Neonatal circumcision - violation of children's rights or public health necessity?

• Date: 01 June 2011
• Published date: 01 June 2011
• Author: Y.A. Vawda,L.N. Maqutu
• Pages: 36-42
• DOI: 10.10520/EJC64523

There is a growing body of scientic evidence that medical male

circumcision substantially reduces the risk of contracting HIV and

other sexually transmitted infections.1-3 The procedure has been

hailed as offering partial protection against HIV infection for men

during sexual intercourse, raising the hope that widespread male

circumcision could signicantly reduce HIV transmission in South

Africa.4 The procedure may also prevent transmission of human

papillomavirus to women.5-7 Neonatal circumcision, considered to

carry the lowest risk,8 is viewed as a vital component of the goal of

realising generalised circumcision in the population.9

This paper investigates the ethical, legal and public health

considerations underlying an HIV prevention strategy that includes

neonatal circumcision. It reviews the impact of the practice on the

rights of children to bodily integrity, and explores whether proxy

consent by a parent or guardian on behalf of a child is appropriate

and justiable on grounds of parental preference, religion, culture

or public health policy. This is a complex debate and transcends

routine classications when exploring ethical dilemmas. The arti-

cle concludes that the rights of neonates to bodily integrity should

not be tampered with lightly, and that only a severe public health

hazard such as the HIV/AIDS pandemic may justify incursion into

this constitutionally protected right.

An appropriate preventive measure

against HIV transmission?

Clinical trials testing the efcacy of circumcision of adult males as

a preventive measure against sexually transmitted HIV infection

from females to males have been conducted in Kenya, Uganda

and South Africa, and demonstrated between 50% and 60% re-

duction in HIV infection3,10-12 (World Health Organization (WHO)/

UNAIDS12 Conclusions and Recommendations 2 reads: ‘The tri-

als ... carried out in Kisumu, Kenya, and Rakai District, Uganda

revealed at least a 53% and 51% reduction in risk of acquiring

HIV infection, respectively. These results support ndings pub-

lished in 2005 from the South Africa Orange Farm Intervention

Trial ... which demonstrated at least a 60% reduction in HIV infec-

tion among men who were circumcised’). On the basis of these

results, the WHO/UNAIDS concluded that ‘the efcacy of male

circumcision in reducing female to male transmission of HIV has

been proven beyond reasonable doubt’.12

WHO/UNAIDS therefore recommended that male circumcision

should form part of country HIV prevention plans, and parents,

who may consent for infant males, should be given adequate in-

formation on the benets and risks of circumcision.12

The biological rationale for the reduction of the risk of HIV

transmission by circumcision is directly related to the foreskin

and its high concentration of Langerhans cells.13 Along with mac-

rophages and CD4 dendritic cells, these Langerhans cells are the

target cells for HIV, and are found in large numbers in the inner

layer of the prepuce.14 However, the correlation between the pres-

ence of Langerhans cells and HIV transmission is not without dis-

pute; Mukherjea15 refers to the argument that ‘Langerhans cells

produce a substance called Langerin that “consumes” HIV, actual-

ly preventing infection and accounting for what is a fairly inefcient

rate of transmission,’ thus associating the high rate of infections

more with sexually risky behaviour. The foreskin is also vulnerable

to ‘epithelial disruptions’ (tears during sexual intercourse), and this

may further increase sites of entry for the HIV.13,14 Healing after cir-

cumcision causes an increase in keratinisation of the glans, reduc-

ing the likelihood of trauma to the penis during sexual intercourse

and therefore penetration of the virus.16

The current South African National Strategic Plan for address-

ing HIV/AIDS and sexually transmitted infections (STIs) aims to

There is a growing body of scientic evidence that medical male circumcision substantially reduces the risk of contracting HIV and other

sexually transmitted infections. The procedure has been hailed as offering partial protection against HIV infection for men during sexual

intercourse, raising the hope that widespread male circumcision could signicantly reduce the incidence of HIV transmission in South

Africa. The literature also suggests that this procedure may prevent transmission of the human papillomavirus to women. Neonatal cir-

cumcision, which is considered to carry the lowest risk, is viewed as a vital component of the goal of realising generalised circumcision

in the population.

This paper investigates the ethical, legal and public health considerations underlying an HIV prevention strategy that includes neo-

natal circumcision. It reviews the impact of the practice on the rights of children to bodily integrity, and explores whether proxy consent

by a parent or guardian on behalf of a child is appropriate and justiable on grounds of parental preference, religion, culture or public

health policy. This is a complex debate and transcends routine classications when exploring ethical dilemmas. The article concludes

that the rights of neonates to bodily integrity should not be tampered with lightly, and that only a severe public health hazard such as the

HIV/AIDS pandemic may justify incursion into this constitutionally protected right.

Neonatal circumcision – violation of children’s rights or public

health necessity?

Y A Vawda, BA, BProc, LLM, LLD

L N Maqutu, BA LLB, LLM

Faculty of Law, Howard College, University of KwaZulu-Natal, Durban

Article

36 June 2011, Vol. 4, No. 1 SAJBL