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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.

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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.

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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.

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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.

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