HEARD senior researcher Gavin George highlighted the factors that influence demand for voluntary medical male circumcision in a presentation at the XI International AIDS Impact Conference in
HEARD senior researcher Gavin George highlighted the factors that influence demand for voluntary medical male circumcision in a presentation at the XI International AIDS Impact Conference in Barcelona, Spain
Creating demand for voluntary medical male
circumcision (VMMC) amongst adolescents in
Presentation to AIDS Impact 2013, Barcelona, Spain
Gavin George with Kaymarlin Govender, Janet Frohlich & Petronella
Health Economics and HIV and AIDS Research Division (HEARD),
University of KwaZulu-Natal, Durban, South Africa
• Voluntary medical male circumcision (VMMC) has been
identified as an essential prevention mechanism in high HIV
prevalence, primarily heterosexual, epidemic settings
• In KwaZulu-Natal (KZN), a province of South Africa, the aim is
to scale up VMMC services to 80% of males aged 0-49 by
2016, a total of over 1.25 million people. By 2012 a little over
200 000 circumcisions had been done
• In a context of high levels of HIV, increasing demand of VMMC
services is imperative if provincial and national targets are to be
met. A clear understanding of the barriers and facilitators of
VMMC is vital for cost-effective and rapid scale-up.
Purpose and Method
Purpose: This study aimed to assess young
people’s perceptions and experience of barriers
and facilitators of VMMC as well as perceptions
about education and counselling on VMMC in
schools. Specifically, this study unpacks the factors
that influence demand for VMMC among high
school learners in Vulindlela, KZN.
Method: The qualitative study was conducted
between September and October 2012 as part of a
prospective cohort study.
A VMMC programme run by the Centre for the Aids
Programme of Research in South Africa (CAPRISA) in the
Vulindlela sub-district of KZN had circumcised 2971 boys
between January 2010 and July 2012.
Twelve out of the 42 schools where the male circumcision
programme was run were randomly selected to participate in
Data was collected using focus group discussions in the local
Zulu language by three trained interviewers.
Twelve focus group discussions (FGDs) were conducted with
boys who had undergone VMMC and seven FGDs with boys
who had chosen not to undergo circumcision.
Focus group discussions with boys who had undergone VMMC
focused on motivations for undergoing VMMC, VMMC counselling
and sexual behaviour after undergoing VMMC.
The focus group discussions with uncircumcised boys asked
questions around their perceptions about VMMC, why they and their
peers would want or not want to get tested for HIV.
Each focus group had approximately 6-8 participants aged 16 years
and older from grades 10, 11 and 12.
An additional five FGDs were held with boys who were randomly
selected from the participating schools to augment the data. Two of
the FGDS were done after boys attended circumcision camps
organized and run by CAPRISA during the school holidays.
• The results are presented according to the issues raised
by the participants.
• Boys expressed concern about a range of issues from a
personal and community perspective.
• Understanding these reasons for circumcision provided a
useful counterpoint to understand why someone might
want to be circumcised or had to date avoided it.
• Results are distilled down to an individual, inter personal
and community wide facilitators and barriers as provided
by the Social Cognitive Theory (SCT) framework.
o Key Motivators
• One of the key motivations and indeed a typical starting
point offered by participants included the need to prevent
themselves from STIs and HIV and also to maintain
hygiene and cleanliness.
• Sexual performance and perception that circumcision
made them more attractive to their sexual partners.
“One of my girlfriends from Sweetwater felt a difference
when I had sex after circumcision and she even asked me
what I did. I told her that this thing that was problematic has
been removed. She asked to come for a second visit since
o Role of culture
Much of this influence is linked to masculinity and that circumcision
represents accepted norms of masculinity. Boys often spoke of these
influences together, including those from their peers.
Where circumcision is seen as a cultural necessity, its modern
medical version is generally well preferred because it was done in a
sterile environment under anaesthetic
‘I prefer medical male circumcision. There’s traditional and the other
is performed by a religion called Shembe, they cut without giving
you an injection, whereas a hospital injects you to alleviate the
pain. I can’t stand to be cut with a razor or knife.’
o Role of family, partner and peers
Boys also expressed the motivations that they had experienced from
their sexual partners, again linked to manhood and sexual pleasure.
‘I was not willing from last year to get circumcised but telling my friends about
this made them to encourage me to for it because, if I don’t go my
girlfriend will get herself another guy who is circumcised then leave me.
That is why I end up doing it.’
‘My friend encouraged me. He told me about the procedure, and he was
healing well. After that my brother went for circumcision I really believed it
was not that painful when I saw him. The penis looks abnormal for a while
and there’s slight pain. You have to be a real man to face that kind of
o Information, timing and facilities
Exposure to quality public information typically distributed by service
providers who then provide those circumcision facilities was expressed by
participants as a positive influence.
“What people need is a lot of knowledge/information around what HIV is
and why testing is important. I think that that would motivate them. Here
at school there was a campaign and now I see there are more people
being tested. Previously when we were tested, there used to only be a
few people. In our class, all but 2 learners were tested today. Because
when you have the knowledge, you are more likely to make informed
Boys who were circumcised at the camp indicated their preference for
VMMC at the camp.
‘Circumcising at the camp during holidays also gives you enough time
for your wound to heal and no one interferes with the healing process
and there are no sports because you are just at home.’
o Barriers to VMMC
Despite the wide availability of antiretroviral treatment for HIV provided for by
the government, participants noted that the greatest barrier to VMMC is
the HIV testing which precedes the procedure. Whilst some participants
were fearful of the testing itself, others were worried about their results.
‘There is still a stereotype [stigma] here that if you have AIDS you
should not mix with other people, that you should lead a solitary life
because you might give it to other people. Some are scared of that.
They are scared of being discriminated against.’
As the testing was sometimes done at school or near the school during
school hours they felt that their reaction will give their results away.
‘I would love to test elsewhere because when we are tested here at
school, it’s in the classroom. So now say you find out that you are
positive, naturally you are in shock, so your schoolmates notice that you
are upset when you come out. Then they start speculating that you are
o Barriers to VMMC
Some boys noted that they would not go through the circumcision procedure
because of fear that it will be done incorrectly and also that the procedure
will be painful.
‘The thing with circumcision is that once you have been incorrectly cut
the vein on your private part will never get erected again.’
‘I was nervous when I saw one of my school mates who were done,
bleeding. As the result he had to return to the surgery to be re-stitched.
That resulted in me being nervous at my turn.’
A few participants noted that some young people still had misconceptions
‘There are people that think that by being circumcised they have a
“condom for life” and they will never contract any diseases.’
Discussion - facilitators
The results of this study showed boys believing
circumcision to be important for reducing risk of
STIs, especially HIV and for enhanced sexual
pleasure and performance. Acknowledging and
interpreting hygiene and sexual performance as
individual facilitators for VMMC, shows consistency
with extant literature
Inter-personal and community level facilitators
include the desire to imitate their peers and
acknowledge the preferences of their sexual
partners as well as following family and cultural
rites of passage.
Discussion - barriers
Individual barriers usually begin with fears of the
procedure itself and the pain (including post-
operative) associated with stitches.
Other notable barriers included the fear of HIV
testing which precedes medical circumcision.
Tackling stigma and ensuring that young people are
well informed of all the procedures at the
community level is important and will reduce
barriers to testing. HIV counseling and testing is a
compulsory prerequisite if boys want to participate
in the free VMMC programme.
The beliefs and attitudes of young men in the target
age for VMMC, and of young women who are their
potential partners, will affect the demand for VMMC
• Swedish Sida for funding this project
• CAPRISA for allowing us to use their facilities
• Learners for taking the time to share their
thoughts and views.