Male circumcision is a surgical technique that has complex social, religious, cultural, and gender implications. The randomised clinical trials (RCT) confirming that voluntary medical male circumcision (VMMC) reduces men's risk of acquiring HIV through vaginal sex also collected data on social and behavioural aspects of the procedure. The introduction and scale-up of VMMC in priority countries in eastern and southern Africa has provided additional opportunities for social and behavioural research to understand how men and their partners experience VMMC and to guide demand generation and service delivery.

Acceptability and uptake

Research conducted before VMMC scale-up suggested that many men in communities that do not traditionally practice circumcision would be willing to be circumcised.1 As VMMC services were introduced in priority countries, researchers moved from assessing theoretical acceptability to examining reasons for adoption of male circumcision. The focus has been on understanding why men do or do not choose to become circumcised and using the study results to increase uptake.

A systematic review published in 2018 identified 23 studies providing empirical data on the factors that facilitate or impede VMMC uptake. The main facilitators of uptake in most countries were believing that VMMC reduces health risks and improves hygiene; family and peer support of VMMC; and expectations of enhanced sexual performance and satisfaction post-circumcision. The top barriers cited in most countries were that the procedure was perceived as being practiced by other or “foreign” cultures or religions; fear of pain; and believing that VMMC was not helpful or needed. However, differences between older and younger men and within and across countries revealed the need for more contextualized approaches to demand generation and programme design.2

In Zambia and Zimbabwe, researchers used an innovative behavioural-psychographic approach to characterize different audience segments among potential VMMC clients based on their needs, perceptions, attitudes, and behaviours toward the procedure. Seven segments were identified in Zambia and six in Zimbabwe, providing data to inform the design of more tailored interventions.3 

Sexual function and satisfaction

Studies have also addressed a range of concerns and beliefs about whether circumcision status affects sexual function and sexual pleasure. Participants in the RCT among 4,500 men in Uganda reported no meaningful changes in any aspect of sexuality studied pre- and post-circumcision. More than 98 percent of the men in both the intervention group and the comparison group rated their sexual satisfaction as "satisfied” or “very satisfied” six to 24 months after enrolling in the trial.4 The VMMC trial conducted among 2,684 men in Kenya also found no reported differences in sexual function between circumcised and uncircumcised men. Sixty-four percent of the circumcised men who were available for follow-up at 24 months reported greater penile sensitivity after circumcision, and 54 percent reported enhanced ease in reaching orgasm.5 

Several reviews have concluded that male circumcision is unlikely to have an adverse effect on sexual function.6,7,8 Most recently, a systematic review published in 2020 found a consensus among high- and medium-quality studies that male circumcision has no or minimal adverse effects on sexual function, sensation, satisfaction, and pleasure, with some studies reporting positive effects.8

Researchers have also explored whether the circumcision status of a male partner affects how women experience sex. A systematic review concluded that studies conducted in sub-Saharan Africa suggest having a circumcised partner does not reduce sexual satisfaction among female partners, but the data from other parts of the world are mixed.9 Another systematic review found that in most studies, women generally preferred sex with circumcised men, citing as reasons better appearance, better hygiene, reduced risk of infection, and enhanced sexual activity.10

Risk compensation

An important question for all partially protective HIV prevention strategies is whether individuals will increase their risk behaviours due to a false sense of security or protection. Such changes in behaviour in response to perceived changes in risk are known as "risk compensation."

The three RCTs of male circumcision for HIV prevention provided some data on this question. Male volunteers in the trials were asked about unprotected sex, numbers of sexual partners and sex acts, and other behaviours at baseline and throughout the studies. The Uganda trial found no evidence of risk compensation among circumcised men.11 In the South Africa trial, circumcised men did report having more sex compared to the uncircumcised men.12 And at the end of the Kenya trial, circumcised participants reported more unprotected sex acts than their uncircumcised counterparts did, but both groups were reporting less unprotected sex than they had at baseline.13

All the trial participants had been counselled that it was not known whether male circumcision would protect them against HIV. As VMMC services were scaled up and knowledge of their partially protective effect increased, additional studies investigated whether post-circumcision risk compensation was occurring.

A systematic review and meta-analysis on risk compensation published in 2021 identified 27 studies, including 24 conducted in sub-Saharan Africa. The authors found no statistically significant association between medical male circumcision and having condomless sex or multiple sex partners. They concluded that promoting male circumcision did not appear to be increasing higher-risk sexual behaviours among heterosexual men but emphasized that ongoing sexual education should be maintained as a vital component of effective VMMC programmes.14

Modelling research indicates that even if some element of risk compensation occurred, it would have to be substantial to offset the benefits of VMMC. One modelling study estimates that complete negation of those benefits would occur only if at least 40 percent of the circumcised men in a country significantly increased risky behaviour.15 Other modelling studies estimate that the benefits of VMMC would be offset only if the rate of sexual partner change doubled16 or if the rate of condomless sex rose by 50 percent.17 However, both of those studies found that lower levels of risk compensation could reduce the indirect HIV prevention benefits of male circumcision for women, underscoring the need for risk-reduction counselling for VMMC clients and their partners.16,17



  1. Westercamp N, Bailey RC. Acceptability of male circumcision for prevention of HIV/AIDS in sub-Saharan Africa: a review. AIDS Behav 2007;11(3):341–355.

  2. Carrasco MA, Wilkinson J, Kasdan B, Fleming P. (Abstract only) Systematic review of barriers and facilitators to voluntary medical male circumcision in priority countries and programmatic implications for service uptake. Glob Public Health 2019;14(1):91–111.

  3. Sgaier SK, Eletskaya M, Engl E, et al. A case study for a psychographic-behavioral segmentation approach for targeted demand generation in voluntary medical male circumcision. Elife 2017 Sep 13;6:e25923. doi: 10.7554/eLife.259.

  4. Kigozi G, Watya S, Polis CB, et al. (Abstract only) The effect of male circumcision on sexual satisfaction and function: results from a randomized trial of male circumcision for human immunodeficiency virus prevention, Rakai, Uganda. BJU Int 2008;101(1):65–70.

  5. Krieger JN, Mehta SD, Bailey RC, et al. (Abstract only). Adult male circumcision: effects on sexual function and sexual satisfaction in Kisumu, Kenya J Sex Med 2008;5(11):2610–22.

  6. Tian Y, Lie W, Wang J-Z, et al. Effects of circumcision on male sexual functions: a systematic review and meta-analysisAsian J Androl 2013;15(5):661–66.

  7. Yang Y, Wang X, Bai Y, Han P. Circumcision does not have an effect on premature ejaculation: a systematic review and meta-analysis. Andrologia 2018 Mar;50(2). doi: 10.1111/and.12851.

  8. Morris BJ, Krieger JN. The contrasting evidence concerning the effect of male circumcision on sexual function, sensation, and pleasure: a systematic review. Sex Med 2020;8(4):577–98 .

  9. Grund JM, Bryant JS, Toledo C, et al. Association of male circumcision with women's knowledge of its biomedical effects and with their sexual satisfaction and function: a systematic review. AIDS Behav 2019;23(5):1104–14.

  10. Morris BJ, Hankins CA, Lumbers ER, et al. Sex and male circumcision: women’s preferences across different cultures and countries: a systematic review. Sex Med 2019;7:145–61.

  11. Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet 2007;369(9562):657–66.

  12. Auvert B, Taljaard D, Lagarde E,et al. Randomized controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 trialPLoS Med 2005;2(11):e298.

  13. Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet 2007;369(9562):643–656

  14. Gao Y, Yuan T, Zhan Y, Qian H-Z, Sun Y. Association between medical male circumcision and sexual risk compensation among heterosexual men: a systematic review and meta-analysis. Lancet Glob Health 2021 Apr 30;S2214-109X(21)00102-9. doi: 10.1016/S2214-109X(21)00102–9.

  15. Londish GJ, Murray JM. Significant reduction in HIV prevalence according to male circumcision intervention in sub-Saharan AfricaInt J Epidemiol 2008;37(6):1246–253.

  16. Alsallaq RA, Cash B, Weiss HA, Longini Jr. IM, Omer SB, Wawer MJ, et al. Quantitative assessment of the role of male circumcision in HIV epidemiology at the population levelEpidemics 2009 Sep;1(3):139–52.

  17. Andersson KM, Owens DK, Paltiel AD. Scaling up circumcision programs in southern Africa: the potential impact of gender disparities and changes in condom use behaviors on heterosexual HIV transmission. AIDS Behav 2011;15(5):938–48.


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Systematic Design for Behavior Change: Discussing the Approach Applied to Voluntary Medical Male Circumcision

This case study describes the application of a human-centred design approach to encourage young men in Zambia and Zimbabwe to become circumcised.

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