More on the Fallacy of VMMC: Infant Volunteers

Following on last week’s post detailing how voluntary is deceptively dropped from “voluntary male medical circumcision” (VMMC) when convenient, it’s worth demonstrating how the U.S. government engages in the same unethical behavior. Both USAID and PEPFAR are guilty.

Starting with USAID, its Technical Brief (pdf) on Medical Male Circumcision and HIV Prevention drops voluntary from the title of the document. Then, despite including the “V” in the document, it writes (italicized emphasis added):

Providing VMMC Services

As targeted activities progress, demand for VMMC services by interested adolescent and adult males and the parents of male early infants has increased. …

Costing and Impact Summary

To further support VMMC program planning, PEPFAR worked through USAID to collaborate with Joint United Nations Programme on HIV/AIDS (UNAIDS) to develop the Male Circumcision: Decision Makers’ Program Planning Tool to assist countries in developing policies for scaling up services to provide VMMC. This tool allows analysts and decision makers to understand the costs and impacts of different policy options regarding the introduction or expansion of VMMC services. It is part of a larger toolkit developed by UNAIDS/WHO that provides guidelines on comprehensive approaches to VMMC, including types of surgical procedures and key policy and cultural issues.

The key policy topics addressed by the model are:

• Identifying all male adults, adolescents, and early infants; targeting coverage levels and rates of scale-up
• …

Key conclusions from an initial desk review study presented at the International AIDS Conference in Vienna,Austria, in July 2010 indicate that scaling up VMMC programs to reach 80 percent coverage of adult and early infant males within 5 years could potentially:

• …

The entire report is preposterous for how uninterested USAID is in dealing with the obvious ethical problem. Society has simply accepted that, as long as someone “volunteers” a person, that person has volunteered for circumcision. There’s no apparent sense that ethics matter, or that language indicts interest and intentions.

Notice, too, PEPFAR’s cooperation with USAID to ignore voluntary. It continues within PEPFAR documents. First, from “Smart Investments: Making the Most of Every Dollar Invested” from February 2011 (italicized emphasis added):

Medical Male Circumcision

Medical male circumcision (MC) is an ideal HIV prevention investment for countries and donors as it is a time limited intervention. The majority of the expenditure required to saturate a country with high levels of adult male circumcision takes place in the first 1-3 years, depending on the speed of the program, and expenditures drop precipitously following this initial investment to support neonatal and adolescent boys. Scaling up of MC to reach 80% of adult and newborn males in 14 African countries by 2015:

• …

As expected, voluntary makes no appearance. Instead, the passage just assumes that adult and infant circumcision are the same. No differences, no questions raised in the latter. It’s pure utilitarian decision-making without concern for the patient. The individual is merely a part to be directed.

Next, more blatantly, PEPFAR’s “Guidance for the Prevention of Sexually Transmitted HIV Infections” (pdf) contains the following (italicized emphasis added):

4.2.2 Voluntary medical male circumcision (VMMC)

Evidence

Voluntary medical male circumcision is the surgical removal of the foreskin from the penis [ed.note: of a consenting adult] by trained medical personnel under aseptic conditions. …
…

Program Implementation

Countries with a low prevalence of male circumcision and high HIV prevalence should initiate and accelerate steps to increase the availability of VMMC services. As with other prevention methods, considerations of access and cost, as well as cultural, ethical, and religious factors can hinder the widespread implementation of VMMC. …

Implementation of the comprehensive HIV package: Where VMMC services are provided, … PEPFAR will support programs, in keeping with national strategies, that: implement the comprehensive package; adopt culturally-appropriate strategies; utilize well-trained practitioners working in sanitary conditions; maintain informed consent and confidentiality; and avoid any form of coercion.

Targeted implementation: UNAIDS and WHO advise that the greatest public health benefit results from prioritizing circumcision for young males (such as those aged 12-30 years), as well as men thought to be at higher risk for HIV (such as those in discordant couples or being treated for STIs). Circumcision of newborn babies should be promoted as a longer-term strategy. VMMC for men living with HIV is not recommended but should not be denied if requested.

Short-term, accelerated implementation: … Once intensive service provision accomplishes “catch-up” circumcision for adolescent and adult males, sustainable services need to reach only successive cohorts of young adolescents and/or newborns. These”catch up” programs require awareness and behavior change communication campaigns wherein political and social leaders promote VMMC. …

PEPFAR didn’t bother to drop the “V” from voluntary medical male circumcision. It just pretends that any circumcision of a male is voluntary. According to PEPFAR (i.e. the U.S. government), a 12-year-old male is the same as an adult and can volunteer with full, informed consent. I believe that’s possible, but not in any way applicable to all 12-year-old males. (This is especially true given how rarely advocates provide any mention of the functions and benefits of the foreskin.) It’s in no way applicable to any infants, yet that is the long-term strategy PEPFAR is pushing. Voluntary has disappeared as a consideration.

Even accepting the flawed view of the success possible from pushing circumcision of infants for HIV prevention, what happens if it proves successful? Those locations become populations with high prevalence of circumcision and low prevalence of HIV. They become the exact opposite of what they say in the above and in this from the Evidence section:

WHO and UNAIDS have concluded that VMMC should be actively promoted as part of comprehensive HIV prevention efforts in settings where circumcision rates are low and HIV prevalence is high. …

Its own success would render it no longer ethical (within the unethical frame of “voluntary” infant circumcision). Would advocates stop pushing circumcision – infant circumcision, specifically – as an HIV risk reduction method? Given the behavior of U.S. advocates, including the AAP, I’m skeptical.

I’m not doubting their sincerity. I believe people can be sincere in their ideas as a result of flawed, poorly examined assumptions. I doubt their sincerity in accepting the correct assumption that voluntary medical non-therapeutic male circumcision may be advisable only in areas with low circumcision rates and high HIV infection rates. Infants do not volunteer, and there’s a long grace period during which better (or complete) prevention methods may be discovered. Or advocates might remember that condoms are necessary, regardless of circumcision status. But they don’t. Somewhere the goal not-so-subtly morphed from “circumcision for HIV prevention” to “circumcision and HIV prevention”. As the last century-plus demonstrates, advocates of circumcision tend to believe that circumcision justifies itself. What an individual might want in the absence of need (i.e. ethical, voluntary circumcision) fades to public policy insignificance, or worse, becomes assumed away to a position where infants beg to be circumcised now. Reports on VMMC that are really just a push for MC provide modern, ongoing proof.

This additional bit from PEPFAR’s guidance is informative, as well:

Current evidence strongly supports VMMC‘s effectiveness in preventing infection of men in penile-vaginal intercourse, but not in penile-anal intercourse. While statistics have been inconclusive thus far on the efficacy of circumcising MSM to prevent infection, the procedure may be worthwhile for individual MSM, especially those who also engage in sex with women. …

Statistics have been inconclusive, but it may be worthwhile. That’s “heads I win, tails you lose” analysis in pursuit of circumcision for the sake of circumcision.