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 Acceptability of Male Circumcision in Kenya 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.’’ Barriers to male circumcision uptake We asked participants, ‘‘What are some of the reasons that Onyango might decide not to get circumcised?’’ All groups responded that the primary barriers to MC uptake included (in order of salience): too much time away from work; cultural and religious values; the possibility of AEs; the post-surgical abstinence period; a desire to maintain the status quo; and increased promiscuity. 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 PLoS ONE | www.plosone.org 3 May 2011 | Volume 6 | Issue 5 | e19814