks and <a href="http://pennjil.com/brian-earp-robert-darby-circumcision-sexual-experience-and-harm-reply-to-stephen-r-munzers-secularization-anti-minority-sentiment-and-cultural-norms-in-the-german-circumcision-cont/">harms</a>. Even so, many people believe that parents should be allowed to choose circumcision for their sons, whether for cultural or religious reasons.</p>
<p>But these attitudes are starting to change. Over the past few decades, and even more strongly in <a href="http://www.tandfonline.com/doi/abs/10.1080/23269995.2013.804757">recent years</a>, scholars of genital cutting have <a href="http://heinonline.org/HOL/LandingPage?handle=hein.journals/hmax11&div=19&id=&page=">argued</a> that there is too much overlap in the physical effects, motivations, and symbolic meanings of these three practices – <a href="https://www.dovepress.com/female-genital-mutilation-and-male-circumcision-toward-an-autonomy-bas-peer-reviewed-article-MB">when their full range across societies is considered</a> – for categorical distinctions based on sex or gender to hold up.</p>
<h2>Making comparisons</h2>
<p>Take the Dawoodi Bohra case. The defendants claim that, like male circumcision, female “circumcision” is <a href="http://www.metrotimes.com/news-hits/archives/2017/04/22/muslim-sect-known-for-female-genital-mutilation-responds-to-charges-against-local-docs">required by their religion</a>. In the Western popular media, this claim is usually <a href="https://www.researchgate.net/publication/316505694_Reason_and_paradox_in_medical_and_family_law_Shaping_children%27s_bodies">dismissed as mistaken</a>, because neither male nor female circumcision is mentioned in the Quran, the central scripture of Islam. </p>
<p>But both practices <a href="http://heinonline.org/HOL/LandingPage?handle=hein.journals/twls1994&div=9&id=&page=">are mentioned in the Hadith</a> (the sayings of the prophet Mohammed), which is another important source of Islamic law. </p>
<p>Based on their reading of the Hadith, some <a href="https://islamqa.info/en/60314">Muslim authorities</a> state that “circumcision” of both sexes is recommended or even obligatory, while others draw a <a href="http://theislamicmonthly.com/a-tiny-cut-female-circumcision-in-south-east-asia/">different conclusion</a>. But there is no “pope” in Islam to make the final call: whether a practice counts as religious, therefore, depends on the local community and its interpretation of scripture. </p>
<p>Motivations for genital cutting and associated “symbolic meanings” <a href="https://www.sfog.se/media/295486/omskarelse_rapport.pdf">differ widely</a> from group to group. The claim that female genital cutting is always about <a href="https://humdev.uchicago.edu/sites/humdev.uchicago.edu/files/uploads/shweder/Disputing%20The%20Myth%20of%20the%20sexual%20dysfunction%20of%20cicumcised%20women.pdf">sexual control</a>, while male genital cutting <a href="http://www.cirp.org/library/psych/boyle6/">never is</a>, is an <a href="http://www.tandfonline.com/doi/abs/10.1080/10532528.2000.10559787">oversimplification</a> based on stereotypes – most anthropologists who study these practices <a href="https://www.sfog.se/media/295486/omskarelse_rapport.pdf">regard</a> this claim as false.</p>
<p>As they emphasise, nearly <a href="https://www.sfog.se/media/295486/omskarelse_rapport.pdf">every society</a> that practices female genital cutting also practices male genital cutting, often in parallel and for similar reasons. When the cutting is part of a rite of passage into adulthood, for example, diminishing sexual experience is <a href="http://www.tandfonline.com/doi/abs/10.1080/10532528.2000.10559787">not typically the intention</a> for either the boys or the girls. Instead, the goal is to ceremoniously “transform” the youths into mature adults, in part by having them show courage in the face of discomfort.</p>
<p>What about the physical effects? These range widely, too. Some groups practice a female <a href="http://theislamicmonthly.com/a-tiny-cut-female-circumcision-in-south-east-asia/">“ritual nick”</a>, which involves cutting part of the foreskin or “hood” of the external clitoris. Although this procedure <a href="https://www.researchgate.net/publication/280238965_Female_Genital_Alteration_-_A_Compromise_Solution">does not usually remove tissue</a>, it may certainly be painful and traumatic, and we have <a href="https://www.researchgate.net/publication/285578712_In_defence_of_genital_autonomy_for_children">argued elsewhere</a> that it should not be done on non-consenting minors. </p>
<p>Nevertheless, despite being federally prohibited in the US, this form of “FGM” is actually less invasive than either male circumcision or cosmetic intersex “normalisation” surgeries – both of which are also painful and can be <a href="http://www.cirp.org/library/psych/boyle6/">traumatic</a>, and neither of which is medically necessary.</p>
<h2>Informed consent</h2>
<p>Based on these and other points of overlap, the <a href="http://www.tandfonline.com/doi/abs/10.1080/23269995.2013.804757?journalCode=rgld20">emerging consensus</a> among some scholars is that the ethics of genital cutting should not be based on the apparent sex of the child (as judged by their external genitalia). Instead, it should be based on their age and ability to give <a href="https://www.researchgate.net/publication/249753235_Female_Genital_MutilationCutting_in_the_UKChallenging_the_Inconsistencies">informed consent</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/169186/original/file-20170513-3689-gykwfc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/169186/original/file-20170513-3689-gykwfc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/169186/original/file-20170513-3689-gykwfc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/169186/original/file-20170513-3689-gykwfc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/169186/original/file-20170513-3689-gykwfc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/169186/original/file-20170513-3689-gykwfc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/169186/original/file-20170513-3689-gykwfc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Consent issues.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/nyc-june-29-2014-anticircumcision-photos-201938419?src=viEH0-YW6i-vaY6y34rz-g-5-1">Shutterstock</a></span>
</figcaption>
</figure>
<p>Now that “binary” conceptions of both <a href="https://www.nature.com/news/sex-redefined-1.16943">sex and gender</a> are generally understood to be too limited to capture the full reality, judgements based on perceived maleness or femaleness will be increasingly hard to defend. For example, at what point along the <a href="https://en.wikipedia.org/wiki/Quigley_scale">intersex spectrum</a> does a small penis (legal to cut) become a large clitoris (illegal to cut)? Any such distinction would be subjective and arbitrary.</p>
<p>In <a href="http://euromind.global/brian-d-earp-and-rebecca-steinfeld/?lang=en">a recent paper</a> for the European Parliament, we spelled out these arguments in greater detail. We encourage you to <a href="http://euromind.global/brian-d-earp-and-rebecca-steinfeld/?lang=en">give it a read</a>. In it, we ask: what are the policy implications of taking a gender-neutral approach to genital cutting? </p>
<p>In other words, what happens when moral considerations centre around medical necessity, autonomy, and respect for the bodily integrity of all children – regardless of their sex or gender? We see three practical advantages to this approach: </p>
<p>1) It deflects accusations of sexism by recognising that boys and intersex children – just like girls – are vulnerable to genital alterations that they may later come to seriously resent.</p>
<p>2) It reduces the moral confusion that stems from Western-led efforts to eliminate only the female “half” of genital cutting rites in communities that practice both male and female forms in parallel.</p>
<p>3) It neutralises accusations of cultural imperialism and anti-Muslim bias by avoiding <a href="https://www.researchgate.net/publication/249753235_Female_Genital_MutilationCutting_in_the_UKChallenging_the_Inconsistencies">racially tinged double standards</a>. </p>
<p>This is because the same moral concern would apply to medically unnecessary genital cutting practices that primarily affect white children in North America, Australasia and Europe, as to those affecting children of colour (and immigrants) from Africa, the Middle East and Southeast Asia.</p>
<p>Adopting such an approach does not necessarily mean “banning” all pre-consensual forms of non-therapeutic genital alteration. History shows that attempting to pass <a href="http://onlinelibrary.wiley.com/doi/10.1111/dewb.12135/full">strict legal prohibitions</a> before cultural readiness can backfire, creating intense resistance among those who are dedicated to modifying children’s genitals for whatever reason, and often driving such practices further underground. </p>
<p>Prohibition of female genital cutting, for example, has been largely unsuccessful in many countries where it is customary and deeply culturally embedded (rates are higher than 90% in Egypt, for instance, where it has been <a href="https://www.theguardian.com/world/2015/feb/06/female-genital-mutilation-egypt">illegal since 2008</a>); and recent attempts to criminalise circumcision of boys, such as in <a href="http://newsfeed.time.com/2012/06/29/german-court-bans-male-circumcision/">Germany</a> in 2012, have been blocked, <a href="http://www.sun.ac.za/english/faculty/healthsciences/cmel/Documents/After%20Cologne%20male%20circumcision%20and%20the%20law.pdf">overturned</a> or ignored. </p>
<p>There are many levers that societies can pull to discourage unethical practices: the law is only one among them, and not necessarily the most desirable or effective. Some authors <a href="http://jme.bmj.com/content/39/7/459">have proposed</a> step-wise regulation of medically unnecessary childhood genital cutting, along with <a href="https://bmcinthealthhumrights.biomedcentral.com/articles/10.1186/1472-698X-14-13">community engagement</a> and education, as alternatives and/or supplements to formal prohibition. </p>
<p>Whatever specific policies are implemented, it is clear that fundamentally different treatment of female, male and intersex children, in terms of their protection from non-therapeutic genital alteration, will become increasingly difficult to justify in the years to come.</p><img src="https://counter.theconversation.com/content/77569/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rebecca Steinfeld received funding from the Brocher Foundation in Geneva to support this research.</span></em></p><p class="fine-print"><em><span>Brian D Earp received funding from the Brocher Foundation in Geneva to support this research.</span></em></p>There are some striking physical and symbolic similarities.Rebecca Steinfeld, Visiting Research Fellow, Goldsmiths, University of LondonBrian D Earp, Associate Director, Yale-Hastings Programme in Ethics and Health Policy, Yale UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/743082017-04-17T08:34:02Z2017-04-17T08:34:02ZMaking circumcision safer for young men with bleeding disorders<figure><img src="https://images.theconversation.com/files/164798/original/image-20170411-31911-dw2quo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Haemophilia impairs the body's ability to make blood clots causing excessive bleeding.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p><em>Circumcision is the <a href="http://www.medicalnewstoday.com/articles/302234.php">oldest and most frequent</a> surgical procedure in the world. In some cultures, it marks a clear break from childhood to adulthood. But, reports of young men <a href="https://www.theguardian.com/commentisfree/2014/aug/25/male-circumcision-ceremonies-death-deformity-africa">dying</a> during traditional initiation rites due to spontaneous bleeding are devastating. The Conversation Africa’s Health and Medicine Editor Joy Wanja Muraya asked Dr Peter Kibet Shikuku for his views on a safe circumcision programme in Kenya for boys with haemophilia – a bleeding disorder.</em></p>
<p><strong>How prevalent is haemophilia in Kenya?</strong></p>
<p>Most patients with haemophilia are born with it, <a href="https://www.rarebleedingdisorders.com/bleeding-disorders/congenital-hemophilia.html">congenital</a>, while others <a href="http://www.haemophiliacare.co.uk/acquired-haemophilia.html">acquire it</a>.</p>
<p>Patients must see a specialist, a haematologist, before any surgery to control their bleeding. While circumcision is not a major operation, it can lead to <a href="https://www.hemophilia.org/Bleeding-Disorders/History-of-Bleeding-Disorders">death</a> because the bleeding is slow, consistent, continuous and prolonged.</p>
<p>The prevalence of haemophilia is the same in all communities and remains at <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4181156/">1 per 10,000</a> in any population. As a country we have only reached awareness of the disease at 14% of those affected.</p>
<p><a href="http://www.hemophiliaprince.com/myths-about-hemophilia.html">Superstitions </a> are driven by lack of awareness in the communities forcing some parents to hide or lock away their children from the general public due to associations of the condition with bad omen.</p>
<p>During circumcision by traditional healers, the injured young men and those slow to heal are abandoned in the forest to die. Circumcision, they say, is not for weaklings.</p>
<p><strong>How different is circumcision for haemophiliacs?</strong> </p>
<p>Circumcision carries different meanings in Africa and globally. In most communities in Kenya, it’s a <a href="http://www.cirp.org/library/cultural/marck/">rite of passage</a> practiced by most communities on boys and/or girls.</p>
<p>It involves either the removal of certain <a href="https://kenyastockholm.files.wordpress.com/2008/08/luocircumcisionrites_03.pdf">teeth</a>, tattooing parts of the body, piercing of earlobes, removal of the <a href="http://www.medicalnewstoday.com/articles/302234.php">foreskin</a> or a combination of practices.</p>
<p>During these rites blood is lost, with a few complications occurring. But, some young men die due to lack of adequate testing for <a href="https://www.haemophilia.org.au/about-bleeding-disorders/haemophilia">haemophilia</a> - a genetic disorder that impairs the body’s ability to make blood clots.</p>
<p>This is complicated by <a href="http://www.who.int/bulletin/volumes/88/12/09-072975/en/">lack of information</a> within the circumcising communities on the bleeding disorder. The uninitiated are often <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0083998">stigmatised</a>, ridiculed and bullied by their peers.</p>
<p>Because of this, some young men do not disclose that they’re haemophiliac and undergo circumcision without the precautionary measures, leading to complications, and even death. </p>
<p>Blood clot elements that manage haemophilia during circumcision are not readily available and are <a href="http://www.hemophiliafed.org/bleeding-disorders/hemophilia/treatment/">expensive</a>. The missing factor protein is <a href="http://www.hemophiliafed.org/bleeding-disorders/hemophilia/treatment/">injected</a> into the affected person’s vein enabling the body to continue the clotting and hence stop the bleeding.</p>
<h2>First case study</h2>
<p>A 23 year old man in high school was under peer pressure to get circumcised. They threatened to forcibly circumcise him themselves. He knew he had haemophilia and needed the <a href="https://www.cdc.gov/ncbddd/hemophilia/treatment.html">factor concentrate</a>.</p>
<p>He travelled from one health facility to another to accumulate enough of the concentrate . But, it wasn’t enough and he was circumcised with these expired products in one of the health facilities. </p>
<p>He developed antibodies to factor eight on the fifth day after the operation and ended up with a by passing agent to overcome the antibodies till he healed. It’s not even possible to establish the reason behind antibody development in this patient.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/eO1HtS0Onbg?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Dr Kibet Shikuku talks about the impact of working with the World Federation of Hemophilia.</span></figcaption>
</figure>
<h2>Second case study</h2>
<p>A young man in his 20’s with haemophilia had suicidal tendencies. Being “uncut” was unacceptable and demeaning in his community.</p>
<p>He got clinicians to take him through the procedure even though they had very limited resources. A group of consultants decided to use blood components, a few factor concentrates and tranexamic acid. This combination worked despite the shortcomings associated with it. He recovered and is now one of Kenya’s paralympic sportsmen. </p>
<p><strong>What strategies and technologies are used to ensure safer circumcision amongst haemophiliacs?</strong></p>
<p>There are 450 young men attending the haemophilia comprehensive care clinic at Kenyatta National Hospital and Moi Teaching and Referral Hospital. They make up about 10% of all haemophiliacs countrywide. </p>
<p>Most of them are not circumcised despite coming from circumcising communities, because of haemophilia. That is because of the lack of factor concentrates which are essential in <a href="http://www.businessdailyafrica.com/Special-circumcision-knife/539444-3437776-8odmfo/">preventing bleeding</a>.</p>
<p>At <a href="http://knh.or.ke/">Kenyatta National Hospital</a>, circumcision was the least of procedures to be offered to haemophiliacs due to lack of factor concentrates. The clinical team opted to use tranexamic acid alternating it with cryoprecipitate to stop heavy bleeding, commonly used in peripheral facilities by uninformed surgeons. </p>
<p>This seemed to have worked though in case of any inhibitor development, there were almost no alternative treatment and fatalities were almost the norm.</p>
<p>Towards the end of 2015, <a href="http://haemophilia-kenya.org/index.php">Kenya Hemophilia Association</a> initiated a “safe” circumcision programme in the two health facilities, that has led to circumcision of about 30 haemophilia patients. All the young men were prepared before the surgery by getting clotting factors and later followed up in the wards until they got fully healed.</p>
<p><strong>What challenges do you face running this safer circumcision programme? What lessons have you learnt?</strong></p>
<p>The lack of cost effective drugs to manage patients during circumcision is the most urgent concern.</p>
<p>The shortage of factor concentrates in public hospitals and clinics forces us to rely heavily on <a href="http://humanpathology.uonbi.ac.ke/node/4270">donations </a>from the World Federation of Haemophilia. The availability of the concentrates in select health facilities locks out families with haemophiliac young men from safe circumcision.</p>
<p>Since the safe circumcision programme started, parents are bringing <a href="https://www.standardmedia.co.ke/evewoman/article/2000120029/silent-medical-condition-that-kills-quietly">their sons </a> for registration. This has enabled the programme to schedule with the surgeons all procedures annually. </p>
<p>We are creating <a href="https://www.standardmedia.co.ke/health/article/2000209632/victim-of-blood-disorder-lends-hand-to-those-with-same-condition">public awareness </a> of the signs and symptoms associated with the disease so that people can seek help early, before the young men reach circumcision age.</p>
<p>For young men who wish to keep to their cultural initiation rites, we have trained nurses to deliver the clotting factors at the village during circumcision supported by the traditional surgeons, elders and other decision makers.</p>
<p>Overall, fewer cases are now being brought to the hospital as emergencies following circumcision as compared to before. The programme intends to determine the best protocol which is cost effective and easily implemented at the lower health facilities in the counties.</p><img src="https://counter.theconversation.com/content/74308/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kibet Peter Shikuku receives funding from.get funding from Novo Nordisk Hemophilia Foundation and world federation of hemophilia
</span></em></p>Circumcision is a rite of passage in various African communities. However, for initiates with haemophilia, extra caution needs to be taken to ensure their safety.Kibet Peter Shikuku, Lecturer, School of Medicine (SOM)University of Nairobi (UON) and Consultant Haematologist, University of NairobiLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/692702016-12-04T18:20:04Z2016-12-04T18:20:04ZMale circumcision in Uganda will only improve if local beliefs are considered<figure><img src="https://images.theconversation.com/files/147947/original/image-20161129-10945-10lk4rv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Reuters/Simphiwe Sibeko</span></span></figcaption></figure><p>For the past 10 years voluntary medical male circumcision has been recommended as a way of reducing female-to-male transmission of HIV. Estimates show that it could <a href="http://dx.doi.org/10.1080/17441692.2014.989532">reduce infections by 60%</a>. Several sub-Saharan African countries with high rates of HIV prevalence but low rates of male circumcision have rolled out the procedure as part of their HIV prevention initiatives.</p>
<p>Since 2007 more than 9 million circumcisions have been performed in <a href="http://www.who.int/hiv/topics/malecircumcision/fact_sheet/en/">eastern and southern Africa</a>. But to cover more than 80% of men on the continent by 2025, about 20 million more men need to be circumcised. If this happens about <a href="http://dx.doi.org/10.1371/journal.pmed.1001132">3.4 million new HIV infections</a> could be averted, reducing the number of people who would need HIV treatment and care.</p>
<p>While circumcision has been encouraged there are <a href="http://dx.doi.org/10.1016/j.socscimed.2015.04.020">many places</a> where it has <a href="http://dx.doi.org/10.1080/13557858.2013.772326">faced challenges</a>. This is linked to misconceptions about the purpose of circumcision as well as religious and cultural concerns which prevent men from getting circumcised. </p>
<p>Uganda is a case in point. By the end of 2015 the country’s health ministry aimed to circumcise 80% – <a href="http://health.go.ug/docs/UAIS_2011_KEY_FINDINGS.pdf">or 4.2 million</a> – men aged between 15 and 49. But between 2008 to 2013 the country only managed to <a href="http://www.aidsuganda.org/resource-center/downloads/%20doc_download/3-consolidated-q-3-supervision-report-may-2014">circumcise 50% of this population</a>. Most of these were young boys.</p>
<p><a href="http://dx.doi.org/10.2989/16085906.2016.1179652">Our research</a> found that religious and cultural beliefs compete with the messages about the purpose of circumcision. We found that this got in the way of men deciding whether or not to be circumcised medically and also affected the way they behaved afterwards. </p>
<p>When medical circumcision is introduced in settings where there are high rates of HIV, it must take into account local beliefs about circumcision. And local religious and social group leaders and women must be involved in the roll-out.</p>
<h2>Conflicts of belief</h2>
<p><a href="http://dx.doi.org/10.1016/j.socscimed.2015.04.020">Several studies</a> have compared uptake of circumcision in societies where there is a tradition of circumcision and those where there are not. </p>
<p>When circumcision is not part of religious or cultural practices, introducing voluntary male circumcision can be problematic because it is associated with ethnic and religious identities. This is the case in <a href="http://dx.doi.org/10.1080/17441692.2015.1006241">Zimbabwe</a>, <a href="http://dx.doi.org/10.1080/09540120220097919">Kenya</a>, and parts of <a href="http://dx.doi.org/10.1080/13691058.2013.807519">South Africa</a> where there are both social and cultural barriers to circumcision. </p>
<p>In Uganda, only <a href="http://www.who.int/bulletin/volumes/88/12/09-072975/en/">20% of men practice traditional male circumcision</a> for cultural and religious reasons. This is considerably lower than Kenya (80%) or Tanzania (70%) but similar to many other southern African countries.</p>
<p>We conducted a study of the beliefs and perceptions about circumcision in fishing villages on the shores of Lake Victoria, Uganda. The villages were part of an HIV combination prevention pilot study. </p>
<p>The overall aim of the trial was to investigate factors limiting access to HIV prevention interventions and to determine the feasibility of conducting an HIV combination prevention effectiveness trial to reduce HIV incidence among fishing communities in Uganda. </p>
<p>HIV combination prevention packages would include male circumcision along with access to antiretrovirals, prevention of mother to child transmission, condom promotion, counselling and testing, and health education. </p>
<p>We looked at the influence that different understandings and beliefs about male circumcision may have on voluntary male circumcision in the fishing communities, which are ethnically mixed and have high HIV prevalence. </p>
<p>In Uganda just over <a href="http://www.avert.org/professionals/hiv-around-world/sub-saharan-africa/uganda">7% of the population</a> is living with HIV. </p>
<h2>How the men felt</h2>
<p>We found that even when men opted for voluntary medical male circumcision, they followed practices afterwards that were informed by traditional beliefs. This at times involved engaging in unsafe sexual behaviour. While men understood the health benefits of medical circumcision, these messages were sometimes mixed with beliefs drawn from traditional circumcision practices. </p>
<p>For example, several respondents believed that vaginal fluids helped them heal after being circumcised. Some also believed that vaginal fluids could heal wounds from cuts and snake bites as a form of first aid. In these villages it was reported that women also used vaginal fluids to treat themselves and their children’s injuries. </p>
<p>They also believed that having sex with a non-regular partner could chase away spirits and that circumcision offered them protection from sexually transmitted infections. These encouraged unsafe sexual practices.</p>
<h2>Changing the mindset</h2>
<p>Both personal and community-wide misconceptions need to be improved if the uptake of male circumcision is going to be improved, and if post-procedure behaviour is going to be changed. This can only be done if local knowledge systems in the community are engaged. </p>
<p>Engagements must include local religious and community leaders and must involve both men and women. And this must happen during the roll out of the circumcision procedures but also afterwards.</p>
<p>Key local actors such as traditional and religious leaders from different ethnic groups could help provide support for an approach that takes into account local beliefs about circumcision.</p><img src="https://counter.theconversation.com/content/69270/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Janet Seeley receives funding from British Medical Research Council </span></em></p><p class="fine-print"><em><span>Martin Mbonye and Monica Kuteesa do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Medical circumcision in settings where there are high rates of HIV will only be successful if these interventions take into account local beliefs about circumcision.Martin Mbonye, Social scientist, MRC/UVRI Uganda Research Unit on AIDSJanet Seeley, Professor of Anthropology and Health, London School of Hygiene & Tropical MedicineMonica Kuteesa, Senior scientist, MRC/UVRI Uganda Research Unit on AIDSLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/548582016-02-18T03:59:30Z2016-02-18T03:59:30ZThe scientific journey of AIDS from despair to cautious hope<figure><img src="https://images.theconversation.com/files/111801/original/image-20160217-19250-830qsp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Treatment has transformed the outlook for people living with HIV from almost certain death to a manageable chronic condition.</span> <span class="attribution"><span class="source">Athit Perawongmetha/Reuters</span></span></figcaption></figure><p>From our current perspective, it is easy to forget that at the beginning of the AIDS pandemic, scientists did not even know the identity of the infectious agent causing a rare immunodeficiency. Rapid scientific advancement was needed to implement even basic public health measures such as laboratory-based testing to identify infected individuals and screen the blood supply. </p>
<p>In 1984, three years after the first AIDS reports, the human immunodeficiency virus was identified, followed the next year by the first licensed test. Following from these early advances, research has revealed the HIV disease process, developed major new therapies, and designed methods of prevention.</p>
<h2>From treatment to combination prevention</h2>
<p>Research has enabled scientists to discover two crucial things: key targets for antiretroviral therapies and then highly effective multi-drug regimens. Treatment has transformed the outlook for people living with HIV from almost certain death to a manageable chronic condition. </p>
<p>Critically, the treatment revolution led not only to vast improvement in human lives but also to crucial vehicles for prevention and public health. Beyond the success of preventing perinatal transmission, the two key public health breakthroughs are treatment as prevention, and pre-exposure prophylaxis.</p>
<p>The extraordinary success of research has brought a shift toward “combination prevention”. This is defined as rights-based, evidence-informed, and community-owned programmes that use a mix of biomedical, behavioural, and structural interventions to have a sustained impact on reducing new infections. </p>
<p>Evidence-based prevention tools include pre-exposure prophylaxis, preventing perinatal transmission, universal treatment and voluntary male circumcision. These happen with testing, counselling, condoms, harm reduction, and education.</p>
<p>These developments have shifted the discourse over AIDS exceptionalism. The issue now is not so much that public health and civil liberties are in tension but rather that AIDS has captured a disproportionate amount of political attention and economic resources. </p>
<p>The very success of the AIDS movement has sparked a debate about the ethical allocation of scarce resources.</p>
<h2>Game changing interventions</h2>
<p>Although there is much to celebrate in the incredible scientific advances of the last three decades, key breakthroughs remain elusive. There is broad scientific consensus that “getting to zero” requires an effective vaccine. </p>
<p>Results from a 2009 trial in Thailand showed a 31% vaccine efficacy in preventing HIV infections. Although the vaccine conferred only modest protection, the results were the “proof of concept”, instilling new hope for a game-changing intervention.</p>
<p>Recent work at Oregon Health and Science University reignited hope of an AIDS vaccine. In this study 16 rhesus monkeys infected with simian immunodeficiency virus were given an experimental vaccine. Nine were protected from the virus’ effects and apparently “cleared” of infection.</p>
<p>The 2012 International AIDS Conference also saw renewed optimism toward a cure, with the report of the “Berlin patient”. The patient was cured of the infection after a bone marrow transplant from a donor carrying the genetic variant, which provided resistance to HIV. There are two cases where people who underwent bone marrow transplants appeared to be virus-free once their antiretrovirals were stopped.</p>
<p>While bone marrow transplants will never be practical for large numbers of people, genetically based HIV treatment could emerge. In 2013, researchers announced that an HIV infected infant treated aggressively with antiretrovirals 30 hours after birth had no detectable viral levels at one month of age. </p>
<p>If confirmed, this case could transform treatment for newborns, providing hope for the estimated 330,000 HIV-infected infants in the developing world. Finding a cure would close a critical innovation gap, removing the need for arduous lifelong treatment regimes.</p>
<p>Another potentially game-changing innovation would be a female controlled prevention method, such as an effective vaginal microbicide gel. Clinical trials show it could be effective in reducing the risk of contracting HIV during sex. The option of taking preventive measures without their partner’s agreement or knowledge would give women greater autonomy over their sexual health.</p>
<p>At the same time, scientists will be pressed to overcome the problems associated with current treatment regimes. These include drug resistance, chronic adverse effects and the need for more easily administered and cost-effective formulations. These breakthroughs require continued investment in research while addressing many pressing needs not only for HIV/AIDS, but in global health more broadly.</p>
<h2>Allocating scarce resources</h2>
<p>Even with considerable global funding devoted to HIV/AIDS (US$7.86 billion in foreign assistance in 2012), resources remain scarce. It requires agonising decisions on how to allocate life-saving interventions. </p>
<p>Who should receive treatment when all cannot access it? Should priority go to research, prevention, or treatment? And, ultimately, should AIDS receive a higher priority than other health threats? These are life-and-death questions for millions of people, and there is no consensus on the right answers.</p>
<p>Although resources have risen, drug scarcity is a fact of life, and will be for the foreseeable future. Without a major decrease in HIV incidence, competition for treatment resources will only become more intense. </p>
<p>While the global community cannot even meet current treatment needs, there will be additional calls for treatment expansion – for example, expanding PrEP. The future portends ever-increasing strains on existing drug resources in a time of scale austerity.</p>
<p>In a resource-constrained world, allocation decisions rest on multiple factors: </p>
<ul>
<li><p>the level of immune dysfunction that triggers treatment initiation; </p></li>
<li><p>treatment costs (first- or second-line); and</p></li>
<li><p>the use of anti-retroviral therapy for prevention or treatment. </p></li>
</ul>
<p>In allocating resources, which population groups, countries and regions deserve priority? Those with the greatest number of HIV-infected people, those with the lowest treatment coverage, or those where the most people can be reached at the lowest cost? </p>
<p>These are excruciating choices, as they often determine who will live when everyone cannot.</p>
<hr>
<p><em>This is the second of <a href="https://theconversation.com/africa/topics/aids-global-health-series">three articles</a> drawn from the book <a href="http://www.hup.harvard.edu/catalog.php?isbn=9780674728844.">Global Health Law</a>, released by Professor Lawrence Gostin.</em></p><img src="https://counter.theconversation.com/content/54858/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lawrence O. Gostin does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Despite the breakthroughs in HIV and AIDS research, without an effective vaccine, the world will not get to zero new infections and deaths.Lawrence O. Gostin, Professor of Global Health and Director, O'Neill Institute, Georgetown UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/543932016-02-17T04:29:07Z2016-02-17T04:29:07ZAIDS: how far the world has come and how far it needs to go to get to zero<figure><img src="https://images.theconversation.com/files/111626/original/image-20160216-19232-18o0se6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A man lights candles as part of a World AIDS Day event in Jakarta.</span> <span class="attribution"><span class="source">Dadang/Tri</span></span></figcaption></figure><p><em>Foundation essay: Our foundation essays are longer than usual and take a wider look at key issues affecting society.</em></p>
<p>There is no story in global health as transformative, awe-inspiring, and yet as tragic as the AIDS pandemic. The disease was unknown only a generation ago — a medical curiosity among young gay men in New York and San Francisco in June 1981. </p>
<p>Within a few short years, AIDS could be found on every continent, enveloping the world to become one of the most devastating pandemics in human history. It has caused untold human suffering, social disintegration, and economic destruction.</p>
<p>In the early days of the pandemic, public health officials relied on prevention strategies devised for other sexually transmitted diseases. This includes testing, counselling, education, condoms and partner notification. </p>
<p>Newly diagnosed people had an average survival period of six to eight months. And their weakened immune systems made them vulnerable to rare cancers, pneumonias, chronic fatigue and horrific wasting until death ensued. </p>
<h2>The early years of fear, pain and despair</h2>
<p>The socio-political response was, at best, denial, ignorance, and silence. Ronald Reagan, US President at the time, did not utter the word “AIDS” in public until 1986. At worst, it was social marginalisation, discrimination, and punishment. People were blamed for their own suffering and criminalised for their behaviour. The fear, pain, and despair faced by people living with AIDS and their loved ones cannot be overstated.</p>
<p>But by 2010, <a href="http://www.unaids.org/">UNAIDS</a> announced a goal that was once unimaginable: <a href="http://www.unaids.org/sites/default/files/sub_landing/files/JC2034_UNAIDS_Strategy_en.pdf">getting to zero</a>. Zero new infections, zero AIDS-related deaths and zero discrimination. </p>
<p>The 2012 International AIDS Conference was held in the US for the first time in 22 years because the US restricted entry of persons living with HIV between 1990 and 2011. At the conference, then Secretary of State Hillary Clinton called for an AIDS-free generation. To be sure, these high hopes provoked a skeptical response, with experts saying the goal was unrealistic and open-ended. What exactly is the definition of “zero” or “AIDS-free,” and which generation are we talking about? </p>
<p>But stepping back from perennial debates about aspiration tempered by realism, it is impossible not to marvel at the technological advances that enabled global health leaders to say the unthinkable: that we may one day see the end of the scourge of AIDS.</p>
<h2>Powerful technological interventions</h2>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/111627/original/image-20160216-19232-nxqh9n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/111627/original/image-20160216-19232-nxqh9n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=913&fit=crop&dpr=1 600w, https://images.theconversation.com/files/111627/original/image-20160216-19232-nxqh9n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=913&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/111627/original/image-20160216-19232-nxqh9n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=913&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/111627/original/image-20160216-19232-nxqh9n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1147&fit=crop&dpr=1 754w, https://images.theconversation.com/files/111627/original/image-20160216-19232-nxqh9n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1147&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/111627/original/image-20160216-19232-nxqh9n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1147&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
</figcaption>
</figure>
<p>The technological advances that made all this possible include, first and foremost, <a href="http://www.who.int/hiv/topics/treatment/en/">antiretroviral</a> treatments. A newly diagnosed 25-year-old today can expect to live another 50 years on treatment. But it also includes combination prevention, which extends well beyond traditional methods of testing, counselling, condoms and education. These do remain vital. </p>
<p>Research has shown remarkable reductions in HIV transmission from <a href="http://www.who.int/hiv/topics/malecircumcision/en/">male circumcision</a>, pre-exposure <a href="https://www.aids.gov/hiv-aids-basics/prevention/reduce-your-risk/pre-exposure-prophylaxis/">prophylaxis</a> (PrEP), and antiretroviral therapy. </p>
<p>At the 2011 International AIDS Conference, scientists announced a jaw-dropping 95% plus reduction in sexual transmission among heterosexual couples adhering to antiretroviral treatment.</p>
<p>What if it were possible to reach every person at risk, or already infected, with these powerful interventions? What if the next discovery could empower women to protect themselves, such as with a vaginal <a href="http://www.who.int/hiv/topics/microbicides/microbicides/en/">microbicide</a>, which is on the horizon? Given the political will, isn’t it imaginable that the international community could “get to zero”?</p>
<p>How did all these technological advances come about, and why did this particular disease forge a pathway toward unprecedented scientific discoveries? Very sadly, science has not been able to match these technological advances for most global health challenges. Not mental illness, cancer, or tuberculosis. </p>
<p>It has been said that these are all highly complex, multi-factorial diseases, while AIDS is not. But this is far from the truth.</p>
<h2>Social mobilisation like never before</h2>
<p>AIDS is one of the most complicated and stubbornly persistent diseases the world has ever known. Yet the sociopolitical dimension of AIDS has galvanised perhaps the greatest social mobilisation around a health crisis that the world has seen. </p>
<p>From the AIDS Coalition to Unleash Power <a href="http://www.actupny.org/documents/capsule-home.html">(ACT UP)</a> and Lambda Legal <a href="http://www.lambdalegal.org/">Defense</a> in the US to the Treatment Action <a href="http://www.tac.org.za/">Campaign</a> in South Africa, courageous individuals and organisations have literally transformed the politics of AIDS, turning neglect and derision into empowerment and social action.</p>
<p>This vast social mobilisation was targeted not only at fighting the social dimensions of this disease with poignant calls for dignity, nondiscrimination, and justice. It was perhaps principally about access to medicines. </p>
<p>AIDS campaigns had crisp clarity, appealing to a basic sense of social justice: the rich have access to life sustaining medicines while the poor do not. This message resonated in developed countries where the poor often were denied access to antiretroviral medication. But it also resonated in developing countries where most people could not afford a life-saving pill that the majority of those in the developed world could access.</p>
<p>The access-to-medicines campaigns brought AIDS advocates to pursue solutions beyond the health sector. Activists directly attacked the prevailing trade liberalisation paradigm, which protects intellectual property, and asserted the higher priority of the right to health.</p>
<p>In South Africa the TAC <a href="http://www.tac.org.za/documents/MTCTCourtCase/ConCourtJudgmentOrderingMTCTP-5July2002.pdf">successfully challenged</a> the government’s restrictions on access to perinatal treatment before the Constitutional Court. At the international level, the AIDS movement energised the World Health Organisation to take access to medicines seriously. This prompted campaigns such as the World Health Organisation’s <a href="http://www.who.int/3by5/en/">3 by 5</a> initiative. It forced the World Trade Organisation to change course, introducing Doha Declaration <a href="https://www.wto.org/english/thewto_e/minist_e/min01_e/mindecl_trips_e.htm">flexibilities</a> to soften a harsh intellectual property regime.</p>
<h2>A global effort</h2>
<p>This social mobilisation also unleashed unprecedented resources in global health — new funding for biomedical research, vaccines, and treatment. Moreover, social mobilisation around AIDS literally transformed global health governance. It fundamentally altered the foreign assistance of the most powerful countries. For example PEPFAR in the United States, and <a href="http://www.unitaid.eu/en/">UNITAID</a>, formed by Brazil, Chile, France, Norway, and the United Kingdom. </p>
<p>For the first time, the major powers began to frame an infectious disease as a national security threat, addressed at the highest political levels at the G8. Social mobilisation drove the United Nations’ response, prompting the first high-level summit ever held on a health issue to be devoted to AIDS.</p>
<p>A novel public-private-partnership emerged, outside the UN/WHO structure, to generate and pool resources — the Global Fund to Fight AIDS, Tuberculosis and Malaria.</p>
<p>Although the international community has rallied to fight AIDS, fierce debates have raged within the movement. Initially, advocates worried that traditional public health strategies such as testing and reporting would undermine privacy or foster discrimination. At the same time, policy makers debated which interventions — and in what combination — were most effective. And then there was the divisive issue of cost-effectiveness. Could governments afford expensive interventions such as lifetime treatment with antiretrovirals? </p>
<p>If not, how could the benefits be fairly allocated among the large population of persons at risk or living with HIV? And should the same level of resources devoted to AIDS be made equally available for other pressing health conditions, such as child/maternal health, injuries, or non-communicable diseases? </p>
<p>These battles ensued within both domestic health sectors and foreign health assistance budget debates. They remain topics of lively debate.</p>
<p><em>*This is the first of three articles drawn from the book <a href="http://www.hup.harvard.edu/catalog.php?isbn=9780674728844.">Global Health Law</a>, released by Professor Lawrence Gostin.</em></p><img src="https://counter.theconversation.com/content/54393/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lawrence O. Gostin does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Globally, the health community is moving to a point where there could be zero new HIV infections or deaths. But it has been a long road.Lawrence O. Gostin, Professor of Global Health and Director, O'Neill Institute, Georgetown UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/464882015-10-07T04:10:42Z2015-10-07T04:10:42ZChanges in gender norms are making initiation safer for South African boys<figure><img src="https://images.theconversation.com/files/97434/original/image-20151006-7337-1g5gtvb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Initiates undergoing the traditional passage to manhood in Qunu, in the Eastern Cape, South Africa. Many either die or get maimed during the winter practice. </span> <span class="attribution"><span class="source">Reuters/Siegfried Modola</span></span></figcaption></figure><p>At least <a href="http://www.news24.com/SouthAfrica/News/Initiation-Government-wants-to-do-away-with-traditional-surgeons-20150909">30 initiates</a> are known to have died by the time the traditional male initiation season ended in South Africa this winter (2015). Most were from Xhosa communities in the Eastern Cape province. </p>
<p>Male initiation is a rite of passage from boyhood to manhood for some ethnic groups in South Africa. <a href="http://www.tandfonline.com/doi/pdf/10.1080/13691050701861447">Ritual male initiation</a> includes circumcision and the initiates spending about a month or longer in seclusion in the bush. </p>
<p><a href="http://tcn.sagepub.com/content/20/4/395.full.pdf+html">Initiation</a> is deemed a necessary rite of passage marking a developmental phase for boys to adulthood among the <a href="http://www.sahistory.org.za/people-south-africa/xhosa">amaXhosa</a>, <a href="http://www.bapedikingdom.co.za/history_bapedi.html">Bapedi</a>, <a href="http://countrystudies.us/south-africa/47.htm">Basotho</a>, <a href="http://www.gaabomotho.co.za/tswana.html">Batswana</a>, <a href="http://repository.up.ac.za/handle/2263/17089">amaNdebele</a>, <a href="https://intercontinentalcry.org/indigenous-peoples/vhavenda/">VhaVenda</a>, <a href="https://vatsonga.wordpress.com/about/">VaTsonga</a> and <a href="https://books.google.co.za/books?id=vRU9AAAAIAAJ&pg=PA7&dq=Amaswazi&hl=en&sa=X&ved=0CEQQ6AEwCTgKahUKEwj7zpuRsa3IAhVBohQKHW5gAUA#v=onepage&q=Amaswazi&f=false">amaSwazi</a> ethnic groups. The initiation process is typically run by the family, with the boy’s father directing proceedings.</p>
<p>Traditional initiation involving circumcision remains an important topic in South Africa for several reasons. At the top of the list is the public health discourse and debates around prevention of initiates’ deaths. But initiation is also important because the practise is still relevant and employed in a range of urbanising communities across the country.</p>
<p>Deaths of initiates resulting from botched circumcisions, related infections and dehydration during this rite of passage are <a href="http://dx.doi.org/10.1016/j.socscimed.2009.11.016">nothing new</a>. And there is some evidence that they may be <a href="http://www.dailymaverick.co.za/article/2015-07-30-sa-is-making-progress-on-making-initiation-schools-safer/#.Vb9jeE8w_4Y">declining</a>.</p>
<p>Deaths of initiates have attracted heightened attention from the government, civil society and the traditional custodians of the <a href="http://dx.doi.org/10.1016/j.socscimed.2009.11.016">practice</a>. </p>
<p>Save for girls, who are related to and who cook for the initiate, women are generally not involved in the traditional process. Women’s role could be described as that of cheer leaders. They participate significantly in the ceremonies to welcome the new men back home. Discussions around the meaningful involvement of women in the initiation process have been met with resistance from custodians of <a href="http://www.sciencedirect.com/science/article/pii/S0277953609008119">culture</a>.</p>
<p>But gender politics, changes in family formations and the high number of single mother households are increasingly pushing some of the traditional boundaries around initiations. </p>
<h2>Role of women</h2>
<p>South Africa has a higher rate of single, women-led families than households led by men. Most South African children under five live with <a href="http://www.statssa.gov.za/?p=2007">only their mothers</a>. </p>
<p>As a result, the practises around male initiation are changing and beginning to encompass women.</p>
<p>We conducted interviews in the Eastern Cape to understand people’s perceptions and experiences of sexual and reproductive health rights. </p>
<p>The study is conducted in collaboration with the AIDS Foundation of <a href="http://www.aids.org.za">South Africa</a>, a non-governmental organisation that supports community-based initiatives to strengthen men and women’s access to sexual and reproductive health rights. </p>
<p>We interviewed men and women of different ages, but older that 16, in single-sex focus group discussions. We also interviewed key stakeholders such as officials in the departments of health, education, social development, a traditional healer and a traditional leader in the Flagstaff district of the Eastern Cape. The people of Flagstaff identify as <a href="http://www.sahistory.org.za/places/pondoland">amaPondo</a> and their traditions slightly differ from those of amaXhosa in the Eastern Cape. </p>
<p>Our study (yet to be published) found people have mixed feelings about initiation. Some feel it is good but that the tradition has changed. Some felt as soon as an initiate required medical attention and went to hospital, they were no longer considered a traditional initiate. </p>
<p>They attributed the change and the undesirable outcomes to:</p>
<ul>
<li>underage initiates, </li>
<li>incompetent traditional nurses, and </li>
<li>substance use at the <em>Ibhoma</em>. The <em>Ibhoma</em> is a temporary hut built for the initiate in the <a href="http://tcn.sagepub.com/content/20/4/395.full.pdf+html">bush</a>. </li>
</ul>
<p>Some problems were related to what the community perceived to be uncanny behaviours by the new men. For example, engagement in violent behaviour, disrespect for adults and increased alcohol drinking and use of other substances. One of the major findings was a concern about the health impacts of the initiation, chief amongst these the death of the initiate.</p>
<h2>Dealing with the death</h2>
<p>Our study shows that men and women are demanding that the government protect the boys and curb the death of initiates. One of the participants explained: </p>
<blockquote>
<p>We are trying to end these deaths out there. I am saying everybody (should) start at (the) hospital and then go (their) separate … ways where a person is going to learn his own isiko (custom).</p>
</blockquote>
<p>The custodians of traditional practices are speaking out against distortions or misinterpretations of culture that threaten young men’s lives. </p>
<p>The House of Traditional Leaders in the Eastern Cape has started advocating for <a href="http://www.gov.za/speeches/leadership-visit-initiation-schools-lusikisiki-18-jun-2015-0000">safe initiation</a>. In one case, traditional leaders openly endorsed and supported women’s involvement in pre-initiation camps to educate and socialise boys and ensure stakeholder commitment to the legal and safe operation of initiation lodges.</p>
<p>Historically, boys who died at initiation lodges or camps were buried there. The boy’s father would take care of the burial ritual while his mother would find solace knowing her husband had buried their child. These deaths were less likely to be reported to the general community. </p>
<p>But as times have changed, so has this practice. As burial rituals, including funerals, have been modernised, bereaved families wish to see and bury their loved ones.</p>
<p>We found that in the event of a death, the mother now demands to know how her child died, to see his body and hold the funeral in the community. The circumstances surrounding his death are now disclosed, despite the fact that the custom stipulates that initiation should not be discussed with the female relatives. </p>
<p>Historically, a father would know what cultural instruction had been imparted to his son during initiation. He could sanction disrespectful behaviour towards women. Research shows that in the absence of male authority figures and role models, women are speaking out against this and demanding that boys are taught respectful and risk-reducing behaviour. </p>
<p>This study’s findings are important in crafting a way for more research to better understand the role of women and mothers in initiation. As society changes, so are there changes in our cultures. </p>
<p>Dialogues are needed at a community level to find ways to include women in the initiation process. These dialogues should involve men and women, children and parents and custodians of culture, in particular the duty bearers within the House of Traditional Leaders.</p><img src="https://counter.theconversation.com/content/46488/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mzi Nduna receives funding from the National Research Foundation and the COE-HUMAN</span></em></p><p class="fine-print"><em><span>Anele Siswana works for Dr George Mukhari Academic Hospital. He receives funding from the Canon Collins Legal Trust. He is affiliated with the Father Connections Study Team at Wits University.</span></em></p><p class="fine-print"><em><span>Deborah Lesley Ewing is affiliated with the AIDS Foundation of South Africa.</span></em></p><p class="fine-print"><em><span>Esmeralda Vilanculos is affiliated with the University of the Witwatersrand </span></em></p>The practices around the traditional passage to manhood in South Africa are changing and beginning to encompass women as family patterns change. But, there are mixed feelings about the changes.Mzi Nduna, Associate Professor in Psychology, University of the WitwatersrandAnele Siswana, Clinical Psychologist, University of the WitwatersrandDeborah Lesley Ewing, Visiting Scholar, School of Human and Community Development, University of the WitwatersrandEsmeralda Vilanculos, Research Assistant: Sexual and Reproductive Health rights, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/203282013-11-18T06:06:02Z2013-11-18T06:06:02ZLike FGM, cut foreskins should be a feminist issue<figure><img src="https://images.theconversation.com/files/35500/original/zvz87g73-1384770780.jpg?ixlib=rb-1.1.0&rect=47%2C2%2C1396%2C989&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">His rights as much as hers. </span> <span class="attribution"><span class="source">Elvert Barnes</span></span></figcaption></figure><p>Making a comparison between male and female genital cutting is usually dismissed or condemned. When, for example, the Council of Europe recently passed <a href="http://assembly.coe.int/nw/xml/XRef/Xref-XML2HTML-en.asp?fileid=20174&lang=en">a motion</a> declaring both female genital cutting (FGC) and the circumcision of young boys for religious reasons “a violation of the physical integrity” of children, Tanya Gold, writing in The Guardian, <a href="http://www.theguardian.com/commentisfree/2013/oct/11/ban-male-circumcision-antisemitic">called it</a>:</p>
<blockquote>
<p>A revolting … juxtaposition of female genital mutilation, which is always torture, and often murder, with ritual male circumcision, which is neither, and, incidentally, is practised by most Muslims, and all Jews.</p>
</blockquote>
<p>Gold’s reaction is understandable. The horrifying damage caused by amputation of a girl’s external genitalia and infibulation (closing up of the vagina) – the most invasive forms of FGC – are incomparable to the harm caused by male genital cutting (MGC). Other less invasive forms of FGC, such as clitoral “<a href="#WHO_Type_IV">nicks</a>”, can <a href="http://www.rcm.org.uk/midwives/in-depth-papers/female-genital-mutilation/">also cause</a> severe bleeding, infections and infertility. </p>
<p>But both FGC <a href="http://www.nhs.uk/Conditions/Circumcision/Pages/Risks.aspx">and MGC</a>, where the erogenous foreskin is removed, can cause serious physical, mental and sexual harm. In 2011, 11 boys under the age of one <a href="http://endmalecircumcision.blogspot.co.uk/search?q=NHS+bosses+silent+as+botched+circumcisions+put+baby+boys+in+A%26E">were treated</a> in Birmingham for life threatening hemorrhage, shock or sepsis relating to circumcision. In the US it’s estimated that 100 boys die <a href="http://www.mensstudies.com/content/b64n267w47m333x0/?p=de1140707d7d4af9877d67cbfc973d9a&pi=5">as a result of</a> circumcisions every year. MGC is also far more common globally: <a href="http://bit.ly/1gkQvTn">13m boys to 2m girls</a> annually.</p>
<h2>It isn’t a ‘harm competition’</h2>
<p>But this isn’t a harm competition. It’s about how FGC, often referred to as female genital mutilation because it’s <a href="http://whqlibdoc.who.int/publications/2008/9789241596442_eng.pdf">widely seen</a> as a violation of women’s rights and a form of oppression and sexual control, is easily accepted when that girl is a boy. </p>
<p>FGC has been banned in the UK <a href="http://www.legislation.gov.uk/ukpga/1985/38/pdfs/ukpga_19850038_en.pdf">since 1985</a> (despite <a href="https://theconversation.com/uk-letting-down-victims-of-female-genital-mutilation-14867">no convictions</a>) and <a href="http://www.legislation.gov.uk/ukpga/2003/31/pdfs/ukpga_20030031_en.pdf">since 2003</a>, it has been illegal to carry out the procedure on British nationals abroad.</p>
<p>But, as bioethicist Dena Davis put it: “When one begins to question the normative status of the male newborn alteration in the West, and when one thinks of female alteration as including even a hygienically administered "nick,” one begins to see that these two practices, dramatically separated in the public imagination, actually have significant areas of overlap.“</p>
<h2>Overriding concerns</h2>
<p>Although FGC is practised because of religious beliefs and seen as an important part of cultural identity (imparting a sense of pride, a coming of age or a feeling of community membership), aversion to it overrides concerns about protecting these religious or cultural freedoms – a view <a href="http://www.theguardian.com/society/2013/nov/04/uk-mutilation-girls-report">also held</a> by some community leaders.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/35409/original/ywwmsrb2-1384523623.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/35409/original/ywwmsrb2-1384523623.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=548&fit=crop&dpr=1 600w, https://images.theconversation.com/files/35409/original/ywwmsrb2-1384523623.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=548&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/35409/original/ywwmsrb2-1384523623.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=548&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/35409/original/ywwmsrb2-1384523623.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=689&fit=crop&dpr=1 754w, https://images.theconversation.com/files/35409/original/ywwmsrb2-1384523623.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=689&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/35409/original/ywwmsrb2-1384523623.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=689&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">For Jews, the ritual is a sign of God’s covenant with Abraham.</span>
<span class="attribution"><span class="source">Cheskel Dovid</span></span>
</figcaption>
</figure>
<p>But when it comes to Male Genital Cutting (MGC) <a href="http://www.nhs.uk/Conditions/circumcision/Pages/introduction.aspx">it’s neither</a> explicitly illegal nor compulsorily regulated. Instead <a href="http://whqlibdoc.who.int/publications/2007/9789241596169_eng.pdf">it’s perceived</a> as a relatively innocuous procedure, a "routine neonatal circumcision”, or brit milah for Jews and khitan for Muslims. </p>
<p>The reasons for male circumcision also vary: for Muslims it’s sunnah, a practice instituted by the Prophet Muhammad; for Jews it’s a sign of God’s covenant with Abraham. It’s also cultural: it marks an entrance into manhood and is also carried out because of perceived social or health advantages (<a href="http://www.who.int/hiv/topics/malecircumcision/en/">reduced HIV transmission</a> among adults in Africa is a specific case, unrelated to most others or children). And in the case of MGC, religious and cultural freedoms are generally respected.</p>
<p>Given these contrasting public perceptions, drawing parallels is controversial. Some feminists interpret comparison as an offensive trivialisation of the harm done to women, while many Jews and Muslims see it as an attempt to restrict their religious and cultural freedom, with some going as far as to <a href="http://www.thejc.com/comment-and-debate/comment/113074/circumcision-could-be-banned">liken the threat</a> to the Nuremberg Laws in Nazi Germany.</p>
<h2>Consent and control</h2>
<p>My research suggests it’s more complex. Leading medical <a href="http://www.case.edu/med/bioethics/facultystaff/denadavis.htm">ethicists</a>, <a href="http://www.historyofcircumcision.net/index.php?option=com_content&task=view&id=33&Itemid=56">historians</a>, and <a href="http://www.birmingham.ac.uk/schools/law/staff/profile.aspx?ReferenceId=18601">legal scholars</a> think that FGC and MGC overlap in ways that question the distinct labels and laws applied to them. </p>
<p>Along with the serious harm that both FGC and MGC can cause, both occur without the consent of the child, and irreversibly violate the child’s <a href="http://jme.bmj.com/content/39/7/469.abstract">human right to physical integrity</a>. In so doing, FGC and MGC both prioritise the cultural or religious beliefs of parents over their child’s right to self-determination and an <a href="http://jme.bmj.com/content/early/2013/01/29/medethics-2012-101182">open future</a>.</p>
<p>Both have also sought to shape bodies and control sexual desire. FGC seeks to <a href="http://whqlibdoc.who.int/publications/2008/9789241596442_eng.pdf">contain women’s sexuality</a> within marriage and reproduction by aiming to reduce sexual pleasure, while the Jewish sage <a href="http://www.cirp.org/library/cultural/maimonides/">Maimonides</a> and the <a href="http://www.cirp.org/library/history/darby4/">Victorians</a> advocated MGC to reduce lust and masturbation. Legal scholars Marie Fox and Michael Thomson <a href="http://www.circinfo.org/Circumcision_and_women.html">have argued that</a> MGC is “a gendering practice tied to masculinity and the management of male sexuality” that “parallels the ways in which feminist scholars have argued that female genital cutting serves to fix gender in women”.</p>
<h2>Double standards</h2>
<p>Given these overlaps, why have the two been treated differently? Alongside the difference in harm and misperceptions about the contrasting settings and ages at which the procedures take place, the double standard stems from two further factors: sexism and ethnocentrism.</p>
<p>Male bodies are constructed as resistant to harm or even in need of being tested by painful ordeals, whereas female bodies are seen as highly vulnerable and in need of protection. In other words, vulnerability is gendered. And little girls are more readily seen as victims than little boys. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/35410/original/3ptqpzfv-1384523936.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/35410/original/3ptqpzfv-1384523936.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=364&fit=crop&dpr=1 600w, https://images.theconversation.com/files/35410/original/3ptqpzfv-1384523936.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=364&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/35410/original/3ptqpzfv-1384523936.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=364&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/35410/original/3ptqpzfv-1384523936.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=457&fit=crop&dpr=1 754w, https://images.theconversation.com/files/35410/original/3ptqpzfv-1384523936.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=457&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/35410/original/3ptqpzfv-1384523936.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=457&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Circumcision in central Asia in the 1800s.</span>
<span class="attribution"><span class="source">Library of Congress</span></span>
</figcaption>
</figure>
<p>The consequence of this, say Fox and Thomson, is that patriarchy often allows men’s experiences to remain unquestioned.</p>
<p>Familiarity also creates comfort, and since MGC has been practised in the West for millennia and been routine in English-speaking countries for a century, we’re desensitised. By contrast, since FGC is geographically or culturally remote, it’s more liable to be seen as barbaric.</p>
<h2>Gender assumptions</h2>
<p>It’s time to re-examine our gender and cultural assumptions about genital cutting, and take a non-discriminatory, intellectually consistent approach. We either accept that the loss of some individual rights of both boys and girls is the price of societal diversity – an approach rooted in a respect for pluralism and multiculturalism – or we respect the rights of all children, both girls and boys, equally. </p>
<p>The first means rethinking opposition to FGC, and perhaps even re-allowing it on the basis of parents’ religious beliefs or cultural preferences. But this would be unconscionable. The better thing would be to recognise that little boys have the same rights as little girls to bodily integrity (as <a href="http://knmg.artsennet.nl/Publicaties/KNMGpublicatie/Nontherapeutic-circumcision-of-male-minors-2010.htm">recently recognised</a> in the Netherlands), an open future and freedom from harm – in spite of their parents’ views. </p>
<p>Recognising overlaps in the cultural and religious arguments used to defend both, and human rights violations in no way trivialises the horror of FGC. And from a strategic point of view, making foreskin cutting a feminist issue would strengthen efforts to eliminate FGC. How can activists expect to convince a mother to leave her daughter uncircumcised if her husband is able to continue circumcising his son?</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/35420/original/8bj9ytkf-1384631179.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/35420/original/8bj9ytkf-1384631179.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=251&fit=crop&dpr=1 600w, https://images.theconversation.com/files/35420/original/8bj9ytkf-1384631179.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=251&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/35420/original/8bj9ytkf-1384631179.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=251&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/35420/original/8bj9ytkf-1384631179.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=315&fit=crop&dpr=1 754w, https://images.theconversation.com/files/35420/original/8bj9ytkf-1384631179.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=315&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/35420/original/8bj9ytkf-1384631179.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=315&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Rights should apply to all.</span>
</figcaption>
</figure>
<p>Rather than criticising the Council of Europe’s motion, we should celebrate it as a move towards greater child protection and gender equality.</p><img src="https://counter.theconversation.com/content/20328/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rebecca Steinfeld has received funding from the Economic and Social Research Council (ESRC). </span></em></p>Making a comparison between male and female genital cutting is usually dismissed or condemned. When, for example, the Council of Europe recently passed a motion declaring both female genital cutting (FGC…Rebecca Steinfeld, Visiting Research Fellow, Goldsmiths, University of LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/101992012-11-02T03:45:00Z2012-11-02T03:45:00ZTradition vs individual rights: the current debate on circumcision<figure><img src="https://images.theconversation.com/files/17023/original/5d365zhc-1351555342.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A protest against circumcision in the United States, where the debate about circumcision is still raging.</span> <span class="attribution"><span class="source">sigmaration/Flickr</span></span></figcaption></figure><p>Non-therapeutic circumcision of male infants and boys has always been a controversial issue – and never has opinion been more polarised. </p>
<p>In the United States, medical authorities have just <a href="http://pediatrics.aappublications.org/content/early/2012/08/22/peds.2012-1989">overturned</a> 40 years of sound science-based policy by deciding that the health benefits of circumcision — while not great enough to recommend the procedure as a routine — are sufficient to allow parental choice in the matter and coverage by medical insurance plans. </p>
<p>This move has been <a href="http://blog.practicalethics.ox.ac.uk/2012/08/the-aap-report-on-circumcision-bad-science-bad-ethics-bad-medicine/">heavily criticised</a> by medical ethicists in both the United States <a href="http://theeuropean-magazine.com/819-van-dijk-gert/820-medical-and-ethical-arguments-against-male-circumcision">and abroad</a>. They fault the new policy not only for downplaying the <a href="http://www.doctorsopposingcircumcision.org/pdf/Dalton_2007.pdf">risks and complications</a> of the procedure, but also for failing to take into account <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1733522/pdf/v028p00010.pdf">basic principles</a> from bioethics as well as human rights.</p>
<p>The rest of the world has moved on. In Europe and elsewhere, <a href="http://www.openforum.com.au/content/should-circumcision-be-illegal">the question is no longer</a> about whether there are any good “medical” justifications for routine circumcision — the consensus is that there are not. Instead, it’s about the much thornier issue of cultural and religious rationales. </p>
<p>In Germany, a court <a href="http://www.circinfo.org/Circumcision_and_law.html">recently found</a> that non-medically-indicated circumcision constitutes bodily harm and is thus unlawful. In Australia, the Tasmania Law Reform Institute has <a href="https://theconversation.com/tasmanian-report-calls-for-groundbreaking-reform-of-circumcision-law-9105">recommended</a> that it be legally prohibited in most cases, with limited exemptions for religious practice. </p>
<p>In Helsinki, an <a href="http://www.nocirc.org/symposia/twelfth/symposium12.pdf">international conference</a> heard many distinguished speakers criticise unnecessary genital surgeries of all types, whether performed for medical or cultural reasons, and whether on boys, girls or intersex children. The resultant <a href="http://www.genitalautonomy.eu/#/helsinki-declaration-2012/4569720986">declaration</a> formally defended the right of all children to bodily integrity.</p>
<p>Given its recent history, Germany is arguably the worst place in the world to see a decision in favour of child rights that could also be interpreted as directed against Jewish religious practice. Both Jewish and Muslim organisations have responded <a href="http://www.bbc.co.uk/news/magazine-18793842">with outrage</a>, attacking the ruling as an assault on <a href="http://blog.practicalethics.ox.ac.uk/2012/10/religious-vs-secular-ethics-and-a-note-about-respect/">religious freedom</a>, and hurling accusations of anti-Semitism and Islamophobia. </p>
<p>Problematically, as Lena Nyhus has <a href="http://www.jpost.com/Opinion/Op-EdContributors/Article.aspx?id=287950">argued</a> in The Jerusalem Post, when such serious charges are raised without adequate care and discretion, they risk losing their force.</p>
<p>“Outrage” is not an argument. But the claim that circumcision is “non-negotiable” for Jews because it is “divinely mandated” in Genesis does carry some weight. </p>
<p>Against this, <a href="http://www.beyondthebris.com/">a growing number of Jews</a> believe that circumcision is <a href="http://kazez.blogspot.de/2012/07/religious-circumcision.html">inconsistent with Jewish ethics</a> and has no place in contemporary religious practice. They point out that many things are “divinely mandated” in the Bible, but are happily “negotiated” by modern Jews — up to and including circumcision. </p>
<p>Biblical literalists will not find these arguments convincing, but they do not have a monopoly on the practice of Judaism.</p>
<p>What we are really witnessing is a <a href="http://blog.practicalethics.ox.ac.uk/2012/10/religious-vs-secular-ethics-and-a-note-about-respect/">clash between traditional patriarchal values</a>, emphasising group conformity, and those of secular modernity, emphasising individual autonomy. </p>
<p>The most honest defenders of circumcision acknowledge that it is a cruel disfigurement, permissible only because God commanded it – witness orthodox Rabbi Hershey Worch quoted in Eliyahu Ungar-Sargon’s <a href="http://www.cutthefilm.com/">documentary film Cut</a>:</p>
<blockquote>
<p>“It’s painful, it’s abusive. It’s traumatic, and if anybody who’s not in a covenant [with God] does it, I think they should be put in prison. I don’t think anybody has an excuse for mutilating a child. … Depriving them of [part of their] penis.” </p>
</blockquote>
<p>But still it must be done, because as the Rabbi concluded, “God owns my morals.”</p>
<p>Since <a href="http://www.historyofcircumcision.net/">at least</a> the mid-19th century, the question for Jewish people has been the extent to which they should relinquish traditional observances and integrate into the broader society. Jewish critics of circumcision first emerged in Germany in the 1840s, igniting a debate within the religion that has flared on and off right up to the present. </p>
<p>In response, their conservative opponents cited both traditional arguments (cultural and religious obligation), and the new discoveries of Anglo-American doctors that circumcision was helpful against such intractable health problems as masturbation, syphilis, epilepsy and tuberculosis. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/17024/original/4qjqs5w4-1351555357.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/17024/original/4qjqs5w4-1351555357.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/17024/original/4qjqs5w4-1351555357.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/17024/original/4qjqs5w4-1351555357.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/17024/original/4qjqs5w4-1351555357.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/17024/original/4qjqs5w4-1351555357.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/17024/original/4qjqs5w4-1351555357.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Arguments for circumcision on medical grounds are also used to justify religious-based reasoning.</span>
<span class="attribution"><span class="source">kityojames/Flickr.</span></span>
</figcaption>
</figure>
<p>We see the same tendency today: supporters of circumcision on health grounds cite religious requirements as a reason for why it shouldn’t be restricted, while those who support it for cultural reasons cite “health benefits” as a reason for why it should be expanded.</p>
<p>Regrettably, a number of analysts in the world of philosophical bioethics have been reluctant to take a public stand against this sort of vacillation. Discussion of circumcision is inhibited by the fear that objective analysis will incite accusations of intolerance. </p>
<p>Writing on the <a href="http://jme.bmj.com/">Journal of Medical Ethics</a> blog, the philosopher Iain Brassington <a href="http://blogs.bmj.com/medical-ethics/2012/07/17/more-on-circumcision-in-germany/">recently stated</a>, </p>
<blockquote>
<p>“Though I [have] mentioned the decision of the German court that ritual circumcision constituted assault, I’ve wanted to stay clear of saying more about it [because] it seemed too potentially toxic.” </p>
</blockquote>
<p>Likewise, the bioethicist Dan O’Connor from Johns Hopkins University <a href="http://bioethicsbulletin.org/archive/piece-i-didnt-want-to-write/">has said</a>, “When [a reporter] calls my work and ask[s] if there is a bioethicist in the house who will give the anti-circumcision viewpoint, I beg off.”</p>
<p>Lingering in the background is an unwritten rule that says critical discussion of certain ideas is automatically out of bounds. As Douglas Adams <a href="http://www.biota.org/people/douglasadams/">observed</a>, “If somebody votes for a party that you don’t agree with, you’re free to argue about it as much as you like.” But if somebody mentions something about their religious practices, “you say, ‘Fine, I respect that’.”</p>
<p>Adams’ point is that this avoidance is not really “respect” at all. It is about discomfort, or fear of ruffling too many feathers, being misunderstood, or being accused of harbouring prejudice. </p>
<p>Respect is something else entirely. Respect assumes that while someone may disagree with you, she will consider your points with an open mind, and judge your argument on its merits. </p>
<p>Respect assumes that we should be able to look at one another’s most cherished practices in light of the ethical advances of recent centuries without getting into a shouting match. </p>
<p>It’s time we took a critical look at the culturally-motivated cutting of the genitals of infant boys. And we call upon our colleagues, both religious and secular, to engage in this important dialogue. Respectfully. </p><img src="https://counter.theconversation.com/content/10199/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Brian D. Earp has written and spoken critically about infant circumcision in academic contexts. He does not stand to profit financially or otherwise from the contents of this article.</span></em></p><p class="fine-print"><em><span>Robert Darby has written and published extensively on male and female circumcision from a critical perspective and has informal links with individuals and organisations that are opposed to circumcision.</span></em></p>Non-therapeutic circumcision of male infants and boys has always been a controversial issue – and never has opinion been more polarised. In the United States, medical authorities have just overturned 40…Brian D Earp, Research Associate, University of OxfordRobert Darby, Independent medical historianLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/91052012-09-05T04:43:27Z2012-09-05T04:43:27ZTasmanian report calls for groundbreaking reform of circumcision law<figure><img src="https://images.theconversation.com/files/14994/original/959bgc6f-1346723028.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A traditional circumcision set from the Jewish Museum of New York.</span> <span class="attribution"><span class="source">istolethetv/Flickr</span></span></figcaption></figure><p>Circumcision lies at the crossroads of religion, custom, human rights, health, commerce, harm, and ethics. From <a href="http://www.abc.net.au/news/2012-06-28/german-court-bans-circumcision-of-young-boys/4096998">high-profile court battles overseas</a> to its recent inclusion on <a href="http://ten.com.au/CanOfWorms-worm-25.htm">Channel Ten’s provocative <em>Can of Worms</em></a>, it’s clear that its regulation is a most divisive issue.</p>
<p>Male circumcision has many features attracting regulation and controversy. It’s invasive, involving blood loss, pain and the removal of genital tissue. It has an inherent risk of harmful complications and is performed in a variety of circumstances by medical professionals, trained ritual circumcisers, and laypersons alike. </p>
<p>Circumcisers usually profit from performing circumcision and often perform it on people too young to express an opinion on whether it’s in their interests. Individuals are also liable to request circumcision on the basis of <a href="https://www.mja.com.au/journal/2009/191/5/adequacy-consent-documentation-specialty-surgical-unit-time-community-debate">insufficient, inaccurate or inadequately contextualised information</a>.</p>
<h2>Grave complexities</h2>
<p>People can and do disagree about the merits of circumcising. Indeed, the circumcision debate is characterised by conflicts between claims that are equally absolute, and ends that are equally ultimate. </p>
<p>Legislatures and courts can’t frame the law to please both circumcision abolitionists and Orthodox Jewish <em>Mohels</em>. And they can’t promote every culturally significant way of circumcising while trying to maximise the health standards of every circumciser. This puts law reform bodies in an unenviable position.</p>
<p>Although it has the kind of features that give rise to the disputes brought before courts every day, circumcision has until recently avoided close legal scrutiny in Australia. There is no Circumcision Act. There has not been a significant test case. In many instances, it’s not clear how criminal and private law regulate circumcision. </p>
<p>Even the basic requirements of lawful authorisation to perform circumcision are uncertain. The shadow cast by the law’s uncertainty provides cover for questionable acts, and ominously follows those acting commendably. This uncertainty in the law provides ample impetus for reform.</p>
<h2>A way forward</h2>
<p>An attempt at reform has been made by the Tasmanian Law Reform Institute, which recently released a report titled <a href="http://www.law.utas.edu.au/reform/documents/CircumcisionFinal.pdf"><em>Non-Therapeutic Male Circumcision</em></a>. The report recommends reforming the legal framework governing circumcision in Tasmania, and provides the most comprehensive formal law reform analysis of circumcision ever undertaken.</p>
<p>The Institute outlined its approach to reform in the report to encourage critical consideration of its recommendations; it adopted a pluralistic path deeply concerned with legal, political, and evidential reality. </p>
<p>It recommended Tasmania provide a clear legislative basis for the legality of circumcision in some circumstances. But it didn’t consider each of the many rationales for circumcision to be equally deserving. </p>
<p>It recommended reform to allow adults and older minors the freedom to determine both their own circumcision status and the circumstances of the performance of their circumcision.</p>
<p>Due to the significant and entrenched acceptance of religious and ethnic circumcision globally, and the ardent support of its proponents, the Institute recommended reform to accommodate circumcision performed on young boys for established religious and ethnic circumcising reasons.</p>
<p>Because it assessed the secular social rationales for circumcising (such as improved appearance, family tradition and familiarity) as rightfully controversial, weakly established, and tenuously linked to the child’s interests, the Institute recommended the prohibition of circumcision performed on young children for the sake of secular social reasons.</p>
<p>Weighing the benefit of its putative <a href="http://www.racp.edu.au/index.cfm?objectid=65118B16-F145-8B74-236C86100E4E3E8E">prophylactic health effect</a> (offering potential benefits of <a href="http://www.theaustralian.com.au/news/health-science/circumcision-no-barrier-to-hiv/story-e6frg8y6-1111119114985">no real significance</a> to the vast majority of Australian males) against the harm of potentially significant costs (and the possibility of other costs with potential consequences ranging from negligible to truly dire), the Institute recommended the prohibition of circumcision performed on young children for preventative health reasons.</p>
<h2>Further reform</h2>
<p>The Institute made several supporting recommendations to:</p>
<p>• protect the interests of children by requiring court authorisation <a href="http://www.mycircumcisiondisgrace.org/How%20easy.html">when parents cannot agree</a> about the merits of circumcising their child;</p>
<p>• improve access to justice for those harmed by circumcision as a child by improving their access as an adult to legal remedies;</p>
<p>• ensure no minor be put at an <a href="http://www.ntnews.com.au/article/2010/01/11/114641_ntnews.html">unnecessarily high risk of suffering</a> from a circumcision by enacting clear minimum health standards for all circumcisers; and</p>
<p>• improve decision-making by requiring clear standards in regard to the quality of information about circumcision provided to the community.</p>
<p>Those who perform or instigate a circumcision do so without knowing the full extent of their exposure to civil and criminal liability. By reforming the law, Tasmania may spare itself the pain of hosting the kind of legal battles making headlines in Europe.</p><img src="https://counter.theconversation.com/content/9105/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Warwick Marshall is a former employee of the Tasmanian Law Reform Institute. He authored the Institute's final report on male circumcision.</span></em></p>Circumcision lies at the crossroads of religion, custom, human rights, health, commerce, harm, and ethics. From high-profile court battles overseas to its recent inclusion on Channel Ten’s provocative…Warwick Marshall, Honorary Associate, University of TasmaniaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/85172012-08-08T20:37:52Z2012-08-08T20:37:52ZInfant male circumcision: stop violating boys’ human rights<figure><img src="https://images.theconversation.com/files/13951/original/xdv4cyyd-1344315845.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Infant male circumcision violates aspects of international human rights law, which Australia is bound to uphold.</span> <span class="attribution"><span class="source">Chris Woods</span></span></figcaption></figure><p>In an article published recently on this site, “<a href="https://theconversation.com/male-circumcision-policy-ignores-research-showing-benefits-8395">Male circumcision policy ignores research showing benefits</a>”, the authors stated some alleged benefits of infant male circumcision and argued the Royal Australasian College of Physicians’ <a href="http://www.kids.vic.gov.au/downloads/male_circumcision.pdf">policy</a> (that infant male circumcision is not warranted in Australia and New Zealand) is misguided and not based on evidence. </p>
<p>The article itself ignores not just research and good policy, but also law – in particular, international human rights law, which Australia is bound to uphold.</p>
<h2>The importance of holistic policy</h2>
<p>Developing good public health policy is more than simply making conclusions based on risks and benefits to physical health. It requires consideration of what is meant by health. The World Health Organization <a href="http://www.who.int/governance/eb/who_constitution_en.pdf">defines</a> health as not only physical, but also mental and social well-being. Any debate about infant male circumcision should take into account the potential long-term trauma (conscious or subconscious) of such a procedure, as well as the sense of violation it engenders.</p>
<p>And if scientific research is used as justification for a medical procedure, it should be applicable to the context. The research cited as showing the utility and benefit of male circumcision for disease prevention is limited exclusively to developing countries, including HIV/AIDS-prevalent societies. This doesn’t make infant male circumcision a necessary procedure in Australia. </p>
<p>The <a href="http://www.kids.vic.gov.au/downloads/male_circumcision.pdf">Royal Australasian College of Physicians</a> (the policy paper of contention in the article in question), the <a href="http://www.kidshealth.org.nz/circumcision">Paediatric Society of New Zealand</a>, the <a href="http://bma.org.uk/-/media/Files/PDFs/Practical%20advice%20at%20work/Ethics/Circumcision.pdf">British Medical Association</a>, the <a href="https://www.cpsbc.ca/files/u6/Circumcision-Infant-Male.pdf">Canadian Paediatric Society</a>, <a href="http://pediatrics.aappublications.org/content/103/3/686.full.pdf+html">American Academy of Pediatrics</a> and the <a href="http://www.acog.org/%7E/media/For%20Patients/faq039.pdf?dmc=1&ts=20120803T0840172025">American College of Obstetricians and Gynecologists</a> all deem infant male circumcision for religious, appearance or even perceived preventative medical reasons as unnecessary medical procedure. They all consider it to be either elective or non-therapeutic surgery.</p>
<h2>Human rights</h2>
<p>Male circumcision and infant male circumcision both ultimately boil down to choice – and that is a human rights issue. At the heart of human rights is the concept of human dignity, and rights such as those <a href="http://www2.ohchr.org/english/law/ccpr.htm#art7">to physical integrity</a>, <a href="http://www2.ohchr.org/english/law/cescr.htm#art12">to the highest attainable standard of physical and mental health</a>, and, in the case of children, <a href="http://www2.ohchr.org/english/law/crc.htm#art3">the obligation to act in their best interests</a>. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/13949/original/32h4kbyn-1344315616.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/13949/original/32h4kbyn-1344315616.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/13949/original/32h4kbyn-1344315616.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/13949/original/32h4kbyn-1344315616.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/13949/original/32h4kbyn-1344315616.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1005&fit=crop&dpr=1 754w, https://images.theconversation.com/files/13949/original/32h4kbyn-1344315616.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1005&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/13949/original/32h4kbyn-1344315616.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1005&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Lack of informed consent makes infant male circumcision a violation of human rights.</span>
<span class="attribution"><span class="source">Matthew Kebbekus</span></span>
</figcaption>
</figure>
<p>These are not only protected under <a href="http://www2.ohchr.org/english/law/crc.htm">international human rights law</a>, but are entrenched in criminal law systems in various forms. Criminal laws consider interference with the physical integrity of another human being as the most serious of offences.</p>
<p>Human rights law reflects the importance placed on such violations and a forced medical procedure on an individual is in breach of a number of human rights. Circumcision without consent or any immediate medical necessity on a healthy adult male would clearly be in breach of his human rights. So how is infant male circumcision without consent any different? </p>
<p>Children are entitled to the same basic rights as adult individuals. Indeed, they have special protections that recognise their unique vulnerability, as made clear under the <a href="http://www2.ohchr.org/english/law/crc.htm">Convention on the Rights of the Child</a>, which Australia has <a href="http://treaties.un.org/Pages/ViewDetails.aspx?src=TREATY&mtdsg_no=IV-11&chapter=4&lang=en">ratified</a>.</p>
<h2>The rights of parents?</h2>
<p>While parents and legal guardians provide consent on behalf of children for necessary medical procedures (such as immunisations) the removal of healthy, functioning genital tissue from an infant (many years before any purported protections from sexual disease are even relevant) is clearly not a necessary medical procedure. </p>
<p>Parental consent to infant male circumcision is insufficient justification in contemporary Australia. It also ignores doctors’ duties to the child to do no harm, is arguably an inconsistent interpretation of the limitations of parental consent and a breach of the child’s human rights. If the purported benefits are, on balance, enough to warrant a male circumcision, then this is a decision for which he, whether as an adolescent or an adult, is solely entitled to.</p>
<h2>Religious rights</h2>
<p>For some, the medical benefit debate is irrelevant. Infant male circumcision is seen as a fundamental ritual in the practise of religion, which is also a human right. While some may interpret the right to freedom of religion as including the right to practise infant male circumcision, it has clearly been accepted under international human rights law that one individual’s right to freedom of religion does not trump another’s right not to have their bodily integrity interfered with. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/13948/original/k5zf9gtq-1344315411.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/13948/original/k5zf9gtq-1344315411.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/13948/original/k5zf9gtq-1344315411.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/13948/original/k5zf9gtq-1344315411.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/13948/original/k5zf9gtq-1344315411.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/13948/original/k5zf9gtq-1344315411.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/13948/original/k5zf9gtq-1344315411.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Circumcision of Christ (1521), Chartres Cathedral France.</span>
<span class="attribution"><span class="source">Walwyn</span></span>
</figcaption>
</figure>
<p>In the seminal United States child rights case <a href="http://www.law.cornell.edu/supct/html/historics/USSC_CR_0321_0158_ZO.html"><em>Prince v Massachusetts</em></a>, the Court held that “[t]he right to practice religion freely does not include liberty to expose the… child to ill health or death… Parents may be free to become martyrs themselves. But they may not make martyrs of their children before they have reached the age of full and legal discretion when they can make that choice for themselves”. </p>
<p>And in May this year, the regional court of Cologne in Germany applied the same reasoning in a case about infant male circumcision. It <a href="http://adam1cor.files.wordpress.com/2012/06/151-ns-169-11-beschneidung.pdf">said</a> “the right of the parents to raise their child in their religious faith does not take precedence over the right of the child’s bodily integrity and self-determination” (<em>translated from German</em>). </p>
<p>Restricting male circumcision to informed adolescents and adults is in no way a restriction on the freedom of religion. If anything, it’s upholding the child’s right to that freedom.</p>
<p>Whether for perceived medical benefit, religious or cultural reasons, until the informed consent of the individual can be freely given, infant male circumcision is plainly, and simply, a violation of human rights. It ignores the child’s rights to bodily integrity, to physical and mental health and to freedom of religion. </p>
<p>Advocates for infant male circumcision in Australia are failing to act in the best interests of Australian children.</p><img src="https://counter.theconversation.com/content/8517/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>In an article published recently on this site, “Male circumcision policy ignores research showing benefits”, the authors stated some alleged benefits of infant male circumcision and argued the Royal Australasian…Claire Mahon, Adjunct Clinical Professor of Law, University of MichiganAlexandra Phelan, International Health and Human Rights Lawyer, Australian National UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/83952012-07-26T20:09:15Z2012-07-26T20:09:15ZMale circumcision policy ignores research showing benefits<figure><img src="https://images.theconversation.com/files/13449/original/7jw44wr3-1343267006.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Circumcising boys in the neonatal period using local anaesthesia maximises benefits and safety.</span> <span class="attribution"><span class="source">TheGiantVermin/Flickr</span></span></figcaption></figure><p>For some time now, all the departments of health in Australia have based their policy on male circumcision on reviews of the scientific literature carried out periodically by the Royal Australasian College of Physicians (RACP). But the lack of a strong basis on evidence means the government should reconsider this reliance. </p>
<p>An RACP policy statement in 2004 argued that the available evidence didn’t justify infant male circumcision being carried out to prevent illness. But when a <a href="http://www.ncbi.nlm.nih.gov/pubmed/16502947">withering critique</a> of that 2004 policy was published in the Australia and New Zealand Journal of Public Health in 2006, the authors of the 2004 report didn’t even attempt to defend their work. This is generally considered an ominous sign in science.</p>
<p>In 2010, the RACP published its most recent policy <a href="http://www.racp.edu.au/page/paed-policy">Circumcision of infant males</a>. Again, the policy argued that the evidence didn’t justify infant male circumcision being carried out to prevent illness. But the 2010 policy statement was not quite as strongly opposed to infant circumcision as the 2004 policy had been.</p>
<p>We have just published <a href="http://www.ncbi.nlm.nih.gov/pubmed/22805686">a comprehensive evaluation</a> of the 2010 RACP policy in the College’s <a href="http://www.racp.edu.au/page/publications/internal-medicine-journal/">Internal Medicine Journal</a>. All nine co-authors of the paper, including ourselves, are public health and public policy experts. </p>
<p>Our critique concludes that the RACP policy is not a fair and balanced representation of the literature on male circumcision because it is not based on research evidence. Instead, the RACP policy ignores, downplays, obfuscates or misrepresents the considerable body of research that shows circumcising males offers strong protection against a number of diseases. </p>
<p>Benefits include reduced <a href="http://www.scirp.org/journal/PaperInformation.aspx?paperID=17415">childhood urinary tract infections</a>, which are common, painful and often cause permanent kidney damage. Male circumcision also provides some protection against many common, as well as not so common, <a href="http://rd.springer.com/chapter/10.1007/978-3-642-14663-3_54">sexually transmitted infections</a>, including the epidemic of cancer-causing types of human papillomavirus and genital herpes, <a href="http://www.scirp.org/journal/PaperInformation.aspx?paperID=17415">genital ulcer disease</a> and <a href="http://www.tandfonline.com/doi/abs/10.1080/09540121.2012.661836?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed">HIV</a>, among others.</p>
<p>Circumcision also helps protect against <a href="http://www.ncbi.nlm.nih.gov/pubmed/16925903">penile candidiasis</a> (thrush), <a href="http://circinfo.net/inflammatory_dermatatoses.html">inflammatory skin conditions</a> and <a href="http://circinfo.net/penile_hygiene.html">inferior penile hygiene</a>. It can help those with <a href="http://circinfo.net/physical_problems.html">physical problems</a>, such as a tight foreskin that interferes with passing urine, and an inability to return the foreskin after it is retracted. It virtually eliminates the risk of <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3113366/?tool=pubmed">penile cancer</a> that occurs in one in 1,000 uncircumcised males over their lifetime. And there may also be some reduction in the <a href="http://www.ncbi.nlm.nih.gov/pubmed?term=morris%20bj%202012%20prostate">risk of prostate cancer</a>. </p>
<p>Women with circumcised male partners are protected to varying degrees against cancer-causing <a href="http://www.ncbi.nlm.nih.gov/pubmed/22734435">human papillomavirus infection</a>, <a href="http://rd.springer.com/chapter/10.1007/978-3-642-14663-3_54">genital herpes</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed/18976733">bacterial vaginosis</a> (Gardneralla), and <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3113366/?tool=pubmed">cervical cancer</a>. Although the RACP’s policy statement claims otherwise, complications of infant male circumcision <a href="http://www.ncbi.nlm.nih.gov/pubmed/20158883">are uncommon</a> and virtually all <a href="http://www.biomedcentral.com/1471-2431/12/20/abstract">minor and easily treated</a>.</p>
<p>The RACP policy statement claims that “the foreskin has a functional role” and “is a primary sensory part of the penis”. However, extensive <a href="http://circinfo.net/circumcision_sensitivity_sensation_sexual_function.html">high quality research</a>, including <a href="http://www.ncbi.nlm.nih.gov/pubmed/18761593">randomised controlled trials</a>, show no adverse effect on <a href="http://www.ncbi.nlm.nih.gov/pubmed/18761593">sexual function</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed/17419812">sensitivity, sensation</a> or <a href="http://www.ncbi.nlm.nih.gov/pubmed/18761593">satisfaction</a>. </p>
<p>Instead of citing good research, such as large meta-analyses and randomised trials, the RACP policy selectively cites a <a href="http://www.ncbi.nlm.nih.gov/pubmed?term=kim%20d%202007%20619%2099">poor quality study</a> that has been <a href="http://www.ncbi.nlm.nih.gov/pubmed/17437447">criticised</a>. The RACP’s claim – without support from a literature-based risk-benefit analysis – that the currently available evidence does “not warrant routine infant circumcision in Australia and New Zealand” is misleading. </p>
<p>A <a href="http://www.scirp.org/journal/PaperInformation.aspx?paperID=17415">risk-benefit analysis</a> by a number of us who also wrote the Internal Medicine Journal article was published recently in the <a href="http://www.scirp.org/journal/ojpm/">Open Journal of Preventive Medicine</a>. We found that the benefits of male circumcision were considerable and exceeded risks by a large margin; the risks are virtually all minor, while conditions prevented are often serious. </p>
<p>The RACP policy fails to explain that circumcising boys <a href="http://www.biomedcentral.com/1471-2431/12/20/abstract">in the neonatal period</a> using local anaesthesia maximises benefits and safety, is convenient and offers <a href="http://www.ncbi.nlm.nih.gov/pubmed/20090910">cost savings</a>.</p>
<p>Our Internal Medicine Journal article concludes that because the RACP’s policy “is not a fair and balanced representation of the current literature it should not be used to guide policy.” We recommend that an extensive, comprehensive, balanced review of the scientific literature and a risk-benefit analysis should be conducted to formulate policy, in the interests of public health and individual well-being. </p>
<p>Such a review was recently undertaken by the <a href="http://www.circumcisionaustralia.org/">Circumcision Foundation of Australia</a>. Health bodies, governments, doctors and the general public should use this evidence-based policy statement as a reliable guide to decision-making and health policy development.</p>
<p>Facing rising health costs, the federal government has recently increased its emphasis on prevention. Infant male circumcision is a good example of how difficult it can be to implement preventative measures. The process starts with basing policy fairly and squarely on evidence and continues with overcoming obstruction from groups opposed to policy based on evidence. Watch this space.</p><img src="https://counter.theconversation.com/content/8395/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>For some time now, all the departments of health in Australia have based their policy on male circumcision on reviews of the scientific literature carried out periodically by the Royal Australasian College…Brian J. Morris, Professor of Molecular Medical Science, University of SydneyAlex Wodak, Emeritus Consultant, St Vincent's Hospital, DarlinghurstLicensed as Creative Commons – attribution, no derivatives.