Psychosocial Motives for Undergoing Male Circumcision (MC) in High HIV Epidemic Areas and the Probable Impact on the Mass MC Strategy of HIV Prevention: A Case Study of Swaziland

While millions of men have been circumcised cumulatively under the mass male circumcision campaigns for the prevention of HIV, the uptake of male circumcision (MC) is below the set targets. This suggests that prevention of HIV is not a convincing motive for circumcision to the majority of men. Notably some men are undergoing male circumcision for other psychosocial motives, rather than the primary public health motive of preventing HIV transmission. These motives have not been explicitly studied in order to ascertain their potential impact on the male circumcision strategy of HIV prevention. This study aimed at assessing the psychosocial motives for undergoing male circumcision in Swaziland and determines their potential impact on the success of the mass male circumcision strategy. A qualitative study design was used, in which in-depth individual face-to-face unstructured interviews were conducted with 17 men seeking health care services at the Family Life Association of Swaziland clinic in Mbabane, Swaziland. All men aged 18 years and above were eligible. Results indicate that some men are undergoing circumcision primarily for psychosocial reasons rather than for HIV prevention. These psychosocial motives include: giving in to pressure from public health advocates, sexual partners and peers; to perceived sexual benefits of the procedure; to demonstrate one’s manhood, as well as to utilise the free and readily available male circumcision services. However, subsequent safe post-MC sexual behaviour is not guaranteed. Nevertheless, it was recommended that these motives be emphasised in the mass male circumcision campaigns, along with appropriate health education, in order to complement HIV prevention in promoting uptake of male circumcision and ensuring safe post-circumcision sexual behaviour. Citation: Maibvise C, Mavundla TR, Nsibandze BS (2017) Psychosocial Motives for Undergoing Male Circumcision (MC) in High HIV Epidemic Areas and the Probable Impact on the Mass MC Strategy of HIV Prevention: A Case Study of Swaziland. J AIDS Clin Res 8: 685. doi: 10.4172/21556113.1000685


Introduction
Male circumcision entails the partial or complete removal of the foreskin in males. This is one of the most widespread and oldest surgical procedures dating back to biblical times. The practice of circumcision differs extensively globally in terms of distribution and trends in popularity depending on the motive or reasons behind the procedure [1]. Traditionally, the major reasons or motives for performing circumcision were cultural, religious, ethical, health and personal hygiene, among others [2][3][4].
As of 2007, about one-third of the world's male population was circumcised, two thirds of them being Muslims, circumcised for religious reasons [1,5]. In Africa, the practice was mainly confined to specific ethnic groups where it was done as a rite of passage from childhood to adulthood [5]. For years the global popularity and hence prevalence of the procedure was on a downward trend [6], until recently when its public health benefit in preventing HIV transmission gained fame. To date, following the recommendations by the World Health Organisation, mass male circumcision campaigns are in progress in 14 selected countries in Eastern and Southern African which have been identified as having high HIV and low MC prevalence [7][8][9]. The target is to circumcise at least 80% of all men aged 15-49 years in the region. This will avert about 3.36 million new HIV infections by 2025, leading to a net cost saving of about US $16.51 billion according to mathematical projections [10].
As of 2013, a cumulative total of 5,820,916 MCs have been performed in the regions, accounting for only 27.9% of the targeted 80% coverage [11], and reaching this target is proving to be difficult. In confirmation of this, only 5.8 million have been circumcised out of the targeted 20 million by 2016 according to the Gap Report [8] and 67 million by 2030 according to UNAIDS [12]. Moreover, some studies have shown some conflicting interests between public health advocates and men who are coming for MC. Apparently the primary motive for MC for some men is not to complement other HIV preventive strategies as intended by public health advocates, but rather to enable themselves to engage in risky sexual behaviour freely assuming total protection from MC [13,14]. From a review of several studies, it was also noted that 'locals in a variety of countries see circumcision as evidence of promiscuity -or the intent for such [15]. Though never quantified in these reports, the widespread of such reports suggests that it is a sufficient cause for concern.
A study conducted in Swaziland, Botswana and Namibia showed that between 9-15% of participants believed that a circumcised man is fully protected against HIV, 14-26% believed that HIV-positive men who are circumcised cannot transmit the virus and 8-34% thought that it was all right and acceptable for a circumcised man to expect sex without a condom [16]. Similarly, in another study conducted in the Western Cape, South Africa, 12.2% of the participants, believed that one cannot get HIV after being circumcised [17]. All these indicate some level of misconceptions and misunderstandings about MC, leaving the researchers wondering as to what exactly is motivating men to come for the procedure. The possibility of underlying risky motives for undergoing the procedure cannot be ruled out. A positive correlation between a state of being circumcised and risky sexual behaviour has also been confirmed in Cape Town, South Africa [18]. The social environment of men, comprising significant others, relatives, friends, and the community at large, has a significant influence on men's decisions to undergo MC and their post-MC sexual behaviour. Knowledge of the psychosocial motives behind uptake of MC is crucial in shaping further MC campaigns and enhances its success as an HIV prevention strategy. Such motives and/or the associated post-MC sexual behaviour among men have not been clearly identified amid the broader primary motive of preventing the spread of HIV from the perspective of public health activists.
This study aimed at assessing the psychosocial motives for undergoing MC from the perspective of men in Swaziland as a high HIV and low MC setting, and ascertain the probable post MC sexual behaviour, in order to inform and strengthen further MC campaigns and clear misconceptions The ultimate objective of the study was to come up with evidenced based recommendations aimed at promoting the uptake of MC and ensuring safe post-MC sexual behaviour among the target population.

Method
A qualitative study was conducted targeting men aged 18 years and above who had been circumcised or have agreed to be circumcised under the scale up campaigns of MC for HIV prevention. Participants were identified as they come for MC or related service at the Family Life Association of Swaziland (FLAS) Clinic, Mbabane, Swaziland. Swaziland is the smallest landlocked country in Southern Africa, bordered by South Africa and Mozambique. FLAS is one of the major providers of MC and related services in the country, located in the capital city of Swaziland, Mbabane. Before conducting the study, ethical approval was obtained from the Ministry of Health [Swaziland] Scientific and Ethics Committee. In addition, permission to conduct the study at FLAS was also granted by the institution's Research and Evaluation Unit.
Participants were identified and approached as they were waiting for their turns to undergo the procedure. Some candidates who had since undergone the procedure some months or years ago but just accompanying their colleagues were also available in the entertainment room, and they were eligible to participate. The researcher approached each potential candidate individually and explained the research process before requesting for their participation. Participants were given an option to be interviewed instantly, or just after their MC procedure or any other time later. For the later, an appointment had to be made at the convenience of the participant. All participants opted to be interviewed immediately, or soon after their procedure for those whose turn was about to come. One or two participants were selected at a time to avoid keeping them waiting for the interviews for too long. Convenience sampling was used. Those who would have agreed were taken to a private room provided by FLAS within their premises for the interviews.
A recap of the description of the research process was done with each participant, and the participant was requested to fill in an informed consent form before data collection. Data were collected using unstructured individual face-to-face interviews based on the grand tour question: "What made you decide to be circumcised?" Further probing questions were posed to elicit the psychosocial motives for undergoing circumcision based on participants' own perceptions as well as views and opinions of their peers as they often discuss the subject in the community. All interviews were conducted by one male researcher for consistency. All participants opted to be interviewed in English, as opposed to SiSwati. In addition to interviews, non-verbal cues were also observed and recorded in the form of theoretical (analytical) field notes [19]. Sampling and data analysis were done concurrently and continuously, one participant at a time, until data saturation was attained. Data were collected during the period 28 th of June to the 11 th of July 2012. As per the study protocol, all interviews were audio-taped. Guba's model for assessing trustworthiness was also used to enhance the rigor of the study [20]. Based on this model, the researchers considered four aspects that contribute to the rigour of the study, namely: truth value, applicability, consistency, and neutrality. These aspects were assessed using the strategies or criteria, of credibility, transferability, dependability, and confirmability, respectively [19,[21][22][23]. Some of the strategies used to ensure credibility of findings include prolonged engagement, persistent observation, methodological triangulation, reflexivity and peer examination, as well as bracketing. Dense descriptions of the study setting, the methodology and the participants were also captured to ensure transferability. By establishing credibility and transferability, researchers also ensured consistency and neutrality of the findings.
The resultant data were analysed manually using the editing analysis style [24], following the basic steps of analysis as described in Creswell [25]. These include: transcribing the audio taped interviews and merging the transcript with the field notes; reading the transcript repeatedly to get the sense of the information; coding the data and grouping similar segments, as well as identifying and describing the main themes for analysis. The resultant findings from this process were as follows.

Results
A total of 17 participants were interviewed. Table 1 summarises their demographic characteristics.
These motives are elaborated as follows: All were Christians, except one who was not affiliated to any particular religion. Data from these participants revealed the psychosocial motive for undergoing circumcision as summarised in Table 2.

Giving in to pressure
Most participants stated that their reasons for undergoing circumcision is that they could not withstand the pressure from public health advocates for MC, sexual partners as well as peers, as elaborated below. When asked why he was avoiding being circumcised, he said he was scared of the procedure, and highlighted that even as he came for the procedure, he was still scared, but apparently no option.
Another participant who felt coerced by the intensive campaigns said: As they were teaching, people from Soka Uncobe, they were all over Swaziland. They came to my area. We were sitting at the markets. Almost every day they were there, preaching us, preaching us [sic].
Apart from public health care workers, another group of people that was shown to verbally create irresistible pressure for males to be circumcised were the sexual partners.

Pressure from sexual partners
Findings show that sexual partners, specifically girlfriends, seem to be pressurising their boyfriends to be circumcised, as reflected in this quotation from one participant: At some point with my girlfriend, ja, she talked about it, that maybe one day I must consider getting circumcised. It took me a while though, because I didn't see a need or reason at that point. I then felt I was ready to come and do it, ja, after quite a while. It took me almost a year [to decide]. I would make excuses here and there -"No, I am busy", and stuff like that.
Another participant also said: Apart from direct verbal influence from peers or partners to undergo circumcision, it appeared that in some instances men are compelled by the situation to act, either to fit in with their peers or to please their girlfriend(s), as elaborated on below.

Pressure from peers
The influence of peer pressure has already been illustrated in the previous quotation. To add to that quotation, another participant said: It's actually kind of embarrassing, if I may tell you, not to know your [HIV] status, and also to say you are not circumcised. It is, now! Because most of my friends and stuff like that, ok, they are, but then, like, there you come. You are still not circumcised. And so, I decided to take the step to come and finally do it.
Apart from the above mentioned pressure as a motive, findings show that men also acknowledge the sexual benefits of the procedure as a sufficient cause to undergo it.

Perceived sexual benefits of MC
It emerged that men believe that MC increases men's sexual performance, and hence satisfaction for both sexual partners and this motivates them to be circumcised.

To increase sexual pleasure for the female partner
Without necessarily being requested by their girlfriends to be circumcised, some men felt compelled to do so, based on their own knowledge of their partner's preferences. One participant expressed this feeling as follows: Everyone knows about it [the benefits of circumcision]. Ladies, men -they know about it, and every lady will want her man to be circumcised at one point.
Another participant with similar sentiments from his girlfriend said: So she [my girlfriend] also heard that from her friends -the enjoyment and everything. She also encouraged me, saying, "Maybe you can even do it. " Notably the circumcision activists also instilled that mentality into man, as one participant said: They [the people from Soka Uncobe] told us that when you are circumcised, you make your partner happy.
Women's increased satisfaction is a result of men's enhanced sexual performance, to which participants in this study also attested as a motive for their circumcision.  This suggests that the duration of each sexual encounter matters as far as sexual satisfaction is concerned. Another participant who had just been circumcised as a way of addressing his problem of premature orgasm remarked as follows: The problem for myself, when I have sex with her (my girlfriend) this foreskin gives me a health problem, you can easily ejaculate. If you circumcise you last.
This participant, who has had many sexual relationships before, went on to emphasize how significant this problem is among colleagues: It was also found that men felt there is need for them to prove their manhood not only to their girlfriends, but also to the community at large, as elaborated on below.

Demonstration of one's manhood
To that effect one participant, who had recently been circumcised for the purpose of demonstrating his manhood, said: I just felt relaxed that I am circumcised. I felt a real man. I feel I am a real man, because I was brave enough to do that thing [circumcision].
Similarly, another participant, who was influenced by the same motive, said: I thought it [undergoing circumcision] was painful, but aah, I am a gentleman. I must try it, because my friends had circumcised too, so I was the one left.
Over and above all the motives discussed so far, the public health sector further promoted the practice by making the service free and readily available to the public, as explained below.

Utilisation of the free and readily available service
Findings show that increased affordability, availability and accessibility of MC services have contributed immensely to the uptake of the procedure.

Availability of the service for free
The waiving of a fee for circumcision services has significantly motivated men to come for the procedure, as reflected in the following quotation from one participant: Emphasising the need to utilise this freely available service, another participant commented as follows: The fact that it is free, you cannot just stay behind, because we are not giving [paying] even a cent here. So, it's helpful for every male who make [sic] that decision to be circumcised.

Service readily available and conveniently accessible
Not only has the free-of-charge aspect of the service attracted men to undergo circumcision, but also the fact that the service is readily available any time and is provided efficiently, as expressed by the following participant: Another thing is that these centres are all over Swaziland. They are many, such that you cannot even think of. The services are always there and available.

Another participant added:
So, when I heard that FLAS is doing [circumcision] and you don't have to wait for a long time to be circumcised, I went in [I decided to undergo the procedure].
From these findings, it is apparent that while the main purpose for the mass male circumcision is to prevent HIV transmission, men have their own psychosocial motives for the procedure. Certainly these motives may or may not be coherent with public health interests of HIV prevention, yet has a bearing on HIV transmission, as discussed on the next section.

Discussion
The psychosocial motives for circumcision identified in this study are not peculiar and unique for Swaziland alone, but characteristic of sexually active men in traditionally non-circumcising ethnic groups and the prevalent circumstances in the country. Similar motives have also been reported elsewhere globally, in similar or different contexts, related to issues of HIV and AIDS or not. In any case, it would ultimately impact on HIV transmission in one way or the other. Of interest is the fact that most of the motives portray men's positive responses to societal influence.
It is worthy to note that majority of the participants in this study were between the ages of 19 and 30 years. From a psychosocial perspective, Eric Erikson, in his theory of psychosocial development, would classify these participants as young adults in the stage of intimacy versus isolation [26]. In this stage, individuals primarily focus on creating and/or strengthening good social relationships with parents, friends, relatives, and other members of the community. Thus, they strive to act or behave in a way that seems more acceptable and appreciated by the society. This explains why men, according to findings of this study, get circumcised in response to male circumcision activists. Since the introduction of the National Policy of Male Circumcision in Swaziland and the subsequent establishment of the Male Circumcision Task Force in 2010, much community mobilisation has been taking place [7,27]. Members of the various stakeholders involved, such as the FLAS, PSI, and JHPIEGO, under the name "Soka Uncobe [Get circumcised and conquer]" have been found almost everywhere in public places trying to persuade men to be circumcised [4,28]. This created overwhelming pressure, as the campaigns seem to suggest that being circumcised is the most acceptable and expected behaviour, failure of which becomes somehow unacceptable. Similarly, studies in Tanzania have shown that being uncircumcised is associated with the stigma of being more prone to sexually transmitted infections such as HIV [29]. Likewise, in a Korean study [30], 61% of respondents believed that they would be ridiculed by their peer group if they were not circumcised. Findings of this study also clearly show that some Swazis come for circumcision simply because all their peers have been circumcised, and it is now embarrassing to remain uncircumcised. For the circumcision campaigns, where the aim is to increase the uptake of the procedure, this is considered as mission accomplished. However, more precisely, the success of MC as an HIV preventive strategy is dependent on uptake of the procedure coupled to safe post-MC sexual behaviour. Given the just described motive for MC, the subsequent sexual behaviour is unpredictable.
Apart from peers, findings also show that sexual partners significantly influence male sexual partners to be circumcised. Coherently, literature has shown that women prefer circumcised men to uncircumcised men as has been revealed in this study [29]. Apparently circumcision enhances sexual pleasure to both the female and the male sexual partner. As an explanation to this, other studies reported that circumcision increases pudendal evoked potentials, leading to a significantly higher ejaculatory latency time [31]. An earlier study also reported an increase in the time required to reach orgasm following circumcision [32]. The amount of sexual pleasure and hence satisfaction is proportional to the duration of sexual intercourse. Participants in this study have also attested to this delayed orgasm and increased pleasure associated with circumcision, and cited it as the primary motive for undergoing the procedure. It may not be disputed that such motives for circumcision may be accompanied by risky sexual behaviours such as promiscuity in order to experiment on, prove and/ or satisfy the enhanced sexual vigour.
Apparently circumcision status was not only associated with better sexual performance and partners satisfaction, but also with bravery and self-identity as "real" men, according to results of this study. According to Erikson's theory of psychosocial development, some of these participants would be classified as adolescents in the stage of identity versus role confusion. In this stage, individuals seek to establish a clear identity for themselves through assuming various roles and activities. Failure of the individual to establish an identity for himself will lead to role confusion [26]. In some cultures, undergoing circumcision shows bravery and manhood, thus giving a man a sense of identity [1,29,33,34]. In such cultures, MC is practised as a rite of passage from childhood to adult. Traditionally, Swaziland used to be a circumcising country, though the practice has been gradually fading out with modernisation [1,5]. Findings of this study show that the influence of these psychosocial motives is still prevalent among Swazi men. Consistent with this, 18.4% of circumcised men in Swaziland cited traditional/religious reason as motives for circumcision in the 2010 Multiple Cluster Indicator Survey [35].
It is not guaranteed, however, that people who are primarily driven by such motives to be circumcised would adhere to the recommended safe post-circumcision sexual behaviours. Chances are that such people may want to demonstrate their ascribed "manhood" by having many sexual partners and or/or having unprotected sex, as encouraged in other cultures. Traditionally, among the Kikuyu people in central Kenya newly circumcised boys are advised to prove their manhood by having sex shortly after the procedure, before the operation even heals [5].
While the primary motive behind the MC campaigns is to prevent HIV transmission as said before, the identified psychosocial motives in this study do not all seem to complement this primary goal. In fact, some studies and media reports have shown that the perception of improved sexual performance, coupled to misconceptions that MC offer total protection from HIV infection, tend to have promoted promiscuity thereby worsening the risk of HIV transmission [13,14,16,18]. Circumcised men feel secured from HIV infection and at the same time want to experiment on their enhanced sexual performance and exercising their "real manhood".
On the other hand, it has been shown that with or without MC risky sexual behaviour is still prevalent in the country, as 15% of all men are believed to indulge in risky sexual behaviour [36]. This is in line with the unstated assumption by WHO and UNAIDS consultants in recommending MC, that 'unprotected, unsafe sex on the part of men in sub-Saharan Africa cannot be changed' according to Bell's observation [15]. Mass MC therefore remains necessary and beneficial in prevention HIV transmission, regardless of the primary psychosocial motive behind it. However, literature shows that for most Swazi men, HIV prevention is not a sufficient, priority or compelling motive for circumcision. According to the Swaziland Multiple Indicator Cluster Survey 2010, only 22% of men cited prevention of HIV as the main reason for their circumcision. In these surveys, contribution of psychosocial motives was not precisely assessed. Possibly some of them were among the non-specified reasons, which accounted for only 3% of all circumcisions in Swaziland by 2010 [35]. The researchers postulate that an added emphasis on the identified psychosocial motives in the mass MC campaigns would go a long way in complementing the primary motive of HIV prevention. Findings also show that availing the MC services freely and accessibly is, on its own, a motive for the uptake of the procedure.

Conclusion
In conclusion, this study showed that there are some psychosocial influences which account for some uptake of circumcision in high HIV epidemic areas among men who may not appreciate the protective effect of MC against HIV. Though the statistical significance of these motives could not be ascertained in this study, as reinforcement to the ongoing mass MC campaigns, MC promoters can potentially capitalise on these psychosocial motives to promote the uptake of MC at various ages across the lifespan. Worth-note is that whether motivated by HIV related factors or not, the resultant MC uptake has a bearing on the spread of HIV. However, if not carefully considered, MCs motivated by some of the psychosocial factors is likely to be associated with some risky sexual behaviour, thereby being counterproductive from a public health perspective.
As such, awareness of such motives and their potential impact is therefore crucial in order to institute appropriate interventions. In the researchers' view, an emphasis or focus on these psychosocial motives, accompanied by appropriate sexual health education and clarification of misconception can therefore form an effective complement to the motive of prevention of HIV transmission in promoting mass the uptake of MC and safe sexual behaviour thereafter.

Limitation of the Study
It is, however, acknowledged that the qualitative nature of the study does not reflect the statistical significance of the identified motives among the target population, but forms a baseline for further quantification of the hypothesised motives. It is therefore recommended that further quantitative studies be conducted to ascertain the significance of the identified motives among the target population.