The girl effect: how teenage boys are likely to listen to girls over VMMC

Programmes aiming to increase uptake of voluntary medical male circumcision (VMMC) among adolescent boys should consider the influence adolescent girls have on their decision-making processes, new research suggests.

This study, carried out between 2015 and 2016 in South Africa, Tanzania, and Zimbabwe by the Johns Hopkins Bloomberg School of Public Health, consisted of focus group discussions with 90 adolescent girls living near VMMC clinics and in-depth interviews with 90 adolescent boys who had undergone VMMC.

While female involvement in VMMC decision-making has been studied among adults, little is known about the influence adolescent girls may have on adolescent boys’ decisions to undergo VMMC.

Evidence has shown that VMMC  reduces female-to-male sexual transmission of HIV by 60% at a population level, so increasing take up of VMMC is an effective way to reduce new HIV infections in high prevalence contexts.

Researchers found adolescent girls preferred male partners to be circumcised for numerous reasons, and crucially, that adolescent boys suggested encouragement from adolescent girls who they were romantically involved with was a motivating factor in seeking VMMC.

Adolescent girls tended to see VMMC as mutually beneficial for healthier sexual relations, with many considering it a prerequisite to whether they would consider dating someone or not. Many said they respected adolescent boys who underwent VMMC, viewing it as a brave decision to undergo the procedure to improve both partners’ health. When female participants were asked about the benefits of VMMC, most mentioned protection against HIV, sexually transmitted infections (STIs), and cervical cancer.

In addition, female participants viewed males with a circumcised penis as more attractive than uncircumcised males. Some also felt that sex was more pleasurable with a circumcised partner because of a belief that a circumcised man can prolong sex.

A number of the female participants said they tried to use their romantic relationships with adolescent boys, or the potential for sex, as leverage to convince them to become circumcised, and demonstrated supportive attitudes in the wound-healing period.

Particularly in Tanzania and Zimbabwe, adolescent girls said they would not initiate relationships, or would readily discontinue them if their partner refused VMMC. Interestingly, while some mentioned using the threat of HIV, STIs and cervical cancer as a means of persuasion, others said they tried to influence their male partner’s decision for the sake of his health, expressing the attitude that, if a female truly cares for her partner, it is her duty to convince him to seek VMMC.

Although VMMC is generally not associated with an increase in the number of sexual partners a man has or a reduction in condom use, some female interviewees felt VMMC encouraged adolescent boys to be promiscuous. This suggests that any programmes that encourage adolescent girls to play a role in convincing adolescent boys to seek VMMC will need to address the issue of promiscuity.

In all three countries, adolescent boys reported rarely considering the opinions of platonic female friends or peers when deciding to seek VMMC. This was echoed by female interviewees, who said their platonic male friends did not talk to them about VMMC. However, adolescent boys confirmed that encouragement from adolescent girls with whom they were romantically or sexually involved was a motivating factor in seeking VMMC.

As this is a qualitative study, it cannot be assumed that results are generalisable beyond the participants. In addition, it is possible participants did not fully disclose personal details to researchers. However, despite these limitations, the findings suggest adolescent girls have a role to play in shaping the social norms that encourage adolescent boys to undergo VMMC and other HIV prevention-related initiatives.