Is female participation in voluntary medical male circumcision of any value? Experiences from Uganda
Uganda adopted voluntary medical male circumcision (VMMC) as part of its comprehensive HIV prevention strategy in 2009. From its inception, the service was designed to target males and most of the efforts were focused on ensuring that as many males as possible were circumcised. In December 2012, a PEPFAR interagency team conducted an external quality assessment for the Uganda program and found several quality gaps. One of the major gaps was the lack of a system for continuous quality improvement. USAID ASSIST was brought on board to provide technical support to VMMC USG implementing partners, health unit teams, and the Ministry of Health to address the quality gaps.
Initially, our focus was to support teams to meet the MoH quality standards that are aligned to the WHO quality standards. However, we soon discovered something very important along the way. Through our interactions with VMMC service providers and clients seeking the service, we realized that the services were targeted exclusively toward male clients, and that it was imperative that we engage the partners of the male clients. The reason for this was because there were various myths surrounding circumcision which led to negative outcomes, and we believed that, by engaging female partners, we could educate them about the process and improve outcomes for males undergoing the procedure. Some of these harmful myths include: having unprotected sex after circumcision promotes wound healing; a painless post-circumcision penile erection is an indication of complete wound healing; as a cleansing procedure, the first post circumcision sexual encounter should be with a partner that will never come into your sexual life again; and there are possibilities that lignocaine may affect penile function and the sooner these effects are tested after surgery through sexual intercourse, the better.
These myths were indeed a point of concern. Here is a service whose main goal is to reduce the chance of HIV transmission, but what is happening is that it’s leading to behaviors that greatly promote HIV transmission because it is promoting unprotected sexual intercourse for clients with fresh wounds, which act as a direct entry portal for the virus! The myths encouraging even males who have been faithful to their partners to have multiple sexual partners- a known risk factor for HIV transmission because of the belief that they need to “cleanse themselves.” (In the video to the right, listen as John explains another challenge related to gender in the Safe Male Circumcision improvement work.)
Through discussions with staff and clients we learned that it was actually the female partners that were encouraging their male partners to have intercourse with other women so that they wouldn’t transmit the bad omen to them, the most common omen being that their foreskins would peel off. Additionally, we heard complaints in which female partners were reluctant to allow their spouses to complete the mandatory six weeks of post-circumcision abstinence to allow complete wound healing. Some circumcised clients reported that when they would inform their partners about the period of abstinence, their female partners would think that their partners were cheating on them, and that it was untrue that they must abstain for that long.
It is against this background that USAID ASSIST team in Uganda thought it would be prudent to bring partners of VMMC clients on board. We developed a list of talking points to guide community mobilizers on how to encourage clients who have partners to bring their partners along with them to the health units so that they receive health education together and have couples’ HIV counseling. Health education covers several “Dos” and Don’ts” including addressing the myths and emphasizing the importance of abstinence. The teams have also set up health packages for women as their husbands head to the procedure. The females are offered services such as screening for cervical cancer, antenatal care for expectant mothers and education on nutrition. As of March 2014, only 30% of the VMMC male clients had partners attend with them. The teams continue to test various changes to encourage their participation.
For more discussion on how gender considerations can improve VMMC, see the Integrating Gender in Voluntary Medical Male Circumcision technical brief published in March 2014.