"Operating the bicycle"

Randomized controlled trials out of Uganda (Gray et al., 2007), Kenya (Bailey et al., 2007) and South Africa (Auvert et al., 2005) have shown that male circumcision conducted by well trained providers in well equipped settings reduces the risk of heterosexually transmitted HIV infection in men by 50-60%. WHO now recommends male circumcision for HIV prevention in "countries and regions with heterosexual epidemics, high HIV and low male circumcision prevalence". Uganda falls into this category.

While an efficacious intervention, safe male circumcision, or SMC, carries with it a number of challenges. Its partially protective effect requires that it be promoted in combination with other prevention strategies, such as condom use, partner reduction, HIV counseling and testing, treatment for STIs and others. There is concern that SMC will result in "behavioral disinhibition", whereby circumcised men engage in high risk sexual behaviors under the false belief that they are completely protected. Its large-scale implementation requires not yet existent infrastructure and human resource capacity, and its effectiveness necessitates that circumcised men abstain from sex until the wound heals - an "impossible" 6 week period, according to Uganda's current recommendations.

While Uganda has been formulating its safe male circumcision policy and communication strategy before promoting SMC at a population level, the Health Communication Partnership, Ministry of Health, and Makerere University School of Public Health developed provider and client counseling materials to answer basic questions, and conducted formative research to better inform upcoming campaigns.

Many of the frequently asked questions gathered have revolved around the expected issues of cost, availability, effectiveness, the procedure, and healing, among others. Here, however, are a few of the more unusual queries, compiled from radio station call-ins, newspaper write-ins, and questions sent to our male circumcision email address:

• Does circumcision make a man look and function like a woman?
• Is it true that if you are circumcised the first woman you sleep with can become a sex maniac?
• I am willing to circumcise but my problem is when I see anything to do with a skirt I get sexually excited. Will they give us medicine to cool down this excitement after circumcision?
• My husband just got circumcised but I want to know if he will continue 'operating the bicycle' (remain sexually effective) as well as he used to before circumcision.
• After circumcision and I see a girl, when I get an erection won't I get injured?
• The day you get circumcised, do you eat?
• Why can't those men with high libido stay in the hospitals until they are healed in order to avoid desire for sex?
• What if someone's penis is cut off and they die? What do you do?
• I am 28 years old but my penis is small like a 10-year old. I fear medical personnel may laugh at me afterwards if I go for SMC.
• If I take my son for SMC, won't I miss the gifts that are given during traditional circumcision?
• If you are circumcised and it's not your religion, do you die?

And my personal favorite:

• If I come riding my bicycle, can I get circumcised and return on my bicycle?