Male Circumcision Part 3: Why Some Men Resist the Next Best Thing to an AIDS Vaccine

In the Zimbabwe campaign Lindsay wrote about yesterday, public health messages have the look of a party invitation for the modern man – and his female partner. An attractive couple looked out from a breezy ad offering a free “summer snip.” A group of legislators underwent the operation in a makeshift clinic outside the Parliament building in Harare. Celebrity musician Jah Prayzah got circumcised and then gave an interview wearing a shirt reading: “I DID IT. Why haven’t you?”

This poster from the "Stand Proud, Get Circumcised" campaign was hung above urinals in Zimbabwe. Used with permission. © 2011, Johns Hopkins University. All rights reserved.

This poster from the “Stand Proud, Get Circumcised” campaign was hung above urinals in Zimbabwe.
Used with permission. © 2011, Johns Hopkins University. All rights reserved.

A study in the new PLOS VMMC Collection, Barriers and Motivators to Voluntary Medical Male Circumcision Uptake among Different Age Groups of Men in Zimbabwe, describes the intent of this campaign to portray circumcised men as “confident, outgoing, sexually appealing, and set to succeed in life.” No question this is a cultural or “social norm” appeal.  And, although progress in Zimbabwe is slow, this message, built as it is around modernity and personal attractiveness, may yet work. Read more about the Zimbabwe VMMC campaign, and in particular the roles played by women, in Lindsay Kobayashi’s recent post.

But another paper in the new PLOS VMMC Collection, Attitudes, Perceptions and Potential Uptake of Male Circumcision Among Older Men in Turkana Couny, Kenya Using Qualitative Methods, suggests that staying away from such a cultural pitch in favor of a strictly health promotion message may prove to be a more viable way to reach different, particularly rural, and older audiences.

Cultural Complications

In Kenya, circumcision rates are generally already high, but men from certain ethnic groups are still vulnerable because they traditionally do not circumcise. One such group, the Turkana, is native to a semiarid area in the northwest corner of Kenya. There is a county headquarters and a few small towns, but most Turkana live outside of them, raising whatever livestock the minimal grass and water supply can support—often camels—and fending off raids from neighboring ethnic groups with whom they’ve been at war for decades.

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Photo by Filiberto Strazzari, CC-BY

 Minding A Significant Gap Between Generations

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Kate Macintyre, a global health and infectious diseases researcher at Tulane University

Among the Turkana, some of the younger men are buying in, but circumcision is very rare in those over the age of 25.

Kate Macintyre set out to find out why. Macintyre, with Moses Natome, a young researcher from Turkana, put together a team of Turkana-speakers to conduct interviews and focus group discussions, asking community leaders to refer people to the study. They spoke with men who weren’t circumcised and men among the 5-10% of Turkana who are. They spoke with women about their opinion of circumcision in their male partners. And they spoke with people in a range of settings, rural, urban, and in-between.

HIV rates are high in this corner of Kenya; the trade route from Sudan and the one that brings fish from Lake Turkana into the desert may also be highways of HIV transmission. Geographically remote and socially isolated, Turkana are hard to reach with public health interventions. Poverty is rampant, and the area includes only a handful of hospitals and health centers. “They have been very isolated and apart from the social development of the country in the last 50 years,” says Macintyre.

Macintyre’s survey showed a range of opinion as to why older men might not want to get circumcised, and confirmed a major barrier: the fact that so many of the Turkana’s neighbors and enemies circumcise. Of Kenya’s 45 ethnic groups, the Turkana are one of just three that don’t practice circumcision as a traditional rite of passage. Natome sums up the consensus: “If you are an older, rural man, to get circumcised is to be ridiculous and to side with your enemies.”

In the interviews, many of the Turkana men explained that their culture’s ritual of Asapan holds the same significance that circumcision holds for the other groups. You can watch a video of Asapan here: it’s a ceremony that celebrates the social promotion of a man to senior elder status, and it is considered a great honor and privilege to go through it. One older uncircumcised man told Macintyre’s researchers: “On my side, God gave me ‘Asapan’ and circumcision to the other tribes as their culture.” Undergoing both, said several men, could cause a person to go mad from being caught between cultures.

But the Turkana may already be caught between cultures: urban and rural. Younger men who live in or near the big towns increasingly see circumcision as a social norm; to them, says Macintyre, forgoing the surgery is old-fashioned. While older rural men fear ridicule from circumcising, younger urban men fear it from not doing so. One described his friend persuading him: “Let’s go and circumcise. How can we continue like this and let other people ridicule us?”

Typical public health campaigns, like the one in Zimbabwe, aim to tie interventions to culture. But Macintyre warns that circumcision won’t take off in the remoter rural communities unless it’s presented as a purely medical intervention. It may not be traditional, but neither is the devastation of AIDS. A circumcised man described the shift:

 We used to hear our parents say ‘it’s the Pokot, Samburu, Borana and Somali who circumcised.’ But somewhere between there emerged this “Lokwakel” (HIV/AIDS), which wiped out families leaving destitute children. We cried and we decided to circumcise because it was important for us to take care of ourselves and our families.

This is the message Macintyre thinks will get through: protecting your family by making a healthy choice.

“It’s an extremely sensitive topic at the moment,” says Macintyre, but not as much as it was even five years ago. She believes some leaders in the rural areas see circumcision as the way of the future, but few are ready to say so publicly. “There’s still considerable resistance in the remotest areas the study reached,” she says. “It depends on leadership, and who’s talking, and whose son has been away to Nairobi and told them about life outside, and whether they see HIV as a risk close at hand.”

The circumcision campaign’s success also depends, she says, on the quality and consistency of health services. Many of the area’s health centers have no running water; ensuring that they can safely perform the operation is possible, but logistically complicated. The better the services the first few men see, she says, the more confidence everybody will have and the more men she expects to come forward.

The Public Health Perspectives introductory post to this seriesPart 1: How Male Circumcision Can Get Us Closer to an “AIDS-Free Generation”

Go here to find all the papers in Voluntary Medical Male Circumcision (VMMC) for HIV Prevention: Improving Quality, Efficiency, Cost Effectiveness, and Demand for Services during an Accelerated Scale-up

 

 

 

 

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22 Responses to Male Circumcision Part 3: Why Some Men Resist the Next Best Thing to an AIDS Vaccine

  1. Pingback: Male Circumcision Part 1: How It Can Get Us Closer to an "AIDS-Free Generation" - Public Health

  2. William says:

    I urge you to take 30 minutes out of your day and watch this lecture by one Dr.Ryan McCallister on the subject of male genital mutilation. http://www.youtube.com/watch?v=Ceht-3xu84I

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  3. Many professionals have criticized the studies claiming that circumcision reduces HIV transmission. The investigators did not seek to determine the source of the HIV infections during their studies. They assumed all infections were heterosexually transmitted. Most HIV infections in Africa are transmitted by contaminated injections and surgical procedures. The absolute rate of HIV transmission reduction is only 1.3%, not the claimed 60%. Even if the claim were true, based on the studies, about 60 men had to be circumcised to prevent one HIV infection. Authorities that cite the studies have other agendas including political and financial. Research shows that circumcision causes physical, sexual, and psychological harm. This harm is ignored by circumcision advocates. Other methods to prevent HIV transmission (e.g., condoms and sterilizing medical instruments) are much more effective, much cheaper, and much less invasive. Please see http://www.circumcision.org/hiv.htm for more information and links to literature.

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  4. Adam Cornish says:

    This whole article is a lie. A vaccine prevents a disease. There is no disease which circumcision prevents. There is very questionable science behind the 3 African studies which purported the 60% reduction, not to mention serious ethical deficiencies.
    Is it really voluntary, as in the euphemistic VMMC, when you are being told that circumcision will prevent a potentially fatal disease, even if it is not the truth?
    It is like having a gun to your head.
    I don’t care what Professor Emeritus Brian Morris, and Gray and Tobian of Johns Hopkins say. Circumcision is in no way like a vaccine. There is no disease which men with foreskins get, which circumcised men do not get. Most studies, including the 10 of the 18 UNAIDS studies, show that circumcised men are at an increased risk, and not the other way around.
    NPR is being irresponsible, and parroting the party line, which is very dangerous when it comes to human health.

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    • Beth Skwarecki says:

      Circumcision’s efficacy against HIV for men is about the same as a flu shot is for flu. You’re right that it’s not complete protection, but it seems to be a very powerful protective measure that can be used together with condoms. I’ll refer you to the studies mentioned in Part 1 and its comments about efficacy and risk.

      Did you mean to leave this comment for NPR?

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  5. William says:

    Condoms prevent HIV. Subjecting men under false pretenses of protection to male genital mutilation is medically unethical. The US has a very high cut adult male population, the US also has proptionally 300% the infected population and infection rate of Europe, which on average has <5% cut adult men. Stop advocating male genital mutilation.

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  6. Vincent says:

    Circumcision has done me no favors! I love when my wife and I partake in one of the most intimate and beautiful experiences in life, but for me it can be a very dark experience on occasion because part of my body was altered against my will. Without the mechanical lubrication provided by a foreskin, I have to use an artificial lubricant or sex would be too painful for my wife and me. Climax is not the same for me as it is for my wife or for Natural (Intact) males. They describe orgasm as a wave all over the body, while a mutilated male (circumcised) expresses it as a singular explosion (bordering on pain) from the penis. Imagine not wanting your wife to touch you as you lay crying on your back from shame and pain due to sores caused by abrasion and/or at times a complete and total loss of erection and feeling. The foreskin contains 20,000 fine touch nerves (like in your fingers) and provides protection of the glans (head) keeping it soft and sponge like, all in an effort to ensure everything works properly. My parent’s chose this painful and unsatisfactory sex life for me and my wife and I simply cannot fathom why. I would never have chosen to have my foreskin removed. Only 1/16,667 intact males will have a problem with their foreskin, 99% of which can easily be treated without surgery. One hundred and seventeen babies die from circumcision a year in the US, which equates to 9/100,000 babies that die each year from a cosmetic surgery. Men have lost their penis, glans, and suffered from deformity caused by the operation performed when they were infants. It isn’t right that these children pay the price for a decision that their parents made, a decision that should be left up to the owner of the penis. Even those who survive still have problems like mine, though they are seldom discussed. 

    [Here there was a very long list of links, which I removed; Vincent, if there's a specific point from this list you want to discuss, or if you'd like to point to one or a few places where people can read more, please do so in a follow-up comment. -Beth]

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    • Beth Skwarecki says:

      Vincent, I’m sorry about your situation. In voluntary adult circumcision, though, men are choosing to undergo the procedure.

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      • William says:

        Beth, it is illogical to promote this. It.does.not.prevent.HIV! The foreskin is the single most pleasurable part of the penis. It’s either use condoms and NOT get HIV, or have that pleasure removed and use condoms and not get HIV? ITs completely illogical to promote male genital mutilation.

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        • Beth Skwarecki says:

          The question of whether it prevents HIV was addressed elsewhere on this blog. If you have new information about that that we haven’t discussed, feel free. But repeating your statement doesn’t help us to understand why you make that point so emphatically.

          Whether circumcision prevents HIV and whether it reduces pleasure are two different (and both important) questions. See Victoria’s comment on Part 1 about what men who underwent adult circumcision have to say about its effect on sexual satisfaction.

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          • William says:

            Show me a source that isn’t heavily biased by cutting cultures that pressure men into it and to be proud of it.
            http://www.youtube.com/watch?v=NAHGFx95D80

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          • Victoria Costello says:

            In response to this and other comments inferring that voluntary medical male circumcision is being “imposed” on non-circumcising cultures, please note….

            Male circumcision is traditionally practiced in Africa, and VMMC is an African solution to an African public health threat. An estimated two-thirds of African men are already circumcised for cultural or religious reasons. The non-circumcising communities in Southern Africa and parts of East Africa have the highest HIV prevalence.

            PEPFAR (the U.S. President’s Emergency Plan for AIDS Relief) does not define HIV prevention strategies for countries in Africa; rather, PEPFAR supports African governments in their fight against the HIV/AIDS epidemic. Most ministries of health in Africa follow international guidance from WHO and UNAIDS, and that guidance recommends VMMC as an important HIV prevention intervention in countries with high HIV prevalence, low male circumcision
            prevalence, and a generalized (heterosexual) HIV epidemic.

            All individuals have the right to know the proven benefits and potential risks of VMMC and todecide for themselves whether they wish to be circumcised (or have their newborn or adolescent son circumcised).

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  7. Patrick says:

    I would venture to guess that one reason people are skeptical of circumcision is that there is no way to prove it has any preventive effect for individual men. The only thing provable, really, is when it fails.

    How can anyone possibly even measure any success from these campaigns in lowering HIV transmission? In these communities, are there no other preventive measures, such as testing, education and condom use?

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    • Beth Skwarecki says:

      Circumcision is not meant to stand alone; the effort to promote it is in concert with promoting testing, education, and condom use.

      I see what you mean about being skeptical on an individual level – if you’re circumcised and HIV negative, maybe it’s because of circumcision or maybe you were just lucky. It is possible to study at a population level though. See the “Part 1″ post from this series for the references on efficacy and how many cases of HIV were/are prevented.

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      • Sarah says:

        Beth, I’m curious to know whether your opinion of female circumcision would change if you could be convinced that subjecting vast numbers of girls to the ritual/procedure would prevent (or delay) in one of them an infection easily avoided by myriad other means. Would you favour offering the ritual/procedure to parents of newborn girls in your country, for example?

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        • Beth Skwarecki says:

          If women were choosing the procedure for themselves, I would leave that decision to each of them individually.

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          • William says:

            Then leave it up to men. Stop propagating lies that have already influenced many to subject their sons to this barbaric mutilation.

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  8. J. Douglas says:

    Imposing circumcision on groups in Kenya is particulary insensitive, given the documented use of forced circumcision and penectomy as a terror tactic following the post-election violence of 2007:

    http://www.amnesty.org/en/news/kenya-s-icc-trials-2013-09-16
    http://www.ncbi.nlm.nih.gov/pubmed/23758644
    http://iwpr.net/report-news/kenyan-victims-sue-authorities-over-electoral-crimes
    http://www.the-star.co.ke/news/article-159731/victims-violence-still-hope-justice

    Please also see the following link for a brief summary, with linked references, of the ethical, legal and methodological flaws with past research informing the present campaign of circumcision-as-HIV-preventative in Africa (which also inform much of the “renewed interest” in circumcision in the English-speaking world), some of the adverse consequences of funding circumcision-as-HIV-preventative in Africa (coercion of men and boys to be circumcised; misdirection of limited medical resources from higher priority areas) and the absence of oversight of organisations promoting and facilitating male circumcision in Africa:

    http://www.academia.edu/5453317/Response_to_PEPFAR_Program_Expenditures_Form_Number_DS-4213_OMB_Control_Number_1405-0208_-_Revision_3

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    • Beth Skwarecki says:

      VMMC is, crucially, voluntary.

      I hadn’t heard about the use of forced circumcision as a war tactic; how terrible. Thanks for the discussion on this.

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      • William says:

        Voluntary after they’ve been fed lies about protection from HIV. Condoms, NOT CIRCUMCISION, prevent hiv.

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      • Sarah says:

        Oh, come on, Beth. How is it ‘voluntary’ when they’re rolling out ‘neonatal’ (that’s babies, for the rest of us) circumcision programmes on ‘cost grounds’? (Of course it has nothing to do with the low uptake of actually as opposed to nominally voluntary circumcision.)

        See, for example, ‘Sex is Never the Same: Men’s perspectives on refusing circumcision in Swaziland’ – a quick Google will take you to the PDF.

        Here’s one man’s account from the above report:

        ‘[s]ometimes you can end the sex session while you have not even ejaculated. I am talking through experience and this is painful (a painful experience).
        Sometimes by the time you finish you find that the woman is already too tired because of my delayed ejaculation. So I would say that the foreskin has a role during sex. My main complaint is delayed ejaculation or not ejaculating at all. But I do not regret too much because I am safer from STIs and I can now easily clean myself.’

        Are these men really giving informed consent? Might word be getting out of circumcision’s sexual sequelae? What impact might this have on the relationships between African populations and HIV/AIDS organisations? Time will tell, one supposes…

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