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 Acceptability of Male Circumcision in Kenya 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 pro- miscuous 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. Female service providers Many organizations and governments providing MC services have wondered how MC clients would respond to female service providers. To explore this issue, we asked participants, ‘‘If Onyango goes to a health facility for male circumcision and finds the following, how might he react: 1. Female staff providing counseling and education on circumcision? 2. Female staff performing the circumcision? 3. Female staff attending to clients during follow-up visits?’’ Most groups started this conversation thread by talking about interactions with female providers in non-professional terms, usually with sexual overtones. For example: P: ‘‘Onyango might be happy if he finds that it is a woman who performs the circumcision because he will be sure that the other girls will know that he has been circumcised and he can play sex perfectly.’’ The most common barrier discussed about a female service provider was that she might make a MC client feel ‘‘shy’’. Some participants believed that Onyango might have an erection when a female provider touches or inspects his penis, thereby creating an awkward situation for both the provider and the client. However, by the end of the discussion, most participants concluded that as long as the provider was a trained professional, and the client did not know her, MC services being provided by females would not be a problem. A few participants believed that a female provider might perform services better than a male provider because women are more ‘‘understanding’’ and ‘‘gentle’’ when providing services compared to men. PLoS ONE | www.plosone.org 4 May 2011 | Volume 6 | Issue 5 | e19814