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Genital Modifications in Prepubescent Minors: When May Clinicians Ethically Proceed? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2024:1-50. [PMID: 39018160 DOI: 10.1080/15265161.2024.2353823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/19/2024]
Abstract
When is it ethically permissible for clinicians to surgically intervene into the genitals of a legal minor? We distinguish between voluntary and nonvoluntary procedures and focus on nonvoluntary procedures, specifically in prepubescent minors ("children"). We do not address procedures in adolescence or adulthood. With respect to children categorized as female at birth who have no apparent differences of sex development (i.e., non-intersex or "endosex" females) there is a near-universal ethical consensus in the Global North. This consensus holds that clinicians may not perform any nonvoluntary genital cutting or surgery, from "cosmetic" labiaplasty to medicalized ritual "pricking" of the vulva, insofar as the procedure is not strictly necessary to protect the child's physical health. All other motivations, including possible psychosocial, cultural, subjective-aesthetic, or prophylactic benefits as judged by doctors or parents, are seen as categorically inappropriate grounds for a clinician to proceed with a nonvoluntary genital procedure in this population. We argue that the main ethical reasons capable of supporting this consensus turn not on empirically contestable benefit-risk calculations, but on a fundamental concern to respect the child's privacy, bodily integrity, developing sexual boundaries, and (future) genital autonomy. We show that these ethical reasons are sound. However, as we argue, they do not only apply to endosex female children, but rather to all children regardless of sex characteristics, including those with intersex traits and endosex males. We conclude, therefore, that as a matter of justice, inclusivity, and gender equality in medical-ethical policy (we do not take a position as to criminal law), clinicians should not be permitted to perform any nonvoluntary genital cutting or surgery in prepubescent minors, irrespective of the latter's sex traits or gender assignment, unless urgently necessary to protect their physical health. By contrast, we suggest that voluntary surgeries in older individuals might, under certain conditions, permissibly be performed for a wider range of reasons, including reasons of self-identity or psychosocial well-being, in keeping with the circumstances, values, and explicit needs and preferences of the persons so concerned. Note: Because our position is tied to clinicians' widely accepted role-specific duties as medical practitioners within regulated healthcare systems, we do not consider genital procedures performed outside of a healthcare context (e.g., for religious reasons) or by persons other than licensed healthcare providers working in their professional capacity.
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Luseno WK, Rennie S, Gilbertson A. A review of public health, social and ethical implications of voluntary medical male circumcision programs for HIV prevention in sub-Saharan Africa. Int J Impot Res 2023; 35:269-278. [PMID: 34702986 PMCID: PMC8545773 DOI: 10.1038/s41443-021-00484-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 10/06/2021] [Accepted: 10/13/2021] [Indexed: 12/22/2022]
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.
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Affiliation(s)
| | - Stuart Rennie
- Department of Social Medicine, University of North Carolina, Chapel Hill, NC, USA
- UNC Center for Bioethics, University of North Carolina, Chapel Hill, NC, USA
| | - Adam Gilbertson
- Pacific Institute for Research and Evaluation (PIRE), Chapel Hill, NC, USA
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Agot K, Onyango J, Ochillo M, Odoyo-June E. VMMC Programmatic Successes and Challenges: Western Kenya Case Study. Curr HIV/AIDS Rep 2022; 19:491-500. [PMID: 36445648 DOI: 10.1007/s11904-022-00644-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
PURPOSE OF REVIEW The Nyanza region of western Kenya is lauded for impressive coverage of voluntary medical male circumcision (VMMC) and remains the bedrock of the VMMC program in Kenya. We conducted literature review on programmatic successes and challenges of implementing VMMC program in the region. RECENT FINDINGS Responsive stakeholders' engagement, robust policy environment, effective technical working groups, prompt capacity building of health facilities, government support, flexible implementation strategies, and sustained donor funding contributed to the successes of the program that saw circumcision prevalence in Nyanza reach between 75.6 and 85.3% among 15-29-year-olds by 2019. However, the lack of support for early infant circumcision, inadequate domestic financing, and slow pace of service integration into government health facilities continue to undermine the progress towards sustainability. While local ownership of the VMMC program has been demonstrated through its inclusion in county annual health workplans and progressive integration into routine health care, continued dependence on declining external funding threatens its sustainability. Furthermore, Kenya is experiencing a youth bulge with a projected high demand for VMMC which calls for increased resource inputs into the program. Strategies are therefore needed to increase domestic resource inflows into VMMC.
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Affiliation(s)
- Kawango Agot
- Impact Research and Development Organization, Mito Jura Road, Tom Mboya Estate, P.O BOX, Kisumu, 9171-40141, Kenya.
| | - Jacob Onyango
- Impact Research and Development Organization, Mito Jura Road, Tom Mboya Estate, P.O BOX, Kisumu, 9171-40141, Kenya
| | - Marylyn Ochillo
- Impact Research and Development Organization, Mito Jura Road, Tom Mboya Estate, P.O BOX, Kisumu, 9171-40141, Kenya
| | - Elijah Odoyo-June
- Centers for Disease Control and Prevention, Center for Global Health, Division of Global, HIV & TB, Kisumu, Kenya
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Earp BD. Genital Cutting as Gender Oppression: Time to Revisit the WHO Paradigm. FRONTIERS IN HUMAN DYNAMICS 2022. [DOI: 10.3389/fhumd.2022.778592] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The World Health Organization (WHO) condemns all medically unnecessary female genital cutting (FGC) that is primarily associated with people of color and the Global South, claiming that such FGC violates the human right to bodily integrity regardless of harm-level, degree of medicalization, or consent. However, the WHO does not condemn medically unnecessary FGC that is primarily associated with Western culture, such as elective labiaplasty or genital piercing, even when performed by non-medical practitioners (e.g., body artists) or on adolescent girls. Nor does it campaign against any form of medically unnecessary intersex genital cutting (IGC) or male genital cutting (MGC), including forms that are non-consensual or comparably harmful to some types of FGC. These and other apparent inconsistencies risk undermining the perceived authority of the WHO to pronounce on human rights. This paper considers whether the WHO could justify its selective condemnation of non-Western-associated FGC by appealing to the distinctive role of such practices in upholding patriarchal gender systems and furthering sex-based discrimination against women and girls. The paper argues that such a justification would not succeed. To the contrary, dismantling patriarchal power structures and reducing sex-based discrimination in FGC-practicing societies requires principled opposition to medically unnecessary, non-consensual genital cutting of all vulnerable persons, including insufficiently autonomous children, irrespective of their sex traits or socially assigned gender. This conclusion is based, in part, on an assessment of the overlapping and often mutually reinforcing roles of different types of child genital cutting—FGC, MGC, and IGC—in reproducing oppressive gender systems. These systems, in turn, tend to subordinate women and girls as well as non-dominant males and sexual and gender minorities. The selective efforts of the WHO to eliminate only non-Western-associated FGC exposes the organization to credible accusations of racism and cultural imperialism and paradoxically undermines its own stated goals: namely, securing the long-term interests and equal rights of women and girls in FGC-practicing societies.
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Remennick L. Joining the tribe: adult circumcision among immigrant men in Israel and its traumatic aftermath. CULTURE, HEALTH & SEXUALITY 2022; 24:702-716. [PMID: 33512277 DOI: 10.1080/13691058.2021.1879272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/18/2021] [Indexed: 06/12/2023]
Abstract
Neonatal male circumcision is closely tied to Jewish identity and is socially normative in Israel. Soon after the mass arrival of secular, uncircumcised Jewish immigrants from the former Soviet Union in the early 1990s, the state sponsored mass circumcision campaigns for adolescents and adult men enabling them to join the Jewish collective, socially and religiously. Some two decades later, these men break the silence exposing their traumatic experiences in the wake of this body-altering surgery. This paper builds on the narratives of these men, belonging to Generation 1.5 of Russian Israelis, emerging in online forums, media features, live events and personal interviews. Driven by social pressure and the need to belong, most young men (and their parents) consented to the operation without proper counselling and unaware of its ramifications. Men share their intimate memories of the rapid surgical procedure, painful recuperation, and their belated regrets, both aesthetic and sexual. The willingness to expose their lingering trauma signals evolving concepts of masculinity and vulnerability among these former Soviet men. Their voices join the local and international movement opposing medically-unnecessary genital surgeries of any kind - on men, women and intersex people.
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Affiliation(s)
- Larissa Remennick
- Department of Sociology and Anthropology, Bar-Ilan University, Ramat-Gan, Israel
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Bershteyn A, Mudimu E, Platais I, Mwalili S, Zulu JE, Mwanza WN, Kripke K. Understanding the Evolving Role of Voluntary Medical Male Circumcision as a Public Health Strategy in Eastern and Southern Africa: Opportunities and Challenges. Curr HIV/AIDS Rep 2022; 19:526-536. [PMID: 36459306 PMCID: PMC9759505 DOI: 10.1007/s11904-022-00639-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2022] [Indexed: 12/05/2022]
Abstract
PURPOSE OF REVIEW Voluntary male medical circumcision (VMMC) has been a cornerstone of HIV prevention in Eastern and Southern Africa (ESA) and is credited in part for declines in HIV incidence seen in recent years. However, these HIV incidence declines change VMMC cost-effectiveness and how it varies across populations. RECENT FINDINGS Mathematical models project continued cost-effectiveness of VMMC in much of ESA despite HIV incidence declines. A key data gap is how demand generation cost differs across age groups and over time as VMMC coverage increases. Additionally, VMMC models usually neglect non-HIV effects of VMMC, such as prevention of other sexually transmitted infections and medical adverse events. While small compared to HIV effects in the short term, these could become important as HIV incidence declines. Evidence to date supports prioritizing VMMC in ESA despite falling HIV incidence. Updated modeling methodologies will become necessary if HIV incidence reaches low levels.
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Affiliation(s)
- Anna Bershteyn
- Department of Population Health, New York University Grossman School of Medicine, 227 East 30th Street, New York, NY 10016 USA
| | - Edinah Mudimu
- Department of Decision Sciences, College of Economic and Management Sciences, University of South Africa, Pretoria, Gauteng South Africa
| | - Ingrida Platais
- Department of Population Health, New York University Grossman School of Medicine, 227 East 30th Street, New York, NY 10016 USA
| | - Samuel Mwalili
- Strathmore Institute of Mathematical Sciences, Strathmore University, Nairobi, Kenya
| | - James E. Zulu
- Zambia Field Epidemiology Training Program, Workforce Development Cluster, Zambia National Public Health Institute, Lusaka, Zambia
| | - Wiza N. Mwanza
- Directorate of Public Health and Research, Ministry of Health, Lusaka, Zambia
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Fleming PJ, Doshi M, Harper GW, Otieno F, Bailey RC. Integration of voluntary male medical circumcision for HIV prevention into norms of masculinity: findings from Kisumu, Kenya. CULTURE, HEALTH & SEXUALITY 2021; 23:1451-1463. [PMID: 33016854 DOI: 10.1080/13691058.2020.1829057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 09/22/2020] [Indexed: 06/11/2023]
Abstract
While it is clear that in many communities ideas about masculinity and circumcision are connected, it is still unclear how young Kenyan men in the former Nyanza province from the traditionally non-circumcising Luo people perceive voluntary medical male circumcision as connected to masculinity and the role of voluntary medical male circumcision in the transition from boyhood to manhood. The objective of this study was to explore norms of masculinity and the decision-making process among Luo young men to provide a better understanding of how circumcision and masculinity relate to cultural norms within this community. The methodology consisted of eight FGDs with male peer groups and 24 in-depth interviews to elicit young men's perceptions of masculinity and voluntary medical male circumcision. Findings from thematic analysis reveal that young men described several key characteristics of masculinity including responsibility, bravery and sexual attractiveness. For some young men, voluntary medical male circumcision has embedded itself into cultural norms of masculinity by being a step in the transition from boyhood to manhood and by being a marker of some of these masculine characteristics. In the case of voluntary medical male circumcision, there may be opportunities to integrate other programming that helps men transition into healthy adulthood.
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Affiliation(s)
- Paul J Fleming
- Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, MI, USA
| | - Monika Doshi
- Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, MI, USA
| | - Gary W Harper
- Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, MI, USA
| | | | - Robert C Bailey
- Nyanza Reproductive Health Society, Kisumu, Kenya
- Department of Epidemiology, University of Illinois at Chicago, Chicago, IL, USA
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Mhagama P, Makono P, Tsitsi C. Communication-related factors influencing the uptake of voluntary medical male circumcision among men in Lilongwe Urban, Malawi. COGENT MEDICINE 2021. [DOI: 10.1080/2331205x.2021.1892289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Affiliation(s)
- Peter Mhagama
- The Polytechnic, University of Malawi, Private Bag 303, Chichiri, Blantyre, 3, Malawi
| | - Patrick Makono
- The Polytechnic, University of Malawi, Private Bag 303, Chichiri, Blantyre, 3, Malawi
| | - Chimwemwe Tsitsi
- The Polytechnic, University of Malawi, Private Bag 303, Chichiri, Blantyre, 3, Malawi
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Rennie S, Gilbertson A, Hallfors D, Luseno WK. The Ethics of Stigma in Medical Male Circumcision Initiatives Involving Adolescents in Sub-Saharan Africa. Public Health Ethics 2021; 14:79-89. [PMID: 34239604 DOI: 10.1093/phe/phab004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Ongoing global efforts to circumcise adolescent and adult males to reduce their risk of acquiring HIV constitute the largest public health prevention initiative, using surgical means, in human history. Voluntary medical male circumcision (VMMC) programs in Africa have significantly altered social norms related to male circumcision among previously non-circumcising groups and groups that have practiced traditional (non-medical) circumcision. One consequence of this change is the stigmatization of males who, for whatever reason, remain uncircumcised. This paper discusses the ethics of stigma with regard to uncircumcised adolescent males in global VMMC programs, particularly in certain recruitment, demand creation and social norm interventions. Grounded in our own experiences gained while conducting HIV-related ethics research with adolescents in Kenya, we argue that use of explicit or implicit stigma to increase the number of VMMC volunteers is unethical from a public health ethics perspective, particularly in campaigns that leverage social norms of masculinity. Ongoing global efforts to circumcise adolescent and adult males to reduce their risk of acquiring HIV constitute the largest public health prevention initiative, using surgical means, in human history. VMMC programs in Africa have significantly altered social norms related to male circumcision among previously non-circumcising groups and groups that have practiced traditional (non-medical) circumcision. One consequence of this change is the stigmatization of males who, for whatever reason, remain uncircumcised. This paper discusses the ethics of stigma with regard to uncircumcised adolescent males in global VMMC programs, particularly in certain recruitment, demand creation and social norm interventions. Grounded in our own experiences gained while conducting HIV-related ethics research with adolescents in Kenya, we argue that use of explicit or implicit stigma to increase the number of VMMC volunteers is unethical from a public health ethics perspective, particularly in campaigns that leverage social norms of masculinity.
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Rennie S, Gilbertson A, Hallfors D, Luseno WK. Ethics of pursuing targets in public health: the case of voluntary medical male circumcision for HIV-prevention programs in Kenya. JOURNAL OF MEDICAL ETHICS 2020; 47:medethics-2020-106293. [PMID: 33148776 PMCID: PMC8144939 DOI: 10.1136/medethics-2020-106293] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 09/15/2020] [Accepted: 09/23/2020] [Indexed: 05/03/2023]
Abstract
The use of targets to direct public health programmes, particularly in global initiatives, has become widely accepted and commonplace. This paper is an ethical analysis of the utilisation of targets in global public health using our fieldwork on and experiences with voluntary medical male circumcision (VMMC) initiatives in Kenya. Among the many countries involved in VMMC for HIV prevention, Kenya is considered a success story, its programmes having medically circumcised nearly 2 million men since 2007. We describe ethically problematic practices in Kenyan VMMC programmes revealed by our fieldwork, how the problems are related to the pursuit of targets and discuss possible approaches to their management. Although the establishment and pursuit of targets in public health can have many benefits, assessments of target-driven programmes tend to focus on quantifiable outcomes rather than the processes by which the outcomes are obtained. However, in order to speak more robustly about programmatic 'success', and to maintain community trust, it is vital to ethically evaluate how a public health initiative is actually implemented in the pursuit of its targets.
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Affiliation(s)
- Stuart Rennie
- UNC Center for Bioethics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Adam Gilbertson
- Pacific Institute for Research and Evaluation, Chapel Hill Center, Chapel Hill, North Carolina, USA
| | - Denise Hallfors
- Retired, Pacific Institute for Research and Evaluation, Chapel Hill Center, Chapel Hill, North Carolina, USA
| | - Winnie K Luseno
- Pacific Institute for Research and Evaluation, Chapel Hill Center, Chapel Hill, North Carolina, USA
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Feldacker C, Murenje V, Makunike-Chikwinya B, Hove J, Munyaradzi T, Marongwe P, Balachandra S, Mandisarisa J, Holec M, Xaba S, Sidile-Chitimbire V, Tshimanga M, Barnhart S. Balancing competing priorities: Quantity versus quality within a routine, voluntary medical male circumcision program operating at scale in Zimbabwe. PLoS One 2020; 15:e0240425. [PMID: 33048977 PMCID: PMC7553309 DOI: 10.1371/journal.pone.0240425] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 09/26/2020] [Indexed: 12/11/2022] Open
Abstract
Background Since 2013, the ZAZIC consortium supported the Zimbabwe Ministry of Health and Child Care (MOHCC) to implement a high quality, integrated voluntary medical male circumcision (VMMC) program in 13 districts. With the aim of significantly lowering global HIV rates, prevention programs like VMMC make every effort to achieve ambitious targets at an increasingly reduced cost. This has the potential to threaten VMMC program quality. Two measures of program quality are follow-up and adverse event (AE) rates. To inform further VMMC program improvement, ZAZIC conducted a quality assurance (QA) activity to assess if pressure to do more with less influenced program quality. Methods Key informant interviews (KIIs) were conducted at 9 sites with 7 site-based VMMC program officers and 9 ZAZIC roving team members. Confidentiality was ensured to encourage candid conversation on adherence to VMMC standards, methods to increase productivity, challenges to target achievement, and suggestions for program modification. Interviews were recorded, transcribed and analyzed using Atlas.ti 6. Results VMMC teams work long hours in diverse community settings to reach ambitious targets. Rotating, large teams of trained VMMC providers ensures meeting demand. Service providers prioritize VMMC safety procedures and implement additional QA measures to prevent AEs among all clients, especially minors. However, KIs noted three areas where pressure for increased numbers of clients diminished adherence to VMMC safety standards. For pre- and post-operative counselling, MC teams may combine individual and group sessions to reach more people, potentially reducing client understanding of critical wound care instructions. Second, key infection control practices may be compromised (handwashing, scrubbing techniques, and preoperative client preparation) to speed MC procedures. Lastly, pressure for client numbers may reduce prioritization of patient follow-up, while client-perceived stigma may reduce care-seeking. Although AEs appear well managed, delays in AE identification and lack of consistent AE reporting compromise program quality. Conclusion In pursuit of ambitious targets, healthcare workers may compromise quality of MC services. Although risk to patients may appear minimal, careful consideration of the realities and risks of ambitious target setting by donors, ministries, and implementing partners could help to ensure that client safety and program quality is consistently prioritized over productivity.
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Affiliation(s)
- Caryl Feldacker
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- * E-mail:
| | - Vernon Murenje
- International Training and Education Center for Health (I-TECH), Harare, Zimbabwe
| | | | - Joseph Hove
- Zimbabwe Association of Church-related Hospitals (ZACH), Harare, Zimbabwe
| | - Tinashe Munyaradzi
- Zimbabwe Community Health Intervention Project (ZICHIRE), Harare, Zimbabwe
| | - Phiona Marongwe
- International Training and Education Center for Health (I-TECH), Harare, Zimbabwe
| | - Shirish Balachandra
- United States Centers for Disease Control and Prevention, Division of Global HIV & TB, Harare, Zimbabwe
| | - John Mandisarisa
- United States Centers for Disease Control and Prevention, Division of Global HIV & TB, Harare, Zimbabwe
| | - Marrianne Holec
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
| | | | | | - Mufuta Tshimanga
- Zimbabwe Community Health Intervention Project (ZICHIRE), Harare, Zimbabwe
| | - Scott Barnhart
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Department of Medicine, University of Washington, Seattle, WA, United States of America
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