AIDS, Culture, and Africa

5. Male Circumcision in the AIDS Era: New Relevance of an Old Topic

5 Male Circumcision in the AIDS Era New Relevance of an Old Topic Judith E. Brown Adolescent Male Initiation: A Classic Subject in Anthropology Rites of passage, particularly circumcision and related initiation rites, have long been of interest to anthropologists. My own generation (which began our studies during the 1960s), like generations of anthropologists before and since, spent many hours reading lengthy and detailed descriptions of rites of passage around the world. Those of us headed for fieldwork in Africa studied with fascination the initiation of adolescents, often just a few years younger than ourselves. I myself was off to Liberia, so I read avidly about the Poro (male) and Sande (female) secret societies, with their initiation rites. As the years passed, most of us have been involved with very different avenues of interest and research. Renewed Interest: Circumcision and the Transmission of Disease Male circumcision has recently taken on new significance, as studies of HIV prevalence have shown that circumcision may provide some protection against HIV and other sexually transmitted infections (STIs). In Africa, the subject is now widely discussed in professional meetings, health forums, and the popular press. Early Findings With the appearance and rapid spread of HIV/AIDS in Africa during the 1980s, medical researchers looked for all possible clues to the physical, microbiological , or behavioral factors that might be facilitating the transmis- 75 Male Circumcision in the AIDS Era: New Relevance of an Old Topic sion of the virus. The first scientific reports identifying male circumcision as a possible factor for inhibiting heterosexual transmission of HIV came from Kenya, at the end of the 1980s. First, a retrospective study (in an STI clinic) found uncircumcised men more frequently infected with HIV than circumcised men (Simonsen et al. 1988). The following year, a prospective study of HIV seroconversion reported new HIV infection more frequently in uncircumcised than in circumcised men (Cameron et al. 1989). Ecological Studies: Society-Level Mapping Teams of demographers, epidemiologists, and anthropologists began to comb the African ethnographic literature, much of it dating from several decades earlier, to learn which African societies practiced male circumcision . They then mapped and charted that information, along with current HIV prevalence rates. Bongaarts and colleagues (1989) published the first analysis. For information on male circumcision, the authors used two classic ethnographic surveys of Africa (Murdock 1959, 1967), plus an article on East Africa (Dodge and Kaviti 1965). In all, the data covered 409 ethnic groups in thirty-seven countries, allowing the authors to make country-level estimates of the percentages of men who were and were not circumcised. For HIV seroprevalence , they used World Health Organization (WHO) figures for the capital city of each country. When the proportion of uncircumcised males was plotted against HIV seroprevalence, the figures were highly correlated. Meanwhile, Moses and colleagues (1990) used the anthropological database of the Human Relations Area Files, and also several other surveys, to determine male circumcision practices for over 700 African societies. For HIV seroprevalence, they used U.S. Bureau of the Census data from 140 urban and rural locations in forty-one countries. The authors produced a map with dots indicating HIV seroprevalence, superimposed on shadings of circumcising and noncircumcising areas. Their conclusion: the exercise supported the hypothesis that lack of circumcision was a risk factor for HIV transmission. A third society-level analysis (Caldwell and Caldwell 1996) appeared in a more popular article for Scientific American. The key map showed a crescent -shaped “AIDS belt” in eastern and southern Africa, where nearly 25 percent of the urban population was infected with HIV. Using overlay maps, the authors explored, and rejected, a variety of hypotheses about why HIV was prevalent in the “AIDS belt,” compared with African cultures outside the “AIDS belt”: 76 Judith E. Brown Widespread sexually transmitted diseases (STDs) (indicated by high levels of sterility) Late age at marriage High levels of polygyny Long postpartum abstinence Women’s financial autonomy One factor, however, did correlate with HIV prevalence on the maps—lack of male circumcision. Epidemiologic Studies of Individuals Meanwhile, during these same years, epidemiologic studies were accumulating evidence on the individual level (and not just at the societal level) that lack of male circumcision was indeed related to HIV infection. Generally , men were asked whether they had been circumcised, and they were tested for HIV. Most of these earlier studies were retrospective—both the circumcisions and the infections had occurred at some unknown...