Conclusion contradicts data

This qualitative study of 28 recently circumcised Kenyan men, and another 18 awaiting circumcision, appeared in Health Education Research last week (click here).

As the authors admit, the design was inappropriate, and the samples too small and unrepresentative, to measure the rate of anything so, correctly for a qualitative study, they reported no numbers. Instead their aim was to tease out the existence of beliefs and behaviours which might have been missed in larger surveys, using in depth interviews and representative quotations. They were interested in whether men realised that circumcision only provided partial protection against HIV infection, and whether they were likely to increase sexually risky behaviour as a result.

For the first question it turned out that all respondents knew that circumcision provided only partial protection against HIV transmission. The authors concluded accurately that “Participants demonstrated good understanding of partial protection”.  

But when they turned to risk compensation, namely whether respondents had used condoms less frequently or had more sexual partners after circumcision, they found the latter reported. Here is the relevant section:

“Only a few men said they would decrease their HIV protective behaviours after VMMC. Circumcised men spoke about sex being more pleasurable following male circumcision; as a result, a few circumcised men indicated they have sex more often (with their current partners) or have added another partner. At least one circumcised man said that prior to VMMC, sex and condom use was painful, but following circumcision he has more sex partners but has also increased his condom use because he does not feel pain anymore.

Two men were quoted:

Pleasure. Now sex is more sweet and enjoyable, so I said let me try another one again and even my former lady came back and I had sex with her. (Circumcised man, Kisumu East, age 27)

Since I got circumcised, I don’t feel pain while having sex and I feel the urge to add more [partners] … . I used to have sex without a condom because I was feeling pain … if I added a condom … but now I am using a condom because I no longer feel pain. (Circumcised man, Kisumu East, recruited into 18–24-year-old age group)

i.e. at least two separate men described actual “my former lady came back” or potential “I feel the urge to add more partners” risk compensation. The use of the expressions “a few” and “at least one” suggests that the actual number was higher.

Of course this tells us nothing about the rate of such behaviour, just that it exists.  But in a qualitative study it should be reported as a positive finding. Instead the authors conclude:

“[…] there was little suggestion of risk compensation following VMMC.”

This is blatant misrepresentation. The correct interpretation is that both potential and actual risk compensation was reported. Further studies are required to measure how frequent and relevant this is.

Readers must assume that the authors, social scientists from Research Triangle Park in North Carolina, rather than being disinterested seekers after truth, are biased advocates of voluntary male circumcision. Can we be sure that the interviews were conducted and transcribed in unbiased fashion?

Jim Thornton