Print version ISSN 0043-3144
West Indian med. j. vol.59 no.4 Mona July 2010
Actitudes hacia la circuncisión masculina entre los asistentes a la Clínica de Infecciones transmitidas sexualmente en Kingston, Jamaica
JP Figueroa; C Jones Cooper
Department of Community Health and Psychiatry, The University of the West Indies, Kingston, Jamaica and Epidemiology and Research Training Unit, 55 Slipe Pen Road, Kingston, Jamaica
OBJECTIVE: To describe the attitudes of Sexually Transmitted Infection (STI) clinic attendees towards male circumcision.
DESIGN AND METHODS: A convenience sample of attendees at the main STI clinic in Kingston was interviewed using a structured questionnaire in June 2008.
RESULTS: One-hundred men and 98 women were interviewed. Over 90% of the men were not circumcised. Although 60% of men and 67% of women reported that they had heard of circumcision, the research nurse assessed that 28% of men and 40% of women actually understood what circumcision was. When asked about the benefits of circumcision, 32% of men and 41.8% of women said that circumcision makes it easier to clean the penis while 13% of men and 20.4% of women said that circumcision lessens the likelihood of STI. Twenty-two per cent of men and 13.3% of women said that the foreskin offers protection while 18% of men and 10.2% of women said that the penis looks more attractive when uncircumcised. When informed that research showed that circumcision reduced the risk of HIV, 35% of men said that they were willing to be circumcised and 67.3% of women said that they would encourage their spouse to be circumcised (p < 0.001) while 54% of men and 72.4% of women said that they would circumcise their sons (p = 0.057).
CONCLUSION: Knowledge of circumcision and its benefits were limited among STI clinic attendees. Significantly more women than men were in favour of circumcision when informed that it reduced the risk of HIV infection.
Key word: Attitudes, HIV prevention, Jamaica, male circumcision, STI attendees.
OBJETIVO: Describir las actitudes de los asistentes a la clínica de infecciones de transmisión sexual (ITS) hacia la circuncisión masculina.
DISEÑO Y MÉTODOS: Una muestra de conveniencia de asistentes a la clínica principal de ITS en Kingston fue encuestada mediante un cuestionario estructurado en junio de 2008.
RESULTADOS: Se entrevistaron 100 hombres y 98 mujeres. Más del 90% de los hombres no estaban circuncidados. Aunque el 60% de los hombres y el 67% de las mujeres informaron que habían oído hablar de la circuncisión, la enfermera de la investigación evaluó que el 28% de los hombres y el 40% de las mujeres realmente entendían que era la circuncisión. Cuando se les preguntó acerca de los beneficios de la circuncisión, el 32% de los hombres y el 41.8% de las mujeres dijeron que la circuncisión facilita la limpieza del pene, mientras que el 13% de los hombres y el 20.4% de las mujeres dijeron que la circuncisión disminuye la probabilidad de ITS. El veintidós por ciento de los hombres y el 13.3% de las mujeres dijo que elprepucio ofreceprotección, mientras que el 18% de los hombres y el 10.2% de las mujeres dijeron que el pene parece más atractivo cuando está incircunciso. Cuando se les informó que las investigaciones mostraban que la circuncisión reducía el riesgo de VIH, el 35% de los hombres dijeron que querían ser circuncidados y el 67.3% de las mujeres dijeron que estimularían a sus esposos a quefueran circuncidados (p < 0.001), mientras que el 54% de los hombres y el 72.4% de las mujeres dijeron que harían circuncidar a sus hijos (p = 0.057).
CONCLUSIÓN: El conocimiento de la circuncisión y sus beneficios eran limitados entre los asistentes a la clínica de ITS. Un número significativamente mayor de mujeres en comparación con los hombres, estuvieron a favor de la circuncisión cuando se dio la información de que reducía el riesgo de infección de VIH.
Palabras claves: Actitudes, prevención del VIH, Jamaica, circuncisión masculina, asistentes a la clínica de ITS
Three randomized controlled trials (RCT) in Africa have shown that among men, the risk of acquisition of HIV infection from women, can be reduced by approximately 60% when adult men are circumcised (1-3). Previous studies have shown a reduction of balanitis and sexually transmitted infections (STI) in circumcised men (4) as well as urinary tract infections in male infants who are circumcised (5). In addition, risk of cancer is reduced in female spouses of circumcised men (6). Given these findings, the WHO and UNAIDS have recommended male circumcision in Sub-Saharan Africa as a means of reducing the spread of HIV infections (7).
However, both WHO and UNAIDS have stressed the importance of clear messages to ensure that persons understand that male circumcision only partially reduces HIV risk and that safe sex remains important including condom use. In all three randomized controlled trials, HIV incidence was considerably lower in the intervention group (circumcised men) than in the control group (uncircumcised men) but nevertheless remained high overall [0.7 to 1.0 per 100 person-years in circumcised men] (7). Therefore male circumcision should always be considered as part of a comprehensive prevention programme. UNAIDS has spelt out what is involved in ensuring that the provision of services for male circumcision are done in a way that fully takes into account public health principles and affirms human rights (8).
In Jamaica, most men are uncircumcised. Anecdotal reports suggest that adult male circumcision would not be popular among men in Jamaica and that many persons would also be opposed to circumcision of male infants. However, given the HIV epidemic in Jamaica, with an adult HIV prevalence of 1.6% (9), and significantly higher HIV rates among those most at risk (10-12), male circumcision needs to be explored as a prevention option.
The aim of this study was to interview a sample of persons attending the main STI clinic in Kingston in order to describe their attitudes towards male circumcision. Attendees at a STI clinic were chosen because they are at higher risk of HIV and therefore a potential target population for male circumcision.
SUBJECTS AND METHODS
A convenience sample of 100 men and 98 women attending the Comprehensive Health Centre, the main STI clinic in Kingston, were interviewed by an experienced research nurse during June 2008 using a structured questionnaire. During the interview, the options concerning the benefits or negative effects of circumcision were read out. The interview took approximately 10 minutes and no financial compensation was offered to the participant. Persons under the age of 16 years were excluded from the sample. Oral consent to participate was requested following a brief explanation of the purpose of the interview. No blood or any other biological sample was taken. The study was approved by the Ministry of Health Advisory Committee on Ethics.
The data were tabulated, frequencies calculated and chi-square tests performed using Epi Info version 6. There were a few missing values for response to some questions so numbers do not always add up to 100%.
A total of 100 men and 98 women were enrolled in the study. There were very few refusals to participate among those approached for an interview. The age distribution of both genders was comparable with approximately 60% of participants aged 20-39 years and 9% being 15 -19 years. Most participants were employed in service or technical jobs or were self-employed artisans.
Sixty per cent of men and 67% of women reported that they had heard of circumcision. However, the research nurse assessed that 28% of men and 40% of women actually understood what circumcision was. Only 8% of men reported being circumcised while 9.2% of women reported that their son was circumcised and 3.1% said that their son's father was circumcised.
When asked about the benefits of circumcision, 32% of men and 41.8% of women said that circumcision makes it easier to clean the penis (Table 1). Thirteen per cent of men and 20.4% of women said that circumcision lessens the likelihood of STI while 7% of men and 10.2% of women said that it lessens the likelihood of HIV infection. Sixteen per cent of men and 13.3% of women said that circumcision increases sexual satisfaction and pleasure.
When asked about the benefits of being uncircumcised, 22% of men and 13.3% of women said that the foreskin offers protection. Eighteen per cent of men and 10.2% of women said that the penis looks more attractive when uncircumcised. Thirteen per cent of men and 7.1% of women said that the foreskin helped to create more orgasm in women, while 11% of men and 2.0% of women said that being uncircumcised gave enjoyment of heightened sensitivity. Thirty-nine per cent of men and 54.1% of women did not know of any benefit of being uncircumcised.
When asked if their was any negative effect because of circumcision, 17% of men and 10.2% of women said that circumcision makes it more difficult to masturbate. Nine per cent of men and 8.2% of women said it was easier to catch an infection, while 6% of men and 3.1% of women said that circumcision lessens sexual pleasure. Forty-eight per cent of men and 57.1% of women did not know of any ill effects of circumcision.
Participants were informed that research had shown that HIV and other STI transmissions occur less in men who are circumcised. Men were then asked if they would consider being circumcised and 35% said yes while 38% said no (Table 2). Eight men were already circumcised. The remaining 19% said they did not know. When women were asked whether they would encourage their partner to be circumcised, 67.3% said yes and 17.3% said no; 5.1% of women said that their partner was already circumcised and 10.2% said that they did not know. Women were significantly more likely than men to recommend circumcision (p < 0.001).
Based on the knowledge that HIV and other STI are less likely if men are circumcised, 54% of men and 72.4% of women said that they would recommend their son to be circumcised as a baby (p = 0.057). Twenty-nine per cent of men and 19.4% of women said that they would not have their son circumcised as a baby, while 17% of men and 7.1% of women said that they did not know.
Forty-eight per cent of men and 72.4% of women said that they would recommend other men to be circumcised based on the knowledge that circumcision reduces HIV and STI transmission (p = 0.03). Twenty-seven per cent of men and 17.3% of women said that they would not recommend other men to be circumcised and 20% of men and 8.2% of women said they did not know. There were a few missing answers.
Among men, 40% said that they always used a condom if having sex with a woman other than their spouse or main partner; 36% said that they used a condom most times, 9% occasionally and 3% said never (Table 3). Eight per cent of men said that they did not have another woman. When asked whether they would continue to use a condom if circumcised, 78% of men said 'yes', 2% said 'no' and 6% said that they did not know.
Among women, 30.6% said that they always used a condom if having sex with a man other than their spouse or main partner, 17.3% said that they used a condom most times, 3.1% said occasionally and 1.0% said never. When asked if they would continue to use a condom if their other man was circumcised, 45.9% of women said yes, 5.1% said no and 46.9% said that they had on other man.
Women were asked why they would not recommend circumcision, 10.2% of women said that they would not recommend circumcision because it causes pain, 4.1% said it may cause bleeding, 4.1% said the penis may become infected, 3.1% said the penis may look deformed and 3.1% said that there may be a problem passing urine. A variety of other reasons for not recommending circumcision were given by 10 women.
Over 90% of the men in this survey said that they were not circumcised and over 90% of the women said that neither their youngest son nor his father was circumcised. This supports the view that most men in Jamaica are not circumcised. However, the findings of this survey cannot be generalized to the Jamaican population because the survey used a convenience sample of persons attending a STI clinic in Kingston and are therefore not representative of the general adult population. On the other hand, STI clinic attendees were a suitable group in whom to do this survey because they are more at risk of HIV infection than the general population. Human immunodeficiency virus prevalence among this group is approximately 5% (10, 12) compared with an estimated 1.6% in the adult population (9, 10).
In this survey, 40% of men and 32.7% of women said that they had not heard of circumcision. However, the research nurse assessed that as many as 72% of men and 60.2% of women did not have a clear understanding of what circumcision was. The majority of persons attending the STI clinic in Kingston is of lower socio-economic status and less well educated than the general population. Nevertheless, the lack of understanding of circumcision appears to be widespread among this population.
Given the level of ignorance about circumcision, it is not surprising that 39% of men and 34.7% of women said that they did not know of any benefit of circumcision. It is difficult to interpret the extent of awareness among those who reported a benefit of circumcision because the possible benefits were read out aloud and the participant might have said yes without really being sure that this was the case. However, it does not appear unreasonable that the most frequently mentioned benefit of circumcision reported was related to hygiene (32% of men and 41.8% of women).
Most women did not see any benefit in being uncircumcised. However, approximately 20% of men said that the foreskin protected the penis or made it more attractive. Most participants did not see any negative effects of circumcision though a minority of men and women said that circumcision made it more difficult to masturbate.
Significantly more women than men were in favour of circumcision when it was explained that research had shown that HIV and other STI transmission occurred less in men who are circumcised. This is not surprising as men are generally considered reluctant to subject themselves to surgical operations especially with respect to their penis. In fact, it is quite likely that the 35% of men who said that they were willing to have circumcision done is an overestimate due to politeness in responding to the nurse asking them the question. This is known as social acceptability bias.
It is important to note that the evidence concerning reduced HIV transmission due to circumcision in adult males is with respect to reduced HIV transmission from women to men following circumcision. There is no evidence that male to female HIV transmission is reduced following male circumcision or that HIV transmission is reduced among men who have sex with men. Moreover, it is likely that HIV transmission may actually increase among men who have sex too early after circumcision before their surgical wound has fully healed. WHO/UNAIDS recommends that the men wait a minimum of six weeks before resuming sexual activity and preferably following confirmation by a health provider that the wound had fully healed (7).
It is encouraging that most participants said that they would continue to use a condom with their 'outside' sexual partner (a sexual partner other than their spouse or main sex partner) if they were to be circumcised. This is important because HIV transmission remains a risk among circumcised men. It is also encouraging that 72.4% of women and 54% of men said that they would recommend that their son be circumcised as a baby.
Most policy-makers and surgeons in Jamaica are unlikely to support a programme promoting widespread circumcision among adult males in Jamaica because of the relatively low HIV prevalence, long waiting lists for elective surgery, the heavy burden of emergency surgery and the cost of such a programme. In fact, such a programme is unlikely to be cost beneficial in Jamaica and it is unlikely to be acceptable among most men. WHO's recommendation to rollout a programme of male circumcision among adult males is restricted to those African countries with high levels of HIV infection and not to the Caribbean (7). However, policy-makers in Jamaica and the Caribbean need to give careful consideration to promoting circumcision among male infants. This could prove to be an important investment in reducing HIV transmission in the future.
Male circumcision is considerably easier to do, and far less costly, in the male infant than the adult male (13). However, such a policy would need to be explored in much more depth and discussions held with a wide cross-section of stakeholders prior to its introduction. More research would also be required because translation of the findings of the three randomized trials in Africa (1-3) into public health policy is complex and context specific (14). This is a small preliminary survey and cannot be the basis for policy formulation. In addition, if circumcision of male infants were judged to be an appropriate policy, the public and health providers would need to be educated and the proper facilities and measures put in place to ensure that the procedure was done on a voluntary basis, in a sanitary and safe manner and with the permission of parents.
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13. UNAIDS. Male circumcision: global trends and determinants of prevalence, safety and acceptability. Geneva: WHO 2007.
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Dr JP Figueroa
Department of Community Health and Psychiatry, The University of the West Indies
E-mail contact: email@example.com