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RHO archives : Topics : Harmful Traditional Health Practices
Annotated Bibliography
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Male circumcision
American Academy of Pediatrics (AAP). Just
the FactsCircumcision. Elk Grove Village, IL: AAP (2001). Available
at: www.aap.org/mrt/factscir.htm).
Upon review of forty years of research, AAP has concluded that they do not
recommend routine newborn male circumcision, as is relatively common in
the United States. AAP recognizes some medical benefit of circumcision:
reduced likelihood of urinary tract infections as well as penile cancer
(a rare disease). AAP also believes pain relief is essential during the
procedure. AAP strongly opposes FGM.
Harryman, G. What is lost to circumcision.
Circumcision Information and Resource Pages (February 1999). Available at:
www.cirp.org).
The author, an anti-male-circumcision advocate, describes nineteen losses
inherent in removal of the male foreskin, in addition to the risk of death
and mutilation. These losses include effects on the frenar band of soft
ridges; about half of the muscle sheath dartos fascia; specialized epithelial
Langerhans cells; an estimated 240 feet of nerves; 10,000 to 20,000 specialized
erotogenic nerve endings; estrogen receptors; half of the multi-purpose
covering of the glans, which shields all of the specialized penile skin;
the immunological defense system of the soft mucosa; lymphatic vessels;
the frenulum, the sensitive "V" shaped tethering structure usually amputated
along with the foreskin, or severed; apocrine glands of the inner foreskin;
ectopic sebaceous glands; the essential "gliding" mechanism; the natural
coloration of the glans; a significant amount of the penis circumference;
as much as one inch of the erect penis length when the connective tissue
is torn apart; several feet of blood vessels.
Hull, T. H. and Budiharsana, M. Male
circumcision and penis enhancement in South Asia: matters of pain and pleasure.
Reproductive Health Matters 9(18):60–67 (November 2001).
Available at: www.rhmjournal.org.uk/PDFs/18T_HULL.PDF.
Using qualitative research, the authors collected information on male circumcision,
"penis enhancement," and womens dry sex practices as they occur in Southeast
Asia, particularly Indonesia. The public health implications of these customs
are not known. Better understanding may provide insight into male reproductive
health and gender issues in these settings, as they relate to sexual health.
Penis implants and augmentation devices (made of ball bearings, silicone,
semi-precious stones, or plastic) appear be popular among unmarried men.
The primary reason given for the use of implants is to increase womens
sexual pleasure—a controversial supposition. Meanwhile, womens dry
sex practices appear to have the goal of maximizing male pleasure through
increased friction during intercourse.
Nnko, S. Dynamics of male circumcision practices
in northwest Tanzania. Sexually Transmitted Diseases 28(4):214–218
(April 2001).
This study found the practice of male circumcision to be on the rise in
Tanzania among traditionally non-circumcising groups. Possible causes included
beliefs about improved penile hygiene, reduced sexually transmitted infections
(STI), and improved STI cure rates.
Royal Australasian College of Physicians (RACP).
Position
Statement: Routine Circumcision of Normal Male Infants and Boys.
Parkville, Victoria, Australia: ACP (1996). Available at: www.racp.edu.au/hpu/paed/circumcision/index.htm.
In 1998, the former Australian College of Paediatrics (ACP) was integrated
into the Royal Australasian College of Physicians (RACP). In 1996, the former
ACP had issued its third position statement on male circumcision. The ACP
recommended that parents be counseled to understand that they may choose
male circumcision for social, aesthetic, or cultural reasons, but that there
are no sound medical arguments in favor of the practice. Moreover, the ACP
went on to declare that male circumcision may be a human rights violation
since it is performed on a minor and without known medical benefit, but
that should be determined in a court of law. In 2002, the RACP issued a
revised statement after conducting an in-depth literature review and analysis
on male circumcision. As a result, the RACP in collaboration with five other
medical societies of Australasia (Australian Association of Paediatric Surgeons,
New Zealand Society of Paediatric Surgeons, Urological Society of Australasia,
Royal Australasian College of Surgeons, and Paediatric Society of New Zealand)
developed a joint position statement on male circumcision. All six medical
societies affirmed that circumcision of newborn males should not be routinely
performed. The revised statement stresses, "There are no medical indications
for routine male circumcision."
Samayende, S. Traditional leaders want to
oversee male circumcision. BuaNews (December 13, 2001).
Traditional leaders in South Africa are demanding the authority to oversee
initiation activities in which young men are circumcised. They insist they
should be empowered with the ability to appoint competent circumcisors,
and feel they will thus be able to prevent deadly infection.
Sidley, P. Eastern
Cape tightens law on circumcision to stem casualties. British
Medical Journal. 323:1090 (November 10, 2001). Available at: http://bmj.com/cgi/content/full/323/7321/1090/b.
Years of apartheid, social problems, and poverty have resulted in increasing
numbers of casualties of male circumcision. In response, the provincial
Eastern Cape government in South Africa has enacted legislation to regulate
the practice, which includes mandatory health standards and certification
requirements for circumcisors. Parents or guardians must give permission
for the process, and those to be circumcised must be at least 18 years old.
Traditional leaders have strongly opposed the legislation on the grounds
that it wrongly encroaches on traditional practices.
Smith, J. "Male
Circumcision and the Rights of the Child." In: Bulterman, M.,
Hendriks, A., and Smith, J., eds., To Baehr in Our Minds: Essays in Human
Rights from the Heart of the Netherlands (SIM Special No. 21). University
of Utrecht, Utrecht, Netherlands: Netherlands Institute of Human Rights
(SIM) (1998). Available at: www.cirp.org/library/legal/smith/.
In an overview of the history and cultural complexity of the male circumcision,
Smith notes similarities between international activism to end FGM and the
grassroots efforts in the USA to stop male circumcision. While the consequences
of the practices are different, the violence is real, whether girls or boys
are victims. Smith makes the case of respecting the rights of children by
forgoing any such operations until age of consent is reached.
Dry sex and vaginal drying agents
Baleta, A. Concern voiced over "dry sex"
practices in South Africa. Lancet 352(9136): 1292 (October 17,
1998).
This short overview of dry sex practices in southern Africa notes that women
primarily use substances to cause their vaginas to be "hot, tight and
dry." The practice is worrisome given the high rates of HIV in South
Africa in particularthe Deputy President estimates 1,500 South Africans
are infected each day. Within South Africa, the practice of dry sex seems
to be most prevalent in Kwazulu Natal, which has the highest rate of HIV/AIDS.
Research has found that 80 percent of sex workers in this region practice
dry sex; most sex workers practice dry sex in order to avoid reminding clients
that they recently have had sex with other men. Researchers urge public
health interventions that address the practice and accompanying issues,
especially the interference in condom use.
Civic, D. and Wilson, D. Dry sex in Zimbabwe and
implications for condom use. Social Science and Medicine Volume
42(1):91–98 (1996).
The impact of dry sex on condom use and effectiveness is examined. Extensive
detail about dry sex practices is uncovered through focus groups. While
potential barriers to condom use are presented by dry sex practices, useful
programming possibilities emerge, including use of lubricated condoms.
Dallabetta, G. et al. Traditional vaginal
agents: use and association with HIV infection in Malawian women. AIDS
9(3):293–297 (March 1995).
This study examined the use of vaginal agents in Malawi through the use
of a questionnaire and STI screening. Of 6,603 women, 13 percent used intravaginal
agents for tightening, and 34 percent for self-treatment of vaginal discharge
and itching. In multivariate analysis, vaginal agent use for treatment was
independently associated with HIV seropositivity. In addition to the increased
risk of HIV infection, vaginal agents may interfere with condom or microbicide
use.
Kun, K. Vaginal
drying agents and HIV transmission. International Family
Planning Perspectives 24(2):93–94 (June 1998). Available online
at http://www.agi-usa.org/pubs/journals/2409398.html.
Kun provides a basic overview of vaginal drying agents, their use, research
findings on HIV transmission, and programming implication. The author notes
the complex nature of vaginal drying agent practices and the need for more
qualitative data on the topic. The author reports on an evaluation of sex
workers in Zaire, who were examined before and after inserting drying agents.
Of the seven participants, only one was left with intact vagina mucosa.
All others had vaginal inflammation resembling a chemical burn or allergic
reaction.
PATH (Program for Appropriate Technology in
Health). Vaginal
douching: unnecessary and potentially harmful? Outlook
15(4):6–7 (December 1997). Available online at www.path.org/outlook/html/15_4_fea.htm#vag.
A short outline of dry sex practices is presented, including a description
of the practice, items used, and reasons. The high incidence of STIs and
HIV/AIDS in regions where the practice is common is noted with concern.
The physiological reasons for concern include vaginal inflammation, abrasion,
and peeling skin, all of which may increase transmission. Health providers
are urged to discuss the practice with clients. A detailed article on risks
associated with douching accompanies it.
Ray, S. et al. Local
voices: what some Harare men say about preparation for sex. Reproductive
Health Matters 7:34–45 (May 1996). Available at: www.rhmjournal.org.uk/PDFs/07ray.pdf.
This article provides extensive qualitative information about Harare men's
knowledge, attitudes, and practices concerning both male and female preparation
for sex, and men's feelings about dry sex practices. Seventeen male factory
workers provided detail about the use of herbs and aphrodisiacs in preparation
for sex. Generally they see sexual lust as a natural, essential desire,
and they view herbs as necessary to strengthening themselves for intercourse.
The men use ground herbs mixed with food or drink, or products that are
applied directly to the genitals. Men prefer a woman's vagina to be dry
(perceiving it to be cleaner and healthier) and tight. Women dry and tighten
their vaginas using cloth, cold water, soap, wool, or herbs taken by mouth,
inserted into the vagina, or tied around the waist. Such practices can result
in pain during sex for both men and women. Condoms are seen to have both
positive and negative potential. These practices, as well as lines of communication
about them between and among men and women must be considered within any
reproductive health interventions.
Runganga, A.O. and Kasule, J. The vaginal use of herbs/substances:
an HIV transmission facilitatory factor? AIDS Care 7(5):639–645
(1995).
This behavioral-analytic study looked at the use of dry sex agents in 75
HIV-positive and 76 HIV-negative women. Ninety-nine percent of the subject
used some dry sex agents. Patterns of use among the two groups were similar,
except 14 HIV-positive and only 7 HIV-negative subjects had used dry sex
herbs known as "Wankie." Problems with potential condom use is
discussed.
Sandala, L. et al. 'Dry sex' and HIV infection
among women attending a sexually transmitted diseases clinic in Lusaka,
Zambia. AIDS 9 (Suppl. 1): S61–S68 (1995).
In a sexually transmitted disease clinic in Lusaka, researchers investigated
prevalence, reasons for, and side effects of dry sex practices, and the
relationship with HIV infection. This study found no strong relationship.
Useful data and discussion of dry sex practices and relevant research are
included.
Sayagues, M. In Zimbabwe, love is a hot, dry
season. Weekly Mail and Guardian (October 1998).
The author of this article investigates the use of dry sex agents in Zimbabwe
by visiting with experts including a doctor who practices both traditional
and modern medicine. She finds that the consensus is that the agents are
used for male, not female, pleasure.
van de Wijgert, J.H.H.M. et al. Intravaginal
practices, vaginal flora disturbances, and acquisition of sexually transmitted
diseases in Zimbabwean women. Journal of Infectious Diseases 181:587–94
(2000).
The authors examine possible links between intravaginal practices and disturbances
of vaginal flora and acquisition of sexually transmitted infections (STIs).
Efforts to find non-users were a challenge, given the apparent widespread
use of such practices, which include cleaning the vagina with fingers, wiping
the vagina and inserting traditional materials. The research found that
users of intravaginal practices were more likely than non-users to have
disturbances of the vaginal flora, yet they were not more likely to acquire
an STI. Some vaginal flora disturbances and the absence of lactobacilli,
however, were associated with increased STI incidence, HIV prevalence, and
association with positive HIV status at baseline.
van de Wijgert, J. et al. Men's
attitudes toward vaginal microbicides and microbicide trials in Zimbabwe.
Family Planning Perspectives 25(1): 115–120. (March 1999).
Available at: www.guttmacher.org/pubs/journals/2501599.html.
Microbicides present an excellent possibility for the many women in Zimbabwe
who can't negotiate condom use and are at risk for HIV and STIs. This article
examines men's views on the topic and finds that their desire for dry sex,
as well as their issues about control and fidelity, might present considerable
obstacles to women's microbicide use. For example, the authors found that
men would only let their wives participate in the microbicide study if the
men were personally approached by the researchers, not just by their wives.
Virginity testing
Daley, S. How
South Africans screen girls for abstinence. The New York
Times (August 17, 1999). Available online at www.nytimes.com/library/world/africa/081799safrica-virginity.html.
(Requires free registration to access).
The author describes the situation in Afakathini, South Africa, in which
about 30 village girls, most between 11 and 14 years of age, are taken up
a hillside by a school principal who also is a traditional healer. The mood
is jubilant as the first girls pass their hymen inspection. By the end of
the exam, those who failed are extremely disappointed, and the group somberly
returns to the village. The author describes the school principal's concerns
about AIDS and abortion, as well as the perception of the center director,
Joan van Niekerk, who believes that the virginity inspections "destroy the
child and divide the family. The children we have seen are quite frightened.
There is so much abuse out there and often it is not the girl's choice."
While Ms. van Niekerk sees "the celebration of chastity as a good thing,"
she feels that there are too many problems with virginity testing.
McGreal, C. Virgin tests come back as AIDS kills
the Zulus. The Guardian (September 29, 1999).
At Qophumlando secondary school in KwaZulu/Natal, about half of the 1,500
students have undergone virginity testing; less than 30 have failed. Performed
by teachers, the testing sometimes takes place during a larger Zulu celebration.
The revival of this tradition is headed by the school's deputy headmaster
and head of the "All Africa Cultural Organisation." South Africa's Commission
on Gender Equality disapproves of the testing, as do those concerned about
the added danger of abuse for declared virgins from rapists trying to cure
AIDS. Others are concerned about privacy rights and the inadequacy of the
test.
Sex-selective technologies
Bélanger, D. Sex selective abortions: short-term
and long-term perspectives. Reproductive Health Matters
10(19):194–195 (2002).
Sex-selective abortion can be empowering to a woman under pressure to bear
a son—she can potentially avoid stigma, ostracism, and even violence.
She will also benefit economically from having a smaller family, and by
avoiding government repercussions she faces in some countries for violating
small family policies. Research in Vietnam indicates that if she bears many
daughters, those girls are more likely to face discrimination than girl
children in smaller families. An alternative to sex-selective abortion is
traditional medicine, often expensive and possibly a long distance away.
However, in the long run, sex-selective abortion will be profoundly disempowering
to women, as they potentially face violence in competition for brides, and
decreased numbers for voting. Ultimately, the only solution to the problem
of sex-selective abortion is through policies and advocacy that support
increased value for daughters.
Gardner, D. Where
have all the girls gone? Financial Times (February
9, 2003). Available at: www.freeindiamedia.com/women/17_feb_women.htm.
Experts estimate that son preference has already created a national "shortfall"
of about 40 million women (out of a population of more than 1 billion) in
India. Sex-selective abortion is intensifying this existing situation, as
indicated by increasing sex ratios. While the practice is illegal, it is
common, and even blatantly advertised on signs and in newspapers. A typical
type of advertisement in India reads, “Pay 500 rupees now to avoid
50,000 later”—meaning that the cost of the test and abortion
are less than the eventual cost of the daughter’s dowry.
George, S.M. Sex selection/determination
in India: contemporary developments. Reproductive Health Matters
10(19):190–192 (2002).
The author describes her efforts to address the neglect of sex-selection
laws in India. In 2000, in partnership with two nongovernmental organizations,
she filed litigation with the Indian Supreme Court, charging the Union of
India and the States of India with failure to implement the Indian laws
against sex-selective practices. According to the law, the government of
India “contends that the practice of sexing embryos violates basic
constitutional values and principles.” At the time of writing, the
outcome was pending. However, the case judge has held many hearings and
directed states to raise awareness of the issue. Extensive media coverage
of the case has also raised awareness. Overall, the author believes the
medical profession and the Indian media have not taken an ethical stance
on the issue, but rather support son preference and sex-selection in both
subtle and overt ways.
Lancaster, J. The
desperate bachelors: India’s growing population imbalance means brides
are becoming scarcer. Washington Post Foreign Service
(December 2, 2002). Available at: www.washingtonpost.com/ac2/wp-dyn/A61642-2002Dec1.
Interviews with citizens of Harayana, India (a state near New Delhi), indicate
that the problem of a “bride shortage” is pervasive and growing.
Families claim to be abandoning standards of caste, family background, age,
and dowry in order to locate brides for their sons. They are also looking
further away—which may indicate that brides will be more isolated
from their families. Harayana meets the conditions that make sex-selective
abortion most common: “traditional values combined with relatively
high levels of education and income,” which enable awareness of and
access to the tests and abortions.
Mallik, R. A
Less Valued Life: Population Policy and Sex Selection in India.
Takoma Park, Maryland: Center for Health and Gender Equity (October 2002).
Available at: www.genderhealth.org/pubs/MallikSexSelectionIndiaOct2002.pdf.
The effects of governmental and international population policies on sex
determination and sex-selective abortion are not well understood. The Indian
government’s small family programs have been changing norms for decades,
yet social, economic, and religious pressures for a son remain as strong
as ever—and in fact, are intensified by the decreased number of “chances”
per family to produce one.
Meanwhile, international donors have largely ignored issues of sex selection.
The 1994 government ban on the practice is generally not enforced. Some
progress has been made by advocacy groups in rousing government involvement,
including a new committee within the Ministry of Health and Family Welfare.
Meanwhile the private sector is exploiting the opportunity for profit—often
by appealing to traditional values of gender bias while simultaneously linking
into progress made by the women’s reproductive rights advocates.
The author presents three recommendations: (1) establishing a new permanent and autonomous commission to address these types of issues, (2) enforcement of laws and policies, and (3) new “gender and rights-based population policies, programs and…strategies to address gender bias.”
Malpani, A. Why shouldn’t couples
be free to choose the sex of their baby? Reproductive Health
Matters 10(19):192–193 (2002).
The author, a doctor who offers sex-selection services, makes the argument
that the sex-selective abortions are used to balance the sex ratio within
families and will not lead to a long-term skewing of the sex ratio. Indian
families who use sex-selective abortions are making a socially and economically
rational decision, and partaking in the “ultimate form of family planning.”
The author believes Ooman and Ganatra’s (see other bibliography item)
argument that sex-selective abortion is only acceptable for genetic reasons
unfairly allows for one form of discrimination (genetic) but not another
(gender). Ideally, individuals should have the freedom to decide these issues
for themselves.
McDonald, J. Chinese trade in baby girls
thrives. Associated Press News Service (March 25, 2003).
Trade in baby girls is thriving in China, apparently driven by the government’s
one child policy. Most buyers of the girls are parents who have a boy and
would like to have a girl to work around the house, and potentially be sold
as a bride as a teenager. In order to avoid government fines, the families
purchase the babies. Reportedly, the infants’ parents often willingly
sell them.
Ooman, N. and Gantra, B.R. Sex selection:
the systematic elimination of girls. Reproductive Health Matters
10(19):184–187 (2002).
Although women themselves often endorse sex-selective abortion, a study
in India found that women having sex-selective abortions were less empowered
then those having abortions for other reasons. This hints at the complex
dilemmas inherent in advocating for reproductive rights and choice within
a gender-biased context. The long-term systematic elimination of females
will likely prove dangerous and harmful to all women. The authors see this
practice as only one on a continuum of discrimination against the girl child,
and feel strongly that the medical profession should not profit from this
unethical practice. Laws banning sex-selective practices should be in place
and implemented (despite the inherent difficulty in enforcement) but only
“aggressive gender justice” will solve the problem in the long
run. Even in non-patriarchal societies, the authors believe the practice
is not acceptable; the only acceptable criteria for selective abortion are
genetic and congenital disorders.
