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Male Circumcision

What is male circumcision?

Medical male circumcision refers to the complete removal of the foreskin from the penis. About 30 percent of men worldwide are circumcised—some shortly after birth and some at adolescence. Circumcision may be performed for health and hygiene reasons. It may also be part of religious or cultural practices. The rate of circumcision varies across populations and often corresponds to a country’s religious and cultural traditions.

Female genital cutting (FGC) is sometimes described as “female circumcision”. This is inaccurate. FGC is not at all equivalent of male circumcision. The World Heath Organisation (WHO) notes that FGC injures “female genital organs for non-medical reasons” and is “a violation of the human rights of girls and women”.[1]

Could male circumcision help prevent the spread of HIV?

Circumcision may reduce a man’s HIV risk if he has unprotected sex with an HIV-positive woman because:

  1. The inner lining of the foreskin (the flap of skin removed during circumcision) has many of the cells that HIV likes to infect. After circumcision, the skin covering the penis has few of these target cells.
  2. The skin of a circumcised penis becomes keratinised (KER-ah-tah-nîzd). That is, it becomes “regular” skin, like the skin on our arms and legs. Regular skin is stronger than the skin of the uncircumcised penis and less likely to get the small tears during sex that can let HIV into the bloodstream.
  3. Finally, circumcised men are less likely to get other sexually transmitted infections (STIs). Becoming infected with any of these STIs can increase his HIV risk.

Is there any evidence that male circumcision can prevent the spread of HIV?

Since 2005, scientific studies in Kenya, South Africa, and Uganda have shown that men at risk of HIV who got circumcised had lower rates of HIV infection than men who did not get circumcised[2]. The circumcised men in these trials were 50 to 60 percent less likely to get HIV from having heterosexual sex. This does not mean that circumcised men cannot get or transmit HIV. It only means that they are about half as likely as uncircumcised men to get HIV from having vaginal sex with a woman who has HIV.

Trial data have not shown that circumcision makes a man less likely to transmit HIV to his partner through vaginal sex. In fact, one trial showed the opposite. This trial enrolled Ugandan married couples in which the husbands were HIV-positive and wives were HIV-negative. The wives of the men who got circumcised in this trial appeared to be at greater risk of getting HIV than the women married to uncircumcised men. The increased risk may have occurred when couples started having sex again before the skin on the man’s penis had fully healed (become keratinised) – a process that takes about six weeks. Trial data also do not show whether circumcision lowers the risk of transmission for either men or women during unprotected anal sex.

What is being done to promote male circumcision in the fight against HIV?

WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS) put out a report in 2007 saying that “the efficacy of male circumcision in reducing female to male HIV transmission has now been proven beyond reasonable doubt”.[3] Major funders are now actively promoting circumcision as part of a comprehensive HIV prevention package in the counties hardest hit by AIDS. They emphasise that it should only be done by well-trained medical professionals, since any surgery can be dangerous if it is done in an unclean setting or by an untrained person. They also note that circumcision should not replace the use of male or female condoms for HIV prevention. Some African countries have started adopting national policies that promote voluntary male circumcision as an HIV prevention tool for men.

What does male circumcision mean for women at high risk of HIV?

Male circumcision does not directly reduce HIV risk for individual women. In fact, if a newly circumcised man with HIV resumes sexual activity too soon after surgery, he may be more likely to transmit HIV to his partner.

But increasing circumcision in areas where it is currently uncommon will likely help women over time because:

  1. Circumcised men are less likely to become HIV infected than uncircumcised men. As circumcision rates in an area go up, HIV infection rates amongst men in that area should start to go down.
  2. With fewer men becoming HIV positive in a given community, a woman’s overall risk of being exposed to HIV through unprotected sex with a man in that community should also become less.

This should eventually result in a decrease in the rate of new HIV infections amongst women in that community. But it will take years to see if increasing circumcision rates really leads to this indirect benefit for women.

Benefits and concerns women have expressed regarding circumcision

Some potential benefits for women

Some pressing concerns

Increasing the number of circumcisions should decrease the number of men getting HIV, HSV2 and HPV. If fewer men are infected with these STIs, women’s risk of becoming infected with them will also decrease.

Circumcision can be promoted as part of a larger package of HIV prevention care and treatment.

The offer of circumcision may motivate men to access sexual and reproductive health care services, and risk reduction counselling.

UNAIDS guidelines direct circumcision programmes to monitor and minimise “potential harmful outcomes”, such as sexual violence, abandonment, and inaccurate beliefs about male circumcision and FGM.

If messages are not communicated clearly, some men may think they are no longer at risk of HIV. They may consequently increase their number of sexual partners and, thus, raise their risk of HIV.

If a man thinks he is protected from HIV, his female partner may have less ability to negotiate condom use or to refuse to have sex with him.

A woman’s risk of violence, stigma, and abandonment may be higher if she gets HIV when her partner thinks he is “immune” to HIV.

If circumcision is seen as “proof” of being HIV negative, men living with HIV, or who do not know their HIV status, may get circumcised and then refuse to use condoms.

Large-scale circumcision projects could divert resources from existing prevention, treatment, and women’s empowerment programmes.

What are the advocacy issues?

Given these concerns, women (HIV-positive and HIV-negative) must be meaningfully involved in developing policy and making decisions around circumcision programme planning and implementation, to ensure that:

  • Circumcision is part of a comprehensive HIV prevention package, not a stand-alone service for men.
  • Public messages regarding male circumcision are communicated very clearly.
  • Circumcision is part of a comprehensive HIV prevention package, not a stand-alone service for men.
  • Public messages regarding male circumcision are communicated very clearly. They must emphasise that male circumcision reduces—but does not eliminate—men’s HIV risk, and that circumcised men still need to use condoms to prevent HIV transmission.
  • Where FGC is pracised, girls and their parents are educated to understand the difference between FGC and male circumcision so that they do not assume that FGC could protect girls from HIV.
  • Resources are not diverted from existing HIV prevention, treatment, and women’s empowerment programmes and channeled into funding large-scale circumcision projects.
  • Circumcision programmes specifically monitor the “potential harmful outcomes” identified by WHO and take effective steps to minimise these harms if they are detected.
  • Community input is solicited on how the religious and cultural meanings of circumcision can incorporate the provision of medical male circumcision so that the procedure is culturally acceptable.
  • Women's voices are central in discussion of the ethics of promoting circumcision for infant boys.

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[1] World Health Organisation. Female Genital Mutilation: Key Facts. Online at http://www.who.int/mediacentre/factsheets/fs241/en/.

[2] Sawires S, Dworkin S, Fiamma A, et al. Male circumcision and HIV/AIDS: challenges and opportunities. The Lancet, Volume 369, Issue 9562, Pages 708-713, 24 February 2007.

[3] Joint United Nations Programme on HIV/AIDS. Safe, Voluntary, Informed Male Circumcision and Comprehensive HIV Prevention Programming: Guidance for decision-makers on human rights, ethical and legal considerations. Online at http://data.unaids.org/pub/Manual/2007/070613_humanrightsethicallegalguidance_en.pdf.