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Risk compensation after male circumcision

December 21, 2013

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

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10 Comments leave one →
  1. December 21, 2013 7:50 pm

    That’s a ludicrous conclusion. The whole push to promote male circumcision to fight HIV is hard to understand anyway.

    From a USAID report:
    “There appears no clear pattern of association between male circumcision and HIV prevalence—in 8 of 18 countries with data, HIV prevalence is lower among circumcised men, while in the remaining 10 countries it is higher.”
    http://www.measuredhs.com/pubs/pdf/CR22/CR22.pdf

    It seems highly unrealistic to expect that there will be no risk compensation. The South African National Communication Survey on HIV/AIDS, 2009 found that 15% of adults across age groups “believe that circumcised men do not need to use condoms”.
    http://www.info.gov.za/issues/hiv/survey_2009.htm

    It is unclear if circumcised men are more likely to infect women. The only ever randomized controlled trial into male-to-female transmission showed a 54% higher rate in the group where the men had been circumcised:
    http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60998-3/abstract

    ABC (Abstinence, Being faithful, and especially Condoms) is the way forward. Promoting genital surgery seems likely to cost African lives rather than save them.

    Recent news from Botswana
    “There is an upsurge of cases of people who got infected with HIV following circumcision.”
    http://www.gabzfm.com/circumcised-men-still-run-risk-hiv-infection

    and from Zimbabwe:
    “SOME circumcised men are contracting HIV and Aids after ditching the use of condoms, under a misguided belief that male circumcision (MC) would prevent them from getting infected”
    http://www.thestandard.co.zw/2013/11/10/circumcised-men-indulge-risky-sexual-behaviour/

  2. December 22, 2013 5:42 am

    The report that most intact men experience pain from using condoms is extraordinary. On what planet is this true?

    If cut men are that sex is more pleasurable with less pleasure-receptive surface and fewer pleasure-receptive nerve endings, that is also extraordinary, and stands as proof that the men need more time to get to a steady state before being questioned. After circumcision the glans and any skin between the glans and scar get progressively drier, duller and less sensitive.

  3. December 22, 2013 5:54 am

    Reblogged this on Don't Get Stuck With HIV.

  4. December 22, 2013 8:40 am

    You clearly don’t understand what “risk compensation” means and it is your conclusion that is inappropriate and biased

    • December 22, 2013 9:04 am

      I think I do. In this context it would be using condoms less or having more sexual partners in the belief that your risk of HIV had been reduced by the circumcision. Please correct me if I’m wrong.

      But my point is not primarily about risk compensation. It is about misusing qualitative methodology to make quantitative statements. This paper will likely get cited in support of the claim that risk compensation following VMMC is rare. The data presented do not say that.

      • December 22, 2013 5:15 pm

        And why do you post something that will support claims that risk compensation following VMMC is rare? Don’t you feel that you’re endangering our lives?Just because we Africans lack quality education,doesn’t give you the chance to capitalise on our ignorance and expose us to risky sexual behaviour.Let’s stop posting things on the web for economic gain.

      • December 22, 2013 5:55 pm

        Jim doesn’t think that. He’s criticising the authors of the recent study who make that claim.

  5. pureform 2000 permalink
    December 22, 2013 2:41 pm

    Two five year old boys are standing at the potty to pee. When one says, ” Your thing doesn’t have any skin on it!” ” I’ve been circumcised.” Says the second boy. ” What does that mean?” “It means they cut the skin off the end.” ” How old were you when it was cut off?” ” My mom said that I was two days old.” ” Did it hurt?” ” You bet it hurt, I couldn’t walk for a year!”

    Date: Sat, 21 Dec 2013 16:37:03 +0000 To: pureform2000@hotmail.com

  6. George permalink
    December 22, 2013 5:58 pm

    This cut or not to cut debate has been abused to the detriment of less informed. Literature is all over that circumcision is not a panacea to HIV AIDS and related infections. Until such a time that we will leave circumcision for adult decision (excuse kids from this irreversible cut), many more will be suffering.

  7. December 23, 2013 12:37 am

    As a man whose foreskin was cut off in childhood, and suffered years of decreasing sensitivity, to the point where I don’t orgasm any more, yet I have had sex with only one woman and no STDs ever. Keep your foreskin, use a condom until you settle down with one partner, and ensure your son/s do the same.

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