A review of public health, social and ethical implications of voluntary medical male circumcision programs for HIV prevention in sub-Saharan Africa

Abstract

Ideally, the benefits of public health interventions should outweigh any associated harms, burdens, and adverse unintended consequences. The intended benefit of voluntary medical male circumcision (VMMC) programs in eastern and southern Africa (ESA) is the reduction of HIV infections. We review the literature for evidence of reductions in HIV incidence, evaluate the extent to which decreases in HIV incidence can be reasonably attributed to VMMC programs, and summarize social harms and ethical concerns associated with these programs. Review findings suggest that HIV incidence had been declining across ESA since before the large-scale rollout of VMMC as a public health intervention, and that this decline may be due to the combined effects of HIV prevention and treatment interventions, such as expanded antiretroviral therapy. The independent effect of VMMC programs in reducing HIV infections at the population level remains unknown. On the other hand, VMMC-associated evidence is increasing for the existence of negative social impacts such as stigmatization and/or discrimination, and ethically problematic practices, including lack of informed consent. We conclude that the relationship between the benefits and burdens of VMMC programs may be more unfavorable than what has been commonly suggested by proponents of global VMMC campaigns.

Child genital cutting and surgery across cultures, sex, and gender. Part 2: assessing consent and medical necessity in “endosex” modifications

“…Such a justification rests on the assumption that these potential future health benefits will in some way "outweigh" the harms of the procedure, whether intrinsic (e.g., pain, damage to or loss of sensitive, prima facie valuable genital tissue [84][85][86]), or accidental (e.g., possible surgical complications, negative psychosexual sequalae) [87][88][89][90]. Whether this is a reasonable assumption, at least for penile circumcision, is debated by several authors in this issue [91][92][93][94][95], while an analogous debate on the potential benefits and harms of intersex surgeries can be found in Part 1.…”

Male Circumcision impacts on Sexual Function, Psychological Well-being, and Overall Quality of Life in Ghana and the sub-Saharan Africa: A Scoping Review

“…Inadequate sterilization practices due to limited resources contribute significantly to post-operative infections. 19 Moreover, a shortage of skilled healthcare providers exacerbates these issues as they may lack sufficient training and experience necessary for safe circumcisions. 20 Furthermore, there are notable gaps in research on male circumcision specifically conducted within Ghana's context.…”

Genital Cutting as Gender Oppression: Time to Revisit the WHO Paradigm

“…Marge Berer, the founding editor of Reproductive Health Matters, has raised numerous concerns about the failure to account for this trial, which she suggests puts African women at risk who are already more vulnerable to HIV and AIDS (Berer, 2007(Berer, , 2008(Berer, , 2009. Additional gender-related, ethical, and public health concerns about the WHO campaign to circumcise millions of African boys and men have been raised by others (Rudrum et al, 2017;Gilbertson et al, 2019;Luseno et al, 2019Luseno et al, , 2021Rudrum, 2020;Fish et al, 2021;Rennie et al, 2021).…”

“…The data regarding HIV-related health benefits for MGC come from studies of adult men in sub-Saharan Africa who, ostensibly, gave their free and informed consent to undergo penile circumcision, hoping this would reduce their risk of acquiring HIV. The population-level effectiveness of such circumcision as a form of prophylaxis against HIV remains contested (Garenne et al, 2013;Rosenberg et al, 2018;Garenne and Matthews, 2019;Loevinsohn et al, 2020;Luseno et al, 2021;Garenne, 2022), perhaps because one's risk of contracting a sexually transmitted virus has more to do with behavioral and social-structural considerations than with anatomical factors such as the presence or absence of healthy genital tissues (Aggleton, 2007;Norton, 2013Norton, , 2017Parker et al, 2015;Earp and Darby, 2019;Fish et al, 2021).…”