Women's experience of male circumcision in Papua New Guinea: a grounded theory study

Background: Understanding how women experience and manage the myriad issues of male circumcision (MC) for themselves, their sexual partners and their sons is essential to understanding broader HIV and sexual health issues in Papua New Guinea (PNG). A great diversity of traditional and contemporary circumcision and foreskin cutting practices exist across the country. Medical MC is currently being investigated as a HIV prevention strategy. Studies have documented mixed responses by women to MC as a HIV prevention method in PNG. Methods: Between 2012 and 2014, a grounded theory study was conducted using a two-phase approach. Data from a large mixed methods multi-site MC study in 2010/2011 was analysed for themes to inform specific questions for women. Semi-structured interviews and focus group discussions, that incorporated visual methods such as storyboarding, were then conducted with 67 women at two of the initial study sites - a rural oil palm plantation and an urban university site. Data were inductively analysed to identify codes, categories and a grounded theory. Results: Women have extensive knowledge about MC and foreskin cutting practices, despite cultural norms that mean most women do not participate in decision-making about MC or other penile modifications. Women gain knowledge through personal (sometimes negative) experiences of their partners or children, through cultural traditions and/or through formal training or education. Women who have formal education or training, or who hold formal roles in their communities reported a greater power of choice about their own decision-making, including how MC affects them. Educated women reported more opportunities to influence their partner's decision about MC or other penile modifications, to choose a new partner or arrange MC for their male child/ren. Conclusions: Increased formal and informal education (such as HIV and sexual health training) results in increased status for women and access to a greater range of choices. The often culturally sanctioned low-status roles for women in PNG can be changed with training and/or formal education, which gives more power and thus more choices. If women have greater power of choice, they are less vulnerable to harmful, unintended consequences that may result from a policy of medical MC