Medical male circumcision and risk compensation
Authors: Max Fish, Arianne Shahvisi, Tatenda Gwaambuka, Godfrey B Tangwa, Brian D Earp
Journal: The Lancet Global Health (2021)

14 years into the medical male circumcision (MMC) campaign for HIV prevention in sub-Saharan Africa, questions about scaling up remain. Researchers have reported evidence of increased sexual risk behaviours among a subset of men in some communities, possibly due to a false sense of security against HIV transmission from MMC. Other studies, involving different samples, assumptions, or measurements, have not found evidence of such risk compensation. Serwadda and Kigozi1Serwadda DM Kigozi G Does medical male circumcision result in sexual risk compensation in Africa?.Lancet Glob Health. 2021; 9: e883-e884Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar acknowledge this heterogeneity and highlight a meta-analysis that found no overall association between MMC and risky sexual behaviour.2Gao Y Yuan T Zhan Y et al.Association between medical male circumcision and HIV risk compensation among heterosexual men: a systematic review and meta-analysis.Lancet Glob Health. 2021; 9: e932-e941Summary Full Text Full Text PDF PubMed Scopus (9) Google Scholar The authors concluded that this finding “refute[s] the alleged associations between MMC and risk compensation”. However, this conclusion is a non-sequitur: an absence of overall association does not invalidate specific reports of marked and significant increases in risky sexual behaviour among circumcised men in specific populations. Rather, these findings suggest that there are unaccounted effects pulling in different directions depending on the study, as depicted in figures 2 and 5 of the meta-analysis by Gao and colleagues2Gao Y Yuan T Zhan Y et al.Association between medical male circumcision and HIV risk compensation among heterosexual men: a systematic review and meta-analysis.Lancet Glob Health. 2021; 9: e932-e941Summary Full Text Full Text PDF PubMed Scopus (9) Google Scholar regarding self-reported condomless sex or sex with multiple partners, respectively. Although these effects might appear to cancel each other out when analysed all together, their individual validity is not, thereby, refuted. Therefore, the appropriate response, both scientifically and in terms of public health, is not to call for a generalised promotion and expansion of circumcision programmes, as Serwadda and Kigozi propose.1Serwadda DM Kigozi G Does medical male circumcision result in sexual risk compensation in Africa?.Lancet Glob Health. 2021; 9: e883-e884Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar By contrast, the response should be to further investigate the contextual factors that might contribute to risk compensation among circumcised men in specific settings or groups, and those that might explain the apparent protection against risk compensation in other settings. Insufficient attention to local cultural variance and other contextual factors has been a problem with scaling up MMC more generally. We are cited by Serwadda and Kigozi1Serwadda DM Kigozi G Does medical male circumcision result in sexual risk compensation in Africa?.Lancet Glob Health. 2021; 9: e883-e884Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar for a footnote containing references to the literature on risk compensation; however, our central argument was that affected communities have not been adequately considered on their own terms and need a greater voice in the ongoing campaigns.3Fish M Shahvisi A Gwaambuka T Tangwa GB Ncayiyana D Earp BD A new Tuskegee? Unethical human experimentation and Western neocolonialism in the mass circumcision of African men.Dev World Bioeth. 2020; (published online Sept 9.)https://doi.org/10.1016/S0140-6736(07)60313-4Crossref PubMed Scopus (8) Google Scholar This concern is particularly salient to efforts to scale up MMC because aggressive quotas have resulted in ethically questionable recruitment practices on the ground.3Fish M Shahvisi A Gwaambuka T Tangwa GB Ncayiyana D Earp BD A new Tuskegee? Unethical human experimentation and Western neocolonialism in the mass circumcision of African men.Dev World Bioeth. 2020; (published online Sept 9.)https://doi.org/10.1016/S0140-6736(07)60313-4Crossref PubMed Scopus (8) Google Scholar, 4Luseno WK Field SH Iritani BJ et al.Consent challenges and psychosocial distress in the scale-up of voluntary medical male circumcision among adolescents in western Kenya.AIDS Behav. 2019; 23: 3460-3470Crossref PubMed Scopus (9) Google Scholar, 5Rennie S Gilbertson A Hallfors D Luseno WK Ethics of pursuing targets in public health: the case of voluntary medical male circumcision for HIV-prevention programs in Kenya.J Med Ethics. 2020; (published online Nov 4.)https://doi.org/10.1136/medethics-2020-106293Crossref PubMed Scopus (3) Google Scholar In light of the outstanding ethical and public health concerns, failure to consider contextual factors related to risk compensation and perspectives from target communities that are already marginalised make the evidence presented insufficient for a generalised scale-up of MMC. We declare no competing interests. Association between medical male circumcision and HIV risk compensation among heterosexual men: a systematic review and meta-analysisThe promotion of circumcision as an HIV preventive measure does not appear to increase higher-risk sexual behaviours in heterosexual men. Ongoing sexual health education should be maintained as a vital component of effective MMC programmes. Full-Text PDF Open AccessMedical male circumcision and risk compensation – Authors' replyAn extensive meta-analysis by Gao and colleagues1 showed that, overall, there is no association between medical male circumcision (MMC) and increased risk of sexual behaviour. In response to our Comment on this Article,2 Fish and colleagues3 have taken exception to our conclusion that such findings “refute the alleged associations between MMC and risk compensation”. The evidence suggests that, in aggregate, there is no evidence of net risk compensation after MMC; however, this does not exclude the possibility of individual risk compensation behaviours. Full-Text PDF Open Access