SCIENTIFIC LETTERS

Only skin deep: limitations of public health understanding of male circumcision in South Africa

Bonginkosi Sithole^I; Lindiwe Mbhele^II; Heidi van Rooyen^III,*; Gertrude Khumalo-Sakutukwa^IV; Linda Richter^V

^IResearch assistant, Human Sciences Research Council, Pietermaritzburg
^IIResearch assistant, Human Sciences Research Council, Pietermaritzburg
^IIIPhD, Human Sciences Research Council, Pietermaritzburg
^IVMMedSc, Center for Prevention Studies, University of California, San Francisco, USA
^VPhD, Human Sciences Research Council, Durban

To the Editor: The recent randomised controlled trials in South Africa, Uganda and Kenya which showed the dramatic impact of adult male circumcision (MC) on HIV transmission have dominated HIV/AIDS public health discourse over the past few years.^1-3 Several authors in the October 2008 SAMJ cautioned against widespread implementation of MC as a prevention intervention. More evidence on the acceptability and effectiveness of male circumcision is required to support the scale-up effort. Particularly in non-circumcising communities, traditional cultural views will influence circumcision's uptake and acceptability.⁴

Following the WHO/UNAIDS announcement promoting widespread MC,⁵ we conducted a pilot study as part of an ongoing community-based voluntary counselling and testing trial (Project Accept) to assess potential challenges to promoting male circumcision in a rural community in KwaZulu-Natal, South Africa.

We conducted four age-segregated, gender-specific (i.e. younger men and women and older men and women) focus group discussions of up to 10 individuals per group. We also interviewed 8 key informants, including community leaders, traditional healers and health workers regarding the feasibility and acceptability of male circumcision in this community.

Our study revealed rich traditional understandings of male circumcision. Participants had strong negative views regarding the practice of male circumcision (ukusoka), involving the removal of the foreskin. These perceptions seem to originate in historical tensions between Zulus and the Xhosas regarding MC. In contrast to the Xhosa practice of full circumcision, Zulus traditionally promoted partial circumcision (ukugweda ). Here, the foreskin is not removed, but an elastic band of tissue under the penis glans is cut, allowing the foreskin to move easily back and forth.

Participants understood the difference between full and partial circumcision but ukugweda was preferred. Men and women felt that partial circumcision (i) helped to prevent infections and (ii ) helped to avoid sensitivity and pain during sexual intercourse, as the external foreskin remains intact. Further, participants reported that the full removal of the foreskin kills certain cells and this may lower sexual pleasure. On the other hand, participants felt that if the tissue under the penis glans is uncut, the foreskin is not able to move back and forth easily, which interferes with erection and causes the penis to bend downward painfully. A partial cut is believed to allow sperm to move freely and to enhance pleasure for men and women.

Male circumcision is being widely promoted on the assumption that the term is unambiguous. Our pilot study shows a widely held alternative meaning among a rural community in KwaZulu-Natal. Public health messages have to be clear and precise, and specifically adapted for different cultural contexts. Information and education materials are needed to distinguish between medical MC (and its benefits) and ukugweda , whose HIV-protective benefits are unknown. For successful uptake in these contexts, strategies to overcome historically negative cultural perceptions of MC among Zulus, as well as positive associations of partial circumcision with enhanced sexual pleasure, are required.

This research was sponsored by the US National Institute of Mental Health as a co-operative agreement, through contracts U01MH066701 (University of California, Los Angeles), and U01MH066702 (University of California, San Francisco). Views expressed are those of the authors, and not necessarily those of sponsoring agencies .

1. Bailey R, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: A randomized control trial. Lancet 2007; 369: 643-656.         [ Links ]

2. Gray R, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: A randomized trial. Lancet 2007; 369: 657-666.         [ Links ]

3. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 trial. PloS Med 2005; 2(11): e2.         [ Links ]

4. Aggleton P. Roundtable: 'Just a Snip': A social history of male circumcision. Reprod Health Matters 2007; 15(29): 15-21.         [ Links ]

5. WHO/UNAIDS. Technical Consultation Male Circumcision and HIV Prevention: Research Implications for Policy and Programme Planning, Montreux, 6 - 8 March 2007. Conclusions and Recommendations. 2007 . http://data.unaids.org/pub/Report/2007/mc_recommendations_en.pdf (accessed 6 March 2009).         [ Links ]

Accepted 25 June 2009.

* Corresponding author: Heidi van Rooyen (hvanrooyen@hsrc.ac.za)