Culture, Health & Sexuality

Male circumcision for HIV prevention – Where are we now?

Male circumcision has been a religious and cultural practice for millennia. Only in the 19th century did it begin to be medicalised by British and North American doctors and promoted for the prevention and management of certain medical conditions and behaviours, including as an alleged cure for masturbation. This set the stage for contemporary beliefs that it may serve various health purposes in addition to ritual ones. While becoming widespread in some countries, e.g. in Australia, New Zealand, the USA and South Korea during the 20th century, medicalised ‘routine’ circumcision was falling into disfavour toward the latter part of the century until the HIV pandemic expanded from the 1980s onwards. In the late 1990s, male circumcision began to be advocated by some for its use as a potential HIV prevention strategy to address ongoing and rising infection rates, particularly in sub-Saharan Africa.

In 2007, a meeting in Montreux, Switzerland, convened by the World Health Organization (WHO) and Joint United Nations Programme on AIDS (UNAIDS), recommended that male circumcision be recognised as an additional intervention to reduce the risk of heterosexually acquired HIV infection in men in certain epidemic contexts. The meeting also identified areas where additional research was required to inform the development of male circumcision programmes. Implementation of the meeting recommendations was supported with considerable funding, particularly by agencies in the USA such as PEPFAR, to enable programmes to begin. There was dissent from those decisions at the time, and critical academic, political and community-based discussion has ensued ever since. Soon termed ‘medical male circumcision’ to distinguish it from cultural and religious genital cutting practices, and later ‘voluntary medical male circumcision’ (VMMC) to address additional issues of consent and coercion, it is estimated that the policy has been responsible for the circumcision of 35 million men in the name of HIV prevention, mostly in sub-Saharan Africa (WHO 2023).

WHO and UNAIDS assert that such circumcisions have prevented millions of infections. However, such claims, based on mathematical modelling, are disputed by some scholars who argue that these estimates do not consider various real-world complexities and potential confounding factors, such as the overlapping roll-out of HIV treatment as prevention (i.e. successfully supressed virus in HIV+ people preventing ongoing transmission to uninfected others), concurrent education for HIV prevention, and more recently HIV pre-exposure prophylaxis. WHO and UNAIDS recommend that VMMC should be promoted only as an additional HIV prevention option within combination prevention in males aged 15 years and older in settings with generalised epidemics to reduce the risk of heterosexually acquired HIV Infection. Hence, many other parts of the world did not adopt this strategy, particularly high- and middle-income countries where HIV is primarily transmitted among men who have sex with men and people who inject drugs, in part due to the subsequent mixed or weak evidence in relation to the efficacy of male circumcision in preventing HIV acquisition in these populations. Effectiveness against HIV transmission from men to women through heterosexual intercourse has also not been demonstrated, and a major trial assessing this question was stopped early based on an interim analysis suggesting a lack of effectiveness in preventing—or even increased risk of—transmission to the female partners of circumcised men.

Two decades have now passed since the publication of the results of the first randomised clinical trial that assessed the efficacy of medical male circumcision in reducing HIV infection risk to men from their (presumed female) partners and it is  timely to ask some questions, including: where do VMMC programmes stand as public health measures in designated ‘priority’ countries? What is the current evidence of population-level effectiveness? Also, what do we know about their broader effects on communities, social practices, cultural identities and sexual health?

This special issue of the journal Culture, Health & Sexuality journal aims to explore the complex interplay, tensions and effects of male circumcision and HIV prevention through the following themes:

• Theme 1: Politics, power, science and translation—including global and local politics and power relations, biomedicine and public health, international agencies’ and national governments' rationale, motivations for and reluctance in adopting circumcision programmes.
• Theme 2: Male circumcision and sexual safety—including a focus on sexual partners: both regular and less regular, women (cisgender and transgender), people with and without penises, gay and bisexual men, sex workers, younger men.
• Theme 3: Bioethics—including analyses of voluntariness and coercion, the medicalisation of traditional practices, gender norms and dynamics, ethics of quotas, mathematical modelling, large-scale surgical campaigns as tools in public health, and the role and use of different male circumcision techniques and devices (surgical and non-surgical), unintended consequences, social determinants of health, bio-reductionism, and other topics.
• Theme 4: Reflections on international responses—including critical reflections on the evidence base for male circumcision interventions, their purported efficacy in medical male circumcision trials compared with real-world effectiveness, the part played by international agencies (e.g. UN, NGO, major donors), and whether VMMC has been a worthwhile public health intervention given the time and cost investment.
• Theme 5: Implementation, effectiveness and responses at national and local levels—including e.g. male circumcision in China and Peru as a technology of protection for men who have sex with men, application in other key populations.
• Theme 6: Male circumcision and broader sexual health issues—including explorations of the relationships and links between male circumcision and sexual health concerns more broadly.

This special issue aligns with the Culture, Health & Sexuality’s ongoing commitment to applying ‘a cultural lens, both conceptually and analytically, as it relates to sex, sexuality, gender and health’. Further details of the journal’s aims and scope can be found here: https://www.tandfonline.com/journals/tchs20/about-this-journal#aims-and-scope.

To be considered for inclusion, papers must engage with the social, cultural and/or political aspects of male circumcision for HIV prevention. The following types of papers are welcome for submission:

• Original research papers (not exceeding 7,500 words in length inclusive of references, footnotes, and all other content)
• Scholarly literature reviews/overviews (not exceeding 7,500 words in length inclusive of references, footnotes, and all other content)
• Critical well-argued commentaries and position papers (not exceeding 5,500 words in length inclusive).