Male circumcision and the impact on women – an ICW response (plus useful resources)

In 2006 three African clinical trials in Kenya, Uganda and South Africa, in which HIV negative men were circumcised, were disbanded when preliminary results indicated that the circumcised men were up to 60% less likely to become HIV infected after sex with an HIV positive woman than the men who were not circumcised. The UN has added their voice to the call for male circumcision programmes to be rolled out, especially in Africa and other resource-poor countries (UNAIDS and WHO 2007) and in June 2008 WHO convened an expert meeting to discuss the implications of scaling up male circumcision as an HIV-prevention method. Prior to that meeting, the AIDS Vaccine Advocacy Coalition (AVAC) organised a civil-society consultation in Mombasa, Kenya, on 22-23 June 2008 to discuss the gender-based and woman-centred issues associated with such a move. ICW urges that any further move to scale-up male circumcision takes seriously the recommendation for further consultations with women (and HIV positive women in particular) regarding the gender and rights implications of any move to introduce male circumcision for specific population groups. Our concerns and recommendations are outlined here in brief.

Reducing the number of new infections among men would mean that fewer women would be exposed to HIV over time and this is something to celebrate. However, ICW members do have concerns about the way male circumcision is being promoted as HIV prevention and the possible impact on women’s sexual and reproductive health (SRHR), as well as on comprehensive approaches to HIV prevention. As happens all too often, how women fit into the story has been left hazy. Although the WHO/UNAIDS recommendations formally recognise the complexities of generalised calls for male circumcision, how does that recognition work out on the ground?

Women’s rights groups have also raised concerns about the impact of male circumcision on men’s sexual behaviour and perceptions. Will men believe that if they undergo circumcision they are not at risk of HIV infection and can have multiple sexual partners and penetrative sex without a condom? Will circumcision be one more excuse for men to engage in reckless, non-consensual sex or to not use condoms? We already know that women face high levels of sexual abuse and struggle to negotiate sex on their terms.

Discussions and programmes on male circumcision are leaving out a consideration of women’s subordination to men and how women are often unfairly blamed for infecting their partners when they are first in the family to have an HIV test.

ICW member - My husband, through whom I was infected, was circumcised because he is a Muslim. The danger about this new message about male circumcision protecting against HIV is that, even though it might provide some protection, it most certainly didn’t protect him or me.

Once more, I can see that if women are tested positive at ante-natal clinics it will be all too easy for their husbands to declare that they are circumcised and therefore could not possibly be the source of their wives’ infection. Health workers are already reporting the emerging crisis of violence against women after an inadequately supported positive diagnosis in the antenatal setting, which is also resulting in danger for their unborn babies. Unless handled extremely sensitively, the male circumcision = HIV negative mantra is going to become yet another enormous barrier to disclosure among men and to care or support for their HIV positive female partners.

If male circumcision is one of a number of ways in which men and women can protect themselves from HIV infection, fine and good. Nevertheless, we must always look beneath the surface of new developments or the results of studies, and ask how will these affect women? Will women’s control over their lives be increased? Will it lead to better health for women? Will it enhance or add to equality between men and women? We do not want male circumcision be the "quick fix" that draws enormous donor resources, while addressing structural causes of women's HIV vulnerability remains the marginalized "hard issue" that no one touches.

ICW member from Namibia – [On hearing Male circumcision discussed on Namibian radio] It provoked a large number of public responses with male callers wanting to know more about male circumcision as a means of preventing transmission of HIV. I feel that if male circumcision is seen as a 100% effective prevention method for men there is a danger that men will not practice safer sex. This could cause distress for women and girls and increase their vulnerability to HIV and male violence. The blame game is going to be intensified, gender relations are going to deteriorate, women’s decision making ability, not just regarding safe sex but on quite a number of issues affecting women, is going to go back to zero, old harmful traditional cultural forms are going to be re-introduced. I am saying all this because when I was listening to the callers most of their concerns were illustrated by questions like, is it going to be safe to engage in sex with more than one woman? Can I impregnate a woman living with HIV and not contract the virus? All the callers were in favour of circumcision for their personal selfishness without thinking or taking into consideration women’s views on the issue and what the negative aspects and experiences for women and girls are.

ICW member Swaziland - We finally, finally have our men using condoms, we women are finally able to negotiate safer sex, and this male circumcision is coming in with all this money and will wipe away our progress because of how it is being understood.

An ICW Response to the Question of Male Circumcision

If male circumcision forms a part of a prevention approach that supports women’s SRHR, then there is reason to be optimistic. Such an approach should be backed up by resources so that women and men, including HIV positive women and men, can be thoroughly consulted over what a comprehensive approach should look. Here are some suggestions from ICW:

  • Comprehensive HIV counseling as part of the circumcision procedure that addresses issues such as sexual responsibility and women’s rights to safe, consensual, satisfying sex.
  • All campaign and information materials to highlight the importance of women’s sexual rights and to be clear that male circumcision does not replace the importance of sexual responsibility, including condom use.
  • Comprehensive and gender sensitive sexuality education for women and men that addresses SRHR.
  • Support for women’s economic rights, for example, inheritance, access to resources and employment opportunities.
  • Programmes to address violence against women.
  • Monitoring by civil society organisations (which includes women’s rights groups) of the impact of male circumcision on HIV positive and HIV negative women.

The Community Response to the Question of Male Circumcision from AfriCASO, SWAA and NAP+ includes:

  • No vertical programmes should be implemented. Circumcision should be implemented as part of a holistic approach to treatment, care, prevention and testing and should include transformational sexuality counselling and access to condoms. In other words circumcision must not be presented as an end in itself but part of a prevention and care consortium.
  • The potential negative effects of circumcision programmes should be monitored, especially the way in which women are treated sexually as a result of men having undergone circumcision.

(African Council of AIDS Service Organizations (AfriCASO) www.africaso.net, Society for Women Against AIDS in Africa (SWAA) www.swaainternational.org, The Network of African People Living with HIV/AIDS (NAP+) www.rapnap.org).

References:
• UNAIDS and WHO, 2007, New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications
Documents produced by Civil Society for the Mombasa meeting 2008
• Lawrence K. Altman, 2008, Male Circumcision No Aid to Women in Study, New York Times


Other useful resource:
• Rochelle Jones, Friday August 3, 2007, ‘Women's rights perspectives on circumcision and HIV prevention’, Resource Net Friday File, Issue 336
• Marge Berer, 2007, Roundtable: Male Circumcision for HIV Prevention: Perspectives on Gender and Sexuality

This resource is a work in progress so please get in touch with us if you have any comments or would like to make any additions.