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Surveying risk subjects: Public health surveys as instruments of biomedicalization

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Abstract

In recent years, epidemiologists have conducted dozens of surveys asking men around the world if they would be willing to be circumcised to reduce their HIV-risk. Men’s responses in turn constitute an important factor in predicting the overall success of circumcision campaigns. Whereas researchers often position survey responses as passive reflections of attitudes, my analysis reveals a more complex picture. The reviewed surveys invite men to consider a part of their bodies as posing a risk to themselves, their partners or their communities, and its removal as a means to permanently transition from the ‘high’ to the ‘low’ risk category. In the process, they position some bodies as inherently riskier than others, thereby carving out new HIV-risk subject positions based not on identity or behavior, but the body itself. Because claims about what one can do to mitigate the spread of HIV are not easily disentangled from what one ought to do, I suggest that these surveys simultaneously imbue willingness to be circumcised with a sense of ethical obligation. In doing so, I argue that circumcision-willingness surveys constitute a discursive technology integral to male circumcision’s emergence as an HIV-risk reduction strategy, not simply a tool that identifies willing subjects passively awaiting the next public health intervention.

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Notes

  1. A Data Safety and Monitoring Board stopped all three trials early when interim statistical analyses revealed a significant difference in infection rates between the groups (Auvert et al, 2005; Bailey et al, 2007; Gray et al, 2007).

  2. This is not to suggest that one is intended to replace the other.

  3. I also take no position regarding the wisdom of offering circumcision as a risk-reduction strategy, nor do I attempt to adjudicate the likelihood of success, however defined. Instead, my interest concerns how surveys communicate facts about circumcision and HIV-risk to respondents and their potential discursive implications for self-making.

  4. According to WHO/UNAIDS (2007a) estimates, one-third of men worldwide (age 15+) have been circumcised, two-thirds of whom are Muslim. The vast majority of male circumcision occurs in infancy or early childhood most commonly for religious reasons (including Islamic and Jewish traditions), as a marker of social or ethnic identity and/or for its perceived health benefits. It is common in Israel, the United States, Canada, Australia, the Middle East, Central Asia (primarily among Muslims in India, Pakistan and Indonesia), and parts of Africa. In Africa, circumcision practices and prevalence vary widely, but at the population level, prevalence rates are generally much higher in northern and western countries than in southern and eastern countries where there is also greater local variation (WHO/UNAIDS, 2007a).

  5. Pointing to biotechnology’s interpellative character, Bryan (2009) makes a similar point about biotechnological interventions generally when he writes: ‘biotechnology ushers in a way that calls each of us to be concerned about the health and safety of others … . The hailing of a cure does not recruit us; the hailing of a cure shows us that we are always already recruited as the kind of “subject” that is in need of something like a cure’ (pp. 92–93).

  6. There have been other critiques of the RCTs themselves, including the effect of stopping trials early in statistically inflating treatment efficacy (Boyle and Hill, 2011; for explanation, see Bassler et al, 2008), high rates of attrition (Boyle and Hill, 2011), inadequate controls to account for alternate modes of infection (Vines, 2006; Potterat et al, 2006; Van Howe and Storms, 2011), and insufficient explanation of the underlying biological mechanism to account for the observed difference (Dowsett and Couch, 2007). For a response to many of these objections, see Auvert et al (2006). Aside from methodological issues of the trials themselves, concerns have been raised about the potential for risk compensation (Kalichman et al, 2007), different ethical standards for male versus female circumcision (Myers and Myers, 2007), ethical concerns about a shift from adult to neonatal circumcision (Myers and Myers, 2007), Western intrusion upon traditionally circumcising African communities (Gwandure, 2012), unexplained regional differences in the association between circumcision status and HIV-incidence (Dowsett and Couch, 2007; Garenne, 2008), the possibility of stigmatizing uncircumcised men (Peltzer et al, 2007; Sawires et al, 2007) and the impact of male circumcision for women given differential power relations (Sawires et al, 2007). There is not enough space here to adequately address these critiques. Regardless of the legitimacy of the critiques or responses to them, the broader epidemiological community views the RCT results as a sufficient basis on which to proceed with circumcision initiatives in high HIV prevalence areas (WHO/UNAIDS, 2007b) and my argument about the way in which surveys communicate RCT results is not contingent upon their validity.

  7. In the African trials, participants randomized to be circumcised were given instructions regarding post-surgical care, encouraged to abstain from sex without a condom before adequate healing, and warned that circumcision does not mean infection will not occur.

  8. Interview with epidemiologist, 2012.

  9. Interview with epidemiologist, 2012.

  10. Permission to cite obtained from Principal Investigator.

  11. John Law (2004) makes a similar point about scientific methods generally.

  12. Information was provided to respondents in an information pamphlet. Permission to cite obtained from lead author.

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Acknowledgements

I am grateful to Joe Dumit, Cristiana Giordano, Gregory Herek, Ozzie Zehner, two anonymous reviewers and the UC Davis Science and Technology Studies graduate group for their helpful comments on earlier drafts of this article. I also thank the UC Davis Psychology department for financial support during the manuscript preparation.

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Norton, A. Surveying risk subjects: Public health surveys as instruments of biomedicalization. BioSocieties 8, 265–288 (2013). https://doi.org/10.1057/biosoc.2013.20

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