A total of 24 FGDs and 65 IDIs were conducted with 276 men across the four research sites (Table ; Figure ). The majority of men in the study were in favour of the PNG government implementing a MC program for HIV prevention among men. There were no differences in the reasons provided for or against the acceptability of MC between men who had previously undergone some form of penile modification and men who had not; and no differences in reported acceptability by geographical location. A small, but important group of educated men from Port Moresby who worked in the area of HIV prevention and care, accepted MC on the grounds of the potential health benefits to PNG men, but ultimately felt the introduction of MC would be ill advised due to the poor state of PNG's current health system and due to concerns regarding the risk of further consolidating male sexual dominance in the negotiation of heterosexual sex.
When interpreting these findings it is critically important to bear in mind that in PNG there is little to no distinction made between different forms of penile cuts. All penile cuts, irrespective of whether the foreskin is removed or not, are grouped together as 'circumcision'. This posed tremendous challenges to the conduct and interpretation of this study. In order to facilitate a more accurate discourse on circumcision in PNG, the authors of this paper have already developed a typology of penile practices [40
]. Our research has indicated that only men who have undergone medical MC report full removal of the foreskin, and that this is rare in both traditional and contemporary penile practices, where dorsal longitudinal slit is the most common penile cut performed. However, most men with a dorsal slit refer to their own cuts as 'circumcision' whilst kutim kok
is typically used to refer to all types of cuts in Tok Pisin
. It is unclear whether they consider such cuts to confer protection against HIV acquisition: our earlier research suggests that enhanced sexual pleasure, promotion of penile hygiene and prevention of sexually transmitted infections are the key motivators for these practices [43
]. A further complication is that dorsal longitudinal slit of the foreskin typically results in the remnant foreskin retracting from the glans resulting superficially in an appearance similar to complete foreskin removal [40
]. Thus, many respondents talk of having had a dorsal slit and then being 'foreskinless' when in fact no skin has actually been excised (e.g. as stated by respondents such as Pierson and Naldo, below). Additionally, in order for men to form an opinion regarding the acceptability of MC for HIV prevention, researchers in the majority of cases, needed to provide a basic overview of the research evidence to date from clinical trials in Africa (e.g. MC provides men with partial protection of around 60% during vaginal sex with a woman; MC does not protect women from being infected from an HIV-positive circumcised male).
Male circumcision is an acceptable intervention for HIV prevention in men in PNG
Men provided a number of key reasons for their acceptance of MC and these were, in order of emphasis: that MC will prevent HIV and STIs; MC would improve penile health and hygiene; MC is a culturally appropriate practice and; MC would increase sexual pleasure (Table ).
Acceptability of MC for HIV prevention among men in Papua New Guinea
MC prevents HIV and STIs
The majority of respondents considered MC an acceptable intervention for HIV prevention, based on the information provided by the research team in regards proven efficacy in Africa. Some men believed that MC would also confer protection against STIs, which further enhanced their view that a future intervention would be acceptable to them and to other men in PNG, as typified in the following remark: 'It's safe for the HIV/AIDS virus not to be transmitted when you sleep with a woman' (Elmo, ESP).
Introducing MC and advocating for the simultaneous use of condoms would allow for what many of the men referred to as 'double protection': 'The way I analyse is it will be like double protection, using condom and you circumcising and using condom together.' (Rodam, ESP). By combining HIV prevention methods, 'it can help us to prevent this [HIV] more effectively' (Kano, ESP); 'Both of them must work together' (Dennet, EHP). In addition to reducing personal risk of acquiring HIV, men also described community and population-based impacts of MC:
When circumcision is implemented and when all the men do that... the number of HIV/AIDS cases will be reduced and we won't see many people and many children whose parents have died ...Our businesses would run properly...and we would see our country change and develop..We will see families with money, children will go to school and there will be food in the house because men and women will have the strength to create gardens. (Augustine, EHP)
Conflating MC with dorsal slits (both referred to as circumcision--kutim kok), some men who had undergone a dorsal slit believed that the protective factor of MC for HIV (and STI) prevention was also available to them. Bolton, who resides just outside of the NCD, had undergone a contemporary penile dorsal slit in the past and carries out this procedure on his peers, stated:
Circumcision from my experience I see that it's a bit all right... If they [young men and upcoming generation] circumcise to prevent AIDS or sexually transmitted diseases such as gonorrhoea, if you circumcise you won't get these diseases as well. (Bolton, NCD)
Providing further cultural narrative of the conflation of MC with dorsal slits, Pierson shared his views:
From those who were circumcised they used to tell us that. 'In the past when we were with foreskin and sleep around with women, we usually get sick frequently. After we've circumcised and now that we are foreskinless we do not get sick.' When they said that we found it really hard to cut this, where will we get the treatment or razor blades and all these. (Pierson, EHP)
Having heard that MC could prevent HIV acquisition a number of the males who had a contemporary dorsal slit reported that they had done so in the belief that their 'circumcision' would provide them with protection: "I didn't want to get the bad disease [HIV] that's why I removed my foreskin.' (Naldo, EHP). Naldo stated that he had removed his foreskin but like Pierson, had in fact undergone a dorsal slit, and therefore his foreskin still remained but had retracted to the sides of the penile shaft, resulting in a superficial appearance consistent with complete removal. Furthermore, many men advocated to others that they too must undergo penile cutting in order to prevent themselves from being infected with HIV or STIs:
In the community I keep on telling the boys like this: 'Listen, you must cut your foreskin. Now we are in a different time, various bad diseases have come...if you cut your foreskin you will remain well. You will remain as a man, not a single disease will find you. (Henriot, ESP).
Having already cut their foreskins, many of men who had undergone a contemporary cut, particularly from Eastern Highlands Province, felt more confident to have sex with an HIV-positive woman having heard that MC conferred protection against HIV infection.: 'I feel that I've already been circumcised so this sickness [HIV] like whatever sickness they [women] acquire, when I have sex with them I will not get it' (Cornelius, EHP).
Although it was clearly HIV and STI prevention in men that respondents saw as key benefits of MC, another albeit smaller subset of men saw that women could also benefit from MC, particularly in relation to cervical cancer, or what they describe in Tok Pisin as sik bilong mama:
[MC means] avoiding the chances in acquiring these diseases usually being transmitted through sexual means, like gonorrhoea, syphilis, donovanosis, HIV/AIDS and cancer of the cervix. Diabetes also comes with them. (Zachariah, ESP).
...the mothers get the illness of the womb, it is related to such dirt sticking to the man's penis and sometimes the men usually come [home] drunk, they don't think about washing, they come throw whatever and go [have sex]. (Sacha, ESP)
ESP is the only province in the country implementing a program, albeit in an ad hoc fashion, of MC for HIV prevention. Community awareness started in October 2006 prior to program implementation in December 2006. In the three-year period between the start of program implementation and this study, the MC program coordinator in ESP reported that a total of 490 men had undergone adult male surgical circumcision. According to the coordinator, prior to the procedure being carried out through mobile clinics in remote areas, both men and women in the communities are informed of the benefits of MC in that it prevents HIV and STIs (specifically gonorrhoea, syphilis and donovanosis) in both men and women, and cervical cancer in women. With this in mind, it is not surprising that men from ESP identified more than any other groups of men, the benefits of MC in reducing both HIV and STI transmission:
I've been to the hospital, you know about HIV, there is more than just HIV, different types of sexually transmitted infections are also there. That's why I thought about this and I went and got myself circumcised at the hospital. (Hadrian, ESP).
MC improves penile health and hygiene
Penile health and hygiene was the second most common reason for men supporting the implementation of MC for HIV prevention in PNG. The primary perceived hygiene benefit of MC was that it would result in a drai (dry) and klin (clean) penis, absent of doti (dirt), gris (grease) and smel nogut (bad smell).
Okay,...this foreskin of the penis, when you leave it for two or three days, you pull it down and you have a look, lots of dirt, this dirt will be inside...Stuff like grease and other things like this will be under the foreskin on the penis. It will smell terribly. It's good to cut the penis in order to remove the dirt. If you leave it exposed the penis will remain clean. (Fredrick, ESP)
From my understanding, a man won't get HIV/AIDS because all the dirt after he has finished having sex and ejaculates, no germs will stay on the penis. When the skin is there, dirt remains. When the foreskin is removed the penis will be clean. (Fabian, NCD)
Drawing on traditional constructions of masculinity, male health and strength as a result of bloodletting (albeit from penile cutting or from urethral bleeding) several participants said the following of MC:
A man who is not fat, a skinny man; when you circumcise his penis, he will fatten ...and some full grown boys, they usually grow slowly slowly so when you cut their foreskins you will see that they grow up very quickly. (Aquinas, ESP)
Building on this belief in health and hygiene, the men from traditional bloodletting communities, particularly in ESP, linked MC and the benefits it offers to those conferred by penile bloodletting practices. Both MC and bloodletting practices are for men; both result in improved physical and penile health; and both result in the release of 'bad' maternal blood, albeit in different ways. For men with penile modification, especially those from traditional circumcising communities, keeping their penises clean and healthy was central to why they had undergone either a traditional or contemporary penile modification. Therefore MC was seen as reinforcing their concerns about penile hygiene, albeit it in a more medicalised setting. This concern with hygiene in the traditional setting was not solely the concern of men, as Korowa, a Chief from WNB said of women's concern about penile hygiene:
...our old women, they usually say that you must cut the foreskin of your penis, it would be clean and dry. Like you know when the boys usually pull the foreskin of their penises back they have this grease, the white stuff remaining there, these are the things that our mothers usually say are unhealthy. ...Sometimes like it will smell or it has got sickness, they usually tell us little boys. (Korowa, WNB)
Highlighting the sociocultural relationship between beliefs about how MC prevents HIV and STIs and the role of penile cutting in promoting penile hygiene, a large number of the men conflated the two reasons for accepting MC:
From my point of view I analyse that circumcision is best because it will prevent us from getting HIV/AIDS. ...from some awareness I attended too I heard they said that if there is skin still remaining and when you have sex with a woman, those grease of woman will be attached if the woman has the disease, HIV/AIDS will be stuck within the grease and it will stick to your skin and remain there and it will be easy to go into the hole of the penis and go give sick.(Alexis, NCD)
MC is culturally appropriate
Taking culture to refer to shared attitudes, goals and practices, MC was considered acceptable in both traditional and contemporary cultural contexts.
Men from traditional penile cutting communities were by and large supportive of MC, many because they believed that their traditional cut, albeit somewhat different from MC, was amendable to a hospital setting cut. That is, they would support their sons to have MC in a hospital if they were then permitted to carry out their traditional practices back in the village men's house. Odilo from WNB, but now living in NCD said:
If the government permits circumcision maybe for us coming from this custom with circumcision, we won't find it hard because we are already in it because it is our custom. But for men who do not come from this kind of custom maybe they will find it a little bit hard. But as I mentioned already for us people who come from this background, we would only agree for our children to go and circumcise, and then we can go back and do our customs. (Odile, NCD)
Other men were more reserved and offered cautionary acceptance. These men foresaw that the skills and personnel to carry out MC were already present in the community where traditional penile cutting was undertaken: '...it's our traditional custom from the past to today. So there is no need for us to go to the hospital.' (Aubert, WNB). Some men suggested that local cutters be trained to carry out full foreskin removal, especially in the area of medical treatment for post-operative care.
This is like it our custom and you said that if the government makes a law we will support it but it is much better for the government to come back again like give us medicines to help us men who cut foreskin and we will cut it. So they can provide employment back to us to circumcise like this will not affect our custom. (Moritz, WNB)
Other participants suggested that male health care workers could participate in traditional customary rituals by providing MC in the men's' house so that the cut would occur in the appropriate socio-cultural context. Several traditionally circumcised participants from Madang and Manus (now residing in NCD) reasoned that MC must be done in a traditional men's' house to achieve the full behavioural change that accompanies initiation because within such a structure, regulations exist in order to control and determine appropriate masculine (and therefore sexual) behaviour:
If the government encourages or enforces this as a country-wide practice or, I still support my brother over there because within a traditional setting ... we have strings attached. There are beliefs and there are disciplines, rules or code of ethics of our traditional practices. So once you go into a men's house you are attached, I mean after you circumcise they have you there with talks and rules and regulations that you follow to control your behaviour and attitude. (Elias, NCD)
Part of the structure, which allows for the regulation of men's behaviour, is that the penile cut and associated rituals are witnessed by the leaders and the community, and furthermore, it is important to the maintenance of the clan's identity, as shared by Irvin from WNB:
I have [such] strong belief in my custom that my son... . I will take him back again to the village to perform this custom so the leaders from the village will know that he is my son and he is part of this clan. I must bring him back so whatever discussions in the future, the people from the village know that this child is from this place too and he is part of this clan. (Irwin, WNB)
Reflecting on the decline in traditional penile cutting practices in many areas of PNG, one of the traditional chief's in WNB whose community continues to initiate boys as young as 5 years, says of accepting MC for HIV prevention, that the PNG government has a responsibility to both advocate for and support the continuation of traditional penile cutting practices as part of men's initiation. He has witnessed that with development 'this practice [of penile cutting] has died away'.
While MC was largely acceptable to traditional circumcising communities, several men from these communities cautioned that their acceptance and the government's desire to implement MC should not mean that MC becomes mandatory for all Papua New Guinean men, particularly those who originate from non-traditional penile cutting communities.
As we have argued previously [43
], traditional and contemporary penile practices share similar socio-cultural meanings with evidence of appropriation observed between traditional and contemporary penile practices. With the appropriation of traditional penile modification practices such as penile cutting and bloodletting ('shooting') by young men, a new culture of penile modification has been cemented into the cultural landscape of PNG. This appropriation provided an additional cultural context within which MC for HIV prevention was perceived as acceptable. This was especially evident in what can be best described as 'prison culture' [39
Men from communities where traditional penile and/or urethral bloodletting practices have died out, and who have undergone contemporary penile cutting in the absence of traditional customary observances, thought that MC was culturally acceptable: '...with regards to circumcision too, like when I talked about custom [of bloodletting] it is similar as well'. In fact, many suggested that MC resulted in the same sociocultural and medical outcomes of traditional penile cutting and bloodletting practices: manhood, strength and the removal of maternal blood. Others however suggested that along with MC, the penis should undergo separate but simultaneous bleeding.
MC increases sexual pleasure
Perceived improvement in sexual pleasure for men and their female partners was another common reason why men considered MC acceptable for HIV prevention:
... the penis without a foreskin when you go to have sex with women, like you feel good. It is good when the penis enters really well and when you release it's much better. (Aaron, ESP)
Alright if you want to satisfy woman and woman feels it probably she gets...sexual satisfaction. She feels that 'oh yeah, you removed foreskin, yeah, you are coming good so she will feel happy with this kind. (Ilanus, NCD)
The notion that MC could increase sexual pleasure was reported by all men, with and without a penile modification, but primarily championed by those men who had an existing contemporary penile cut. Men who had undergone a traditional or contemporary penile cut or MC, reported that circumcised penises became 'extra thick and extra long', and that cutting results in 'prolonged erection' thus allowing the men to go 'round after round'. Increased pleasure was also achieved by the absence of both the foreskin and a condom so that sexual intercourse was truly 'skin-to-skin':
I used to think 'leave condom use, I have not gained any pleasure from condoms'. If I used the 'bald man' [circumcised penis] plainly my bald man will really test you. When I use the bald man and we have direct sex skin-to-skin, then the woman usually gets the real feeling. (Henriot, ESP)
Male circumcision is unacceptable for HIV prevention in PNG
A minority of men from across all study sites said that they would not support the introduction of MC for HIV prevention. The primary reason provided was that MC would have a negative overall effect by promoting sexual risk compensation among men. Others were concerned that MC would be culturally-inappropriate and go against prevailing religious beliefs (Table ).
MC would promote sexual risk compensation
Men who were against the introduction of MC in PNG almost exclusively objected because they feared men would develop what they called a 'false sense of security'. While this is how men phrased their concerns about possible behavioural changes post circumcision, men's sense of security is not accurately best described as false because circumcision does reduce risk, although not totally. Risk compensation is used in the literature to describe the notion that individuals modify their behaviour in response to real or perceived changes in risk [54
]. Men described what has been defined as 'sexual risk compensation' whereby the likelihood of men continuing with or adopting measures associated with lower HIV acquisition risk, such as partner reduction or condom use, are reduced. Respondents were concerned that men who undergo MC might perceive themselves to be totally protected from HIV risk post-circumcision. Participants felt that if men perceive MC to offer complete protection from HIV, there is a risk that condom use would decrease. Many men spoke of the new (absent) position that condoms would have in men's sexual relationships post-MC.
If it's [circumcision] marketed as a way to prevent you from contracting AIDS, people might get the false impression: 'if I am circumcised, no matter how many times I go out with how many different women, I'll be ok'. And when they are under the false impression you know that the risks of contracting the disease are far higher. (Percy, NCD)
Okay with that now it will be like the usage of condom they will say, 'Ha, I am circumcised already so there's no need for me to use condom and with that now condom [use] will drop. (Nelson, NCD)
Providing anecdotal evidence of the fears expressed in the above quotes, male health care workers reported that many men who were circumcised returned with STIs because they did not use a condom, thinking circumcision protected them.
Most of the guys I've talked to, and especially those who came with STDs, they have been telling me that they've been circumcised already and they think that they are safe, so most of the time they don't use condoms. (Dr. Mal, WNB)
The other big problem is that those of us who have been involved for a long time in sexual health issues in PNG are very concerned about the idea that 'I'm circumcised already so I won't get it now. Forget about using condoms.' (Dr. Bill, NCD)
Many participants who felt MC was ill advised for PNG pointed out that removing the foreskin would stimulate men to increase their sexual activity due to increased sexual desire, leading men to increase their number of sexual partners and potentially promoting physical and sexual violence against women, including their wives and regular sexual partners. Young men in NCD were concerned that a kela kok (circumcised [literally 'bald'] penis) would result in men being more easily and frequently aroused, for example when the penis rubs against their trousers, or when a men sees a woman 'dressing up nicely'.
Okay from my experience is when you still have your foreskin, your sexual arousement is not that high. When I am circumcised, and if you see a woman not walking properly or dressing up nicely or if she is sitting down wrongly or you used to think of her, then quickly your penis will be erecting. You won't control it... it automatically it will aroused. So every time those of us who are circumcised have gone through this experience, and we wore pants to avoid this...and once if you are wearing the trousers without your pants and the penis touches the trousers, even if there is no woman walking or you see them, you'll be aroused. So that's one disadvantage that I see, from circumcision. It will now depend on your individual control. Like if this is our tradition than you follow it. And if it isn't your tradition don't try it because if you tried it you will feel something different that you've never experienced it before will happen to you. And if it happens to you and you cannot control it, that's when troubles occurs from this kind... you will feel differently and sometimes you cannot control your brain, you will rape [her] on the spot. (Jarret, NCD)
Like just from my personal experience, when they cut my foreskin, I feel like having sex every now and then, but my wife used to dislike it. But now I go to the extreme... I hit her and all this. It's not good. And if we are going to say, 'okay now, everyone will be circumcised', we are going to create more problems again because the men will want to have [more] sex. (Barry, EHP)
MC is culturally inappropriate
For a small group of men, MC was considered against customary tradition because they thought the purpose of MC was not in alignment with the purpose of a traditional penile cut. These men were concerned that introducing MC into traditional penile cutting communities would result in the cultural meanings associated with penile cutting being distorted:
Mainly when they go to the 'haus tambaran' [spirit house] for initiation, circumcision usually happens too ... they go through to obtain the strength to hunt for meat, build a house, make a big garden. Not in regards to sex or such... lately now we are using circumcision like we are talking about the sexual side. (Galen, NCD)
Not only is the meaning different but an essential aspect to traditional penile cutting--the shedding of 'bad' maternal blood--would be lost and tradition interfered with:
Yes it looks like, the behaviour of penile cutting has increased and I will also be concerned because my elders have not being circumcised... yet, they cut it in the white man's way, just cutting the skin, pull and remove only, they did not shoot the blood. They did not cut everything and the blood did not come down, it's like that and they just cut and did not remove the blood yet. If it [MC] is implemented I will not be circumcised. I will just shoot the penis and cut and remove so the blood will come down. (Nicholas, ESP)
In penile bloodletting communities the issue was that MC was a one-off event while penile bloodletting was a continuous practice that enabled men to maintain their health and to prevent disease:
I think many of them will be a bit scared to remove their foreskin and many of them, if we teach them properly the way of using condom, I think they will go for the condom. Why will I have this thing of penile cutting and all this because I already went into my custom [of penile bloodletting] in the haus boy? So from my initiation [I know] that when I have sickness, it's something I can still do myself [penile bloodletting] to protect myself... to prevent sickness. (Sailor, ESP)
For others, MC was culturally unacceptable because in these men's communities there was no tradition of penile cutting or bloodletting:
In my place, it is a taboo. I mean Western Highlands, Southern Highlands both areas, it is forbidden to cut this kind of thing. I mean from our custom we don't have this kind of thing [circumcision]. (Hubert, NCD)
MC goes against religious beliefs
Although the specific Christian denomination of each respondent was not sought, as a Christian nation, it is not surprising that some participants considered MC unacceptable for religious reasons. For some men HIV prevention was to be found in God, and specifically, by observing a faithful Christian life and by respecting God's creation:
With regards to circumcision maybe we remain like this because when the Lord created us, he didn't talk about us circumcising or cutting or shaping our skin here and there. He said no. How He shaped us, we must remain like this. So those of us who have cut it, it is one thing that wouldn't look good and we must stop ourselves, we shouldn't. Marry only one person and stay. It is not to go and become promiscuous. That's where we will get [HIV]. So from my opinion, it is no to circumcision and no to promiscuity. (Jaspar, NCD).