Women's voices have largely gone unheard in the debate on male circumcision as an HIV-prevention method, but informal discussions with women reveal a range of concerns, preferences and views that researchers and governments would do well to consider before drawing up plans for rolling out a national circumcision programme.
Women’s voices have largely gone unheard in the debate on male circumcision as an HIV-prevention method, but informal discussions with women reveal a range of concerns, preferences and views that researchers and governments would do well to consider before drawing up plans for rolling out a national circumcision programme.
In an unscientific poll, Irin/PlusNews found a high degree of ambivaÂlence among wives, girlfriends and mothers about the implications of a mass male circumcision campaign.
“It’s going to be an advantage for women who are married to men who are cheating,” said Carol Masombuka (19) from Mpumalanga, zeroing in on the fact that even the partial protection circumcision provides could make a difference to women who are powerless to insist on the use of condoms.
Other women were wary of an initiative that could give men one more excuse not to use condoms. “Most women are shy when it comes to things concerning sex. It’s always the man who knows better, so he will decide when we have sex and, if he wants to use a condom, he will. Whatever he says goes, so it’s going to suppress women even more,” said Kgaugelo Khuto (20) a student from Limpopo.
Studies have found higher levels of acceptability for male circumcision among women than among men.
Three clinical trials have demonstrated that circumcision reduces a man’s chances of contracting HIV by about 60%. The expected numbers of male HIV infections averted by a large-scale male circumcision programme would translate, eventually, into fewer infections in women. There is also evidence that circumcised men are less likely to harbour the human papilloma virus, which causes cervical cancer—a major killer of women in sub-Saharan Africa.
A set of guidelines issued by the World Health Organisation and UNAids in March, however, makes it clear that we do not know whether male circumcision, specifically, reduces the sexual transmission of HIV from men to women.
Preliminary results from a study in Uganda suggest that HIV-positive men who resume sex before their circumcision wounds have healed are more likely to infect their female partners. The findings are too small to be conclusive, but they have raised the alarm about the need to inform both sexes about the potential risks and benefits.
One of the greatest of those risks is that circumcised men will misunderstand or exaggerate the degree to which they are protected from HIV and stop using condoms.
The only experience many African women have of male circumcision is as part of a traditional rite of passage that their sons, brothers and male friends go through if they belong to certain ethnic groups.
Women are barred from attending such rituals and men are “not supposed to talk about it with women—they tell them they can go crazy if they do”, said Masombuka.
Several of the women interviewed said they observe a positive change in men who attend traditional circumcision “schools”. “Most of the guys who’ve been through it know how to respect a woman and elders; a person not coming from circumcision school, they’re very rude and they use power,” said Gloria Mphekgwana (44) from Limpopo, where traditional circumcision is practised.
“They tell them to be faithful to a girl and to marry that girl and not to go ‘jolling’ [sleeping] around,” said Masombuka.
Rachel Jewkes, who heads the gender and health unit of South Africa’s Medical Research Council, believes that efforts to introduce male circumcision as an HIV intervention should borrow from traditional approaches that view the procedure as part of a “transformative process”.
“If we see it purely as a medical intervention, it’ll be a mistake. It’s a social intervention,” said Jewkes. “I think culture is highly flexible and, to the extent that circumcision has been associated with manhood, I think that gives it enormous potential for equating it with better manhood.”
By “better manhood” Jewkes means men who are sexually responsible and more willing to view women as equals. She sees male circumcision programmes as a valuable opportunity to engage men in discussions about safer sex and gender equity.
“The critical thing is that male engagement in HIV prevention must not stop at the surgical knife. Circumcision programmes must be accompanied by gender-transformative approaches to HIV prevention,” she said.
Dr Yassa Piere, a virologist who treats HIV-positive patients at the University Teaching Hospital in Lusaka, believes women could play a role in motivating their male partners to be circumcised. The women interviewed cited hygiene as another reason for preferring their sexual partners to be circumcised. “I prefer a guy who’s circumcised. I think it’s safer and cleaner,” said Khuto. “But I wouldn’t ask him to do it.”
Mothers were much more vocal in their support of medical circumcision. Mphekgwana is under pressure from her former husband to send their son to a traditional circumcision school, but she has read media reports about botched procedures and fatalities and refuses to send her son to one.
“No one wants her kids to go there now, because they don’t clean their utensils. They’re using only one blade. I want to take him to the hospital [to be circumcised],” she said.
At the male circumcision clinic at the teaching hospital, where about 80 procedures are performed every month, half of the patients are young boys brought to the clinic by their mothers.
“Studies show high acceptability by women of this,” said Dr Kasonde Bowa, the clinic’s director. “I think they’re keen on anything that is healthy for their children and their husbands.”