This panel discussion was very lively and engaging to the audience. The discussion was unique because there were differing opinions among the presenters and conflicting points of view voiced during the presentations. This allowed for a better understanding of the different view points regarding male circumcision (MC). The focus of this panel was less about the empirical evidence for implementation of male circumcision in public health, but more about cultural and religious sensitivity and the impact of this practice on women. However, it is concerning that strong views were expressed by some of the panelists without providing evidence to support these views.

Supreme Mafalapitsa of South Africa presented about circumcision in a South African cultural framework and how it is important for mitigating the spread of AIDS in the country. Male circumcision in some parts of South Africa is a part of traditional life. MC often symbolizes sacrifice, ancestor worship and a covenant between man and God. Additionally, the ritual of circumcision represents a rite of passage from boyhood to manhood. He explained that the reinforcement of masculinity that accompanies MC is problematic for women. Gender normative socialization and the role of men become increasingly important after circumcision; men become manly and women are assigned to traditional roles. Supreme concluded his presentation with the recommendation that MC needs to be part of a greater sexual and reproductive health package in South Africa with special inclusion of gender transformative approaches to oppose harmful ideas of masculinity.

Karen Smith considered the religious and cultural sensitivities that must be observed if male circumcision is implemented. She explained that religious and cultural activity control important parts of daily life, organize social relations and are integral in the structure of value systems and norms. Situation specific behavior is thought to flow logically from belief system. For example, Catholics historically reject the use of condoms, but it was eventually decided that the clergy did not have the right to obstruct transmission and prevention of STIs and HIV/AIDS.  She concluded her presentation by saying that in order for MC to be successfully implemented as part of the SRH and HIV/AIDS prevention package, cultural and religious sensitivities must be given consideration.

Marge Berer gave the opposing commentary. She was especially critical of the fact that including MC in the prevention package of HIV/AIDS would drastically discourage the use of condoms, and would undermine the position of women in some societies. She explained that many men and women in high HIV prevalence countries welcome MC because they are desperate for anything that could help mitigate the problem. She outlined that men should have a right over their own bodies and pressures from organizations such as UNAIDS that are pushing for male circumcision impair this decision making process. In the end, she concluded that MC is dangerous because it will reduce condom use, and marginalize women.

Despite the well documented success of MC in reducing female to male HIV transmission, challenges and concerns are arising.  For countries willing to implement a roll-out, challenges include service delivery in terms of human resources and facilities, potential emergence of risk compensation, the interaction with other prevention strategies, the theoretical aspect of cost-effectiveness, messaging issues and the psychological impact of HIV infection post-circumcision.  Controversies that need to be addressed include issues of sexual satisfaction, cultural and behavioral dynamics and on a broader perspective gender equity issues. 

 Religious and cultural sensitivities remain important areas to assess as MC may be situation or country specific. Behaviors that logically flow from belief system may be in conflict with MC by introducing a mismatch between norms, values and actions.  From a gender perspective there the partially protective aspect of MC among HIV-negative men does not address the ongoing vulnerability of HIV for women. To achieve a herd protection, including women, with high proportion of men being circumcised, it may take up to a decade. Promoting safer sex should still continue to be part of any intervention.

THBS01 Male circumcision: to cut or not to cut?

Four papers were presented in this session which showed the complexities of adopting male circumcision as a major preventive measure. After acknowledging WHO's recommendation regarding MC as an effective prevention measure in high prevalence countries, all presentations emphasized the dangers of considering this procedure as the potential solution to the epidemic.

For all presenters many issues have to be considered regarding MC and the vertical way in which it is being promoted:

<!--[if !supportLists]-->•         <!--[endif]-->Health systems preparedness to handle demand?

<!--[if !supportLists]-->•         <!--[endif]-->Cultural and religious implications?

<!--[if !supportLists]-->•         <!--[endif]-->Impact on Gender norms and masculinity?

<!--[if !supportLists]-->•         <!--[endif]-->Behavioral change post MC?

<!--[if !supportLists]-->•         <!--[endif]-->Gender based violence increase?

<!--[if !supportLists]-->•         <!--[endif]-->Implications for women?

<!--[if !supportLists]-->•         <!--[endif]-->Issues of stigma and consent?

<!--[if !supportLists]-->•         <!--[endif]-->Communication strategies?

All presenters agreed a lot of research is needed still in order to evaluate the possible impact of this practice, mainly in terms of the cultural dimension of sexuality, bodies and gender relationships. For instance, it is the only HIV prevention intervention to date that does not protect his sexual partner(s), even to some extent. “Herd” protection, including for women, requires 70% of the male population being circumcised and is predicted to take up to 10 years in a highly successful programme.  This leaves women in a particularly vulnerable situation, even in the danger of being accused of infecting the circumcised male partner.

Also, issues of rights should be taken into consideration, specially related to informed consent and decisions over men’s own bodies.

A special mention was made that the message that MC protects men from HIV infection is easily understood as the possibility to abandon all other preventive measures.  Quote: “I don't want to give up sex, so I am getting circumcised." When told that he would be advised to carry on using condoms after the operation, he said, "If I have to wear a condom anyway, what is the point?" (man, age 25) .

Berer: The snip alone won’t do it; there must be a link between the penis and the brain.