Social complexities of informed consent and assent among young males undergoing voluntary medical male circumcision in Eswatini

Introduction:
As part of an effort to meet ambitious male circumcision targets in Eswatini, programme implementers have increasingly focused on young males, raising questions about informed consent. Males aged 10-19 years account for more than two-thirds of those circumcised since 2008 when internationally funded circumcision campaigns began in Eswatini. The ethical guidelines of these programmes conform to international standards, requiring that informed consent or assent be obtained prior to surgery. This article examines clients' levels of circumcision-related knowledge following the assent process, as well as how ethical guidelines were enacted in everyday practice in a setting where family dynamics and norms relating to autonomy and consensus make obtaining informed consent complex, especially when clients are incentivised with football kits and other material goods to encourage circumcision.

Methods:
We conducted qualitative research in a health clinic where circumcision services for HIV prevention were being offered. Methods included focus group discussions, in-depth interviews, participant observation and informal interviews with young men undergoing circumcision in the clinic.

Results:
Implementers paid little attention to risks, focusing more on benefits of circumcision. Incentives, usually in the form of sporting goods, increased participation, while also limiting autonomy. We also found that parental authority overpowers young males' preferences regarding circumcision. Young males' understanding of the risks associated with circumcision was poor. Most assumed HIV testing was obligatory.

Conclusion:
The drive to eliminate HIV infections in Eswatini has opened the door for interventions such as targeted circumcision campaigns. In contradiction to international ethical guidelines and the policies of the Ministry of Health and voluntary medical male circumcision (VMMC) implementers, we conclude that, in practce, respect for young males' rights and decision-making in the VMMC consent process is limited by complex social, economic and political realities.