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Hundreds of thousands of men in Africa — several % of the more than 15 million men circumcised in VMMC (Voluntary Medical Male Circumcisions) programs — have suffered temporary or permanent health damage from the operation. Circumcision can go wrong in many ways.
WHO and others report men’s problems from circumcisions as “adverse events” (see Tool 23 in ): mild adverse events do not require medication (eg, pain, swelling); moderate events require some treatment (eg, antibiotics); while serious adverse events require surgery or extensive treatment or result in permanent damage (eg, disfigurement, sexual problems, death). (Note: Adverse events are not men’s only damage from circumcision. Even operations which are safe and successful remove sensitive tissues, affecting men’s and partners’ sexual experiences. I don’t discuss such effects here.)
In 2007, when WHO recommended circumcising millions of men, anyone who looked knew it would hurt many men in Africa. When VMMC programs got underway in 2008, many clinics did not do a good job monitoring and reporting adverse events. In recent years, populations at risk are paying more attention to harms from circumcisions.
What WHO managers knew in 2007
In 2007, WHO managers, with US experts’ urging, set a target to circumcise 20 million men in Africa by 2015.[3,4] At the time, a lot of evidence warned the program would harm a lot of Africans.
Recognized risks from medical circ’s in Africa: Four studies of adverse events after 100s to 1,000s of circumcisions in Africa during 2002-5 report rates of adverse events of 2.1-17.7 per 100 circumcisions. Were the studies biased? Unlikely; authors of all four studies endorsed WHO’s 2007 recommendation to circ millions of men in Africa beginning in 2008.
Table 1: Adverse events after adult circumcisions in Africa, 2002-5
||Number of circ’s
||Adverse events: number (rate per 100 circ’s)
|Orange Farm, South Africa, 2002-3
|Kisumu, Kenya, 2002-4[6,7]
|Rakai, Uganda, 2003-5
|Bungoma, Kenya, 2004
* After ≥ 1 year 3 men had problems urinating, 4 were dissatisfied with the appearance of their penis, and 4 reported mild or moderate erectile dysfunction. † The study team recognized 4 HIV infections one month after circumcision, but did not acknowledge them as possible adverse events from unsterile conditions during circumcision.
HIV infections from circumcisions: Using data from national surveys, Brewer and partners report HIV infections were more common in circumcised vs. intact virgin boys and men in Kenya (1.8% vs. 0%), Lesotho (6.1% vs. 1.9%), Tanzania (2.9% vs. 1.0%), and Mozambique (2.1% vs 1.0%).[10,11]
What about HIV after adult circumcisions? One study reported new HIV infections in 4 (0.3%) of 1,334 men one month after circumcising them, but did not acknowledge the infections as adverse events. Otherwise, it’s hard to say what’s happening, because no one has been looking for bloodborne infections (HIV, hepatitis B and C) as adverse events.
WHO and USAID experts aware of unsafe healthcare: Here’s what UNAIDS advises UN employees in Africa (p 4 in : “Use of improperly sterilized syringes and other medical equipment in health-care settings can also result in HIV transmission. We in the UN system are unlikely to become infected this way since the UN-system medical services take all the necessary precautions and use only new or sterilized equipment.” In other words, UNAIDS urges millions of men to get circ’d in facilities in Africa that it considers to be dangerous for UN employees.
Beginning from 1999, USAID has paid for random sample surveys of clinics and hospitals in African countries. In countries where USAID subsequently proposed to circumcise millions of men, random sample surveys of hospitals and clinics during 2004-7 reported poor infection control. Surveys in Kenya, Tanzania, Uganda, and Zambia reported that only 60%-75% of facilities had equipment to sterilize instruments; Rwanda was the best, with 83% of facilities equipped to sterilize instruments.
Diverting doctors and nurses: Plans to circumcise millions of men take thousands of doctors and nurses away from other healthcare delivery. WHO recommends a ratio of 2.28 doctors, nurses and midwives per 1,000 people. Ratios from 2005 are available for six countries targeted for circumcising millions of men: Ratios ranged from 0.24 to 2.15 (middle ratio: 0.65) in Ethiopia, Kenya, Rwanda, Uganda, Tanzania, and Zambia. People will suffer as health staff are diverted to circumcise.
Early circ program: Lots of adverse events, but weak monitoring
As VMMC programs got underway in 14 countries beginning from 2008, responsibility for reporting adverse events fell to the same staff responsible for circumcising men. At least three studies critically reviewed these clinic reports; two found more adverse events than clinics had reported, while a third provided a first estimate based on clinic documents. In these three studies, rates of severe plus moderate adverse events were 2.9, 6.8, and 8.4 per 100 circumcisions (Table 2).
Kenya, 2008-10: A study in Kenya reassessed reported adverse events in men circumcised during 2008-10 in 16 aid-financed clinics that did nothing but circumcise men. Clinics reported 119 adverse events among 3,705 men (3.2 per 100 circumcisions), but a home-based survey with genital exams 28-45 days after circumcision reported 437 adverse events in a sample of 1,449 of the 3,705 men (30.2 per 100 circumcisions).
Swaziland, 2011: A telephone hotline diagnosed adverse events, referring callers to clinics. Because many callers did not subsequently go to clinics, clinics did not record and report their adverse events. Including adverse events diagnosed by phone but not reported by clinics, total of adverse events in 8,862 men from clinic records and telephone interviews increased from 341 to 772 (from 3.5 to 7.8 per 100 circumcisions) and severe and moderate events increased from 184 to 283 (from 1.9 to 2.9 per 100 circumcisions).
Malawi 2012: A study team reviewed clinic records for 3,000 aid-supported circumcisions at a hospital in Lilongwe, the capital. The study team identified 257 adverse events (8.6 per 100 circumcisions), almost all of which were moderate or severe (Table 2). The study also found mismanagement of adverse events and poor record keeping.
Table 2: Reports of adverse events by clinics vs. reports after review
||Adverse events/circumcisions (rate of adverse events per 100 circs)
|Nyanza Province, Kenya, 2008-10
|| 119/3,705 (3.2)
|Including events diagnosed by phone
||Severe and moderate: 283/9,862 (2.9)
|Review of records
Increasing awareness of dangers from circumcising
As VMMC programs continue, people are becoming more aware of the dangers of circumcision. Here are some recent events and issues.
Deaths from tetanus: During 2012-2016, five countries reported 13 cases of tetanus in men within 14 days after VMMC circumcisions. Eight of the 13 died – 1 each in Kenya, Rwanda, Tanzania, and Zambia and 4 in Uganda. WHO in 2015 advised governments to require men to get vaccinated for tetanus before circumcision. Subsequently, Uganda required two tetanus vaccinations before circumcision; whether men became more aware of risks or were deterred by the need to be vaccinated, fewer men in Uganda chose to get circumcised in 2016 compared to 2015.
Zambian baby dies after a research circumcision: A US-funded study tested different methods to circumcise babies in Zambia. One baby, circumcised when he was 2 days old, died the next day. Without seeing the body, the study team and committees responsible to protect participants decided “it was extremely unlikely that the baby’s death was related to the circumcision procedure.” Here’s what Jim Thornton, former editor of the British Journal of Obstetrics and Gynecology writes about that decision: “Am I going mad? ‘Extremely unlikely’! How can any sane doctor possibly conclude that? Researchers’ lame response to the baby’s death shows that power beats evidence; thugs with money run the show.
Kenyan newspaper reports circumcision deaths, penile damage: In March 2018, the Standard reported 5 deaths after circumcision, five boys with penile damage, a tetanus infection, and other serious outcomes during 2014-17.
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23. Gathura G. How negligence, untrained staff led to five boys losing their manhood. Standard, 11 March 2018. Available at: https://www.standardmedia.co.ke/health/article/2001272720/boys-loss-of-manhood-due-to-negligence-untrained-staff (accessed 11 May 2018).