Women's voices have gone largely unheard in the debate on male circumcision as an HIV prevention method, but informal discussions with women reveal a range of concerns, preferences and views that researchers and governments would do well to consider before drawing up plans for rolling out a national circumcision programme.

In an unscientific poll, IRIN/PlusNews found a high degree of ambivalence among wives, girlfriends and mothers about the implications of a mass male circumcision campaign.

"It's going to be an advantage for women who are married to men who are cheating," said Carol Masombuka, 19, a Sesotho woman from Mpumalanga Province, in South Africa, zeroing in on the fact that even the partial protection circumcision provides could make a difference to women who are powerless to insist on condom use.

Other women were wary of an initiative that could give men one more excuse not to use condoms. "Most women are shy when it comes to things concerning sex - it's always the man who knows better, so he will decide when we have sex, and if he wants to use a condom he will, and whatever he says goes, so it's going to suppress women even more," said Kgaugelo Khuto, 20, a student from South Africa's Limpopo Province.

"Women should be informed so they do not get fooled by the men, because some girls might get told by the men that because he's circumcised she can't be infected," said Masombuka.

Gloria Mphekgwana, 44, a receptionist and single mother of two, who lives in a Johannesburg township and has watched a number of her relatives succumb to AIDS-related illnesses, was strongly in favour of male circumcision. "Women should fight for this," she said. "They can refuse to have sex unless their man goes for circumcision."

The evidence, or lack of it

Studies have found even higher levels of acceptability for male circumcision among women than among men. This is despite the fact that very little is known about how a large-scale male circumcision campaign would affect women.

Three clinical trials have demonstrated that circumcision reduces a man's chances of contracting HIV by about 60 percent. The expected numbers of male HIV infections averted by a large-scale male circumcision programme would eventually translate into fewer infections in women. There is also evidence that circumcised men are less likely to harbour the human papilloma virus (HPV), which causes cervical cancer - a major killer of women in sub-Saharan Africa.
However, a set of guidelines issued by the World Health Organisation and UNAIDS in March 2007 makes it clear that we do not know whether male circumcision, specifically, reduces sexual transmission of HIV from men to women.

Preliminary results from a study underway in Uganda suggest that HIV-positive men who resume sex before their circumcision wounds have healed are more likely to infect their female partners. The findings are too small to be conclusive, but they have raised the alarm about the need to inform both sexes about the potential risks and benefits.

One of greatest of those risks is that circumcised men will misunderstand or exaggerate the degree to which they are protected from HIV and stop using condoms; no one knows how real this risk is or to what extent it could be offset by education campaigns and individual counselling.

A route to "better manhood"?

The only experience many African women have of male circumcision is as part of a traditional rite of passage that their sons, brothers and male friends go through if they belong to certain ethnic groups.

Women are not only barred from attending such rituals, men are also "not supposed to talk about it with women - they tell them they can go crazy if they do", said Masombuka.

Several of the women IRIN/PlusNews spoke to said they could observe a positive change in men who had attended traditional circumcision 'schools'. "Most of the guys who've been through it know how to respect a woman and elders; a person not coming from circumcision school, they're very rude and they use power," said Mphekgwana, who is from Limpopo Province, where traditional circumcision is practiced.

According to Masombuka, "They tell them to be faithful to a girl, and to marry that girl, and not to go 'jolling' [sleeping] around."

Rachel Jewkes, who heads the gender and health unit of South Africa's Medical Research Council, believes that efforts to introduce male circumcision as an HIV intervention should borrow from traditional approaches that view the procedure as part of a "transformative process".

"If we see it purely as a medical intervention, it'll be a mistake; it's a social intervention," said Jewkes. "I think culture is very flexible and to the extent that circumcision has been associated with manhood, I think that gives it enormous potential for equating it with better manhood."

By "better manhood" Jewkes means men who are more sexually responsible, and more willing to view women as equals. She sees male circumcision programmes as a valuable opportunity to engage men in discussions about safer sex as well as gender equity.

"The critical thing is that male engagement in HIV prevention must not stop at the surgical knife, but that circumcision programmes must be accompanied by gender-transformative approaches to HIV prevention," she stressed.

What role for women?

Although public health experts have paid lip service to the idea of involving women in efforts to roll out national male circumcision programmes, details of what form such involvement would take are sketchy.
Dr Yassa Piere, a virologist who treats HIV-positive patients at the University Teaching Hospital in Lusaka, Zambia's capital, believes women could play a role in motivating their male partners to be circumcised.

He pointed to evidence that circumcised men experience slightly less sensation during sexual intercourse, a side effect some women might consider an advantage. The latest research contradicts this, but according to Piere, "some women prefer circumcised men because they last longer."

The women IRIN/PlusNews spoke to were more likely to cite hygiene as a reason for preferring their sexual partners to be circumcised. "I prefer a guy who's circumcised, I think it's safer and cleaner," said Kgaugelo Khuto, the student from Limpopo. "But I wouldn't ask him to do it."

Mothers were much more vocal in support of medical circumcision. Gloria Mphekgwana is under pressure from her ex-husband to send their son to a traditional circumcision school, but she has read media reports about botched procedures and even fatalities, and refuses to send her son to one.

"No one wants her kids to go there now, because they don't clean their utensils, they're using only one blade. I want to take him to the hospital [to be circumcised]," she said.

At the male circumcision clinic at Lusaka's University Teaching Hospital, where around 80 procedures are performed every month, about half of the patients are young boys brought to the clinic by their mothers.

"Studies show high acceptability of women for this," said Dr Kasonde Bowa, the clinic's director. "I think they're very keen on anything that is healthy for their children and their husbands."