Study from Zambia highlights importance of comprehension and consent in male circumcision programmes

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A study from Zambia has found that the majority of adolescent boys attending male circumcision programmes have done so by choice and with their parents’ approval, although some said it had been primarily their parents’ idea.

It found that, though understanding of the meaning and purpose of male circumcision was high in both adolescents and adults, that there were a couple of specific aspects of the procedure that were widely misunderstood. Zambia is one of the countries in Africa that has been expanding male circumcision programmes as part of its HIV prevention strategy.

However the study also found that a significant minority of adolescents had got themelves circumcised without parental consent, and that both parents and teenagers were confused about the rules of informed consent. Furthermore, in a relatively small sample of 28 qualitative interviews, it found one boy, aged 14, who had clearly been pressurised against his will to get circumcised.



A patient’s agreement to take a test or a treatment. In medical ethics, an adult who has mental capacity always has the right to refuse. See also ‘capacity’ and ‘informed consent’.


Abbreviation of a Latin term meaning after food.

informed consent

A patient’s agreement to continue with a clinical trial, a treatment or a diagnostic test after having received a full written or verbal explanation of the risks, benefits and the possible alternatives. See also ‘consent’.

Dr Katie Schenk of the Population Council (PC) in the United States told the Tenth AIDS Impact conference last week that, as part of the research programme of the Male Circumcision Partnership, a consortium of family-planning and STI NGOs, the PC had conducted 95 qualitative interviews and six focus groups between November 2009 and March 2010 to assess the feelings and understanding of adolescent boys, adults, family members and key opinion leaders regarding circumcision and the experience of undergoing it. It also got 115 adolescents and 311 adults who were contemplating circumcision to fill in multiple-choice questionnaires to gauge their comprehension of crucial aspects of circumcision.

One-to-one interviews were conducted with 28 boys aged 13-17 (mean age 15.4) and 34 adult men aged over 18 (mean age 26) who had undergone circumcision, and also 13 opinion leaders and key informants. There were six focus groups conducted with a total of 36 parents or guardians of boys who had got circumcised.


The comprehension questionnaire was given out when boys/men attended for voluntary HIV counselling and testing prior to circumcision, and the qualitative interviewstook place a week after having been circumcised.

The questionnaire found that potential participants had high levels of understanding about most aspects of circumcision, with 85% to 100% of answers correct, in both adolescents and adults, to all questions but one; in some areas adolescents scored better. Correct answers were more likely to be given by adults with better literacy and education and who were counselled in their most familiar language. There was also a tendency for people who attended smaller clinics to understand more.  

However it was also found that a large minority of participants (30% of adults and 45% of boys) gave incorrect answers to one question; they believed that getting circumcised was risk-free and did not have side-effects. Dr Schenk commented that information given out about circumcision may have under-emphasised potential risks.

Importantly, however, adolescents were more likely than adults to report that they were ‘somewhat’ or ‘very’ uncomfortable with the idea of getting circumcised: sixteen per cent of boys said they were ‘very uncomfortable’ compared with 3% of adults and 28% ‘somewhat uncomfortable’ compared with 10% of adults. Conversely only 46% of boys said they were ‘very comfortable’ with the idea of getting circumcised compared with 70% of adults.     


The post-circumcision one-to-one interviews, however, showed that the adolescents and adults who had actually undergone the operation were almost universally happy that they had done so. Most emphasised that it had been their choice and in some cases they had persuaded their parents or guardians to consent. One 17–year-old said:

“I made this decision because I heard of the father was refusing that you can’t go there, giving some reasons, but I was determined, telling myself that it’s my life, I think these things will benefit me in future...and at last he said okay, I will take you.”

A 13-year-old saw guardian or parental assent and attendance as important and as a kind of ‘certification’ of their choice:

“It was my uncle, my mother told him to represent her...I was happy because I knew that they will not say that they need to sign for me, so that I get circumcised, because he was there for me.”

However they also talked on one 14-year-old boy who had clearly been forced into circumcision and was unhappy about it:

“I never wanted to be circumcised, I thought it was very painful, I never used to know about or think about father was insisting I went for the operation. I felt bad about it.”

In contrast, several adolescents said they had been able to have the operation without parental consent, and it was apparent that clinic workers were confused about consent requirements for adolescents, which were viewed as complex and constantly changing. Attitudes about adolescents giving informed consent varied from one ethics committee worker who emphasised that teenagers had to understand exactly what was involved “because that minor will have to live with the consequences for the rest of their lives” to workers who voiced much more authoritarian positions: one said “I strongly feel a child is a child, therefore should be silent on issues of health.” 

Based on the above research, the Population COuncil is recommending that circumcision programmes make improvements to consent procedures for adolescents, including conducting refresher training for clinic staff, training providers to actively seek assent from minors, providing appropriate counselling to adolsecents with doubts, and ensuring that counselling includes actively establishing that adolescents understand key concepts, rather than waiting for them to ask questions.  


Schenk K et al. On the cutting edge: research to improve the informed consent process for adolescents in Zambia undergoing male circumcision for HIV prevention. Tenth AIDS Impact conference, Santa Fe, New Mexico. Abstract 199. 2011.

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