Condom avoidance not a motivation for circumcision among blacks and coloured in Johannesburg

The protection circumcision provides against HIV will be a major motivation for South Africans to seek the procedure, a study published in Health Policy and Planning suggests. Study participants were generally “repulsed” by the suggestion that circumcision would provide an alternative to consistent condom use. However, individuals of white race found this suggestion attractive.

“Our study…shows that demand for circumcision is largely determined by the perceived benefits of reduced HIV/STI transmission,” comment the investigators. They add, “condom avoidance is not perceived as a benefit of circumcision.”

Three randomised controlled trials have shown that circumcised men have a low risk of infection with HIV than uncircumcised men. The World Health Organization (WHO) recommends that male circumcision programmes should form part of comprehensive HIV prevention strategies in high prevalence countries.

Kenya has rolled out a national circumcision programme. However, despite having a high HIV incidence, South Africa has yet to adopt a policy of promoting male circumcision. This is partly because of concern that the promotion of circumcision could undermine other HIV prevention efforts, especially consistent condom use.

A team of investigators from South Africa and the US wanted to see which factors would motivate individuals to seek circumcision, and if there was a perception that circumcision would mean that men would not need to use condoms.

The study was conducted in Johannesburg and involved individuals from the main racial groups: black, coloured and white.

Its population included “decision makers” about circumcision: 403 mothers and fathers. It also included 237 sons aged between 14 and 30 who were uncircumcised. Of the 201 fathers who completed the study, 94 were circumcised. This included 40% of black participants, 33% of coloured fathers and 21% of whites.

Participants were interviewed to see what would motivate them to seek circumcision, and if circumcision would lead to condom avoidance.

Factors that would motivate individuals to seek circumcision were:

• Reduced risk of infection with HIV (p< 0.001)

• Reduced risk of sexually transmitted infections (p < 0.001)

• Hygiene (p < 0.05)

• Improved sexual performance (p < 0.05).

Significant racial differences were apparent. Coloured participants were the only group who identified a reduced risk of cervical cancer in sex partners as a motivation for circumcision. Black participants were the only group who focused on the reduced risk of sexually transmitted infections.

In addition, the reasons why fathers would be motivated to seek circumcision for their sons varied according to their own circumcision status.  Circumcised fathers would seek circumcision for their sons because they believed it would provide protection against sexually transmitted infections (p = 0.02) and HIV (p < 0.001). Uncircumcised fathers did not have these motivations.

Similarly, circumcised fathers would be motivated to have their sons circumcised because of its perceived hygienic benefits (p = 0.05), but uncircumcised fathers did not find this an attractive benefit of the procedure. 

Overall, the suggestion that circumcision would reduce the need for condoms was rejected.

But racial differences were apparent. Black and coloured participants were strongly repulsed (p < 0.001) by this suggestion. However, white respondents found it attractive (p = 0.04).

Sons aged under 18 found the suggestion that circumcision reduced the need to use condoms somewhat attractive, but not significantly so (p = 0.15).

“We conclude that the implementation of a national male circumcision programme in South Africa should not be delayed over concerns about its potential impact on condom avoidance,” write the researchers.

However, they stress that any such programme must “take into account that whites may value circumcision as a means to avoid subsequent condom use”.