Male Circumcision: Implications for Women as Sexual Partners and Parents
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A 2007 Reproductive Health Matters.
All rights reserved.
Reproductive Health Matters 2007;15(29):62–67
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www.rhm-elsevier.com PII: S 0 9 6 8 - 8 0 8 0 ( 07 ) 2 9 311 - 5 www.rhmjournal.org.uk
ROUNDTABLE
Male Circumcision: Implications for Women as
Sexual Partners and Parents
Catherine Hankins
Associate Director, Department of Policy, Evidence and Partnerships and Chief Scientific
Adviser to UNAIDS, Geneva, Switzerland. E-mail: hankinsc@unaids.org
T
WENTY years of observational data demon- male circumcision on HIV transmission to women
strating an association between male circum- was stopped; it may never be known whether or
cision and lower HIV prevalence followed the not male circumcision affects the probability of
first publications in 1986 suggesting a possible sexual transmission of HIV from men to women.7
role for male circumcision in HIV prevention.1,2 This paper highlights some of the implications of
However, randomised, controlled trials were neces- the results of the male circumcision trials for
sary to determine the level of the protective effect, women as sexual partners and parents and dis-
ascertain adverse surgical events rates and docu- cusses some gender-related concerns.
ment sexual behaviour post-surgery.
The now-published trials opened a space for
Non-HIV-related benefits to women of
public debate among stakeholders, even before
male circumcision
all the results were known, in countries such
as Lesotho, Kenya, Malawi, Swaziland, Tanzania Women benefit as sexual partners if men have
and Zambia. WHO and UNAIDS also organised fewer penile infections. Systematic reviews show
a regional consultation in Nairobi in November that circumcised men are at significantly lower
2006;3 one on strategies and approaches to male risk of syphilis and chancroid.8,9 Circumcised
circumcision programming in Geneva in Decem- men in the United States are also at significantly
ber 2006;4 one on perspectives from social sci- lower risk of invasive penile cancer,10–13 and a
ence in Durban in January 2007;5 a meeting on lower risk of cervical cancer in partners of circum-
male circumcision and young men’s sexual and cised men has also been reported.14 This may be
reproductive health in Geneva in January 2007; due to decreased human papillomavirus infection,
and the WHO/UNAIDS international consultation which causes ano-genital and cervical cancer.
on the policy and programming implications in Women also benefit when men have better
Montreux in March 2007.6 penile hygiene and are less likely to transmit
What do the results of these trials mean at infections. In contrast to the rapid drying of the
the population level for women? Indirectly, it is circumcised penis, the foreskin of the uncircum-
anticipated that women currently living in high cised penis creates a moist environment where
HIV prevalence settings with low male circumci- secretions can be trapped and pathogens flour-
sion prevalence may benefit 10–20 years hence, ish, requiring regular cleaning. A study of male
if there is a reduction in HIV incidence among partners of women with bacterial vaginosis in
men who are circumcised in programmes achiev- Nairobi, Kenya, found that both increased post-
ing wide coverage. This is because women would coital washing and male circumcision were inde-
have a lower probability of encountering a sexual pendently associated with lower prevalence of
partner with HIV infection. As for a direct effect HIV infection.15 Thus, improved penile hygiene
on risk for women, recruitment in a Rakai trial may reduce the risk of HIV and other sexu-
looking to confirm or disprove previous obser- ally transmitted infections, irrespective of cir-
vational data suggesting an important effect of cumcision status. Among both circumcised and
62C Hankins / Reproductive Health Matters 2007;15(29):62–67
uncircumcised men in Malawi, a study of post- the hospital setting have found higher neonatal
coital penile wipes containing a topical micro- male circumcision prevalence of 76–92%.21 On the
bicide concluded that the wipe was safe and other hand, declines were seen both in Canada
acceptable, and could decrease the frequency of and Australia following similar statements by
penile colonisation with micro-organisms.16 the medical authorities in those countries, and
Whether frequent penile cleaning with a micro- in the United Kingdom following the decision
bicide wipe could cause inflammation and not to cover neonatal male circumcision on the
micro-abrasions leading to increased risk of HIV National Health Service.17
acquisition remains to be evaluated. Efforts to The published literature on the acceptability
improve penile hygiene practices in general of male circumcision in sub-Saharan Africa,
need to be developed and assessed in different South Korea, the USA and other locations saw
socio-cultural and economic contexts, alongside the light of day prior to the announcement of
work promoting new social norms for safer the partially protective effect of male circum-
sexual behaviour. Raising the importance of cision against female-to-male transmission of
good genital hygiene practices in discussions HIV. A recent review of 13 acceptability studies
about male circumcision is important because of in Botswana, Kenya, Malawi, South Africa,
the benefits with respect to reduction of sexually Swaziland, Tanzania, Uganda, Zambia and
transmitted infections that can be achieved for Zimbabwe reported that acceptability of male
both partners. circumcision was already high. Women were
interviewed or participated in focus groups in
half the studies. Overall, approximately the same
Epidemiology and acceptability of proportion of women said they would prefer
male circumcision circumcision for their partners or their sons as
Worldwide, the prevalence of male circumcision men who said they would prefer circumcision for
is highly variable, depending on its acceptability themselves or their sons. In some cases, women
and the religious, cultural, social and medical were asked if they would prefer their partners
reasons for which it is performed. An estimated to be circumcised ‘‘if male circumcision were
665 million men (30% of all men) over 15 years of proven to be protective against HIV and STIs’’;
age worldwide are circumcised. Of these, approxi- in others, they were asked their views ‘‘if it
mately two-thirds (68%) are Muslim, 0.8% are were safe and affordable’’. Overall, 69% (range
Jewish, and 13% are men in the United States 29–87%) of women favoured circumcision for
who are not Muslim or Jewish.17 Religious, social their partners and 81% (range 70–90%) were
and cultural reasons for circumcision far out- willing to circumcise their sons.22 The main con-
weigh medical ones, such as difficulties retract- cerns were pain, cost and complications; the most
ing the foreskin (phismosis) or returning it to its important factors influencing acceptability were
original position (paraphimosis), in influencing safety, affordability and evidence that male cir-
acceptability of the procedure. cumcision was protective against HIV and STIs.
Social desirability or the desire to conform For women in KwaZulu Natal, South Africa,
to social norms plays an important role, some- the relationship between male circumcision
times more so than advice provided by medical status and acquisition of STIs was key.23
authorities.18 For example, the American Acad- In countries where male circumcision is already
emy of Pediatrics has issued several statements socially accepted, e.g. in Turkey,24 parts of West
on neonatal circumcision since 1971, with its most Africa and among some Asia-Pacific cultures,25
recent statement in 1999 saying there are insuf- boys do not consider themselves as men unless
ficient data to recommend routine neonatal cir- they are circumcised. In South Korea, male
cumcision.19 Yet, there appears to have been circumcision was rare before 1945, was intro-
little decline in prevalence of neonatal circum- duced in the 1950s and increased dramatically
cision in the USA as a result. An estimated 61% in the 1980s and 90s. Now, greater than 90%
of male newborns were recorded as being cir- of secondary schoolboys have been circumcised
cumcised on hospital discharge sheets in 2000,20 by age 12,26 and social acceptability is currently
and community surveys that include newborns high. A nationwide study in 2002 found that 91%
circumcised for religious and other reasons outside of South Korean parents thought circumcision
63C Hankins / Reproductive Health Matters 2007;15(29):62–67
was necessary, principally to improve hygiene. may be irrelevant to women’s pleasure, with any
Mothers also cited improved future sexual difference arising from how the woman responds,
potency as a reason.27 Circumcision status of her preconceived ideas about male circumcision
the father was the main determinant of the deci- and how she has been socialised.30
sion to circumcise an infant in one US study,18
while another found ease of hygiene as the main
motivator.28 Still another US study found over Women as parents considering male
80% uptake of newborn circumcision despite dif- circumcision for infants
ferences in health care coverage status and race, Male circumcision is an irreversible procedure
indicating that economic factors did not out- which provides a child with no benefits in rela-
weigh social desirability.29 tion to HIV before sexual debut, except for
reduced likelihood of urinary tract infections in
infancy.36 Social, cultural, religious and medical
Effect on sexual pleasure? factors may influence the decision whether to
Discussions of sexual pleasure in relation to male circumcise an infant boy. Parents of uncircum-
circumcision status are often heated. Although cised boys in a US study were more likely to feel
published studies are lacking among adult men less respected by their health care provider and
pre- and post-circumcision and there are few to reconsider their decision when they were not
among sexual partners who have had sex with asked whether they wanted their child circum-
both circumcised and uncircumcised men, cised or did not receive adequate information
women have been asked about their preferences, about the procedure.37 This underscores the respon-
which are not uniform. sibility of health care providers, particularly mid-
In several acceptability studies a significant wives and others attending childbirth, to be
proportion of women preferring a man to be knowledgeable about the advantages and dis-
circumcised cited reasons of hygiene.30,31 Con- advantages of neonatal male circumcision in
cerns about hygiene have also been reported societies where it is done and to discuss this with
anecdotally among sex workers. For example, a parents.38 Parents may prefer to leave the deci-
sex worker in Nkhotakota, Malawi, said ‘‘the sion to the child, waiting until he has the capac-
uncircumcised can harbour husks (m’deya) and ity to decide on his own. Or they may view
sperm are trapped within the foreskin and so get the lower risk of surgical complications associ-
disease easily’’.30 Both sex workers and young, ated with the procedure when it is performed in
unmarried women in focus groups conducted in infancy as being in the child’s best interests.39
four diverse districts in Malawi believed that In societies in which male circumcision is
circumcised men both enjoy sex more and give performed in childhood or adolescence, signifi-
more pleasure to their partners than uncircum- cant socialisation on what it means to become a
cised men.30 man may be part of the circumcision rite. For
Women who had experienced sex with both example, in the Malawi study, women indicated
circumcised and uncircumcised partners in a that there were expectations that boys would
US study reported a strong preference for cir- be counselled on sexuality, genital hygiene and
cumcised over uncircumcised sexual partners, good behaviour.30 The WHO/UNAIDS Montreux
both for aesthetic reasons and for various sexual recommendations called for male circumcision
activities, ranging from fellatio and manual stim- programmes to maximise opportunities for edu-
ulation to sexual intercourse32 while in another cation and behaviour change communication,
US study circumcised men reported more varied promoting shared sexual decision-making, gender
sexual experience than uncircumcised men.33 equality and improved health of both women
On the other hand, a survey of women recruited and men.6 Such services for adolescents and young
through magazines and anti-circumcision web- adults can use social change communication
sites found a great preference for uncircum- strategies to question and support transformative
cised men,34 and in a New Zealand study women changes in gender norms and roles. Whether
reported more vaginal dryness during intercourse or not a boy has been circumcised, mothers and
with circumcised men.35 However, as women in fathers also have important roles to play in
the Malawi study concluded, male circumcision socialising their sons in this regard.
64C Hankins / Reproductive Health Matters 2007;15(29):62–67
Potential gender-related effects of male tive sex, reduction in the number of sexual part-
circumcision for HIV prevention ners, and correct and consistent use of male or
Monitoring and minimising potential negative female condoms. Regardless of the male circum-
gender-related impacts of male circumcision cision prevalence in a community or country,
programmes, such as conflation of male circum- people need to be encouraged to learn their HIV
cision with female genital mutilation (FGM), status through HIV testing and counselling and
unsafe sex and sexual violence, will be impor- to attend services for the treatment of sexually
tant in countries that include male circumcision transmitted infections. In all settings, the ‘‘par-
within HIV prevention programmes. FGM, like tial protection’’ message needs to be reinforced
male circumcision in some societies, is rooted in so that men who are circumcised understand
traditional culture, but its health consequences that it does not afford them full protection.
can be serious.40 Partial or total removal of the As sexual partners, women should not aban-
external female genitalia is a manifestation of don negotiation of condom use with circum-
cised men, and this will be greatly facilitated
deep-rooted gender inequality, intended to
if everyone understands that with circumcision
reduce women’s sexual desire and functioning.41
alone, men are not fully protected and their
It has no health benefits whatever, and compli-
partners are not directly protected from HIV
cations can include severe pain, shock, haemor-
infection. If circumcised men abandon or do not
rhage, tetanus or sepsis, urine retention and
adopt other prevention strategies, women may
ulceration of the genital region. The WHO colla-
find themselves at increased risk of HIV infec-
borative prospective study in six African coun- tion. Campaigns to create new masculine social
tries on female genital mutilation and obstetric norms need to convey protection and prevention
outcomes, published in June 2006,42 showed that as ‘‘real man’’ attributes, e.g. ‘‘I’m circumcised
deliveries to women who underwent all types and I use condoms every time’’, ‘‘I’m circumcised
of FGM were significantly more likely to be and I’m staying with my partner’’, ‘‘I’m circum-
complicated by caesarean section, post-partum cised and I’m waiting to start sex’’, ‘‘He’s cir-
haemorrhage, episiotomy, extended maternal cumcised and we use condoms to be safe’’.
hospital stay, resuscitation of the infant and Women need to support men who undergo
hospital inpatient perinatal death than deliveries male circumcision in their intentions to follow
to women who had not had FGM. Multilateral through on combination HIV prevention, and
agencies and medical and nursing professional they must not abandon their own HIV preven-
organisations consider FGM to be universally tion strategies. When their partner undergoes
unacceptable as an infringement on the physical male circumcision, regardless of his HIV status,
and psychosexual integrity of women and he must abstain from sex until complete wound
girls and a form of violence against them.43 It healing preferably until this can be certified by a
is therefore critical that messaging about male health care provider. Complete healing normally
circumcision for HIV prevention not only clearly takes six weeks. Women need to support their
distinguishes it from FGM but also contributes partner in following this important post-operative
to efforts to eradicate FGM. instruction and in the initial post-operative period
The risk that unsafe sex may increase or that assist him in avoiding erections. Early resump-
violence against women will be provoked during tion of sexual activity before complete wound
male circumcision programme scale-up should healing may increase the risk of complications
not be under-estimated. Much will depend on and place HIV negative men at higher risk of
the extent to which messaging about male cir- HIV acquisition. If the man is HIV positive,
cumcision and HIV at both the individual and the risk to his sexual partner(s) may also be
community level creates a common understand- increased, although the data are limited.7
ing about the benefits of male circumcision for Couples in sero-discordant partnerships in
HIV prevention. Clear and consistent messages which the woman is HIV-positive may consider
must emphasise that male circumcision is an the possible benefits of male circumcision as
additional prevention method for men, but that part of their strategy to prevent HIV trans-
it does not replace measures such as delay in the mission. It may be an option that would lead
onset of sexual relations, avoidance of penetra- to reduced anxiety during sexual relations by
65C Hankins / Reproductive Health Matters 2007;15(29):62–67
providing additional protection, if it is in concert the circumcised arm in the Orange Farm study,
with their other HIV prevention strategies. risk enhancement was not striking in any of the
three trials is not reassuring enough. None of the
trial participants were told that male circumci-
Conclusion sion provided any degree of protection against
In the high HIV prevalence settings in which HIV – in fact they were told that the trials were
men may be offered male circumcision, women being conducted to find this out.
will face the challenge of negotiating for safer As sexual partners and as mothers, women
sex with men who may mistakenly think that have personal views toward male circumcision
they can stop condom use and other safer sex that are conditioned by their own backgrounds
measures. If risk compensation44 occurs in the and personal experience. Through their influ-
wake of the news that male circumcision is par- ence in various contexts women can contribute
tially protective against HIV acquisition in men, to ensuring that male circumcision for HIV pre-
women will not be protected, and the indirect vention is used appropriately and ethically, does
benefits of male circumcision for women may more good than harm, and helps to improve
not materialise. Already mathematical modelling the sexual and reproductive health of both men
suggests that in the medium term the proportion and women. Whether it can help to change
of people living with HIV in sub-Saharan Africa gender norms and roles and promote gender
who are women may rise as male circumcision equality and equity or whether it leads to
programmes are scaled up in high HIV preva- increased HIV risk for women will depend on
lence settings, due to the lag time for indirect societal engagement, both within and outside
effects for women to be felt.45 The fact that, other male circumcision services, and in comprehen-
than an increase in the number of sexual acts by sive HIV prevention programming.
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