Varieties of Male Circumcision: a Study from Kenya Judith Brown Chogoria Hospital

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January 2001 Varieties of male circumcision: a study from Kenya Judith Brown Chogoria Hospital

Kenneth D. Micheni Chogoria Hospital

Elizabeth M.J. Grant Chogoria Hospital

James Mwenda Aga Khan University, [email protected]

Francis Muthiri Chogoria Hospital

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Recommended Citation Brown, J., Micheni, K. D., Grant, E. M., Mwenda, J., Muthiri, F., Grant, A. R. (2001). Varieties of male circumcision: a study from Kenya. Sexually Transmitted Diseases, 28(10), 608-612. Available at: http://ecommons.aku.edu/eastafrica_fhs_sonam/84 Authors Judith Brown, Kenneth D. Micheni, Elizabeth M.J. Grant, James Mwenda, Francis Muthiri, and Angus R. Grant

This article is available at eCommons@AKU: http://ecommons.aku.edu/eastafrica_fhs_sonam/84 Varieties of Male Circumcision A Study From Kenya

JUDITH E. BROWN, PHD, KENNETH D. MICHENI, ELIZABETH M. J. GRANT, PHD, JAMES M. MWENDA, KRCHN, DAN, MCOMMH, FRANCIS M. MUTHIRI, KRCHN, DAN, AND ANGUS R. GRANT, MBCHB, MRCGP

Background: Because male circumcision has been linked to From Chogoria Hospital, Chogoria, Kenya a lower risk of HIV infection, it is advocated tentatively as a possible preventive intervention. Most studies, however, have relied on men’s self-reports of their circumcision status. Goal: To document varied techniques of male circumcision frenulum during intercourse; an environment under the pre- in one area of Kenya and the visible results. Study Design: Researchers interviewed men who had per- puce favoring microorganisms and making cleanliness dif- formed or undergone various forms of circumcision. They also ﬁcult; increased risk of genital ulcer disease or balanitis; and did genital observations on a subsample of respondents. the presence of HIV target cells on the inner surface of the Results: All the men reported undergoing circumcision dur- prepuce.4–9 ing adolescence, and most were able to tell which technique At this writing, most studies of male circumcision have was used. According to the circumcisers, in type A, approximately 4 cm of the prepuce is removed; in type B, 1 to 2 cm of been from sub-Saharan Africa, and most have relied on the prepuce and some of its inner surface are removed. Types men’s self-reports of their circumcision status. However, A and B result in the same genital appearance. In type C, 1 to Chogoria Hospital personnel have long been aware that not 2 cm of the prepuce and some of the inner surface are re- all “circumcision” is the same. Although virtually all ado- moved. The remaining prepuce is slit and suspended below the penile shaft. lescent boys in the area are circumcised, several different Conclusions: Asking a man “Are you circumcised?” is not techniques are used, with differing results. The current sufﬁcient. Classifying his circumcision status requires both a study aimed to document these styles of circumcision, how genital examination and an understanding of the precise local men name and describe each one, and how the various surgical techniques used. Even in a small geographic area, considerable variety may exist in the techniques of cutting, techniques alter the foreskin. removing, altering, or leaving different portions of the foreskin. Each variation may affect the transmission of HIV and other infections. Setting

A NUMBER OF EPIDEMIOLOGIC STUDIES and re- On African maps showing circumcision practices and views1–3 have identified a link between male circumcision disease patterns, societies in the central and eastern part of and a reduced risk of HIV and other sexually-transmitted Kenya are shown as practicing male circumcision.10–14 infections. Several biologic mechanisms have been sug- Chogoria Hospital lies in that “circumcision zone,” on the gested as possible links between the presence of a foreskin eastern slopes of Mt. Kenya (Figure 1). The area is home to and disease transmission: trauma to the glans, prepuce, or various subgroups of the Meru people. All the groups speak Bantu languages, and all consider circumcision of adolescent boys to be an important, time-honored ritual. The The authors thank James M Mungiriria, who conducted the first interviews and helped to produce an initial set of drawings. Arthur Andere, Scottish Protestant missionaries who established Chogoria Richard Brown, Wamathaga Kuria, and Jack Richards commented on Hospital in 1922 began soon afterward to offer adolescent earlier drafts of this report. Andrew Koske of the Kenya Medical Research male circumcision in the hospital as a way of reducing the Institute (KEMRI). Nairobi, did the final illustrations. Supported by the Overseas Medical Fund of Charlottesville, Virginia. morbidity and mortality they associated with traditional Reprint requests: Judith E. Brown, PhD, PO Box 35, Chogoria, Kenya. circumcision practices. The hospital continues to provide E-mail: [email protected] Received for publication December 27, 2000, revised March 1, 2001, circumcision services to approximately 300 adolescent boys and accepted March 6, 2001. each year.

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with the boy under anesthesia. Currently, the term implies the use of anesthesia, regardless of the location: a hospital, a dispensary, or the boy’s home. Meru traditional circumcision (gutanwa kimeru): This term indicated that the foreskin was cut without anesthesia, and that the boy was circumcised at home or with a group of other boys in an open ﬁeld. The term also implied that during the healing period, the boy was secluded, physi- cally beaten, and instructed on “how to be a man.” Men who had undergone Meru traditional circumcision were then asked a further question, “Which style did you have?” Each man then named the particular technique used in his local area.

Gaining the conﬁdence of the respondents was not always easy. Some who had been circumcised in a traditional way hesitated to disclose the details. At times, the interviewer encouraged reluctant respondents by declaring his own traditional circumcision status, or by signaling it with secret hand gestures. Men who had been circumcised in a hospital did not always admit it readily. Meru men and boys who had undergone hospital circumcision knew they might be ridi- culed and called kiroge (“anesthetized,” “bewitched”) by men circumcised traditionally. Some men have been beaten or even “recircumcised” by advocates of the traditional procedures. Further observations and interviews with male nurses and Fig. 1. Map of Kenya, showing central Mt. Kenya area. traditional circumcisers revealed the details of three distinct circumcision techniques, all of which are performed cur- Research Methods rently in the Chogoria area. Technique A removes the entire To respect the traditions of Meru culture, only male prepuce, both inner and outer layers. Techniques B and C health personnel collected information for this study. These appear to remove most of the inner surface of the prepuce, men were native to the Chogoria area and thus able to but leave a small portion of the outer layer. With technique describe circumcision techniques as participant observers C, the remaining outer layer becomes an appendage on the who had performed or undergone the procedures them- under side of the penile shaft. The ﬁnal appearance of the selves. They held long discussions in the local languages penis after technique C is quite different from that after with circumcisers and elderly area residents. They admin- techniques A and B. The details of the three techniques istered short questionnaires to more than 150 men and follow, as illustrated in Figure 2. observed the genital appearance of a subsample during clinical examinations or surgery. Type A: The prepuce is retracted and injected with local anesthetic, then pulled forward and clipped with artery forceps just beyond the tip of the glans penis (Figure 2, Results column A). Approximately 4 cm of the tip is cut off, and All the participants in this study who grew up within 30 the remaining prepuce retracts behind the glans. If too km of Chogoria Hospital answered “yes” to the question much of the outer layer of the prepuce is judged to “Have you been circumcised?” They all reported undergo- remain, this layer is again pulled over the glans, trimmed, ing the procedure during adolescence, generally between and allowed to retract. The inner layer of the prepuce the ages of 13 and 17. When asked a follow-up question, (attached to the corona) then is trimmed, and the cut edge “What circumcision did you have?” the men gave one of of outer skin is stitched to the corona. Functionally, this two replies: technique removes the entire prepuce, both inner and outer layers. Hospital circumcision (gutanwa kithibitari): This term orig- Type B: The prepuce is pulled forward and approximately 1 inally implied that the procedure was done in hospital to 2 cm of the tip is cut off (Figure 2, column B). The 610 BROWN ET AL Sexually Transmitted Diseases ● October 2001

Fig. 2. Three techniques of male circumcision. Vol. 28 ● No. 10 VARIETIES OF MALE CIRCUMCISION 611

remaining prepuce is pulled back forcefully, tearing 1 to reported by Urassa et al.17 Researchers asked each man 2 cm of skin and leaving a ring of raw, exposed skin on about his circumcision status on two different occasions. the penile shaft behind the glans. The prepuce is pulled The agreement between the men’s own first and second forward again, and a 1- to 2-cm ring of its inner surface reports was only 77% in one study and 90% in another. One is scraped off. Finally, the prepuce is allowed to retract of the studies did include a physical examination of the behind the glans, so that its raw inner surface is in contact genital area. Each man was asked to pull down his foreskin, with the raw outer surface of the shaft. A bandage is then release it. Observers classified the men in three cate- applied for several hours to hold these surfaces together gories: not circumcised: foreskin completely covered the as healing and adhesion begin. This technique, believed glans penis; partially circumcised: foreskin partly covered to remove most of the inner surface of the prepuce, leaves the glans; completely circumcised: foreskin did not cover a small portion of the outer layer. the glans at all. Type C: The prepuce is pulled forward and approximately 1 The agreement between men’s reported and observed to 2 cm is cut from the tip (Figure 2, column C). The circumcision status was 81%. remaining prepuce is pulled back forcefully, tearing ap- Other African studies that included genital examinations proximately 3 cm of skin from the shaft. The prepuce is also suggest that at least three categories are necessary. again pulled forward, and approximately 3 cm of its inner Pe´pin et al18 classified 16% of their Gambian subjects as surface is scraped off. The prepuce is pulled further “functionally uncircumcised.” Lavreys et al8 examined 992 forward, and the circumciser inserts his thumb under the men in the city of Mombasa, Kenya. They reported exclud- prepuce, above the glans. With his thumb protecting the ing from their study six “partially circumcised” men. glans, he cuts a small slit transversely in the top of the Although previous authors have proposed three catego- prepuce. The glans then is pulled through this slit, leaving ries, the current study shows that the “partially circumcised” the prepuce suspended below the penis. The suspended category is not homogeneous. In the Chogoria area, a man’s prepuce shrinks over time, but usually remains visible self-report of having been “circumcised” can mean several throughout life. This technique removes approximately different things. Each of the local circumcision techniques the same amounts of both outer and inner layers of prescribes that particular portions and amounts of the fore- prepuce as technique B, but leaves part of the outer layer skin be cut, removed, altered, or left in place. Discussion as an appendage on the underside of the shaft. with colleagues in other parts of Kenya suggests that many other styles may also exist. In summary, all the men in the immediate area of Chogo- Therefore, detailed knowledge of local circumcision ria reported that they had been circumcised, but different techniques and their physiologic results are necessary as we parts and amounts of the foreskin had been removed. The attempt to discover whether and in what way the presence of circumcision styles differed among ethnic Meru subgroups. a foreskin may increase the risk of infection. Currently, In choosing a circumciser and a technique for their adoles- seven possible intervening mechanisms have been pro- cent sons, families are influenced by cultural and social posed: 1) the large numbers of HIV target cells (Langerhans traditions as well as religion. cells and macrophages coated with CD4 receptors) on the Three very different surgical techniques of male circum- inner surface of the foreskin8,9; 2) more genital ulcer dis- cision have been identified and described. The resulting ease, which is associated independently with noncircumci- genital appearances vary considerably. During clinical ex- sion and risk of acquiring HIV4–6; 3) inflammatory condi- aminations of adult men, health personnel could easily tions, such as balanitis, which may be more common in recognize the results of type C circumcision, but could not uncircumcised men4; 4) less keratinization of the prepuce or distinguish type A from type B. Both genital examination glans in uncircumcised men5,7–9; 5) trauma to the frenulum and careful questioning were necessary. or prepuce of uncircumcised men4,6,7,9; 6) a microenviron- ment under the prepuce especially favorable to the acquisition, survival, and replication of bacteria and viruses4,5,8,9; Discussion 7) difficulty in maintaining good hygiene of the prepuce.5,8 These findings demonstrate that simply asking men “Are The current study, which documented the variety of cir- you circumcised?” is not sufficient. Moses et al,1 reviewing cumcision techniques performed in one limited area of evidence of the relation between circumcision and HIV Kenya, raises several new questions about possible modes infection, warned in 1994 that researchers should, whenever of genital infection. For instance, techniques B and C re- possible, clinically confirm men’s reported circumcision move only the tip of foreskin, plus some of its inner surface. status. Nevertheless, many subsequent studies have contin- Does a partial foreskin put a man as much at risk as a ued to rely on men’s self-reports, without clinical complete foreskin? Does the partial foreskin still contain verification.2,3,15,16 Langerhans cells or other receptors? One notable exception is the set of Tanzanian studies Technique C partially detaches the remaining outer layer 612 BROWN ET AL Sexually Transmitted Diseases ● October 2001 of the foreskin and leaves it suspended from the penis. Does 6. Halperin DT, Bailey RC. Male circumcision and HIV infection: 10 the suspended portion provide an environment in which years and counting. Lancet 1999; 354:1813–1815. 7. Kelly R, Kiwanuka N, Wawer MJ, et al. Age of male circumcision and infectious organisms can accumulate and multiply? Does a risk of prevalent HIV infection in rural Uganda. AIDS 1999; 13: suspended foreskin affect the use and effectiveness of con- 399–405. doms? These questions warrant investigation. Furthermore, 8. Lavreys L, Rakwar JP, Thompson ML, et al. Effect of circumcision on incidence of human immunodeficiency virus type 1 and other sexu- can the variation in observed effects among past studies of ally transmitted diseases: a prospective cohort study of trucking male circumcision and the risk for HIV infection be attrib- company employees in Kenya. J Infect Dis 1999; 180:330–336. uted partly to differences in types of circumcision? 9. Szabo R, Short RV. How does male circumcision protect against HIV infection? BMJ 2000; 320:1592–1594. Finally, male circumcision is now being suggested as one 10. Dodge O, Kaviti J. Male circumcision among the peoples of East possible intervention to help reduce the risk of HIV and Africa and the incidence of genital cancer. East Afr Med J 1965; other genital infections among African men.6,19–21 If young 42:98–105. 11. Bongaarts J, Reining P, Way P, Conant F. The relationship between men in noncircumcising societies begin to seek circumci- male circumcision and HIV infection in African populations. AIDS sion, they are likely to request the types already being 1989; 3:373–377. performed among their neighboring ethnic groups. Medical 12. Moses S, Bradley J, Nagelkerke NJD, Ronald AR, Ndinya-Achola JO, Plummer FA. Geographical patterns of male circumcision practices practitioners and researchers need accurate knowledge of in Africa: association with HIV seroprevalence. Int J Epidemiol local circumcision techniques and their consequences to 1990; 19:693–697. make clear recommendations in both circumcising and non- 13. Caldwell JC, Caldwell P. The African AIDS epidemic. Sci Am 1996; 274:62–68. circumcising areas. 14. Marck J. Aspects of male circumcision in subequatorial African culture history. Health Transition Rev 1997; 7(suppl):337–359. References 15. Gray RH, Kiwanuka N, Quinn TC, et al. Male circumcision and HIV acquisition and transmission: cohort studies in Rakai, Uganda. Rakai 1. Moses S, Plummer FA, Bradley JE, Ndinya-Achola JO, Nagelkerke Project Team. AIDS 2000; 14:2371–2381. JD, Ronald AR. The association between lack of male circumcision 16. Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and hetero- and risk for HIV infection: a review of the epidemiological data. Sex sexual transmission of human immunodeficiency virus type 1. Rakai Transm Dis 1994; 21:201–210. Project Study Group. N Engl J Med 2000; 342: 921–929. 2. Moses S, Bailey RC, Ronald AR. Male circumcision: assessment of 17. Urassa M, Todd J, Boerma JT, Hayes R, Isingo R. Male circumcision health benefits and risks. Sex Trans Infect 1998; 74:368–373. and susceptibility to HIV infection among men in Tanzania. AIDS 3. Weiss HA, Quigley MA, Hayes RJ. Male circumcision and risk of HIV 1997; 11:73–80. infection in sub-Saharan Africa: a systematic review and meta- 18. Pe´pin J, Quigley M, Todd J, et al. Association between HIV-2 infec- analysis. AIDS 2000; 14:2361–2370. tion and genital ulcer diseases among male sexually transmitted 4. Cameron DW, Simonsen JN, D’Costa LJ, et al. Female-to-male trans- disease patients in The Gambia. AIDS 1992; 6:489–493. mission of human immunodeficiency virus type 1: risk factors for 19. Cohen MS. Preventing sexual transmission of HIV: new ideas from seroconversion in men. Lancet 1989; ii:403–407. sub-Saharan Africa. N Engl J Med 2000; 342:970–972. 5. Bailey RC, Neema S, Othieno R. Sexual behaviors and other HIV risk 20. Potts M. Male circumcision and HIV infection. Lancet 2000; 355:927. factors in circumcised and uncircumcised men in Uganda. J AIDS 21. Moench TR. Neglected opportunities [letter]. J Infect Dis 2000; 181: 1999; 22:294–301. 804–805.