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Keywords:

  • sexual satisfaction;
  • male circumcision;
  • women

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

OBJECTIVE

To investigate the effect of adult medical male circumcision on female sexual satisfaction.

SUBJECTS AND METHODS

We investigated self-reported sexual satisfaction among 455 women partners of men circumcised in a randomized trial of male circumcision for the prevention of human immunodeficiency virus in Rakai, Uganda. Women aged 15–49 years were interviewed about their sexual satisfaction before and after their partners were circumcised. We analysed female-reported changes in sexual satisfaction using chi-square or Fisher’s exact tests.

RESULTS

Only 2.9% (13/455) of women reported less sexual satisfaction after their partners were circumcised; 57.3% (255/455) reported no change in sexual satisfaction and 39.8% (177/455) reported an improvement in sexual satisfaction after their partner’s circumcision. There were no statistically significant differences in sexual satisfaction before and after partner’s circumcision by age, religion and education status.

CONCLUSION

The overwhelming majority of women (97.1%) report either no change or improved sexual satisfaction after their male partner was circumcised. These findings suggest that male circumcision has no deleterious effect on female sexual satisfaction.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

Three randomized controlled trials conducted in Uganda, Kenya and South Africa showed that male circumcision reduces HIV acquisition among HIV-negative men by 50–60%[1–3] and the WHO now recommends the procedure as a component of HIV-prevention programmes [4]. Studies in Uganda and Kenya show no deleterious effects of circumcision on male sexual satisfaction or function [5,6]. However, there is limited information on sexual satisfaction among female partners of circumcised men [7,8], and there has been speculation that removal of the foreskin might reduce female sexual satisfaction because the gliding action of the foreskin is thought to facilitate vaginal penetration [7,8]. Sociologists and gender specialists have urged that circumcision ‘roll-out’ programmes consider social factors that might affect women, including acceptability of male circumcision and female sexual satisfaction [9]. A Spanish study of 19 women showed no effect of male circumcision on overall female sexual satisfaction [10].

We investigated female-reported sexual satisfaction before and after circumcision of their male partners who were enrolled in a randomized trial of male circumcision for HIV prevention in Rakai, Uganda.

SUBJECTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

Two randomized controlled trials conducted in Rakai were described previously [3]. Briefly, the trials enrolled consenting HIV-negative and -positive uncircumcised men and their consenting spouses aged 15–49 years. Men provided informed consent for randomization to immediate circumcision (the intervention arm), or circumcision delayed for 24 months (the control arm). All surgeries were performed by well-trained medical officers using the sleeve procedure, and were conducted in fully equipped outpatient operating rooms (theatres) located in a central facility [3].

In all, 616 women who were partners of circumcised men were consented and interviewed by same-sex interviewers in a follow-up study, using structured questionnaires; 455 women who had had sexual intercourse with their male partners before and after they were circumcised were included in this analysis. Sociodemographic information and self-reported sexual satisfaction before and after the partner was circumcised were collected. Sexual satisfaction was categorized into ‘less satisfied’ if the woman reported that she was less sexually satisfied after her partner’s circumcision, ‘no change in satisfaction’ if the woman reported no difference in sexual satisfaction, and ‘more satisfied’ if the women reported that she was more sexually satisfied. The partners circumcision status was confirmed by interview and genital examination during trial follow-up visits. Women who reported less or more sexual satisfaction after surgery were also asked why they were less or more sexually satisfied.

All participants provided written informed consent and were provided with education on safe-sex practices (i.e. sexual abstinence, faithfulness with an uninfected partner and consistent condom use with a partner who is HIV-positive or whose HIV status is unknown), were offered free condoms, free voluntary HIV counselling and testing, free treatment for sexually transmitted disease, and were referred for free HIV care in the Rakai PEPFAR funded ART programme if they were found to be HIV-positive.

Women who reported any problem with sexual satisfaction or function had access to a programme medical officer for management, including counselling and referral when necessary.

This trial was reviewed and approved by the Uganda Virus Research Institute Science and Ethics Committee in Uganda and the Uganda National Council of Science and Technology that oversees research in Uganda. The study was also approved by the Western Institutional Review Board in the USA and was monitored by a Data Safety and Monitoring Board for Trial registration number NCT00124878.

We analysed female-reported change in sexual satisfaction before and after their male partner was circumcised. Tests of statistical inference were based on chi-square or the Fisher’s exact tests for proportions.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

In all, 455 of the 616 (73.9%) enrolled women had had sexual intercourse before and after their partner was circumcised, and were included in this analysis. As shown in Table 1, these women were significantly older than the 171 women who did not have sexual relations before and after their partner’s surgery (P = 0.03), but the two groups were comparable in other sociodemographic characteristics.

Table 1.  Selected social-demographic characteristics of women enrolled in the study
CharacteristicsSex before and after surgery, n (%) P, chi-square
YesNo
All455 (100)171 (100) 
Age, years   
 15–24159 (36) 74 (43)0.03
 25–29153 (34) 48 (28) 
 >30133 (30) 49 (29) 
Religion   
 Catholic324 (73)137 (80)0.45
 Protestant 79 (18) 25 (15) 
 None/Muslim/Saved/other 42 (9)  9 (5) 
Education   
 None/primary336 (76)133 (81)0.34
 Secondary/tertiary109 (24) 38 (19) 

Table 2 shows reported change in sexual satisfaction by social and demographic characteristics. Only 2.9% (13/455) of women reported less sexual satisfaction after their partners were circumcised. In all, 255/455 (57%) of women reported no change in sexual satisfaction, while 39.8% (177/455) reported an improvement in sexual satisfaction after their partners’ circumcision. There were no statistically significant differences in female-reported change in sexual satisfaction before and after their partner’s circumcision by age (P = 0.14), religion (P = 0.09) and education status (P = 0.25).

Table 2.  Self-reported sexual satisfaction among women who had sexual intercourse before and after their partner’s circumcision
CharacteristicRelative level of sexual satisfaction (after vs before), n (%) P
LessSameMoreTotal
All13 (2.9)255 (57.3)177 (39.8)455 (100) 
Age, years     
 15–244 (2.5)80 (50.3)75 (47.2)159 (100)0.14
 25–294 (2.6)90 (58.8)59 (38.6)153 (100) 
 >305 (3.8)85 (63.9)43 (32.3)133 (100) 
Religion     
 Catholic 11 (3.4)178 (54.9)135 (41.2)324 (100)0.09
 Protestant1 (1.3)56 (70.9)22 (27.9)79 (100) 
 Muslim/none/saved/other1 (2.4)21 (50.0)20 (47.6)42 (100) 
Education     
 None/primary12 (3.6)195 (58.0)129 (38.4)336 (100)0.25
 Secondary/tertiary1 (2.9)60 (55.1)48 (44.0)109 (100) 

Table 3 shows problems reported by 13 women who reported reduced sexual satisfaction. Women could report more than one reason for their dissatisfaction. The most common problems included reduced female sexual desire (six), lower male sexual desire (six), male partner had difficulty achieving (three) or maintaining an erection (five). None of the male partners of women who reported reduced sexual satisfaction had any moderate or severe surgically-related adverse events after circumcision.

Table 3.  Reason cited for reduced female sexual satisfaction in 13 women and improved satisfaction in 177 women
Reason for change in sexual satisfactionn or n (%)
  1. Women could report more than one reason for reduced or improved satisfaction.

Reduced (13) 
Level of sexual desire was reduced6
Male partners’ desire for sex was reduced6
Male partner had difficulty maintaining an erection5
Male partner had difficulty getting erections3
Male partner’s took longer to achieve orgasm2
Male partner had difficulty with penetration2
Male partner had difficulty with ejaculation2
Male partner wanted sex too often1
Male partner has pain on intercourse1
Woman had pain on intercourse1
Woman could not achieve orgasm or achieved orgasms less often1
Prolonged intervals between female orgasms0
Improved (177) 
Better hygiene51 (28.8)
Male partner takes longer to achieve orgasm45 (25.4)
Partner wanted sex more often44 (24.9)
Partner had less/no difficulty maintaining erection26 (14.7)
Female achieved orgasm more often20 (11.3)
Partner had less/no difficulty getting erections18 (10.2)
Partner had less/no sexually transmitted infection18 (10.2)
Partner had less/no problem of insertion16 (9.0)
Partner had less/no pain on intercourse7 (4.0)
Partner had less/no difficulty in ejaculation5 (2.8)
Partner had less/no genitourinary disease5 (2.8)

Table 3 also shows reasons cited for increased female sexual satisfaction by 177 women. The commonest reasons mentioned included better penile hygiene in 28.8% (51/177), more frequent orgasms for the male partner in 25.4% (44/177), male partner wanted sex more frequently, 24.9% (44/177), the male partner had less difficulty maintaining an erection, 14.7% (26/177), and the woman achieved orgasm more frequently, 11.3% (20/177).

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

This is the first study with a substantial sample size to assess the effect of adult male circumcision on female sexual satisfaction. Over 97% of women reported no change or an improvement in sexual satisfaction, compared to only 3% of women who reported less sexual satisfaction after their partner’s circumcision. A study conducted by Coates et al.[10] concluded that circumcision had no effect on female partner’s perception of sexual satisfaction. However, this study included only 19 women and was conducted in a hospital setting, where men were highly selected for circumcision due to pre-existing medical indications for surgery.

Our findings provide information of importance in designing education messages for circumcision programmes that promote male circumcision as an HIV prevention strategy. In South Africa, men who believed that women would enjoy sex more with circumcised men were over five times more willing to have the procedure [11]. In the present study, 39.8% of women reported an improvement in sexual satisfaction after circumcision of their partners, and this information can be used to encourage women to accept male circumcision for their partners or children. Our finding that male circumcision is much more likely to improve female sexual satisfaction suggests that it might have social benefits in addition to established health benefits, and addresses previous speculative concerns about the possible adverse effects of male circumcision on female sexual satisfaction.

In conclusion, >97% of women reported no change or an improvement in sexual satisfaction after their partners were circumcised. This finding should be integrated into programme messages to address fears that male circumcision might lead to reduced sexual satisfaction in women partners of circumcised men.

CONFLICT OF INTEREST

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

None declared. Source of funding: Gates Foundation.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES