The preliminary findings of a five-country study exploring voluntary medical male circumcision and its implications for women are the subject of this newsletter article.
Male circumcision and women
Data from randomised clinical trials show that male circumcision can reduce men's risk of acquiring HIV from their female partners by about 60 percent. This intervention also has important implications for women. In the near term, much of this impact may relate to the ways that uptake of male circumcision for HIV prevention affects men’s sexual behaviours and assumptions about risk. There are currently no known direct benefits of male circumcision for women. The available data suggest that there are important indirect health benefits of male circumcision for women, in particular a reduced risk of exposure to HIV and other sexually transmitted infections. These indirect benefits would be longer term, emerging over time in communities where male circumcision is widely accepted.
It is critically important to develop male circumcision programmes that maximize benefits and minimize potential harms. Such potential harms include reductions in rates of condom use, increases in coercive sex, increased number of sex partners, and difficulties for women to negotiate safe sex or insist on condom use, particularly with a circumcised man. These harms may be most likely to emerge in the context of community or individual beliefs that male circumcision is completely protective against HIV, and therefore eliminates the need for other risk reduction strategies. This is one reason why male circumcision for HIV prevention must incorporate ongoing communications targeting both women and men.
Advocates, civil society, and other stakeholders are also interested in understanding and translating, at a community level, the potential indirect benefits to women of male circumcision. Scientific modelling studies to date suggest that expanded uptake of male circumcision for HIV prevention in specific epidemics will translate to an eventual reduction in HIV incidence and prevalence in women as they are exposed to fewer HIV-infected men. Such a shift would happen over a matter of years.
Additional potential indirect benefits for women come from strategies that use male circumcision programmes for HIV prevention to reach young men and their partners with information and services on HIV risk reduction, gender equity, contraception, and shared sexual decision-making.
The limited data on male circumcision, HIV infection and the impact on women leave important unanswered questions. A trial in the Rakai district of Uganda of male circumcision in HIV-positive men was halted early and did not have sufficient power to demonstrate any direct effects in their HIV-negative women partners. This study also found a trend suggesting that discordant couples (HIV-positive man, HIV-negative woman) who resumed sex before the recommended six weeks of abstinence were more likely to experience transmission of HIV to the female partner than those who delayed resumption of sex.
Due to the high incidence of HIV infection among women, particularly young women, it is important to assess potential risks and benefits of expansion of male circumcision programmes on women.
Some specific critical issues related to women include:
Messages around male circumcision, its risks and benefits; its place in the spectrum of proven prevention options; and its impact on women's ability to negotiate safer sex with stable and casual partners.
Impact of male circumcision on women's risk of acquiring HIV from circumcised, HIV-positive partners (who may or may not know their status and may or may not wait for full wound healing before resuming sexual activity).
Impact on men's behaviour, such as changes in rates of high-risk sex, coercive sex, and condom use.
Research on men's and women's sexual satisfaction and pleasure following male circumcision.
Impact of new male circumcision programmes on national- and community-level priority-setting around HIV prevention and on staff at health facilities who may be asked to add male circumcision to existing services.
Impact on women's involvement in pre-existing customs and/or cultural rituals involving male circumcision for neonates and/or for adolescent boys as a rite of passage.
The implications for women of the scale-up of voluntary medical male circumcision were the subject of the five email forums described in this report.
This poster summarises the results and conclusions of a civil society dialogue on male circumcision and its implications for women.
In June 2008, AVAC convened more than 35 civil society representatives—the majority of whom were women living with HIV in sub-Saharan Africa—to discuss the implications of male circumcision for HIV prevention.
Based on a meeting in 2008, this brief summarises what is known about the indirect health benefits of male circumcision for women and makes recommendations for determining the impact of scale-up on women.