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Luseno WK, Rennie S, Gilbertson A. A review of public health, social and ethical implications of voluntary medical male circumcision programs for HIV prevention in sub-Saharan Africa. Int J Impot Res 2023; 35:269-278. [PMID: 34702986 PMCID: PMC8545773 DOI: 10.1038/s41443-021-00484-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 10/06/2021] [Accepted: 10/13/2021] [Indexed: 12/22/2022]
Abstract
Ideally, the benefits of public health interventions should outweigh any associated harms, burdens, and adverse unintended consequences. The intended benefit of voluntary medical male circumcision (VMMC) programs in eastern and southern Africa (ESA) is the reduction of HIV infections. We review the literature for evidence of reductions in HIV incidence, evaluate the extent to which decreases in HIV incidence can be reasonably attributed to VMMC programs, and summarize social harms and ethical concerns associated with these programs. Review findings suggest that HIV incidence had been declining across ESA since before the large-scale rollout of VMMC as a public health intervention, and that this decline may be due to the combined effects of HIV prevention and treatment interventions, such as expanded antiretroviral therapy. The independent effect of VMMC programs in reducing HIV infections at the population level remains unknown. On the other hand, VMMC-associated evidence is increasing for the existence of negative social impacts such as stigmatization and/or discrimination, and ethically problematic practices, including lack of informed consent. We conclude that the relationship between the benefits and burdens of VMMC programs may be more unfavorable than what has been commonly suggested by proponents of global VMMC campaigns.
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Affiliation(s)
| | - Stuart Rennie
- Department of Social Medicine, University of North Carolina, Chapel Hill, NC, USA
- UNC Center for Bioethics, University of North Carolina, Chapel Hill, NC, USA
| | - Adam Gilbertson
- Pacific Institute for Research and Evaluation (PIRE), Chapel Hill, NC, USA
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2
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Rosen JG, Carrasco MA, Traub AM, Kumoji E‘K. Barriers, benefits, and behaviour: Voluntary medical male circumcision ideation in a population-based sample of Zambian men. AFRICAN JOURNAL OF AIDS RESEARCH : AJAR 2021; 20:314-323. [PMID: 34905454 PMCID: PMC8994851 DOI: 10.2989/16085906.2021.2006727] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Reaching ambitious voluntary medical male circumcision (VMMC) coverage targets requires a deeper understanding of the multifaceted processes shaping men's willingness to access VMMC. Guided by the Ideation Model for Health Communication, this population-based study identifies correlates of Zambian men's future VMMC intentions. Multistage cluster sampling was used to identify households with adult men in 14 districts. Multivariable Poisson regression with robust standard errors modelled associations of future VMMC intent with ideational factors (e.g. perceived benefits and barriers) and sexual behaviours respectively. Forty per cent (40%) of uncircumcised men (N = 1 204) expressed future VMMC intentions. In multivariable analysis, VMMC intent was associated with secondary education or higher (Adjusted Prevalence Ratio [APR] 1.30, 95% Confidence Interval [95% CI]: 1.02-1.66), perceiving VMMC to increase sexual satisfaction (APR 1.45, 95% CI: 1.11-1.89), reporting distance to services as a barrier to VMMC uptake (APR = 0.54, 95% CI: 1.27-1.87), unprotected last sex (APR 1.54, 95% CI: 1.11-2.14), and ≥ 2 sexual partners in the past 12 months (APR 1.45, 95% CI: 1.05-1.99). Being aged ≥ 45 years (vs 18-24 years: APR 0.23, 95% CI: 0.13-0.40) and perceiving that circumcision: (1) is unimportant (APR 0.71, 95% CI: 0.51-0.98); (2) is incompatible with local customs (APR 0.41, 95% CI: 0.18-0.94); or (3) reduces sexual satisfaction (APR 0.10, 95% CI: 0.02-0.62) were inversely associated with future VMMC intent. Demand-creation efforts must confront salient cognitive and social barriers to VMMC uptake, including concerns around incompatibility with local customs. Simultaneously, promotional efforts should emphasise relevant VMMC benefits beyond HIV prevention that resonate with men (e.g. penile hygiene) without reinforcing harmful gender norms.
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Affiliation(s)
- Joseph G Rosen
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Maria A Carrasco
- Office of Family Planning and Reproductive Health, United States Agency for International Development, Washington DC, USA
| | - Ariana M Traub
- Office of HIV/AIDS, United States Agency for International Development, Washington DC, USA
| | - E ‘Kuor Kumoji
- Research and Evaluation Division, Johns Hopkins Center for Communication Programs, Baltimore, USA
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Tseng PC. Subordinated agency: Negotiating the biomedicalisation of masculinity among gay men living with HIV. SOCIOLOGY OF HEALTH & ILLNESS 2021; 43:1486-1500. [PMID: 34170515 DOI: 10.1111/1467-9566.13322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 05/29/2021] [Accepted: 06/02/2021] [Indexed: 06/13/2023]
Abstract
Health practices are shaped by gender relations and constructs. Utilising qualitative data, this study explores a shift in medication practices among gay men living with HIV (GMLH) in light of changing HIV/AIDS responses in Taiwan. In the 1980s and 1990s, the mobilisation of moralising discourses forged a gender hierarchy that subordinated HIV-positive gay males. In the 2000s, new state programmes on HIV/AIDS were implemented to enhance patients' adherence to treatment, but GMLH often expressed ambivalence towards medication, which could lead to HIV disclosure and, consequently, social exclusions under the gender hierarchy. Starting in the 2010s, the knowledge of HIV 'treatment as prevention' and a policy on early treatment have offered a new path for GMLH to navigate gender power dynamics and to strive towards an inclusive social life by taking medicine and optimising health, which facilitates a biomedicalisation of subordinated masculinity. This study contributes to the scholarship on HIV/AIDS by underscoring the significance of biomedicine for configuring masculine identities and practices among a subordinated group of men, as well as by highlighting the gender power relations and everyday 'nonbiomedical' negotiating practices that legitimise biomedicalisation.
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Affiliation(s)
- Po-Chia Tseng
- Department of Sociology, University of Illinois at Urbana-Champaign, Urbana, IL, USA
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Rennie S, Gilbertson A, Hallfors D, Luseno WK. The Ethics of Stigma in Medical Male Circumcision Initiatives Involving Adolescents in Sub-Saharan Africa. Public Health Ethics 2021; 14:79-89. [PMID: 34239604 DOI: 10.1093/phe/phab004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Ongoing global efforts to circumcise adolescent and adult males to reduce their risk of acquiring HIV constitute the largest public health prevention initiative, using surgical means, in human history. Voluntary medical male circumcision (VMMC) programs in Africa have significantly altered social norms related to male circumcision among previously non-circumcising groups and groups that have practiced traditional (non-medical) circumcision. One consequence of this change is the stigmatization of males who, for whatever reason, remain uncircumcised. This paper discusses the ethics of stigma with regard to uncircumcised adolescent males in global VMMC programs, particularly in certain recruitment, demand creation and social norm interventions. Grounded in our own experiences gained while conducting HIV-related ethics research with adolescents in Kenya, we argue that use of explicit or implicit stigma to increase the number of VMMC volunteers is unethical from a public health ethics perspective, particularly in campaigns that leverage social norms of masculinity. Ongoing global efforts to circumcise adolescent and adult males to reduce their risk of acquiring HIV constitute the largest public health prevention initiative, using surgical means, in human history. VMMC programs in Africa have significantly altered social norms related to male circumcision among previously non-circumcising groups and groups that have practiced traditional (non-medical) circumcision. One consequence of this change is the stigmatization of males who, for whatever reason, remain uncircumcised. This paper discusses the ethics of stigma with regard to uncircumcised adolescent males in global VMMC programs, particularly in certain recruitment, demand creation and social norm interventions. Grounded in our own experiences gained while conducting HIV-related ethics research with adolescents in Kenya, we argue that use of explicit or implicit stigma to increase the number of VMMC volunteers is unethical from a public health ethics perspective, particularly in campaigns that leverage social norms of masculinity.
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Ledikwe JH, Mawandia S, Kleinman NJ, Ntsuape C, Ramabu NM, Semo BW, Wirth KE. Voluntary Medical Male Circumcision and Perceived Sexual Functioning, Satisfaction, and Risk Behavior: A Qualitative Study in Botswana. ARCHIVES OF SEXUAL BEHAVIOR 2020; 49:983-998. [PMID: 31997131 DOI: 10.1007/s10508-019-01589-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 11/07/2019] [Accepted: 11/12/2019] [Indexed: 06/10/2023]
Abstract
This article examines perceptions of sexual functioning, satisfaction, and risk-taking related to voluntary medical male circumcision (VMMC) in Botswana. Twenty-seven focus group discussions were conducted in four purposively selected communities with community leaders, men, and women. Discussions were analyzed using an inductive content analytic approach. Perceptions of VMMC's impact on sexual functioning and satisfaction varied. Increased satisfaction was attributed to improved penile health and increased ejaculatory latency time, whereas decreased satisfaction was attributed to erectile dysfunction and increased vaginal irritation during sex. Most participants thought sexual disinhibition occurred after circumcision; nevertheless, some women said they used male circumcision status as a marker of HIV status, thereby influencing sexual decision-making and partner selection. Messaging should emphasize that VMMC does not afford complete HIV protection. Optimizing VMMC's impact requires increasing uptake while minimizing behavioral disinhibition, with a balance between potential messaging of improved sexual functioning and satisfaction and the potential impact on sexual disinhibition.
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Affiliation(s)
- Jenny H Ledikwe
- Department of Global Health, University of Washington, Seattle, WA, 98104, USA.
- Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana.
| | - Shreshth Mawandia
- Department of Global Health, University of Washington, Seattle, WA, 98104, USA
- Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana
| | - Nora J Kleinman
- Department of Global Health, University of Washington, Seattle, WA, 98104, USA
- Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana
- NJK Consulting, Seattle, WA, USA
| | - Conrad Ntsuape
- Department of HIV/AIDS Prevention and Care, Botswana Ministry of Health and Wellness, Gaborone, Botswana
| | - Nankie M Ramabu
- Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana
| | - Bazghina-Werq Semo
- Department of Global Health, University of Washington, Seattle, WA, 98104, USA
- Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana
| | - Kathleen E Wirth
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Botswana-Harvard School of Public Health AIDS Initiative Partnership for HIV Research and Education, Gaborone, Botswana
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Wiginton JM, Fleming PJ, Barrington C, Donastorg Y, Lerebours L, Brito MO. Masculine gender norms, male circumcision, and men's engagement with health care in the Dominican Republic. Glob Public Health 2019; 15:654-665. [PMID: 31874065 DOI: 10.1080/17441692.2019.1704817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Overall, adult men are less likely to seek and receive health care than women, but male circumcision for HIV prevention has been successful in engaging men in health services. The purpose of this paper is to examine the relationship between masculine norms and health care-seeking among men participating in a voluntary male medical circumcision (VMMC) programme in the Dominican Republic (DR). We employed a mixed methods approach integrating survey data collected 6-12 months post-circumcision (n = 293) and in-depth interviews with a sub-sample of these men (n = 30). In our qualitative analysis, we found that health care-seeking is connected to masculine norms among men in the DR, including the perceptions of medical facilities as feminine spaces. Participants' narratives demonstrate that male circumcision programmes may facilitate men overcoming masculinity-related barriers to health care engagement. In quantitative analysis, we found that being concerned about being perceived as masculine was associated with health care-seeking behaviour in the past five years, though this association was not retained in multivariable analyses. Findings indicate that male circumcision programmes can familiarise men with the healthcare system and masculinise health care-seeking and utilisation, easing associated discomfort.
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Affiliation(s)
- John Mark Wiginton
- Department of Health, Behavior and Society, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Paul J Fleming
- Department of Health Behavior & Health Education, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Clare Barrington
- Department of Health Behavior, Gillings School of Global Public HealthUniversity of North Carolina, Chapel Hill, NC, USA
| | - Yeycy Donastorg
- HIV Vaccine Trials Unit, Instituto Dermatológico y Cirugía de Piel, Santo Domingo, Dominican Republic
| | - Leonel Lerebours
- Centers for Disease Control and Prevention, Santo Domingo, Dominican Republic
| | - Maximo O Brito
- Division of Infectious Diseases, University of Illinois at Chicago, Chicago, IL, USA
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Fleming PJ, Barrington C, Maman S, Lerebours L, Donastorg Y, Brito MO. Competition and humiliation: how masculine norms shape men's sexual and violent behaviors. MEN AND MASCULINITIES 2019; 22:197-215. [PMID: 31190723 PMCID: PMC6561655 DOI: 10.1177/1097184x17715493] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
We use data collected from in-depth interviews with men (n=30) in the Dominican Republic to explore how men's concern about being perceived as masculine influences their interactions with their social networks and how those interactions drive men's sexual behaviors and use of violence. Men's sexual and violent behaviors were shaped by the need to compete with other men for social status. This sense of competition also generated fear of humiliation for failing to provide for their families, satisfy sexual partners, or being openly disrespected. In an effort to avoid humiliation within a specific social group, men adapted their behaviors to emphasize their masculinity. Additionally, men who were humiliated recouped their masculinity by perpetrating physical or emotional violence or finding new sexual partners. These findings emphasize the need for understanding these social dynamics to better understand men's violent and sexual behaviors.
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Affiliation(s)
- Paul J Fleming
- Department of Health Behavior & Health Education University of Michigan School of Public Health 1415 Washington Heights Ann Arbor, MI 48109-2029
| | - Clare Barrington
- Department of Health Behavior Gillings School of Global Public Health University of North Carolina 302 Rosenau Hall Chapel Hill, NC, USA 27599-0304
| | - Suzanne Maman
- Department of Health Behavior Gillings School of Global Public Health University of North Carolina 302 Rosenau Hall Chapel Hill, NC, USA 27599-0304
| | - Leonel Lerebours
- Clinica de Familia Calle Gastón Fernando Delignes #68 La Romana, Dominican Republic
| | - Yeycy Donastorg
- HIV Vaccine Trials Unit Instituto Dermatológico y Cirugía de Piel Santo Domingo, Dominican Republic
| | - Maximo O Brito
- Division of Infectious Diseases University of Illinois at Chicago 808 S. Wood St. (MC 735) Rm 888 Chicago, IL, USA 60612
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Carrasco MA, Wilkinson J, Kasdan B, Fleming P. Systematic review of barriers and facilitators to voluntary medical male circumcision in priority countries and programmatic implications for service uptake. Glob Public Health 2018; 14:91-111. [PMID: 29695201 DOI: 10.1080/17441692.2018.1465108] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Voluntary medical male circumcision (VMMC) is an effective biomedical HIV prevention strategy. There is a need to identify key barriers and facilitators to VMMC uptake in priority countries to improve uptake. In this paper, we report findings from a systematic review of the barriers and facilitators of VMMC uptake, comparing them across countries in order to provide programmers critical information to design effective VMMC uptake interventions. Our review followed PRISMA protocol. Twenty three articles from 10 of the 14 priority countries were included. The top three barriers cited were: MC negatively perceived as being practiced by other or foreign cultures and religions, fear of pain caused by the procedure, and perceptions of VMMC as not helpful/needed. The top four facilitators cited in most countries were: Belief that VMMC reduces health risks and improves hygiene, family and peer support of MC, and enhanced sexual performance and satisfaction. The barriers and facilitators highlighted in this paper can help inform programmatic strategies in these countries. More research is needed to ensure that all sub-populations are being adequately reached. By applying this information to new research and programming, these countries can achieve greater VMMC uptake - and thus reductions in HIV transmission and prevalence.
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Affiliation(s)
- Maria A Carrasco
- a Department of Health, Behavior and Society , Johns Hopkins Bloomberg School of Public Health , Baltimore , USA.,b Office of HIV/AIDS, United States Agency for International Development , Washington, DC , USA
| | - Jessica Wilkinson
- b Office of HIV/AIDS, United States Agency for International Development , Washington, DC , USA
| | - Benjamin Kasdan
- b Office of HIV/AIDS, United States Agency for International Development , Washington, DC , USA
| | - Paul Fleming
- c Department of Health Behavior and Health Education , University of Michigan School of Public Health , Ann Arbor , USA
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Fleming PJ, Barrington C, Powell W, Gottert A, Lerebours L, Donastorg Y, Brito MO. The Association Between Men's Concern About Demonstrating Masculine Characteristics and Their Sexual Risk Behaviors: Findings from the Dominican Republic. ARCHIVES OF SEXUAL BEHAVIOR 2018; 47:507-515. [PMID: 27844313 PMCID: PMC5429985 DOI: 10.1007/s10508-016-0880-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 10/08/2016] [Accepted: 10/12/2016] [Indexed: 06/06/2023]
Abstract
Quantitative analyses exploring the relationship between masculinities and men's sexual risk behaviors have most commonly used one dimension of masculinities: men's gender ideology. Examining other dimensions may enhance our understanding of and ability to intervene upon this relationship. In this article, we examined the association between gender role conflict/stress (GRC/S)-men's concern about demonstrating masculine characteristics-and three different sexual risk behaviors (having two or more sex partners in the last 30 days; never/inconsistent condom use with non-steady partners; and drinking alcohol at last sex) among a sample of heterosexual men in the Dominican Republic who were participating in an HIV prevention intervention (n = 293). The GRC/S Scale we used was adapted for this specific cultural context and has 17 items (α = 0.75). We used logistic regression to assess the relationship between GRC/S and each sexual behavior, controlling for sociodemographic characteristics. In adjusted models, a higher GRC/S score was significantly associated with increased odds of having two or more sex partners in the past 30 days (AOR 1.33, 95 % CI 1.01-1.74), never/inconsistent condom use with non-steady partners (AOR 1.45, 95 % CI 1.04-2.01), and drinking alcohol at last sex (AOR 1.56, 95 % CI 1.13-2.17). These results highlight the importance of expanding beyond gender ideology to understanding the influence of GRC/S on men's sexual risk behaviors. Interventions should address men's concern about demonstrating masculine characteristics to reduce the social and internalized pressure men feel to engage in sexual risk behaviors.
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Affiliation(s)
- Paul J Fleming
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI, 48109-2029, USA.
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA.
| | - Clare Barrington
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Wizdom Powell
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | | | | | - Yeycy Donastorg
- HIV Vaccine Trials Unit, Instituto Dermatológico y Cirugía de Piel, Santo Domingo, Dominican Republic
| | - Maximo O Brito
- Division of Infectious Diseases, University of Illinois at Chicago, Chicago, IL, USA
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Hudson FP, Miller WC, Rao S, Agot K, Thirumurthy H. Prevalence and Predictors of Uncircumcised, Kenyan Men's Desire for Circumcision for Their Infant Sons. AIDS Behav 2018; 22:471-478. [PMID: 28101789 DOI: 10.1007/s10461-017-1681-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Men are key decision makers for their son's circumcision, so understanding their beliefs is important for the uptake of early infant male circumcision in countries in sub-Saharan Africa that have high HIV prevalence. We analyzed men's preferences for circumcising their sons using data from a population-representative survey of 1501 uncircumcised men aged 25-49 years in western Kenya. Most men (59%) reported they would "definitely" want their son circumcised if a son was born to them within the next year. However, only 25% intended to become circumcised themselves. In multivariable Poisson regression models to estimate prevalence ratios, key predictors of the desire to circumcise their sons included knowledge that circumcision reduces HIV acquisition, having a supportive partner, discussing circumcision with the partner, altruism, and intention to be circumcised himself. Focusing on partner dynamics may have the greatest capacity to increase demand since 55% had not talked to their partner about circumcision.
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Affiliation(s)
- F Parker Hudson
- Department of Internal Medicine, Dell Medical School, University of Texas at Austin, 1912 Speedway, SZB 546.05, Austin, TX, 78712, USA.
- Institute for Global Health and Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - William C Miller
- Institute for Global Health and Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Samwel Rao
- Impact Research and Development Organization, Kisumu, Kenya
| | - Kawango Agot
- Impact Research and Development Organization, Kisumu, Kenya
| | - Harsha Thirumurthy
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Exploring drivers for safe male circumcision: Experiences with health education and understanding of partial HIV protection among newly circumcised men in Wakiso, Uganda. PLoS One 2017; 12:e0175228. [PMID: 28362880 PMCID: PMC5376336 DOI: 10.1371/journal.pone.0175228] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 03/22/2017] [Indexed: 01/01/2023] Open
Abstract
Introduction About 2.5 million men have voluntarily been circumcised since Uganda started implementing the WHO recommendation to scale up safe male circumcision to reduce HIV transmission. This study sought to understand what influences men's circumcision decisions, their experiences with health education at health facilities and their knowledge of partial HIV risk reduction in Wakiso district. Methods Data were collected in May and June 2015 at five public health facilities in Wakiso District. Twenty-five in-depth interviews were held with adult safe male circumcision clients. Data were analysed using thematic network analysis. Findings Safe male circumcision decisions were mainly influenced by sexual partners, a perceived need to reduce the risk of HIV/STIs, community pressure and other benefits like hygiene. Sexual partners directly requested men to circumcise or indirectly influenced them in varied ways. Health education at facilities mainly focused on the surgical procedure, circumcision benefits especially HIV risk reduction, wound care and time to resumption of sex, with less focus on post-circumcision sexual behaviour. Five men reported no health education. All men reported that circumcision only reduces and does not eliminate HIV risk, and could mention ways it protects, although some extended the benefit to direct protection for women and prevention of other STIs. Five men thought social marketing messages were ‘misleading’ and feared risk compensation within the community. Conclusions Participants reported positive community perception about safe male circumcision campaigns, influencing men to seek services and enabling female partners to impact this decision-making process. However, there seemed to be gaps in safe male circumcision health education, although all participants correctly understood that circumcision offers only partial protection from HIV. Standard health education procedures, if followed at health facilities offering safe male circumcision, would ensure all clients are well informed, especially about post-circumcision sexual behaviour that is key to prevention of risk compensation.
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Fleming PJ, DiClemente RJ, Barrington C. Masculinity and HIV: Dimensions of Masculine Norms that Contribute to Men's HIV-Related Sexual Behaviors. AIDS Behav 2016; 20:788-98. [PMID: 26696261 PMCID: PMC4799765 DOI: 10.1007/s10461-015-1264-y] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Numerous studies have documented a relationship between masculine norms and men's HIV-related sexual behaviors, but intervening upon this relationship requires a nuanced understanding of the specific aspects of masculine norms that shape men's sexual behaviors. We integrate theories on masculinities with empirical HIV research to identify specific dimensions of masculine norms that influence men's HIV-related sexual behaviors. We identify three major dimensions of masculine norms that shape men's sexual behavior: (1) uncontrollable male sex drive, (2) capacity to perform sexually, and (3) power over others. While the existing literature does help explain the relationship between masculine norms and men's sexual behaviors several gaps remain including: a recognition of context-specific masculinities, an interrogation of the positive influences of masculinity, adoption of an intersectional approach, assessment of changes in norms and behaviors over time, and rigorous evaluations of gender-transformative approaches. Addressing these gaps in future research may optimize prevention efforts.
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Affiliation(s)
- Paul J Fleming
- Division of Global Public Health, University of California, San Diego, 9500 Gilman Drive MC 0507, La Jolla, CA, 92093, USA.
| | - Ralph J DiClemente
- Department of Behavioral Sciences and Health Education, Emory University, Atlanta, GA, USA
- Center for AIDS Research, Prevention Sciences & Epidemiology Core, Atlanta, GA, USA
| | - Clare Barrington
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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