Only skin deep: limitations of public health understanding of male circumcision in South Africa.

To the Editor: The recent randomised controlled trials in South Africa, Uganda and Kenya which showed the dramatic impact of adult male circumcision (MC) on HIV transmission have dominated HIV/AIDS public health discourse over the past few years.1–3 Several authors in the October 2008 SAMJ cautioned against widespread implementation of MC as a prevention intervention. More evidence on the acceptability and effectiveness of male circumcision is required to support the scale-up effort. Particularly in non-circumcising communities, traditional cultural views will influence circumcision’s uptake and acceptability.4 Following the WHO/UNAIDS announcement promoting widespread MC,5 we conducted a pilot study as part of an ongoing community-based voluntary counselling and testing trial (Project Accept) to assess potential challenges to promoting male circumcision in a rural community in KwaZulu-Natal, South Africa. We conducted four age-segregated, gender-specific (i.e. younger men and women and older men and women) focus group discussions of up to 10 individuals per group. We also interviewed 8 key informants, including community leaders, traditional healers and health workers regarding the feasibility and acceptability of male circumcision in this community. Our study revealed rich traditional understandings of male circumcision. Participants had strong negative views regarding the practice of male circumcision (ukusoka), involving the removal of the foreskin. These perceptions seem to originate in historical tensions between Zulus and the Xhosas regarding MC. In contrast to the Xhosa practice of full circumcision, Zulus traditionally promoted partial circumcision (ukugweda). Here, the foreskin is not removed, but an elastic band of tissue under the penis glans is cut, allowing the foreskin to move easily back and forth. Participants understood the difference between full and partial circumcision but ukugweda was preferred. Men and women felt that partial circumcision (i) helped to prevent infections and (ii) helped to avoid sensitivity and pain during sexual intercourse, as the external foreskin remains intact. Further, participants reported that the full removal of the foreskin kills certain cells and this may lower sexual pleasure. On the other hand, participants felt that if the tissue under the penis glans is uncut, the foreskin is not able to move back and forth easily, which interferes with erection and causes the penis to bend downward painfully. A partial cut is believed to allow sperm to move freely and to enhance pleasure for men and women. Male circumcision is being widely promoted on the assumption that the term is unambiguous. Our pilot study shows a widely held alternative meaning among a rural community in KwaZulu-Natal. Public health messages have to be clear and precise, and specifically adapted for different cultural contexts. Information and education materials are needed to distinguish between medical MC (and its benefits) and ukugweda, whose HIV-protective benefits are unknown. For successful uptake in these contexts, strategies to overcome historically negative cultural perceptions of MC among Zulus, as well as positive associations of partial circumcision with enhanced sexual pleasure, are required.