Social and Behavioural Research on Male Circumcision for HIV Prevention
Male circumcision is a surgical technique that has complex social, religious, cultural and gender implications. The clinical trials that found that male circumcision reduces men's risk of acquiring HIV through vaginal sex also collected data on social and behavioural factors, including rates of risk behaviours pre- and post-circumcision and the acceptability of the practice. These data are complemented by results from qualitative and quantitative studies that used a variety of methodologies. Some of the key findings from this literature are summarized below.
The research to date suggests that many men in communities that do not traditionally practice circumcision would be willing to undergo the procedure. A review of acceptability studies conducted in sub-Saharan Africa found that in the eight studies from six countries that included quantitative data, the median proportion of uncircumcised men who said they would be willing to be circumcised was 65 percent.
All of these studies were conducted in communities that do not traditionally circumcise. Some studies asked whether the participants would be willing to be circumcised should it be shown to protect against HIV, while others were asked if they would undergo the procedure if it were provided in a hospital at low or no cost.
Four of the eight studies included male and female participants. In these studies, almost 70 percent of the women said that they would prefer that their partners be circumcised. About three out of four parents in these studies said that they would circumcise their sons if the procedure was safe, affordable, and protective against HIV (1).
In a study in India, after 795 women with uncircumcised children were informed of the risks and benefits of male circumcision, 81 percent said that they would definitely circumcise their children if the procedure were offered in a safe hospital setting free of charge (2).
Sexual function and satisfaction
There are a range of concerns and beliefs about how circumcision status affects sexual function and sexual pleasure. Data on changes in the sexual performance or sexual satisfaction of adolescents or men following circumcision are limited and conflicting. One study conducted among 138 Korean men an unknown time (possibly years) after circumcision found that 20 percent reported decreased sexual pleasure and 8 percent reported increased sexual pleasure following the procedure (3). Forty-two Turkish men who were interviewed 12 weeks or longer after circumcision reported no adverse effects on sexual function (4).
Two randomised controlled trials of male circumcision for HIV prevention compared data on sexual function and sexual satisfaction before and after circumcision and also between the intervention group (circumcised men) and the control group (uncircumcised men) in each of the studies. Participants in the trial among 4,500 men in Rakai, Uganda, reported no meaningful changes in any area of sexuality studied (including sexual desire or satisfaction, erectile function, ability to achieve penetration, or pain with intercourse) pre- and post-circumcision. More than 98 percent of the men in both the intervention and the control groups rated their sexual satisfaction as "satisfied” or “very satisfied” six to 24 months after enrolling in the trial (5). In the trial conducted among 2,684 men in Kisumu, Kenya, there were no reported differences in sexual function between circumcised and uncircumcised men. Sixty-four percent of the circumcised men who were available for follow-up at 24 months reported greater penile sensitivity after circumcision, and 54 percent reported enhanced ease in reaching orgasm (6).
As access to medical male circumcision improves, it will be possible to gather additional data on these topics in the specific context of HIV prevention programming.
One key question for all partially protective HIV prevention strategies is whether individuals will increase their risk behaviours due to a false sense of security or protection. Such changes in behaviour in response to perceived changes in risk are known as "risk compensation."
The three randomised controlled trials of male circumcision for HIV prevention provide some data on this question. Male volunteers in the trials were asked about unprotected sex, numbers of sexual partners and sex acts, and other behaviours at baseline and throughout the study. The data from their responses allowed researchers to draw some conclusions about whether male circumcision made the men less likely to practice safer sex and more likely to have multiple partners or unprotected sex acts.
The Uganda trial found no evidence of risk compensation among circumcised men (7). In the South Africa trial, circumcised men did report having more sex compared to the uncircumcised men (8). And at the end of the Kenya trial, circumcised participants reported more unprotected sex acts than their uncircumcised counterparts did, but both groups were reporting less unprotected sex than they had at baseline (9).
However, in these trials the men were counselled that it was not known whether male circumcision would protect them against HIV. Now that the data showing partial protection have been announced and widely publicized, it is possible that assumptions about levels of protection and rates of risk behaviour could change. Follow-up studies of both the Rakai and Kisumu trials will assess risk compensation, among other factors, for up to five years after initial enrolment, and research on this topic is one of the emerging priorities as pilot projects and scale-up proceed.
A separate study, conducted in the Siaya and Bondo districts of Kenya, compared the sexual behaviour among 324 recently circumcised men and 324 uncircumcised men before and during the year after circumcision or study enrolment. It found that circumcised men in the study were no more likely to report inconsistent condom use, nor did they report having more non-spousal partners than the uncircumcised men, even though 47 percent of the men who became circumcised cited protection from HIV and other sexually transmitted infections as their reason for doing so (10).
Men in all of these studies received extensive risk-reduction counselling, condoms, and other HIV prevention services. Researchers therefore emphasize the need to provide male circumcision as part of comprehensive HIV prevention services that include HIV counselling and testing, condom distribution, and diagnosis and treatment of sexually transmitted infections.
Modelling research estimating the decreases in HIV prevalence that could be achieved in sub-Saharan Africa through widespread adoption of male circumcision indicates that even if there is some element of risk compensation, it would have to be substantial to offset the benefits of circumcision. Complete negation of the benefits would occur only if at least 40 percent of the circumcised men in a country significantly increased risky behaviour (11).
Embe Halijamenywa: The Unpeeled Mango. A Qualitative Assessment of Views and Preferences Concerning Voluntary Medical Male Circumcision in Iringa Region, Tanzania (2011, PDF, 1.19 MB)
- Westercamp N, Bailey RC. Acceptability of male circumcision for prevention of HIV/AIDS in sub-Saharan Africa: a review. AIDS Behav 2007;11(3):341-355.
- Madhivanan P, Krupp K. Chandrasekaran V, et al. Acceptability of male circumcision among mothers with male children in Mysore, India. AIDS 2008; 22(8):983-88.
- Kim DS, Pang MG. (Abstract only) The effect of male circumcision on sexuality. BJU International 2007;99(3):619-22. Full article (PDF, 2007, 109 KB).
- Senkul T, Iseri C, Sen B, et al. (Abstract only) Circumcision in adults: effect on sexual function. Urology 2004;63(1):155-8.
- Kigozi G, Watya S, Poli CB, et al. The effect of male circumcision on sexual satisfaction and function, results from a randomized trial of male circumcision for human immunodeficiency virus prevention, Rakai, Uganda. BJU International 2008;101(1):65-70.
- Krieger JN, Mehta SD, Bailey RC, et al. (Abstract only) Adult male circumcision: effects on sexual function and sexual satisfaction in Kisumu, Kenya. J Sex Med 2008;5(11):2610-22.
- Gray, RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. The Lancet 2007;369(9562):657-666
- Auvert B,Taljaard D,Lagarde E,et al. Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: The ANRS 1265 Trial PLoS Medicine 2005;2(11):e298
- Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. The Lancet 2007;369(9562):643-656
- Agot KE, Kiarie JN, Nguyen HQ, et al. Male circumcision in Siaya and Bondo Districts, Kenya: prospective cohort study to assess behavioral disinhibition following circumcision. J Acquir Immune Defic Syndr 2007;44(1):66-70.
- Londish GJ, Murray JM. (Abstract only) Significant reduction in HIV prevalence according to male circumcision intervention in sub-Saharan Africa. International Journal of Epidemiology 2008;37(6):1246-53.