Will male circumcision protect women, ask advocates?

Roger Pebody
Published: 18 August 2008

Male circumcision is the only HIV prevention intervention that does not offer some protection to both partners, and may actually put a man’s sexual partner at greater risk of infection, argued the women’s health advocate Marge Berer at the International AIDS Conference in Mexico City on August 7th.

Randomised controlled trials in high prevalence African settings have demonstrated that circumcision reduces female-to-male transmission of HIV by 50-60%. Circumcision does not reduce male-to-female transmission, and may actually increase transmission, particularly if men with HIV resume sex before healing is complete. However modelling studies do suggest that reductions in HIV prevalence among men in a community will lead to reductions in infections among women.

Marge Berer highlighted confusion among men about the degree of protection that circumcision affords, and the danger that men may use condoms less frequently or not at all following the operation. To counteract such problems, she suggested that circumcision should be publicly described as like a cheap condom that breaks 40% of time.

Berer gave the hypothetical example of a man who had refused an HIV test at the time of circumcision, and was unknowingly HIV-positive. He thinks that circumcision will now protect him from HIV and so stops using condoms. “If he continues depositing semen in his partner’s body every time they have sex, his partner is in a worse position than he or she was before," she said.

Berer suggested that there needs to be couple counselling before circumcision, so that both partners fully understand the implications. Moreover she railed against circumcision being rolled out as a top-down solution with minimal involvement or advocacy from those affected, especially women.

Urging a renewal of condom promotion, she noted that condoms were one of the least discussed topics at the Mexico conference. In response to several criticisms of the recommended roll-out of circumcision, Catherine Hankins from UNAIDS insisted that circumcision had to be seen as part of combination prevention” – in other words, it is one extra choice, rather than the replacement for another intervention.

In the same session, Mogomotsi Supreme Mafalapitsa noted that circumcision is often imbued with religious and cultural meanings, and very often forms part of ceremonies that mark a transition from boyhood to manhood.

Drawing on his experience in South Africa, he said that these traditional circumcision rituals often emphasise specific ideas of masculinity which can be harmful to women. He urged that the implementation of circumcision be linked to “gender transformative programmes” which help boys become men “who respect women, respect themselves and are faithful to their partners.”

However he warned that attempts to change practices around circumcision are fraught with difficulties. Health officials may prefer circumcision to take place at a different age, or under medical supervision in a sterile environment, but Mafalapitsa said that “cultures who are already circumcising adolescent males do not take kindly to the possibility of alteration of their culture by medical circumcision and neonatal circumcision.”

In such societies, circumcision of infants would be particularly difficult to promote, he said, as there would be no ritual left to mark adolescence.

Moreover, in many cases, bearing the pain is part of the ritual, so those who opt for a “safe” circumcision in a clinic may be seen as cowards.

Karen Smith underlined how specific and local the impact of religion and culture can be. She gave the example of Indonesia, which is predominantly Muslim, and where circumcision is associated with Muslim coming of age. For Indonesian Christians, practising circumcision would suggest conversion to Islam. However in the neighbouring but largely Catholic country of the Philippines, circumcision does not have those connotations and the practice is common during childhood.

However she said that culture is not always as unchangeable as it is assumed to be, but that cultural and religious sensitivities need to be worked with carefully. Obstacles need to be identified and worked on in partnership with leaders from the communities concerned.

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