Background: Papua New Guinea is a diverse country with a population of 6.8 million people speaking more than 800 languages. PNG has more than 90% of all reported cases of HIV in Oceania. Following trials that showed male circumcision reduces the risk of heterosexual men acquiring HIV, MC is now recommended in comprehensive HIV prevention packages for populations with a heterosexual, generalised epidemic and where most men are not circumcised. The 'Acceptability and Feasibility of Male Circumcision for HIV Prevention in PNG' study documented reasons for penile cutting in four locations across PNG.\ud
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Methods: Both men and women completed structured questionnaires about penile cutting. Sites were two university campuses in large urban centres, a remote mountain gold mine and coastal oil palm plantation. These are locations where people from across the country gather for work or study. The questionnaire included specific questions on the reasons for penile cutting.\ud
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Results: 864 males and 560 females completed questionnaires. 57% of males reported some form of penile cutting. Reasons reported by men were both historical and contemporary: being a part of custom/tradition; cleanliness; peer influence; to increase the size of the penis; avoid STI; increase sexual pleasure; prolong sexual intercourse; perceived increase in female sexual pleasure.\ud
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Conclusion: There was a diverse range of reasons for penile cutting reported in this study population. Any potential male circumcision for HIV prevention programs in Papua New Guinea need to take into account the wide range of traditional and contemporary penile cutting practices, and the reasons these cuts are being done

Browne, K.

MacLaren, D.

Mafile'o, T.

Manineng, C.

McBride, W.J.H.

Redman-MacLaren, M.

Tommbe, R.

Background: Papua New Guinea is a diverse country with a population of 6.8 million people speaking more than 800 languages. PNG has more than 90% of all reported cases of HIV in Oceania. Following trials that showed male circumcision reduces the risk of heterosexual men acquiring HIV, MC is now recommended in comprehensive HIV prevention packages for populations with a heterosexual, generalised epidemic and where most men are not circumcised. The 'Acceptability and Feasibility of Male Circumcision for HIV Prevention in PNG' study documented reasons for penile cutting in four locations across PNG.



Methods: Both men and women completed structured questionnaires about penile cutting. Sites were two university campuses in large urban centres, a remote mountain gold mine and coastal oil palm plantation. These are locations where people from across the country gather for work or study. The questionnaire included specific questions on the reasons for penile cutting.



Results: 864 males and 560 females completed questionnaires. 57% of males reported some form of penile cutting. Reasons reported by men were both historical and contemporary: being a part of custom/tradition; cleanliness; peer influence; to increase the size of the penis; avoid STI; increase sexual pleasure; prolong sexual intercourse; perceived increase in female sexual pleasure.



Conclusion: There was a diverse range of reasons for penile cutting reported in this study population. Any potential male circumcision for HIV prevention programs in Papua New Guinea need to take into account the wide range of traditional and contemporary penile cutting practices, and the reasons these cuts are being done

ResearchOnline at James Cook University

10/20/20111‘Stronger or Tougher’Reasons for penile cutting in Papua New Guinea Acceptability of Male Circumcision for HIV Prevention in PNG Study                                 A Joint JCU, PAU, DWU Study 2010-2012: NHMRC Project Grant 601003 MacLaren D, Tommbe R, Mafile’o T, Redman-MacLaren M, Browne K, Manineng C, McBride WJHon behalf of theAcceptability of Male Circumcision for HIV Prevention in Papua New Guinea Study TeamPapua New GuineaSouth Pacific country of great diversity 6.8 million people600 Islands 800 languages22 provinces4 regions87% people live in rural or island villages HIV in Papua New Guinea • More than 90% all HIV infections in Oceania are in PNG• 34,100 people living with HIV in 2009• 3,200 new HIV infections in 2009• 1,300 HIV related deaths 2009• Main transmission heterosexual• National HIV Prevalence 15-49 yrs 0.9%Southern 1.17%Highlands 1.02%Momase 0.63%New Guinea Islands 0.61%• Surveillance data suggest some levelling off in spread of HIV in PNG http://www.unaids.org/en/dataanalysis/monitoringcountryprogress/2010progressreportssubmittedbycountries/papuanewguinea_2010_country_progress_report_en.pdfNACS (2010) Papua New Guinea HIV Prevalence: 2009 Estimates. PNG National AIDS Council. Port Moresby. Male Circumcision and HIV • Clinical trials in Africa have show male circumcision can reduce HIV acquisition in men by 60% • WHO/UNAIDS recommend that Male Circumcision – be recognized as an additional strategy in a comprehensive HIV prevention package in populations where HIV is primarily heterosexually acquired, there is a generalized epidemic and relatively few men are circumcised. – be evidence based and responsive to the local contexts  • Male circumcision is a prioritized research area in the 2008-2013 Papua New Guinea National AIDS Council Research Agenda Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med. 2005 Nov;2(11):e298.Bailey RC, Moses S, Parker CB, Agot K, Maclean I, Krieger JN, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. The Lancet. 2007;369(9562):643-56.Gray RH, Kigozi G, Serwadda D, Makumbi F, Watya S, Nalugoda F, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. The Lancet. 2007;369(9562):657-66.UNAIDS & WHO 2007 New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications. Geneva: UNAIDS.Investigating Male Circumcision in Papua New Guinea The Acceptability of Male Circumcision for HIV Prevention in PNG study is at 4 sites in PNG where people from across the country come to study or work. • Describe and categorise male genital cutting• Examine social, cultural and religious understandings and practices of male genital cutting • Assess the capacity of health providers to deliver male circumcision services. Porgera : Gold MinePopondetta: Oil Palm PlantationMadang: Divine Word University  Port Moresby: Pacific Adventist University Data Collection • 869 male & 520 female structured questionnaires  • 40 male & 16 female semi-structured individual interviews• 36 male & 10 female Focus Group Discussions• 309 male clinical examination by medical professionalEthics approval by JCU, DWU, PAU and  PNG National AIDS Council10/20/20112Demographics of Participants0102030405060708018 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 54 56 59 62 65Frequency Age of Respondants MaleFemale0100200300400500600Single Married Separated Divorced WidowFrequencyMarital Status ParticipantsMaleFemale050100150200250FrequencyProvince of OriginMaleFemale050100150200250300FrequencyChurch Affliation MaleFemaleTypes of Penile Cuts Classification Frequency & Number Definition No foreskin cut 43% (n= 369) The prepuce has not been cut Longitudinal foreskin cut 47% (n= 400)Any form of longitudinal incision of the prepuce which does not remove the prepuce but exposes the glans Circumferential foreskin cut 10% (n= 88) Full removal of the prepuce with full exposure of glansMultiple types of penile cutting reported. Three broad classificationsNo cut Longitudinal cut Circumferential cutAge and Foreskin Cutter• Average age longitudinal cut 17.0 years       (Range 2-38)• Average age circumferential cut 14.8 years (Range 1- 30)01020304050601 3 5 7 91113151719212325272931333537FrequencyAge (Years) Age when foreskin cut Longitudinal cutCircumferential cut05101520253035404550Percentage of ParticipantsPerson Performing Foreskin Cut Longitudinal CutCircumferential Cut Location of Foreskin Cutting0510152025303540longitudinal cut circumferential cut Location of Foreskin Cuttingbush/plantationclinic/hospitaltraditional man's houseurban houseschoolrivervillageTool Used to Cut Foreskin010203040506070Razor Blade Surgical Blade Needle and RubberScissors/knife Bamboo Don't knowPercentage of Participants longitudinal cutcircumferential cut Remove foreskin if reduce risk of HIVYes 71%No16%Maybe13%No Penile Cut: Remove if Reduce Risk of HIVYes 84%No16%Already Split: Complete Removal if Reduce Risk of HIV10/20/20113Reasons for Penile Cutting• Cultural • Health • Sexual  • Biblical • Peer influence • Partners influence • Parents decision Reason - Cultural  Cultural Practice Taim yu kam through long disp’la process em bai yu ken go attendim ol bikp’la bikp’la bung b’long olbikman.  Yu speak bai ol man respect; em man toktok ia, kain olsem.[Translation] When you go through this process you can attend big gatherings with elders. When you speak, men will respect you and say, he is a man now – this kind of thing. Entering manhoodThe initiating ceremony is practiced and noted in my area to be very important because it mould a male child into adulthood. Community acceptance  if you no circumcised na yu marit, bai ol man mekim funny long yu, bai yu nonap pilim gutp’la long kam aot na raon.[translation]  if you are not circumcised and you are married, then men will make fun of you, and you will not feel comfortable to walk around in publicSpiritual Beliefs Male circumcision is culturally practiced in Morobe Province at the age of 16 years. Going through the initiation ceremony the young person receives supernatural power from the elders.Reason – Cultural  Body Cleansingtaim yu katim skin b’long kok b’long yu, em kain olsem yu raosim blood nogut ia – blood we mama karim yu long en ia, yu raosim i go na niup’la blood we i kam, em bai mekim olsem yu baigrow, or strong na muscel[translation] When you cut your foreskin, it is like you remove bad blood – your mother’s blood from during childbirth, you will remove it and new blood will come, it will make you grow  strong and muscular.  It was believed by the elderly persons that MC was done to remove mother’s blood and prepare to change into manhood particularly preparing towards having basic human need of good and safe sex. In my area the people, the youths tend to circumcise the other youths. When doing circumcision, they`ll ask them when you were born, you formed from the blood which belongs to your mother like that and than if, when go for circumcision, it`s a way which you will remove the dirt or dirty blood and after that you eat, you will grow well built when doing this.Reason – Sexual Obtain good sexual pleasure For sexual pleasure  to obtain good pleasure of having sex  Prolong Ejaculation Sex save longpla na sweet na man ino save kapsait hariap.  [translation] Sex is for longer and sweeter and man does not ejaculate quicklyTo prolong ejaculation that will satisfy me and my partner too which they express they are happy when having sex with me Sexual satisfaction to partnerBlo givim more feelings lo meri. Meri too bai singaut . [translation]  To give better satisfaction to women. Women will yell (with excitement).•Just to give pleasure to women in order that they won’t forget meFor Erection You can koap 2 or 3 raun [translation] you can have sex 2 or 3 times Avoid weakness of the erect penis while having sexPenile Enlargement Taim yu katim skin nau stik blong yu bai olsem, bai yu rausim olpela blood na olsem stik blong yu bai bikpela. [translation] when you cut the foreskin from your penis you will remove the old blood and your penis will become big.  Taim yu katim stik blong yu bai em kamap bikpela na yu ken silip wantaim ol bikpela meri [translation] When you cut your foreskin your penis will become big and you can have sex with older women. Reason - HealthPrevention of STI/HIVTo prevent or reduce risk of getting infected with STI To keep it clean so as to protect myself from STDs Personal Hygiene To prevent odours/offensive smell  To keep my penis clean and healthy at all timesSkin stap dirty ba pulap inside long skin so mi cuttim to keep my penis clean [translation] when there is foreskin it will collect dirt under the foreskin, so I cut it to keep my penis clean Strong and Healthy Believing that it would become strong and healthyI want to become strong and healthy personMedical Reasons I was told to remove due to health reasons (penis tighten by the foreskin)My mum told me that it was for health reason. I did not urinate well when I was small so they remove my foreskin which I am happy they didReason – Biblical  Positive ViewsGod instructed that Jesus to be circumcised and because of that I did it as a believer If Jesus can do it, He set an example so why not practising it Bible encourages circumcision so why not practising MC as Christians   Negative ViewsSupos God em wokim man wantaim skin larim stap olsem[translation] If God created man with foreskin then just leave it alone. Noken bagarapim creation bilong God na katim skin nating nating[translation]  Don’t spoil God’s creation by cutting the foreskin unnecessarily. 10/20/20114Influence from Others  Peer Influence My friend recommended me to do so we can be looked up at just like other boys in the school Partners InfluenceMy girl friend told me that she prefers circumcised men so I did it Parent’s Decision My father and mother decided on that but I appreciate this decision as I think it is a clean idea What do women think about male circumcision? • What do women think are the good things about male circumcision? • What do women think are the bad things about male circumcision?And we asked about lots of other things too!Results: Positives for women8 major themes identified:• Health• Sexual pleasure• Religion • Cultural• Masculinity• Maturity• Sense of happiness/satisfaction• Sense of safetyPhoto Credit: http://4.bp.blogspot.com/hH816ptiZyA/TdPpHspwSpI/AAAAAAAABpY/ru1yHwSYzfE/s1600/ghjty.bmpHealth and Sexual Pleasure  Health Prevent cervical cancer and infectionsA women with partner who has a round cut has the low risk of developing cervix cancerClean and HealthyAvoid smell and other infection that her husband will release during sexPrevention of STI/HIVEm bai aburisim ol kainkain sik olsem gonoria,sipilis or ol arapela kain sik[translation] He will avoid contracting  sickness like gonorrhea, syphilis and other STIs Sexual Pleasure Sait bilong slip wantaim man bilong mi, em mi save pilim gut bikos,  em nogat skin bilongkok na em save smooth tasol. [translation] In relation to having sex with my husband, I feel good because there is no foreskin and its just smooth Happiness and satisfaction She would not leave her husband and go having sex with other men because she would feel comfortable and more enjoyable because of the desires, feelings and pleasuresMasculinity, culture, religion MasculinityFrom what I heard from my girlfriends that the boys from their village, like when they are circumcised they look healthy, they look strong, they look like fit and they look handsome.  CultureThe boys will lose those bad blood. Taim ol lusim dispela bai ol grow healthy or strong. Emgutpela long kastom sait. [translation] The boys will lose those bad blood, when they remove this they will grow healthy and strong. It is good for the culture. ReligionEven Jesus himself was circumcised; we must always remember thatResults: Negatives for women8 major themes identified:• Men more sexually active/aroused• Sex with many women• Unsafe outside of health care setting• Pain and healing• Changes to penis• Inserts and injections• Risks: STIs, domestic violence and divorce• Culture10/20/20115Sexual Activity  Men want more sexual activityI heard from people that men who are circumcised easily get into sexual relationships, they feel sexually active at any time. He will want to sleep with his wife all the time and if there is no family planning they are likely to produce many children that are un-plan.Men want sex with many women I think it might encourage the husband to have more sexual partners thus might easily contract the disease.Man will have uncontrollable penis because most of the time they will be erected and the sexual desire will be so high. This cause man to be unsatisfied with one woman and so will be looking for sexual partners/ places to satisfy them ever erecting penis.Unsafe cutting, Pain and Healing  Unsafe CuttingBleeding can occur if not cut well. For example, my cousin almost bled to death because his peers did not do a proper cut. He almost fainted because he lost a lot of blood. And we have to take him to the hospital.  Pain and HealingTaim ol katim pikinini mi no save wanbel bikos em pikinini tumas nae em bai pilim plantipain. [translation] when they are doing circumcision on children, I do not like it because  he is too young and the child will feel a lot of pain.Having a round cut is massive, and negative change is that it would take a long time to heal. Thus meaning that we won’t have sex for a long period of time.Changes to penis Changes from circumcision/cuttingSometimes I feel that his penis are growing into an extra ordinary thing and I don’t enjoy having sex with him.I think the penis would become smaller or decrease in size and the woman would not enjoy sex as she would. Family and Culture Domestic Violence and Family Problems Em bai laik slip wantaim meri bilong em olgeta taim, everyday em bai no nap rest,eventhough meri pilim les. still em bai go out na painim narapela na causim femli problem. Sampla taim em ken forcim na paitim you bicos em no nap kontrolim sense blo em.[translation] He will want to have sex with his wife all the time, he will not rest from having sex every day, even though the wife is tired, he will still look for other women which brings family problem. Sometimes he can force and beat you because he could not control himself.CultureCircumcision is not common in other parts of PNG and women may not accept it in the beginning but educating and making awareness of the positive results can change all that. Summary • There is a great diversity of foreskin cutting and ‘Male Circumcision’ practices in Papua New Guinea reflecting the diversity of the country    • Most foreskin cutting in Papua New Guinea are longitudinal  cuts performed during teenage years or early adulthood by a friend or family member• There are a wide range of social, cultural and religious reasons for foreskin cutting in Papua New Guinea • There was a wide variety and sometimes conflicting responses by women.• Many women highlighted the health benefits and increased sexual pleasure if men are circumcised. • Key negative responses included: men desiring more sex, unsafe circumcision practices, physical and emotional pain for women and negative change to expectations of women as sexual partners.• Any potential male circumcision for HIV Prevention programs in Papua New Guinea need to take into account this wide range of traditional and contemporary penile cutting practices, the reasons these cuts are being done and perspectives from women.    Acknowledgements• Provincial and Regional Student Leaders and Village/Community leaders from the 4 study site • Study participants • Pacific Adventist University • Divine Word University • James Cook University• Porgera Joint Venture• Higaturu Oil Palms• NDOH/ADB HIV Prevention in Rural Enclaves Project • PNGIMR with University of Queensland and UNSW MC study team• PNG National AIDS Council/ PAC 4 sites • National Health and Medical Research Council of Australia 

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Stronger or tougher: reasons for penile cutting in Papua New Guinea

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Stronger or tougher: reasons for penile cutting in Papua New Guinea

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