Contextual Barriers and Motivators to Adult Male Medical Circumcision in Rakai,Uganda

Fear of possible medical complications

Fear of medical complications was mostly raised by decliners, on fewer occasions by community members, and never among acceptors. The most salient medical complication participants expressed concern about was sepsis: “To be cut? An old person to be cut, if I become septic, what do you do?” Other participants feared that circumcision would cause diseases, swelling, and deformities of the penis, as revealed in a focus group: “The penis can develop diseases and swelling as a result of circumcision. I cannot take it up.” In addition, participants were concerned that if they had other ailments they were not aware of, undergoing surgery might worsen or cause their health to deteriorate. On probing for further details about those ailments, a participant described them as endwadde z’ekisajja (male diseases):

There are several male diseases which might worsen once one is circumcised, and unfortunately many of us do not know whether we have them or not. This might make one get bedridden and fail to work, resulting into other sicknesses not acquired before to develop. All caused because one accepted to be circumcised.

Concerns about the possibility of male infertility

Some participants were concerned that circumcision might reduce fertility. Whereas decliners never mentioned this as one of their fears, there were strong perceptions among acceptors that men in their communities declined for fear that the procedure might lead to infertility. An interview participant stated, “Other people say that in the process of circumcision bakutta akasolo [they destroy the penis]. They want Uganda to stop producing children. The man’s sexual manhood reduces, meaning you cannot get a woman pregnant.”

Lack of empirical efficacy of MMC for HIV prevention

In many of the focus groups, especially with decliners and occasionally among acceptors, at least 1 or 2 participants wondered why a research study was needed, given that they (participants) knew a Muslim man or at least a circumcised man who either died of HIV or who was believed to have had HIV:

I know of a Muslim man. He died; it was silimu [HIV].

Sometimes we look at those who have been circumcised culturally or religiously and find that they also die of HIV/AIDS as much as us who are not circumcised. It causes me to wonder, if one has died yet he was circumcised when he was still young, me who is not circumcised, I become doubtful [about circumcision].

Participants’ beliefs about the lack of empirical efficacy were based on their knowledge that some people in their village had died or were considered to be HIV infected, yet they were presumed to be circumcised.

Time too long to wait before sex resumption

During the MMC trials in Rakai, we required men to abstain from intercourse after surgery until their wound had been certified (by a research clinician) as fully healed. This period generally lasted between 4 and 6 weeks (Kigozi et al., 2008). Many participants, particularly decliners, believed this period was too long for them to wait to resume sexual intercourse: “Again, as he said, you might find that some people say that they cannot live through this abstinence period. It could be that they are too greedy for sex.”

Time too long off work, leading to loss of income

Participants mentioned that the waiting time before resuming work was a deterrent to undergoing the procedure/enrolling in the trial. Waiting time could lead to loss of employment and/or income. Participants who mentioned this were either engaged in the informal sector (including operating a small market stall) or in formal employment (at institutions such as schools or armed forces). In one of the FGDs with decliners, a participant indicated,

I am a school truck driver at [school]. For that reason, my boss might want to go somewhere, so I have to work. Even for those who are self-employed, that day which he sacrifices or he is told to rest, he finds it hard to get what to eat.

Association of circumcision with Islam

Some participants reported that there were community members who worried that the goal of the circumcision program was to wipe out Christianity, because circumcision is traditionally associated with the Islamic faith:

They [some community leaders] look at this practice with a feeling that these people want to promote Islam. There is someone that I talked to. He asked how an old man like him could be circumcised into Islam. . . . They will soon wipe us [Christians] out in that way.

Prevention and treatment of STIs

In all focus groups with acceptors and in more than half of the interviews, participants mentioned either prevention and/or treatment of STIs as a reason for their acceptance of MMC. Many stated that health educators had alluded to this benefit; some indicated that they had made observations from among the people they knew as circumcised who were not as frequently affected by STIs, whereas others had been advised by their peers to consider MMC as a response to their “endless” STIs problems. This perceived efficacy contributed to acceptability of MMC:

The reasons which made me participate in this research . . . these colleagues who follow Islamic faith are required to be circumcised. . . . Basing on these colleagues, I saw it that their condition was admirable because they are not so easily attacked by diseases, especially ez’obukaba [STIs].

What made me join the circumcision trial—I used to be frequently attacked by infections like ekiwo [chancroid] and kabotongo [syphilis]. The penis used to bulge every time I had sex. When the ballot randomized me to immediate circumcision and they circumcised me, now am very okay.

Access to ancillary care

Participants and community members viewed enrolment into the trial as an opportunity to access free medical care; others considered circumcision itself a treatment or solution to their health problems. Diseases including back pain, leg pain, penile infections, and loss of sexual potency were commonly discussed. Participants sought free treatment for STIs and other ailments through the trial. Others felt that trial participation was a form of medical insurance in case they needed free treatment in the future. One man said, “Well me, what made me join Rakai Project circumcision research was largely because of free medical treatment . . . even another time, who knows, if I get sick, they will provide that treatment, free, free of charge.” Urban and rural acceptors and community members strongly and equally raised the incentive of free treatment for HIV, STIs, and other ailments as an incentive for MMC acceptance.

Penile/personal hygiene

Participants linked penile hygiene with “smelling of the body” and STIs. Most participants alluded to the challenges of having to bathe frequently because of limited access to water and modern facilities. Many felt that if one was circumcised he might not have to bathe so often:

At times people are lazy at bathing. It brings to them the issue of contracting the diseases [STIs] which might seem to be destructive to their bodies. If this prepuce is present and they get little time for bathing, it is not the same as those who do not have. If they have sex with a woman and just put on their trousers without minding to bathe, the disease which would have easily been gotten rid of gets a hiding place and infects the penis.

Peer influence

Peer influence was mentioned in about half of the interviews and focus groups, and was more commonly mentioned by participants aged less than 20 years:

What influenced me . . . was Joel. I was with Joel one day. Joel is the one who forced me [laughter] to bring him [Joel] here [Rakai offices]. I found out that there was something. [Laughter] I joined the seminars and I learned something. . . . I also accepted and participated in it.

Desire to contribute to HIV-prevention research

In about half the focus groups with acceptors, participants said they simply wanted to contribute to HIV prevention research and the good of their communities. Approximately one third of interview participants alluded to this altruistic motivation, as well. In this respect, some said they had been part of RHSP research for so long, and just wanted to continue contributing: “I only wanted to participate in this research because it could be of some help in the future and the future generation; tomanya [you never know].”

Financial incentives

All trial participants were given transport compensation and the equivalent of approximately US$2 as compensation for each day they spent at the research site. They also received approximately US$15 for time lost during the surgery and postoperative recovery period. Compensation for time and transportation were procedures approved by the CAB and IRBs. Most participants who mentioned financial compensation as a motivator stated this was true for others, but not for themselves. Decliners frequently reported that acceptors were motivated by financial compensation. Older acceptors reported that their younger counterparts could have been attracted by money, and vice versa:

There are others who had come because of the financial incentives. But as an individual, it was because of my health. And even at this time I usually go to Rakai and get tested to know my health status. I have the [trial appointment] cards as well. Might be the youths needed money. For me, no.

Therapeutic misconception

The trials’ communication protocols emphasized that the efficacy of MMC for HIV prevention had not been proven. Despite this, some participants, particularly acceptors, mentioned that they joined the trial because they believed circumcision would prevent them from getting HIV infection. Prevention was mostly discussed in the context of other STIs and sometimes in the context of unhygienic circumstances. One participant stated, “What influenced men, including myself, was to prevent diseases I told you about—diseases like AIDS, syphilis, and sexually transmitted diseases. And I think my friend thinks like me.”

HIV testing and counseling

Across participants, HTC was more of a motivator than a barrier to MMC. Both decliners and acceptors viewed circumcision as an opportunity to access HTC and subsequently HIV care and treatment if needed. Acceptors were more spontaneous in raising HTC as a motivator than decliners. One participant revealed,

I wanted to know how I was standing. My basirikale [antibodies] had been depleted long time ago. . . . I did not know. When I turned up, I was told the news [that I was HIV positive]. I was also given medication. It’s why I came.

Nevertheless, some participants saw HTC as a barrier to MMC. During the trials, all participants in the trial sponsored by the U.S. National Institutes of Health were required to receive HIV test results and posttest counseling; however, participants in the trial sponsored by the Bill and Melinda Gates Foundation were free to decline receipt of results. Both MMC acceptors and decliners raised HTC as a barrier to circumcision, but decliners raised it as a barrier more than acceptors. Echoing comments made in almost all focus groups with decliners, one interview participant explained,

You have to get your blood tested to establish whether you are positive or negative for HIV. It is one other important issue that they fear a lot. Most people in the villages fear learning that truly they are sick; indeed, they fear this.

Partner influence

The influence of one’s female sexual partner toward MMC featured commonly as a barrier and occasionally as a motivator. This was contrary to our initial assumption that women would be supportive of MMC. Men reported that their female partners expressed concern that husbands might have more sexual partners as a result of perceived protection from circumcision: “They [women] think that as a man, you will become increasingly promiscuous, sleeping around, but if you do not involve in such [MMC], you might protect yourself by being faithful as you have been before.” Men were also concerned about the possibility that their spouses would become sexually involved with other men during the wound-healing abstinence period:

I hear the period you have to wait [before resuming sex] is long . . . you might get your wife into problems when she needs sex and she chooses to go in for sex with some other person. This one also fails us.

Partner influence was sometimes cited as a motivator for MMC, especially among acceptors. Some of those who raised sexual partner influence stated that either their partner was Muslim, or just liked a circumcised penis, or that it was more enjoyable to have sex with a circumcised man. One participant felt that most women actually preferred circumcision:

Every woman that I have seen or talked with wants a man who is circumcised. . . . I cannot see how one can refuse [woman stopping the husband]. They [women] enjoy so much during that activity with her husband who is circumcised; far more than with one who is not circumcised.

Fear of loss of sexual potency

The perception that MMC improved or restored sexual potency was commonly reported. Local terms frequently used to describe it included amaanyi (sexual strength, sexual power, stamina). Often, lack of or deterioration of sexual potency was connected with being omulwadde wa kabotongo (syphilitic). Syphilis has a long history in Buganda as a nonstigmatizing disease, with many regarding it as a disease of the lineage. Kabotongo is implicated in causing sexual impotency or loss of sexual power. Many participants felt that circumcision would override the effect of kabotongo by restoring sexual strength:

A circumcised man has sexual power. I could say that if I am not circumcised, I cannot be okay, sirina manyi [I lack power]. I have to go to the Muslims to get circumcised because circumcision will increase his sexual potency.

However, participants were more likely to associate MMC or anesthesia for MMC with loss of sexual potency (and therefore a barrier) than with improvement in sexual potency (and therefore a motivator). Local terms meaning “loss of manhood,” “fire disappears,” and “weak man” were used to describe decreased sexual potency: “People say that these injections [for anesthesia] might cause someone to lose his sexual manhood.” “I know that by getting circumcised my fire disappears [laughter].”