Introduction
HIV/AIDS is currently one of the greatest impediments to Africa’s development. “Of more than 40 million people estimated to be HIV-infected worldwide, 95 percent live in middle- or low-income countries.” (Biehl & Eskerod, 2007:4) Society is exposed to the risk of contracting the disease either due to ignorance or because of risky cultural practices. The situation is aggravated by the fact that it is extremely difficult to fight the spreading of this disease for “no one knows where to start with AIDs.” (Monette, 1988: 2) In this paper, therefore, I will concentrate on two culturally rich nations, one in India and the other in Africa: Sri Lanka and Kenya.
A crucial issue to examine with regard to HIV transmission is male circumcision. While modernization, with its negative implications such as mushrooming of prostitution, has been significantly responsible for facilitating the spread of HIV, modern techniques of education and community mobilization have been active in fighting the spread of HIV through condoms and other preventative measures. However, despite such milestones in understanding the infection, the battle is far from being over. Lorber and Moore suppose that circumcision is one of the main reasons for HIV spreading in Africa.
For the past decade, there have been reports in epidemiological and medical journals about the possible link between circumcision and HIV transmission. When the AIDs epidemic burgeoned in Africa, researchers noted that there was a lower incidence in areas where male ritual genital surgeries were common than where men were not circumcised. (Lorber and Moore 2002: 97)
Across the Indian Ocean to India, for instance, a similar situation prevails. HIV is spread because of the circumcision which is obligatory due to religious convictions. Religion as the basis of social culture in India has been a facilitator of the spread of the AIDS pandemic. In India, religion and culture have been identified as impediments to the fight and prevention of HIV-AIDS (Pisani 2008:83). Nevertheless, it is to be noted that religion and culture do not necessarily oppose prevention measures, but that some beliefs and practices found in these societies can facilitate HIV transmission.
Male circumcision, as a cultural practice among some traditional societies in Kenya, has contributed to HIV transmission of HIV, while the lack of circumcision in Sri Lanka has also led to high prevalence. In this paper, therefore, I set to prove that circumcision is an impediment in the fight against HIV and related infections.
The World Health Organization has estimated that 34% of men 15 and above worldwide were circumcised as of 2006 (CITATION). This translates to 665 million males. The larger uncircumcised percentage is largely due to religion, culture, and lifestyle. Religion as the main basis of culture has resulted in the entrenchment of the ban on circumcision to the culture itself. In the case of Kenya, we have seen that the Luos in Nyanza do not recognize circumcision as a rite of passage into adulthood, but just an unnecessary interference with human genitalia (Juma, 2005, p. 21). Pizer and Meyer (2008, p.136) say that 0.3 million HIV-related deaths and 2 million new infections over ten years can be averted through circumcision assuming an efficacy of 60% as has been observed in studies. According to the BBC, trials in Kenya found a 53% reduction in new HIV infections in heterosexual men who were circumcised while the Ugandan study reported a drop of 48%. Results last year from a study in 3,280 heterosexual men in South Africa, which was also stopped early, showed a 60% drop in the incidence of new infections in men who had been circumcised.
Circumcision
Circumcision is simply the surgical removal of the foreskin or the prepuce on the penis covering the glans. Conventional circumcision was done with the purpose of affecting hygiene and rite of passage into adulthood in Kenya and more so among the famous Maasai Tribe (Juma 2005:9). Circumcision in Sri Lanka is done purely for religious reasons. Some research has shown that the practice lowers the risk of contraction and transmission of the disease from another infected person during sexual contact. According to the Centers for Disease Control and Prevention (2008), there are four main reasons why the uncircumcised foreskin increases the risk of HIV transmission. These factors include:
- The foreskin is more prone to keratinization, whereby the deposited cells are very likely targets for the HIV virus unlike the inner skin or any other penile tissue.
- The foreskin is more susceptible to “traumatic epithelial disruptions” (which in other words may be explained as damage to the skin integrity due to the influence from the outside).
- The microenvironment in the preputial sac between the unretracted foreskin and the glans penis may be conducive to viral survival. (which means that the foreskin may serve as a place for bacteria accumulation).
- The higher rates of sexually transmitted genital ulcerative disease, such as syphilis, observed in uncircumcised men may also increase susceptibility to HIV infection.
Other reports have indicated that Jewish women rarely get cervical cancer, a fact that Pizer and Meyer (2008: 142) partly attribute to male circumcision among Jewish men.
In Sri Lanka, the prevalence rate is less than 0.1%, based on the fact that approximately 3,800 Sri Lankans were found to be living with HIV as of the end of 2007. 60% of the total amount of HIV-positive people (280 cases) were male. As far as Kenia is concerned, 1.4 million people were registered as HIV-positive in 2007 (three out of five people were women).
Attitude to Circumcision in Kenya and Sri Lanka
Traditionally, circumcision is viewed skeptically in Sri Lanka. In Sri Lanka, there are no exact figures on circumcised males but given that the population is mainly Hindu, who religiously abhor circumcision, then it would be expected that a majority of men are not circumcised. In fact, according to Narvan (2008, p. 212), a circumcised man cannot be converted into a Hindu as his body is mutilated.
In Kenya, circumcision is very diverse given that over forty ethnic communities are found in the country. Several communities, such as the Luo and Teso in the western region of the country around Lake Victoria, do not practice male circumcision. As LA Times informs, other communities which embrace circumcision in the country as a rite of passage into adulthood have been accused of forcing their uncircumcised neighbors to undergo the cut.
HIV infection rates in Kenya have been declining at a steady rate prior to a surprising increase in 2008. In 2006, it stood at 5.9%, down from a high of 6.1% in 2005 and 6.7% as of 2004. In 2007, however, the rate increased to 7.8%. Women constitute the higher percentage among the infected at 65% thus being higher than the Sub-Saharan regional estimate of 57% according to a Kaiser family foundation report.
The Nyanza region, a province of Kenya situated on Lake Victoria, is largely occupied by the uncircumcised Luos has a relatively higher infection rate than other areas. However, this is not directly related to the fact that they are uncircumcised, but due to a lack of information about HIV. Circumcision rules are a bit different for the Maasai community. Among the Maasai community, circumcision is a must and performed for both boys and girls. Unfortunately, the community’s circumcision techniques can encourage HIV transmission. This is because the circumciser will often use one knife with no anesthetic to circumcise a single age group that could number over 50 boys at the same time. The practice has more often than not been extended to girls despite medical and religious opposition to the practice. As a result, the rate and chances of HIV transmission remain relatively high among communities practicing circumcision (Juma 2005:12).
In Kenya, circumcision is a sign of adulthood among majority communities. When performed as a part of an initiation ritual, the boys are expected to receive the surgery without flinching, lest they disgrace their families. It is preceded by a cold dip in a river to deaden the senses. Circumcision is such a public symbol, it is not unusual to hear a man say “I have been to the river,” to mean “I know what I am talking about.” Because of its social significance, youths who do not undergo initiation, either because the family lives away from the tribal area or they are in school, will arrange for private circumcision from a doctor or clinician. After his teens, an uncircumcised male is on the butt of ridicule and is at a considerable disadvantage in finding sex partners. A youth who cries out during the surgery is disgraced for life and will be able to find a wife only among the handicapped, elderly, or those with illegitimate children.
Many communities that do not practice circumcision avoid it for cultural reasons. 70% of Sri Lankans are Buddhist. Buddhism openly discourages circumcision by teaching that anyone who chooses to be a Buddha in following the eight paths to enlightenment must have a fully retractable penis (Nirvan, 2008, p. 188). The author goes ahead and says that Buddhism prohibits one from harming himself or another person. As a result, many Buddhist women will not condone a circumcised man. Therefore, the fear of rejection from women has also played a vital role in discouraging circumcision even as the world moves into encouraging circumcision in the fight against HIV.
In Kenya, the Kikuyu tribe believes that a circumcised man is wiser than an uncircumcised one. Though this might be viewed to have been directly picked from the Bible, Juma (2005, p. 13) notes that the community practiced this rite before the coming of missionaries; hence, it is engraved in their culture. The debate of circumcision has even been a source of tribal hostilities taking the form of forced circumcision. The Kenyan government together with NGOs has campaigned against circumcision in the cultural setting citing medical reasons. As such, some of the communities are having circumcision done on their young male members of society at hospitals. However, the project is facing resistance due to the relatively high levies charged. In the case of Kenya, hospitals’ charges range from $15 USD to $150 USD. Charges depend on the level of services offered, such as daily cleaning of the wound. With a majority of Kenyans surviving on less than two dollars a day, circumcision in hospitals is way out of reach for many of them; thus, they stick with the relatively cheaper traditional way (Juma, 2005, p.15).
Churches in Kenya have stepped in the rescue of the poor locals by offering subsidized services. Unfortunately, the locals are skeptical in a way as they still insist that the young circumcised boys miss an opportunity of getting some informal education about life and their culture. Pizer and Meyer (2008, p.136) note that demand for circumcision among the locals and Africa in general, would present a novel public health challenge for the financially challenged governments.
In Sri Lanka, however, there has been slow but encouraging progress in the number of persons embracing circumcision. Nirvan (2005, p. 218) attributes this to cultural interaction. He says that a majority of Sri Lankans living out of the country have undergone circumcision and, on their return home, recommended others to undergo the procedure. Similarly, women have realized medical and sexual benefits of circumcise and started slowly and carefully encouraging their men to be circumcised. Applying circumcision to the caste system would mean violation of culture. This is because circumcision would tend to bring about equality in the castes, which would not customarily be preferred.
Education in Fight Against HIV
Formal education has a large role to play in the fight against HIV. The fact that literacy levels in Africa in general remain low has led to the high prevalence rates in the sub Saharan region. As of 2004, literacy level in Kenya was 80.8%. This has presented a great challenge in the fight against the HIV pandemic. The government has, however, made substantial effort in the fight. For instance, it has been providing free condoms in public hospitals and other public social facilities (Juma, 2005, p. 11).
In the recent past, the government has also conducted campaigns for encouraging circumcision for men and banning circumcision for women. However, the progress in this direction is facing resistance from cultural taboos and perceptions. For instance, the Luo community has, in one way or another, felt that they are losing their cultural identity by undergoing circumcision. Information on the medical benefits of the procedure is not flowing fast enough amongst the folks in the rural areas due to low literacy levels (Juma, 2005, p. 11, 9).
In the global war against HIV, Sub Saharan Africa has largely been the recipient of billions of dollars in terms of aid from the US and other international parties. Much of this aid is utilized in informing and educating the public. The government has also introduced free anti-retroviral medication for all HIV victims. In part, this has encouraged the population to embrace HIV victims who are commonly associated with “sin”. The social stigma has, in many occasions, been blamed for the spread of the disease. According to the local dailies, the harsh treatment form the society has resulted into some of the victims hitting back by intentionally infecting other members of the society (Juma, 2005, p. 19).
Sri Lanka, as a relatively rich country, has been receiving little help in fighting with AIDs. This is because prevalence rates remain relatively low. The problem with African countries is that lack of information, such as on the dangers of unprotected sex, has been the main cause of high prevalence rates. For instance, among the Luo, wife inheritance is a common practice. This has been one of the major ways of HIV transmission (Juma, 2005 p. 21). In the case with Sri Lanka, prostitution is the number one method of transmission (Nirvan, 2007, p. 218).
Women’s Views on Male Circumcision
Women in Kenya have been known to reject uncircumcised men. The men who refused to undergo circumcision are viewed as cowards as in the traditional setting, the practice is done with no anesthesia with the rest of the community watching. In Sri Lanka, “uncircumcised male cannot be heir to his father’s wealth, cannot marry or officiate in tribal rituals” Jones, 2006:92) In fact, he is considered to be not a man but a boy, and he is unlikely to attract any woman’s attention.
Some women believe that circumcision can be of great benefit for wives whose husbands are having sex with other women, since these women are often powerless to insist on the use of condoms. Other women were wary of an initiative that could give men an extra excuse not to use condoms. Most could assume that women from third world countries are shy when it comes to matters concerning sex. They consider that men know more about sex, so it is their right to decide when there will be sexual intercourse and what kind of protection will be used. Whatever he says goes. Some women may see this as the opportunity for men to suppress women even more.
Kenya’s and Sri Lanka’s Government Fighting with HIV
In Africa, specifically Kenya, steps are already being taken to promote circumcision in a non-direct and forceful way. As circumcision is still considered culturally taboo, the Kenyan government is setting an example to show its people that it is okay to go through such a procedure. In other words, the government is sending a message that the Kenyan population will be safe, irrespective of the other cultures’ attitude towards their traditions.
The Kenyan government has a target of circumcising two million people, particularly in the Luo province, as this province abhors the idea of circumcision and needs more support in presenting the issue to the public. Top politicians from the area announced they had been circumcised to increase awareness about circumcision as a means of HIV prevention. In front of a wide audience in Kisumu, key figures such as Prime Minister Raila Odinga, three government ministers, and an MP said they had secretly undergone the operation.
Medical researchers are spreading the knowledge that most others in Africa cannot or will not acquire. They contend that circumcision reduces the risk of HIV infection among men. However, they will not mislead the public and assure them that circumcision is the only prevention. To maintain and promote basic safety, they have assured the public that using condoms is still far more effective and circumcision is just another step in fighting the infection and the spread.
The prevalence of HIV is high in the Luo community and the government has recently introduced a programme to promote the practice to curb the spread of AIDS. Unlike the nearby Luhya community, who last month turned out in large numbers to undergo circumcision in an annual festival, removing the foreskin is not performed as rite of passage amongst the Luo. Hundreds of young men have begun to turn up for circumcision at public and private hospitals. At the Lumumba Health Centre in Kisumu, more than 80 medical practitioners have already received training. “We are teaching young men and older people about circumcision. They usually come for circumcision of their own free will,” says Wycliffe Omondi, one of the doctors providing training at the centre.
Nearly 1,000 men have been circumcised since March and medical workers receive two days of training, claims Omondi. However, the Luo Council of Elders is not convinced that circumcision lowers the risk of infection. “I don’t think it will be a solution to fight the spread of Aids,” said Joe Asila, a pastor and Luo elder. “Other communities practise circumcision, but there is still a high prevalence of HIV.”
The support of the local people in Luo has spread the idea that circumcision is indeed a safe approach to fighting the infection socially and medically. The forecoming success in Luo is bringing commotion in other parts of Africa as well. For example, in Malawai, hundreds of men are reported queuing at medical centres to be circumcised.
Unfortunately, after much research, there is hardly any evidence regarding the solutions for Sri Lanka either from the government, the people, or doctors. It seems as though the cultural and religious views of male circumcision are much more stricter and enforced in Sri Lanka than in Kenya or other parts of the world.
WHO and other international bodies have embarked on providing circumcision funding to governments and informing the public about the benefits of circumcision. Also, Family Health International (FHI), the Bill & Melinda Gates Foundation, and the Government of Kenya have come together to address this challenge. FHI has received a five-year, US$18.5 million grant from the Gates Foundation to establish the Male Circumcision Consortium (MCC). The Consortium, in consultation with the Government of Kenya, will conduct a range of research and training activities to determine the safest and most effective ways to provide voluntary male circumcision services. It will also help Kenya provide comprehensive and accessible HIV prevention in areas with the lowest levels of male circumcision and the highest prevalence of HIV.
Conclusion
Research has been directed at increasing the efficacy rate by combining it with other preventive measures. Unfortunately, the realization that circumcision lowers the chances of HIV transmission has encouraged more irresponsible sexual behavior. The sudden increase in HIV prevalence in Kenya, though not explicitly stated, can be attributed to this. Also, it is important to note that support is greatly needed from key figures in society. The idea to use persons of high caliber as an example for the public is a strong strategy to promote and encourage healthy lifestyles and to show to the public that looking after one’s health plays a vital role in saving other people’s lives.
Despite current efforts to bring prevention and treatment to an ever increasing number of HIV-positive people, many hope for the availability of new approaches, including male circumcision. Not to be confused that this is a cure for the spread of HIV or AIDS, this promising prevention strategy must be counterbalanced with caution about the potential downfalls that could be encountered.
Health services in many developing countries are weak and there is a shortage of skilled health professionals. There is a need, therefore, to ensure that male circumcision services for HIV prevention do not unduly disrupt other health care programs, including other HIV or AIDS interventions. In order to both maximize the opportunity afforded by male circumcision and ensure longer-term sustainability of services, male circumcision should, wherever possible, be integrated with other services. Modeling studies suggest that male circumcision in sub-Saharan Africa could prevent 5.7 million new cases of HIV infection and 3 million deaths over 20 years.
Since male circumcision has been found to decrease risk of HIV infection among men, it is important to determine its acceptability as a potential HIV prevention strategy in Kenya and Sri Lanka. This reality and knowledge can finally bring us closer to bringing down the statistics of such a horrid pandemic.
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