KENYA: Men who choose to undergo circumcision have a history of unsafe sexual behavior over men who choose to remain intact

Aidsmap reports on a study released this month showing that Kenyan men who choose to undergo circumcision have a history of engaging in unsafe sexual behavior at a higher rate than men who choose to remain intact.

Significantly, this finding mirrors at the psychological level if not the physical level Laumann et al’s findings that circumcised men are more likely to engage or continue to engage in riskier sexual behaviors:

The investigators found that men who chose to be circumcised were significantly more likely than men who chose to remain uncircumcised to have had risky sex in the three months before entry to the study (p = 0.025) and to have had unprotected risky sex during this period (p = 0.03).*

Interestingly, this study touched upon an issue not accounted for in the widely reported studies purportedly showing a prophylactic effect against HIV infection from circumcision, namely a period of “disinhibition” following the procedure:

In the month following circumcision, men undergoing the procedure were 60% less likely to report risky sex than men remaining uncircumcised, and 87% less likely than uncircumcised men to report unprotected risky sex. The investigators attribute this to sexual disinhibition due to healing of the penis following the circumcision operation and counselling about safer sex.

These prior studies have been criticized for failing to factor in the time that the circumcised control group were not sexually active due to healing from the reductive procedure. Failure  to factor in the inactive period would necessarily skew the results towards a greater protective effect against HIV infection than would actually be the case.

The researchers make a confusing and inconclusive observation regarding the year following the procedure. They say that the circumcised control group did not report “any appreciable [ … ] excess of risky sex or unprotected risky sex” over the group who chose to remain intact.

Yet the question remains, Were the men less likely to engage in risky sex because they were counseled appropriately? Had the men already decided to reduce risky sexual behaviors prior to opting for the procedure and thus the procedure was itself merely evidence of self-initiated behavior change?  Or was something about the procedure permanently “disinhibiting?”**

* “Risky sex” was defined as sexual intercourse with an individual other than the man’s wife or regular partner, and “unprotected risky sex” was sex without a condom with an individual other than a wife or regular partner. Clearly, this further confuses any conclusions from the study due to the fact that the two categories are not comparable. Sexual intercourse with a condom provides a level of protection unrelated to whether the partner is one’s wife or regular partner.

** These observations, though inscrutable, echo previous rationales for circumcision, i.e. its “disinhibiting” effects on sexuality and sexual activity. Of course judging by context, the authors probably mean inhibiting rather than “disinhibiting” as a century ago the purpose was to reinforce inhibitions regarding such activity.

Complete text of the article after the jump.

Circumcisions not leading to increase in risky sex in Kenya

Men undergoing circumcision in Kenya are no more likely than their uncircumcised peers to engage in risky sex in the first year after the procedure, a study published in the January 1st edition of the Journal of Acquired Immune Deficiency Syndromes has found. This finding is in contrast to some previous randomised controlled trials that found that the potentially protective effects of circumcision against HIV and other sexually transmitted infections was off-set by increased sexual risk-taking by men who had been circumcised.

The investigators believe that a strength of their study was the setting in which it was conducted – a public health facility where circumcision is provided, as opposed to the “highly controlled research settings where circumcision studies have been conducted.”

The study was conducted between 2002 and 2004 and involved men 324 men undergoing circumcision and an equal number of demographically matched men remaining uncircumcised attending the Siaya and Bondo district hospitals in Kenya. The study was not linked to a randomised trial taking place in the Kisumu district of Kenya. That trial was halted in December 2006 after an interim analysis showed that circumcision of adult males
reduced the risk of HIV acquisition by around 50% during the follow-up period.

Men joining the Siaya/Bondo study provided sexual histories at enrollment to the study and returned for follow-up visits at which they provided details of their sexual activity throughout the first year following circumcision. The investigators defined “risky sex” as sexual intercourse with an individual other than the patient’s wife or regular partner, and “unprotected risky sex” was sex without a condom with an individual other than a wife or regular partner. Data were also gathered on the frequency of sex acts.

The investigators found that men who chose to be circumcised were significantly more likely than men who chose to remain uncircumcised to have had risky sex in the three months before entry to the study (p = 0.025) and to have had unprotected risky sex during this period (p = 0.03).

In the month following circumcision, men undergoing the procedure were 60% less likely to report risky sex than men remaining uncircumcised, and 87% less likely than uncircumcised men to report unprotected risky sex. The investigators attribute this to sexual disinhibition due to healing of the penis following the circumcision operation and counselling about safer sex.

However, in the year following circumcision, there ceased to be any difference in the amount of risky and unprotected risky sex reported by circumcised and uncircumcised men. The investigators stress, “at no point during this year was there any appreciable reported excess of risky sex or unprotected risky sex among circumcised men.”

The most common reason cited for circumcision was protection from HIV/sexually transmitted infections (47%). Yet the investigators found that men who reported this motivation for circumcision were no more likely than those citing hygiene (24%), the avoidance of injuries during sex (14%), or the influence of friends (10%) to have risky or
unprotected risky sex in the year after the operation.

“Our results suggest that, within the context of adequate counselling on risk reduction, any physical benefits arising from circumcision are not likely to be appreciably offset by an adverse behavioural impact of the procedure”, conclude the investigators.

Reference

Kawango EA et al. Male circumcision in Siaya and Bondo districts, Kenya: prospective cohort study to assess behavioural disinhibition following circumcision. J Acquir Immune Defic Syndr 44: 66 – 70, 2007. 

http://www.nam.co.uk/en/news/281ADC9B-AB02-49BE-AC1E-6A986B5823B2.asp

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