Hygiene.

Improved hygiene was the most common facilitator of MC. Participants described the improvement in hygiene resulting from MC in several ways, including: “good smelling”, “easy to wipe clean”, “no smell after sex or bathing”, and “HIV and other germs don't have a place to hide”.

Social pressure.

Social pressure was a very common facilitator of MC uptake, especially among young men. Participants discussed, without prompting, several scenarios or social mechanisms that might affect Onyango's MC decision-making process.

1. A recently circumcised man shares his experience with Onyango and encourages him to become circumcised.
2. Onyango is the only one among his male friends or family who is not circumcised, and he is being teased about being uncircumcised, especially while bathing.
3. Onyango's female sex partner says that she will leave Onyango or withhold sex until he is circumcised.
4. Female sex partners and/or men from other ethnic groups might call Onyango “kehe”, or other derogatory names, to mean that he is a child and not a man since he is not circumcised.

Many participants remarked that if a man chose to be circumcised, he might be able to mix more freely with women and men from non-Luo ethnic groups in political, professional, and personal settings.

HIV and STI prevention.

When participants were asked to discuss all HIV prevention methods, the “ABC” approach was the most common response, although other prevention strategies, such as HIV testing, were mentioned. One-third (2/6) of FGDs with young participants and 5/6 FGDs with older participants identified MC as an HIV prevention strategy without prompting. Additionally, when asked why Onyango might decide to get circumcised, HIV prevention was one of the reasons mentioned, although not the most common. A range of protective effect estimates were mentioned by the participants (range: 30%–100%). Most participants reported that they had heard that MC “reduces the chance of getting HIV”; however, they were confused or uncertain about two issues: 1) how MC protects against HIV acquisition; and 2) whether the MC-HIV connection is a myth or truly protective.

Although young men were less likely to identify MC as an HIV prevention strategy without prompting, they had more knowledge than older men about the HIV-MC association, and the mechanisms by which MC is protective against HIV. Some mechanisms discussed by young participants included MC “hardens the tip”, germs cannot live on a circumcised penis, and the foreskin has many HIV target cells.

Among older men, many comments about the MC-HIV association began with “Some say…,” indicating that they might have some skepticism or inadequate information about this association.

Participant (P): “Some say that after circumcision you cannot acquire HIV easily.”

Moderator (M): “Why?”

P: “I don't know the reason but I hear them say so.”

Participants also reported that MC reduced the incidence of STIs, specifically gonorrhea, syphilis, boils, and cervical cancer. The magnitude of the protective effect afforded by MC against HIV and STIs was often discussed as equivalent.

Sexual performance and satisfaction.

Improved sexual performance and satisfaction, defined as male sexual satisfaction, female sexual satisfaction, and male sexual performance, were common facilitators to MC uptake, especially among young men. There was general consensus across all groups that MC improves sexual performance and satisfaction for men, and sexual satisfaction for female partners. Some reported that MC acts as a “natural condom,” and for this reason circumcised men can enjoy sex “skin-on-skin” without needing a latex condom. Additionally, participants reported that MC reduces cuts and bruising on the foreskin during sexual intercourse (this was discussed more by older men). Finally, participants believed that MC improves male sexual satisfaction by several other mechanisms, especially by reducing the worry of acquiring HIV or a STI during sex, by making condom use easier, and by making the penis more “rough” which increases friction during sex. Many participants reported additional sexual benefits for men after MC: men can have sex several times in the same night; the time to ejaculation is increased; penetration is easier; and circumcised men have more “energy” for sex.

The positive effect of MC on female sexual satisfaction was mentioned during all discussions. Most participants believed that women find circumcised men more sexually satisfying than uncircumcised men. Also, some participants believed that MC might encourage faithfulness if the female partners of circumcised men are more sexually satisfied. Finally, easier penetration, increased time to ejaculation, and increased friction were believed to affect female sexual satisfaction positively.

P: “What women will tell him is that in the past other tribes have been saying that this [MC] can help with this job, it penetrates well and it's sweeter than the one that has not been cut.”

Other facilitators.

Other motives for MC uptake included the following beliefs: that adolescence is the ideal time for MC (11–18 years); that MC clients would receive material incentives ranging from soda to a substantial monetary compensation; that the Christian religion approves of MC because Jesus was circumcised; that MC is offered in a medical setting; and that parents, elders, and celebrities support MC.

Participants agreed that MC is preferable for males before they reach age 18 years; no participant discussed a man over 30 years being circumcised.

P: “I've heard the old men say that circumcision should start at the age of 10 up to 18. Because beyond that, the muscles become mature.”

Nearly all participants believed that MC services should be performed in a medical setting by a trained provider. Participants discussed several reasons for this opinion, but the two most common were these: 1) if MC is “medicalized,” it may minimize resistance among the Luo people because they will not see it as a counter-cultural practice being thrust on them; and 2) if MC is “medicalized,” AEs would be handled more propitiously by trained medical staff.

In September, 2008, before the launch of the national VMMC program in Kenya, Prime Minister Raila Odinga, a Luo political and cultural leader, encouraged Luo men to go for MC for HIV prevention. This endorsement especially impacted younger men.

P: “As youths we go for circumcision because we are his disciples. So we will say, ‘If Raila did it, why not us?’ So we follow our leader.”

Time away from work.

Participants reported that too much time away from work, especially if the man is the sole provider for the family, is the most significant barrier to seeking the service. This barrier was especially noted among older men, and men working in the informal sector, including bicycle transporters, security guards, fishermen and others. Participants believed that men might be away from work for a minimum of one week up to a maximum of 12 weeks after circumcision.

Cultural and religious values.

Traditionally, the Luo removed the lower six teeth as a rite of passage into adulthood (while the neighboring Bantu groups practiced MC as a rite of passage). Recently, the practice of removing teeth has nearly ceased, and no practice has taken its place.[10] In this cultural context, the community has considered the role of MC as a medical practice versus a cultural rite.

Young participants viewed MC as a medical intervention that exists outside of culture, but older men often talked about MC as a cultural practice that is meant for other ethnic groups. Although young men discussed the health benefits afforded by MC, many still believed that getting the approval of elder males in their family was essential if one wished to be circumcised, and the consequences resulting from an unapproved circumcision could include being estranged from family, being forced to move off family land, and even dying.

P: “In our community they [elders] say that circumcision is not good… They even say that that is the reason why the young people are dying because they are going against the rules of our ancestors.”

Several participants, especially those who were young, reported that they believed that it would be a sin to get circumcised since circumcision would change God's creation. Older men talked about religion in the sense that if a man is “saved,” then he will not be promiscuous, and as a consequence, he will have no need for MC to protect him against HIV.

Adverse events.

The possible incidence of AEs was a common barrier to uptake. The most common AEs discussed included pain and bleeding during- and post-MC, and delayed healing. Other AEs mentioned included negative effects on male reproduction resulting from the anesthetic injection, problems with appearance, torsion, infection, reduction in penile size, and surgical “accidents” that would mar appearance or impair function. Some participants noted that clients who have a bad experience will share their experience in the community.

P: “So they [recently circumcised men] say there is a lot of bleeding… Another thing is some misconceptions like this local injection can cause you to be infertile in future and another thing is that an accident can occur…”

Abstinence period.

Almost all participants knew that an abstinence period of some duration was recommended after MC, and they discussed this as a barrier for both men and their female sex partners. Participants believed that men, especially young men, would be concerned that their female sex partners might seek other lovers while they are recovering. Older men reported that sleeping in the same bed with a wife would make it difficult to observe the abstinence period. Various durations of the abstinence period were discussed (range: 1 week – 8 weeks); some participants who knew the recommended duration of the abstinence period reported that six weeks was too long to abstain from sexual intercourse.

Status quo.

Some participants believed that men did not need or desire MC. Several reasons were given to explain why MC is not “necessary”: the protection against HIV and STIs is not 100%, and if a man is already HIV-positive, has good hygiene, or is already practicing other HIV prevention methods (ABC method, HIV counseling and testing, etc.), he will not benefit from the procedure.

Participants offered other reasons, too, that men might not have the desire to go for MC: they and their sex partner(s) are already sexually satisfied; they do not wish to change the appearance or sensation of the penis; they are too old; and/or they do not want to introduce doubt in their relationship by going for MC.

P: “When I told my wife that I wanted to go for circumcision, she told me that I am not faithful to her and so I want to go for circumcision so that I don't get infected. Secondly she told me that she liked that thing the way it was and she didn't want me to change it.”

Promiscuity.

The fear that MC will make a man promiscuous was mentioned frequently. On the individual level, participants said that if a man wants to get circumcised, his female sex partner(s), neighbors, and/or friends might think that he is promiscuous. As a community, it is believed that MC might create a generation of men, especially young men, who think that they can have sex without any risk. Some participants feared that if MC led to more promiscuity, it might produce more HIV transmission in the community, not less.

Other barriers.

Other barriers to MC uptake included: a long distance to the health facility; a decrease in male and female sexual satisfaction; and peer influence against MC. Distance as a barrier to uptake was discussed in terms of reaching the facility, getting home from the facility (especially if the MC client is believed to be weak and in pain), and seeking follow-up care.

Discussed mechanisms for decreased male and/or female sexual satisfaction included less natural lubrication on a circumcised penis and decreased male penile sensitivity.

P: “Even…circumcised persons have problems when having sex. In fact, when one is erect there are some fluids that lubricate him and after circumcision that place dries up and you'll be harming the girl because it's like you are stepping on her with a sole.”

Finally, other barriers to MC uptake included opposition from girlfriends, reports from MC clients who say they have had a bad experience, and resistance from community leaders who oppose MC.