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HIV/AIDS
Research
‘The body we leave behind’: a qualitative study of obstacles and opportunities for increasing uptake of male circumcision among Tanzanian Christians
  1. Jennifer A Downs1,2,
  2. Lucas D Fuunay3,
  3. Mary Fuunay3,
  4. Mary Mbago3,
  5. Agrey Mwakisole4,
  6. Robert N Peck1,2,
  7. David J Downs5
  1. 1Department of Medicine, Weill Cornell Medical College, New York, New York, USA
  2. 2Department of Medicine, Bugando Medical Centre, Mwanza, Tanzania
  3. 3P.A.G. Bible College, Mwanza, Tanzania
  4. 4Pentecostal Assemblies of God Tanzania, Mwanza, Tanzania
  5. 5School of Theology, Fuller Theological Seminary, Pasadena, California, USA
  1. Correspondence to Dr Jennifer A Downs; jna2002{at}med.cornell.edu

Abstract

Objectives Male circumcision (MC) reduces HIV infection by approximately 60% among heterosexual men and is recommended by the WHO for HIV prevention in sub-Saharan Africa. In northwest Tanzania, over 60% of Muslims but less than 25% of Christian men are circumcised. We hypothesised that the decision to circumcise may be heavily influenced by religious identity and that specific religious beliefs may offer both obstacles and opportunities to increasing MC uptake, and conducted focus group discussions to explore reasons for low rates of MC among Christian church attenders in the region.

Design Qualitative study using focus group discussions and interpretative phenomenological analysis.

Setting Discussions took place at churches in both rural and urban areas of the Mwanza region of northwest Tanzania.

Participants We included 67 adult Christian churchgoers of both genders in a total of 10 single-gender focus groups.

Results Christians frequently reported perceiving MC as a Muslim practice, as a practice for the sexually promiscuous, or as unnecessary since they are taught to focus on ‘circumcision of the heart’. Only one person had ever heard MC discussed at church, but nearly all Christian parishioners were eager for their churches to address MC and felt that MC could be consistent with their faith.

Conclusions Christian religious beliefs among Tanzanian churchgoers provide both obstacles and opportunities for increasing uptake of MC. Since half of adults in sub-Saharan Africa identify themselves as Christians, addressing these issues is critical for MC efforts in this region.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/3.0/ and http://creativecommons.org/licenses/by-nc/3.0/legalcode

https://doi.org/10.1136/bmjopen-2013-002802

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    Article summary

    Article focus

    • Male circumcision (MC) has been shown to reduce HIV transmission by ∼60% and is recommended by the WHO in sub-Saharan Africa.

    • In many areas of sub-Saharan Africa, the decision to circumcise depends strongly on religious identity, and Christians make up ∼50% of the population.

    • Very little data exist exploring the impact of religious beliefs on uptake of MC among traditionally non-circumcising Christians.

    Key messages

    • Frequently mentioned obstacles to Christians’ uptake of MC included perceptions of MC as a Muslim practice, as a practice that endorses sexual promiscuity or as unnecessary since they are taught to focus on spirituality over physical well-being.

    • Christians were eager for additional teaching on health-related topics, including MC.

    • Church-based educational campaigns that take into account these specific concerns and that target male infants and children may be an effective way to promote MC among African Christians.

    Strengths and limitations of this study

    • This study explores the innovative possibility of taking advantage of the opportunity offered by the influence of the Christian church in Africa in order to enhance uptake of MC.

    • As the study was conducted in one region of Tanzania, the views reported are not necessarily generalisable to the views of Christians throughout sub-Saharan Africa.

    Introduction

    Male circumcision (MC) has been shown reduce the risk of HIV transmission among heterosexual men by about 60%.1–3 Models suggest that implementation of routine MC in sub-Saharan Africa could prevent six million new HIV infections and three million AIDS-related deaths in the next 20 years.4 These findings have led the WHO and many African governments to endorse MC for HIV prevention in settings with a high prevalence of HIV.5

    In many areas of sub-Saharan Africa, practices related to MC depend heavily on religious identity. In eastern Tanzania, where the majority of the population is Muslim, over 80% of men are circumcised.6 In contrast, the western regions of Tanzania are populated mainly by Christians, and the prevalence of MC ranges from 26% to 69%.6 7 Prior studies in Mwanza (in northwest Tanzania) found that, while over 60% of Muslim men are circumcised, fewer than 25% of Christian men are circumcised.7 ,8

    We hypothesised that the decision to circumcise may be heavily influenced by religious identity and that specific religious beliefs may offer both obstacles and opportunities to increasing MC uptake. Therefore, we conducted focus group discussions to explore reasons for low rates of MC among Christians in Mwanza.

    Methods

    Single-gender focus group discussions were held in private settings at local churches from a variety of Protestant denominations in both rural and urban areas of Mwanza, Tanzania. The Mwanza region is populated predominantly by the traditionally non-circumcising Sukuma tribe, although within Mwanza city itself, inhabitants come from a variety of tribal backgrounds.

    A convenience sample of adult parishioners older than 18 years were informed about the opportunity to participate in the study prior to the day of the sessions. Participation was entirely voluntary. Discussions took place in Kiswahili and were led by a team of two native Kiswahili speakers of the same gender as the participants. Leaders used a structured list of open-ended questions (box 1) but also had freedom to deviate from the structured questions to facilitate discussion.

    Box 1

    Guiding questions used in focus-group discussions

    • What are some attitudes you have heard about male circumcision?

    • When boys or men are not circumcised, what are the reasons that male circumcision is not practiced?

    • What role do women play in the decision to circumcise or not circumcise?

    • What role does religion play in the practice of male circumcision, especially for Muslims and Christians?

    • A recent study has shown that 74% of Muslim males in the Mwanza region are circumcised, but less than 25% of Christian males are circumcised.7 Why do you think this is the case?

    • What has been said in your church about male circumcision?

    • What do you know about the relationship between male circumcision and HIV?

    • What do you think the Bible says about male circumcision?

    • In Galatians 5 : 6, Paul writes that ‘neither circumcision nor uncircumcision counts for anything’. How might this text teach us a Christian understanding of the practice of male circumcision?

    • Do you think Christians would be more inclined to circumcise their male children if they knew that the practice of male circumcision reduces the rate of HIV/AIDS infection? Why or why not?

    Focus group discussions lasted between 60 and 120 min and were recorded using a digital audio recorder. Data were subsequently transcribed verbatim into Kiswahili and translated into English by a professional translation service in Mwanza. Transcripts were imported and coded using NVivo software V.10 (QSR International, Doncaster, Australia). The goal was to perform a thematic survey9 using interpretative phenomenological analysis to explore participants’ views of a variety of issues related to MC.10 This analytical method aims to explore participants’ perspectives on an issue rather than to describe the issue objectively.10

    The stepwise analysis involved an initial independent reading of transcripts by study investigators to determine prevailing themes. The study team, including all focus group leaders, then participated in a collaborative group process to refine and clarify themes. Next, transcripts were re-read and coded extensively using themes that had been identified, as well as in vivo coding for additional themes noted. Finally, themes were organised and illustrative quotations were selected. All study team members reviewed the final text for accuracy and clarity. Only minor discrepancies in themes or coding emerged, and these were resolved by a group process.

    This study was approved by the Human Subjects Review Committee of the School of Theology at Fuller Theological Seminary, the Institutional Review Board at Weill Cornell Medical College and the Medical Research Coordinating Committee of the National Institute for Medical Research in Tanzania. All participants provided written informed consent for participation.

    Results

    In total, 67 people (32 women and 35 men) participated in 10 focus group interview sessions in August and September 2011. This included 15 women and 15 men from rural settings, 8 women and 13 men from urban settings and 9 women and 7 men from a semiurban setting. Focus groups ranged in size from 3 to 9 participants (median 7.5). The majority of study participants stated that they were from the Sukuma tribe. The following themes were identified from analysis of all focus groups.

    Determinants of MC status

    Tribal identity

    All 10 groups mentioned the importance of tribal identity in determining circumcision status. Many described traditional tribal practices of certain ethnic groups in which ceremonial MC is a test of courage that signifies the transition of adolescent boys into ‘heroic’ men. In contrast, a woman from the Sukuma tribe explained that Sukuma parents feel embarrassed when their children are circumcised. Rural Sukuma Christian men expressed suspicion, fear and reticence to break from traditional ancestral beliefs related to circumcision: When [the Sukuma people] hear so and so has already been circumcised first of all they are very sad saying, ‘What happened? What is wrong with that young man, what happened? He has gone mad.’ If you are circumcised you'll… have broken clan laws and therefore you'll have created problems for yourself… maybe those ancestral spirits will get to you now… to punish you.

    Religious identity

    These Christians affirmed that religion also plays a key and possibly dominant role in the decision to circumcise. MC was uniformly described as a compulsory practice for Muslims that is regularly taught as essential to ‘enter paradise’, regardless of tribal mores. This contrasted with Christians’ experiences in Protestant churches, where only 1 of 67 study participants had ever heard physical circumcision discussed in church. As Christians were not regularly taught about MC in churches, they tended to default to their traditional tribal beliefs, which for the Sukuma people is non-circumcision: Even if we say many ethnic groups who don't circumcise, you will find … the Muslims in those ethnic groups have been circumcised but the Christians have not been circumcised. [Urban female] Many of us who are in the church, we carry our [ethnic] traditions and come with them to the church … if we find that something is not talked about at all we take our tradition and go along with it. [Urban male]

    Contemporary influences for and against MC

    A number of individuals, particularly those in urban groups, expressed the belief that MC is a ‘modern practice’ that promotes cleanliness and prevents disease. Nine groups were aware that, apart from HIV, MC can also prevent other sexually transmitted infections, and two groups mentioned preventing urinary tract infections in children.

    Other related stories of uncircumcised children and young men being mocked for being ‘Philistines’ or for ‘wearing a sweater’. Many groups discussed the growing tendency of young women to refuse to speak with, let alone marry, uncircumcised men. Two groups mentioned that economic constraints may preclude MC, a procedure that typically costs ∼US$10. Costs mentioned included not only those incurred by the procedure itself, but also the cost of lost labour time while a recovering man is unable to work.

    Role of women in the decision to circumcise

    Many participants believed that women often wield influence in the decision to circumcise. Most often, this was expressed in the context of mothers urging fathers to circumcise sons: I remember that the advice came from my mother … she motivated the father and he took what? Took action! [Urban male] I was the one who got courage when I heard they [my children] were called Philistines had to take it upon me to tell their father. [Semi-urban female]

    Men furthermore described the influence of women on their partners or husbands: If she finds out you have a foreskin it ends right there. She refuses absolutely! [Rural male] Women see a man who has not been circumcised as someone who can't plan ahead. Therefore it means that in the marriage you will automatically be despised so … women contribute a lot to cause men to be circumcised so that the man can guard his respect in marriage. [Urban male]

    Should christians circumcise?

    The breadth of participants’ answers demonstrated that these Christians did not share a singular understanding of Christian teaching on MC (table 1). Many participants stated that Christianity does not teach whether or not to be circumcised, but others felt that Christian scripture strongly mandates either for or against circumcision: The one whose heart has been opened to follow the word of God will surely be circumcised. [Semi-urban female] I think if we go very deep in the Bible it will be difficult to circumcise … I see as if it goes against circumcision. [Urban male] The Bible says that Jesus was circumcised … and that is why I say they are just not taught but it is important and compulsory because we also learn from Jesus himself. [Rural female]

    View this table:
    Table 1

    Key issues raised by focus groups regarding male circumcision for Christians

    Drawing on a well-known biblical tradition that contrasts ‘outward’ circumcision of the flesh and ‘inward’ circumcision of the heart (Romans 2 : 25–29), all groups discussed the common teaching that Christians should focus on being ‘spiritually circumcised’ and ‘removing the foreskins from our hearts’: We Christians when we look at what the Bible says that first … your heart should be circumcised so that you can enter heaven, not that if you are circumcised you should be circumcised down there so that you enter heaven. It is the heart. [Rural male] If you are circumcised outside but in your soul you have not yet what, you not yet cleaned it is useless. It is better to first purify your soul and then you circumcise. [Rural female]

    Christians and the physical world

    As an extension of the concept of ‘spiritual circumcision’, five groups went on, unprompted, to explore the spiritual versus physical dichotomy that is mapped onto their understanding of the Christian faith. In contrast to Muslims, these Christians characterised themselves and their teachings as disinterested in the physical world: In the Christian churches we teach people mainly about the spiritual life alone, but the body we leave behind. [Semi-urban female] [The Christian] is concerned with spiritual matters rather than with physical matters. That does not apply to the Muslim. The Muslim is very much concerned with physical matters and he talks more about issues of cleanliness rather than stressing spiritual issues … when his body is clean that is when he is noticed by God. That is not like that for a Christian, he says God deals with the heart. [Semi-urban male]

    Many participants expressed a desire for their churches to teach physical/health issues: Apart from spiritually it should just be taught. There should be a good time for youth even if not in the church during the main service … Churches like for example the Adventists, they have health teaching … They have a special time to learn about health-related matters. [Semi-urban male]

    Male circumcision and promiscuity

    Six of the 10 groups worried about the sexual implications of promoting MC within churches. Some felt that HIV risk reduction via MC, like the promotion of condom usage, was irrelevant for monogamous Christian men: A man of God takes hold of faith… he believes that nothing will happen [such as becoming HIV-infected] because first of all I have one lover for a wife. [Semi-urban male]

    Others pointed out that MC is a practice associated with coming of age, sexual desirability and first sexual encounters in many tribal traditions. Therefore, they worried that promoting MC would encourage promiscuity among Christians: If you say that in the church we should preach if you are circumcised you reduce the probability of being infected with AIDS it is like saying use a condom and you won't get AIDS. You see, it means you will legalize sex in the church. [Rural male] Our goal is not to enhance promiscuity; our goal is … to build our youth in good Christian faith and to live in it and to be patient to get your partner. For us it is meaningless that it [MC] reduces [HIV transmission] because we do not teach our children to be promiscuous. [Semi-urban male] Those youth, if we begin to talk … ‘It appears that maybe the pastor encourages us to be circumcised so that we should have a girlfriend to the side and what not.’ Things like that I think many pastors … have such concerns [Rural male]

    Potential influence of the Christian Church

    A number of groups concluded by exploring the highly influential role that the Christian church could have in promoting MC. They proposed a variety of appropriate settings for such education, not only during church services but also in seminars for parents, premarriage classes, or youth gatherings. Parishioners suggested beginning by educating the pastors so that they would feel emboldened to discuss this issue: The churches [should] begin to educate the believers in the church. It means the pastors and the evangelists should not close their eyes to this issue. There are still those who keep hiding this issue … as leaders are educated when they come to the topic … they must do away with shame. [Rural male] Therefore the pastors themselves should be educated and other people [at] various seminars. I think if the people are educated there is no problem. They will understand. [Urban female]

    Discussion

    MC is recommended by the WHO as one of the most effective HIV-preventive measures,5 but uptake remains low in many regions of sub-Saharan Africa. Our study illuminates how religious beliefs among Christians provide both obstacles and opportunities for increasing the uptake of this intervention in sub-Saharan Africa, where the church exerts formative influence among the vast majority of the 470 million people who identify themselves as Christians. Key obstacles expressed by focus group participants included the beliefs that they should focus on ‘spiritual circumcision’ rather than physical circumcision, concerns about promoting sexual promiscuity if MC is touted as an HIV-prevention measure, and confusion about whether the Bible supports or refutes MC. On the other hand, our participants described that religion could override cultural aversion to MC, expressed openness to the idea that MC coheres with Christian beliefs, and desired more teaching regarding MC in churches. With the vast majority of African Christians characterising religion as ‘very important’ in their lives and attending religious services at least once weekly,11 exploring and addressing these obstacles and opportunities and harnessing the influence of the Christian church will be tantamount in enhancing uptake of MC.

    Our findings reveal that public-health education campaigns encouraging African Christians to pursue circumcision as an HIV prevention measure may not be sufficient if they do not address the religious implications of the practice. One focus group participant likened MC to condom promotion in church, which has been a controversial HIV prevention message espoused by some churches but hotly renounced by others since early in the AIDS epidemic.12–16 Similarly, African Christians worried that offering MC to adolescents would send the message that the church condones sex outside of marriage. Many suggested that, instead, MC should be promoted within the church context for health and cleanliness, and that its HIV-preventative effects should be de-emphasised.

    Another possibility for promoting MC within churches while decoupling it from sexual behaviour is to emphasise circumcision of boys during infancy and early childhood. Routine MC for children (either at the time of in-hospital birth or with routine immunisations) is seen as acceptable in a variety of African populations.17–21 Moreover, MC performed during childhood has lower rates of complications than adult MC,22 may mitigate the transiently increased of HIV acquisition from sexual encounters during wound healing and/or from increased sexual partners due to postcircumcision risk compensation,17 and is more cost-effective than adult MC.23 In a faith-based setting, MC might effectively be linked with religious milestones in childhood including infant baptism or dedication, first communion or confirmation classes. We are conducting further operational research to determine the most feasible strategies for facilitation of MC for children of Christian parishioners in Mwanza.

    Our findings suggest that Christian churches in sub-Saharan Africa play a highly influential role in parishioners’ beliefs and actions and therefore represent an efficient venue though which MC can be promoted. Christians who participated in this study were eager for their churches to address MC and other health topics, and were quick to suggest educational training for their pastors and subsequent targeted seminars for parishioners. These findings were consistent among both urban and rural Christians, and among Christians of both genders. Additionally, our data suggest that the success of this strategy may be maximised by providing education to mothers, who are able to play a prominent role in the decision to circumcise while the child is young and who frequently make up a dominant portion of churchgoers.24

    Our participants’ common sentiment that Christians should focus on ‘spiritual’ rather than ‘physical’ concerns has far-reaching ramifications for provision of healthcare for African Christians. Focus group participants endorsed the concept of ‘spiritual circumcision’ (a phrase mentioned by all 10 groups regardless of gender or urban vs rural setting) and, more broadly, the notion that Christian witness and mission does not involve care for the body but should focus on the cultivation of an internal spirituality. Such a body-soul binary reflects the lingering influence of Western missionary teaching, and many contemporary African and Western theologians have rejected this dualistic anthropology in favour of a holistic view of the human person in which the physical cannot be separated from the spiritual.25 ,26 Given the authority that the church has in members’ lives, an increasing number of Christians have advocated holistic, faith-based approaches for preventing HIV infection and other avertable medical conditions in sub-Saharan Africa.15 27–29 Discussants in our focus group sessions indicated that such an approach would be both acceptable and desirable.

    In conclusion, our focus group discussions revealed specific, surmountable obstacles to widespread uptake of MC among traditionally non-circumcising Christians in sub-Saharan Africa. A church-based educational campaign that takes into account Christians’ concerns about sexual promiscuity, addresses frequent injunctions to ‘leave the body behind’, and targets male infants and children may be an effective way to promote MC among African Christians. Given that recent estimates suggest one HIV infection averted for every 5–15 MCs performed,30 taking advantage of the opportunity offered by the influence of Christian church in Africa in order to increase MC uptake is both prescient and urgent.

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    Footnotes

    • Correction notice This article has been corrected since it was published. One of the authors' names has been corrected from ‘Lucus D Fuunay’ to ‘Lucas D Fuunay’.

    • Acknowledgements We thank the Association of Theological Schools in the USA and Canada and the Lilly Endowment Incorporated for their generous support that made this project possible. In addition, we thank the International Languages Training Centre in Mwanza, Tanzania for their outstanding transcription and translation work. Finally, we thank the pastors and church members in Mwanza for their willing and enthusiastic participation in this project.

    • Contributors JAD, LDF, MF, MM, AM and DJD participated in study concept and design and data collection. JAD, LDF, MF, MM, AM, RNP and DJD participated in data analysis and interpretation and wrote the manuscript. All authors have read and approved the final manuscript.

    • Funding This work was supported by the Association of Theological Schools in the USA and Canada and the Lilly Endowment Incorporated.

    • Competing interests None.

    • Ethics approval Weill Cornell Medical College; Fuller Theological Seminary; National Institute for Medical Research—Tanzania.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement Transcripts from focus group discussions are available upon request from Dr Jennifer Downs.