International news roundup: Updates on Brazil, Circumcision, and UN Commission on the Status of Women

25 Mar

Brazilian doctors’ group urges decriminalization of abortion

As in many countries in Latin America, abortion is extremely restricted in Brazil. Currently, women can only legally have an abortion if the pregnancy results from rape, if their lives are threatened by the pregnancy, or if the fetus has a brain anomaly. Despite these restrictions, abortion is widespread, with an estimated 1 million Brazilian women undergoing abortions yearly. As in many countries where abortion is restricted, women with money can still get safe abortion care, while poor women must resort to unsafe abortions. The end result is an estimated 200,000 women per year hospitalized due to complications of unsafe abortions, making unsafe abortion the third most common reason for obstetrical hospital admissions and one of the top causes of maternal mortality in the country.

A group representing Brazilian doctors, the Federal Council of Medicine, is now urging federal lawmakers to allow abortions on demand in the first 12 weeks of pregnancy. The group has noted the strong impact unsafe abortion has had on public health in Brazil and also pointed out that current abortion laws in the country “are inconsistent with humanitarian commitments” and act paradoxically against “social responsibility and international treaties signed by the Brazilian government.” The Council represents 400,000 physicians; let’s hope they get more attention than the National Conference of Brazilian Bishops, which has already registered its distaste for this development.

No surgeon needed with new circumcision device

What do circumcisions have to do with abortion? Not a whole lot. But you may or may not know that circumcision does have a lot to do with reproductive justice for men and women living in countries with high HIV prevalence. Male circumcision, when performed by a skilled provider, reduces a man’s risk of acquiring HIV from an HIV-positive woman by about 60%. Unfortunately, it doesn’t appear to work the other way; that is, circumcision of HIV-positive men does not protect their female partners. However, by protecting men from acquiring HIV, their partners are likewise protected. Because many women do not have control over condom use in their relationships, and because try as we might we are still nowhere near 100% condom use, offering voluntary circumcision to men is one of the most promising interventions available to decrease the spread of HIV.

Despite this, scale up of voluntary male circumcision has been slow. Although there are many reasons for this, the skilled health worker shortage in low-income countries is a major barrier to increased implementation of male circumcision. The New York Times reported this month on the PrePex device, an inexpensive tool that, after being left on for about one week, causes the foreskin to drop off. Best of all, applying it takes less time than surgery and no surgeon is needed; nurses and medical officers can learn to use the device quickly.

UN Commission on the Status of Women makes important strides

Although some activists feared that, as happened last year, no outcome document would be agreed upon after this year’s Commission due to attempts from conservative actors (such as the Holy See, Iran and Syria) to derail negotiations, in the end a document was produced (see a draft here).

In addition to reaffirming important previous international agreements made in Beijing and Cairo, the document condemns violence against women, calls upon states to protect women and girls from violence, promotes education for all as a human right, and recognizes the need for women to be fully integrated into economic and social life. It also states that women who have been raped have the right to emergency contraception and safe abortion where permitted by local laws.

I of course would have liked to see more about the right to contraception (which is a right for all women, not exclusively those who have been raped) and safe abortion regardless of context or local laws, but with conservative forces working for months behind the scenes to prevent any progress, I consider this a small step forward.

3 Responses to “International news roundup: Updates on Brazil, Circumcision, and UN Commission on the Status of Women”

  1. Mark Lyndon March 27, 2013 at 10:36 pm #

    Promoting male circumcision isn’t good for men or women.

    From a USAID report:
    “There appears no clear pattern of association between male circumcision and HIV prevalence—in 8 of 18 countries with data, HIV prevalence is lower among circumcised men, while in the remaining 10 countries it is higher.”
    http://www.measuredhs.com/pubs/pdf/CR22/CR22.pdf

    It seems highly unrealistic to expect that there will be no risk compensation. The South African National Communication Survey on HIV/AIDS, 2009 found that 15% of adults across age groups “believe that circumcised men do not need to use condoms”.
    http://www.info.gov.za/issues/hiv/survey_2009.htm

    It is unclear if circumcised men are more likely to infect women. The only ever randomized controlled trial into male-to-female transmission showed a 54% higher rate in the group where the men had been circumcised:
    http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60998-3/abstract

    ABC (Abstinence, Being faithful, and especially Condoms) is the way forward. Promoting genital surgery seems likely to cost African lives rather than save them.

    • NYCprochoiceMD March 28, 2013 at 12:07 pm #

      Re: the USAID report you cite: The benefits of medical male circumcision are clear from randomized controlled trials. This kind of evidence is better than evidence from ecological data such as that available from MeasureDHS. When you randomize men to treatment or no treatment, you know that the effects you see are due to the treatment. When you use observational data you can’t know why HIV prevalence is higher or lower in one group than another.

      Risk compensation, or men who are circumcised using condoms less consistently than uncircumcised men, is a valid concern. However a more appropriate way to look at this concern is to see if men who are circumcised for prevention actually use condoms less than those who are not circumcised, rather than simply asking men their opinion about circumcision. Fortunately, the authors of one of the RCTs did just that 5 years after the intervention and found that there was no difference in condom use between the circumcised and uncircumcised groups (http://www.ncbi.nlm.nih.gov/pubmed/22210632)

      As to your assertion that circumcised men may be more likely to infect women, there is no evidence of that. The study you cite, despite having a 49% increased chance of risk, has an extremely wide confidence interval (adjusted hazard ratio 1.49, 95% confidence interval 0.62—3.57). We cannot infer an increased risk from this study; it was stopped partway through due to lack of protective effect. We do not know what result would have occurred had the study continued to recruit the necessary number of participants to detect an effect of circumcision (or lack thereof).

      “ABC” has been the go-to motto for years. The fact that it’s not enough is evidenced by global failures to stop the HIV epidemic. We need much more than “ABC”. Other proven interventions include voluntary medical male circumcision, as I’ve discussed here, as well as treatment of HIV-positive people who have HIV-negative partners, universal access to voluntary HIV counseling and testing so people know their status, and diagnosis and treatment of other STIs. We also need to prevent HIV transmission due to blood transfusion and medical procedures and treatment of women and their babies to prevent vertical HIV transmission. This document has a nice overview http://www.globalhivprevention.org/pdfs/HIV_Prevention_Strategies_0604.pdf

      • Hugh7 April 3, 2013 at 8:48 pm #

        “When you randomize men to treatment or no treatment, you know that the effects you see are due to the treatment.”

        Not when the trials are neither double-blinded nor placebo-controlled, opening them up to all kinds of experimenter and experimentee effects.

        * The experimental groups, but not the control groups, were required to sign a consent form that instructed them not to have sex for sex weeks after their operations, or to use condoms if they did. This could well have habituated them to condom use.

        * One of the reasearchers has indicated that circumcised men who showed signs of risk-compensation were given additional counselling.

        * Several times as many men dropped out, their HIV status unknown, as were known to be infected. Since learning you were HIV+, after a painful and marking operation you expected to prevent it, would be a strong incentive to drop out, this would preferentially incline circumcised HIV+ men to drop out. (The number of controls who dropped out was similar, but they may have simply changed their minds about getting circumcised, an option not open to the experimental groups.)

        The studies were cut short, a well-known source of bias towards positive effects.

        According to the date of first entry, only the Kenyan trial was prospectively registered. The South African trial was registered a year and a half after recruitment ended and seven days before the results were published! The Ugandan one a month after recruitment ended,and a month before publication. This is a way of drawing the target around where the arrow has landed.

        The study you cite, claiming no risk compensation, comes from the same researchers who claim to have found the protective effect, and no detriment to sexuality, and that it is safe to circumcise HIV+ men (so that they can tell women they are safe?). In fact the whole recent battery of studies claiming benefits from circumcision comes from one small interconnected group of researchers, many of whom were promoting it for other reasons before HIV was involved. The same group carried out the study of transmission to women:

        “it was stopped partway through due to lack of protective effect. We do not know what result would have occurred had the study continued to recruit the necessary number of participants to detect an effect of circumcision (or lack thereof).”

        Exactly. They were only looking for protective effect. They didn’t WANT to find any harm. More time would also have yielded statistical significance. And if it couldn’t in principle find harm, aren’t there additional ethical issues involved in putting those women at risk?

        Here in New Zealand, we have been using a device like the PrePex for decades, but not on humans, on sheep, and not on their foreskins. It’s called an Elastrator.

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