Over the last 25 years I have often heard comments and talks by many public health officials and STI and skin specialists that circumcision reduces the risk of many fungal and bacterial infections and that this vulnerability becomes more pronounced with age. Similarly, there is talk of reduced risk of cervical cancer to partners of circumcised men.
Far more important, since 1989, over three dozen not fully rigorously controlled studies have indicated that circumcision reduces the risk of HIV infection to the male (inserting) partner. Lacking compelling evidence, in both 1992 and 1997, when we had to make a choice on whether or not to circumcise our sons, we opted not to!
This issue has acquired clarity with the study conducted by Dr. Bertran Auvert of the University of Paris and Adrian Puren of South Africa's National Institute for Communicable Diseases in South Africa (2005), and results of two more recent studies in Kenya and Uganda (Dr Jeckoniah Ndinya-Achola at the University of Nairobi, Kenya, is co-principal investigator), that circumcised men have about 50-60% lower risk of contacting HIV when having sex with an infected partner. Assuming that these findings are correct and universally applicable -- what do they imply for Hindus for whom not being circumcised is part of their religious identity?
In addition to the question of religious identity I am stumped by two additional educational challenges that need to be overcome if we are to achieve behavior change for a large society in which HIV is spreading rapidly -- Hindus living in India.
1) In a country where only about 30 percent of births are in registered medical facilities, how does one guarantee implementation of proper sterilization procedures for circumcision? We need to quantify the risk of infection from circumcision in India and determine if that is an acceptable risk?
2) How does one educate a parent that circumcision will protect their precious male child from HIV (a stigmatized infection) if the child indulges in risky sex (unimaginable) once he grows up? In other words, how does one ask parents, in a country where parents have a strong belief that a child will grow up to be what they wish for him, to take preventive action at birth against possible risky behavior by the child in distant (say 20 years) future?
If the public health debate settles on recommending circumcision universally then India (or any other country with similar religious, public health, low education and cultural impediments) faces a very difficult challenge of developing a compelling national strategy that will motivate parents to accept circumcision of their male children when most parent's overriding belief is that by even entertaining such thoughts of possible risky behavior they have doomed their son to that fate.
Even highly educated professional parents will struggle to simultaneously overcome their religious beliefs, contemplate possible risky behavior by their precious newborn and take preventive action at such a joyous moment. In view of this challenge, should one spend energy and resources on promoting circumcision or redouble efforts on other risk reduction methods like the use of condoms for all risky sex, education on delaying start of sexual activity and on reducing the number of different sexual partners and empowerment of sex workers and women in general?
I will be very grateful to readers for their suggestions, solutions, or appropriate educational material based on their experiences in addressing this issue.
Rajan Gupta