|Ritual circumcision in South Africa|
The following article on the current status of traditional "bush" circumcision among the Xhosa people of South Africa was published in the South African Medical Journal in August 2003.
EDITORIAL: Astonishing indifference to deaths due to botched ritual circumcision
“Circumcision leaves 24 dead, 10 in hospital”, read the headline in The Star of Kuala Lumpur, Malaysia, on 16 July 2002. The report continued: “South Africa’s initiation season ended this weekend with a gruesome toll of 24 deaths reported to police and more than 100 teenagers hospitalised with gangrene and septicaemia after botched circumcisions and severe beatings. One boy’s penis dropped off as a result of gangrene, at least one other had to have his penis amputated, and another will have to have both legs amputated, authorities said”.
Similar horrifying circumcision outcomes have been observed again this year, with reports of the deaths and mutilations being beamed across the world by all the major news services. No one understands why we as a country – or as communities – have seemingly stood by and done little or nothing as these deaths rock the country year after year. Anywhere else in the enlightened world, this kind of mayhem would have evoked community outrage and led to urgent and drastic action to prevent it.
Why are we not sufficiently agitated by the slaughter to find ways to stop it? Perhaps in today’s South Africa, where violence constitutes one of the leading causes of death (including 23,000 officially acknowledged murders per annum), we have become hardened against the horror of needless death. In any event, deaths due to ritual circumcision largely occur in the impoverished and faceless rural and peri-urban communities, and those of us north of he railroad are in denial about this, just as we are about much of the other misery in that quarter. The communities themselves have perhaps come to accept these occurrences as part of their fate, along with unsafe minibus taxis and random street shootings. Middle class families from circumcising backgrounds ensure that their sons are circumcised in safe and nurturing environments. Unless this elite is moved and inspire to do something about the circumcision deaths among the less privileged, nothing will change.
A further reason for playing down the deaths may be a deep-sated fear among the affected communities (largely in the eastern Cape and the Limpopo provinces) that this hallowed ancient tradition is under threat of extinction, and that any move to modernise it may push it over the edge. Certainly, some voices coming through on radio talk shows seem much more concerned with the survival of the ritual itself (often rather broadly if inaccurately labelled “our African culture”) than about the reported deaths and mutilations.
The modern-day ritual is largely a hoaxIn fact, the barbarism perpetrated on today’s hapless youth has little in common with what the ancient rite was all about. The ritual was about preparing youngsters for the challenges of manhood in he rural and pastoral world in which they lived. Furthermore, it was performed by experienced operators and overseen by traditional sages who served as teachers and sources of wisdom to the youths. The traditional practice was much like modern military training: hard, but intended to nurture. Importantly, the community, through its traditional leaders and healers – not individual entrepreneurs – set up and supervised the circumcision schools.
That was then. What about now? H.G. Matjeke, who has done an in-depth study of the practice in the Bolopedu district in the Limpopo province, sums up the modern-day ritual as follows:
“Of late, the practice has degenerated into a money-making operation. People pay as much as R400 per boy for the attendance of (circumcision) schools. The schools are launched annually at some localities (as opposed to the old tradition of every five years). Boys as young as six years are admitted at the schools.” Matjeke goes on to observe how “as more and more boys are opting for clinical circumcision, the school leaders have resorted to the radical practice of abducting males to these schools. Many youths are mutilated or even die as a result of malpractices at thee schools.”
These malpractices include gratuitous beatings and other forms of physical abuse, extreme exposure to the elements, nutrition deprivation, and the withholding of medicines from the chronically ill. Matjeke observes how, instead of traditional herbal medicines, substances such as brake fluid and used motor car oil are used to treat the wounds of the victims. He concludes that “negligence and lack of accountability lie at the root of the problem”.
In short, many of the so-called “circumcision schools” of today are fake, and deadly. They have very little to do with the traditional ethos and practice of this ancient ritual, and something must be done to stop the carnage.
I can think of three things that, if legislated immediately and enforced with the same vigour as the laws to enforce the ban on cannabis, could see many lives saved and the ritual of circumcision regain its traditional dignity:
1. Establish a registry of circumcision schools, and require that school be registered.
2. Require that circumcisers undergo training and be certified.
3. Require that bush circumcision venues pass inspection.
Daniel J. Ncayiyana
South African Medical Journal, Vol. 93, No. 8, August 2003
NOTECircumcision is practised, traditionally when a boy reaches his mid- to late teens, among the Xhosa people of South Africa, but not among the other main tribal group, the Zulus. In the late nineteenth century medically rationalised circumcision was taken up by the British colonists, but not of course among the Dutch-originating Boers. It was realised as early as the 1980s that the circumcision ordeal was leaving a trail of ruin and despair among young Xhosa men, but it appears that little or nothing was done to rein in the carnage. One can imagine the feverish activity, in the United Nations, the World Health Organisation and other western agencies, if it had been women rather men who had been the victims of this barbarity. At least nobody (with the notable exception of the US Agency for International Development) has had the effrontery to try to claim that these traditional circumcision practices were some sort of miraculous anticipation of Victorian discoveries about the health benefits conferred by such surgery. It is also interesting to note that the South African Medical Association has not tried to argue for the retention of circmcison on the basis that it is might help to restrain the spread of HIV-AIDS. On the contrary, despite what Americans like to claim, and whether or not circumcision (by personal choice) of sexually-active adult men in areas of high heterosexual HIV prevalence can offer some protection against infection, SAMA recently issued a statement that there was no medical justification for routine circumcision of infants.
South African Medical Association rejects circumcisionIn response to an inquiry from Nocirc of South Africa, the South African Medical Association has formally stated that there is no justification for routine circumcision of infants or children. In letter to Nocirc SA, dated 4 February 2005, and signed by Professor Ed Coetzee, Chairperson of the SAMA Education, Science and Technology Committee, the Association states:
“After lengthy DISCUSSION on the matter, the Committee RESOLVED that it be conveyed to NOCIRC-SA that, from a medical point of view, there was no medical justification for routine circumcision in males and children.”
In this conclusion, SAMA joins medical authorities in Britain, Canada, the USA, Australia and New Zealand in agreeing that there is no medical case for routine circumcision. In fact, it goes slightly further than the Royal Australian College of Physicians, which states that there is “no medical indication”; SAMA says there is “no medical justification”, an even stronger rejection.
Coming from a country with an extremely high incidence of HIV infection (and also a high incidence of male circumcision), this is a significant declaration.
ReferencesA.N.N. Ngxamngxa, “The function of circumcision among the Xhosa-spe tribes in historical perspective”, in E.J. de Jager (ed.), Man: Anthropological essays presented to O.F. Raum (Capetown, 1971), pp. 183-204
Lumka Sheila Funani, Circumcision among the Ama-Xhosa: A medical investigation (Braamfontein: Skotaville Publishers, c.1990)
N.C. Roles, “Tribal surgery in East Africa during the XIXth century: Part 1 – Ritual operations”, East African Medical Journal, Vol. 43, 1966, pp. 579-94
Nancy Scheper-Hughes, “Virgin territory: The male discovers the clitoris”, Medical Anthropology Quarterly, Vol. 5, 1991, pp. 25-8
Statement on circumcision and HIV-AIDS by Nocirc South AfricaHIV cannot be prevented by mass circumcisions
Circumcision may result in a false belief that safe-sex practices are no longer required, implying a worsening of the incidence of HIV infection.
Two separate papers were presented at a conference in Brazil, claiming that male and female circumcision has the potential to reduce HIV acquisition. Such claims may conversely have negative consequences in the struggle against HIV and AIDS. At the recent congress of the Treatment Action Campaign (TAC), the findings of a study conducted amongst male South African participants were presented, suggesting that the circumcised penis is more resistant to HIV infection. TAC has been reported to be considering advocating circumcision as a result. We are encouraging them to reconsider their new strategy.
This study could dangerously mislead people into believing that if they are circumcised, they would be protected against HIV. The natural response of a circumcised male to these reports is to assume that he is more resistant to HIV infection than is the intact male. The implication being that even more circumcised men may engage in unsafe sexual practices under the false impression that they won't contract HIV. Equally troublesome is the fact that this study offers no indication on whether or not the receptive partner of the circumcised male will become more or less vulnerable to HIV infection. The female receptive partner’s risk will likely increase without adequate protection.
Asecond study, performed by Stallings amongst African females in Tanzania shows that HIV transmission is also reduced among circumcised FEMALES. [See abstract below.] This has gone unreported by the media. Such selective reporting suggests the need for analysis from a gender prejudice point-of-view and suggests that male and female circumcision should be dealt with as a unity.
The foreskin is not just a piece of skin, but rather a highly specialized erogenous and immunological structure, which cannot be cut off like hair or fingernails. We are therefore concerned about the frequent uncritical reference to particularly the male study in the media. The promotion of its uncorroborated findings, without adequate understanding of the behavioral consequences, is highly irresponsible. Feedback offered to our organization indicates that some individuals are now advocating “chop-shops,” where parents will be able to bring their children for the non-consensual, non-therapeutic removal of their foreskins.
The Lancet, the pre-eminent medical journal in the world, rejected the publication of the above French study. The broad quotation within the media is therefore, premature and irresponsible since the study has not been peer reviewed as yet.
When extrapolating globally, the hypothesis of this study could be proven to be wrong. The United States has a very high rate of circumcision coupled with the highest HIV infection rate in the developed world. Scandinavia on the other hand has one of the lowest rates of circumcision in the world coupled with a comparatively low incidence of HIV infection. Global trends should be more accurate than one, demographically limited study. Neither does current research point to a significant difference in infection rates in South Africa amongst the non-circumcising tribes such as the Zulus, and the circumcising tribes such as the Xhosas.
Other studies have thus far failed to corroborate that circumcision could prevent HIV. The highly respected Cochrane Review, which conducted a meta-analysis of circumcision and its relationship to HIV, “found insufficient evidence to support an interventional effect of male circumcision on HIV acquisition in heterosexual men.” The most important emphasis of HIV prevention should focus on education, the use of non-contaminated medical equipment, and behavioral changes such as condom use, and not foreskin amputation.
The amputation of the male prepuce removes the only movable part of the penis, causing increased friction during sexual intercourse, leading to micro-tears of tissue, and subsequent increased vulnerability to possible infection. In South Africa, ‘dry sex’ practices, whereby lubrication mechanisms are purposely removed, make HIV infection even more likely to occur. It has also previously been demonstrated that circumcised men don’t like using condoms as they suffer from a progressively desensitized penis.
UNAIDS has cautioned against circumcision. “If circumcision were promoted as a way of preventing HIV infection, people might abandon other safe sexual practices, such as condom use. This risk is far from negligible – already rumours abound in some communities that circumcision acts as a “natural condom”. A sex worker interviewed in the city of Kisumu in Kenya summed up this misconception, saying, “I can sleep with circumcised men without a condom because they don’t carry a lot of dirt on their penis.” Circumcision does not eliminate HIV infection. In one study in South Africa, two out of five circumcised men were infected with HIV, compared with three out of five uncircumcised men. Relying on circumcision for protection is like playing Russian roulette with two bullets in a (five-shot) revolver rather than three.”
National Organisation of Circumcision Information Resource Centres of South Africa implores all organizations associated with the fight against HIV/AIDS to take note of these developments. We should not lose foresight in the fight against HIV/AIDS by these irresponsible statements promoting circumcision of healthy body parts of boys and girls as a preventative strategy. All children have a right to bodily integrity, and such procedures violate that right. This right is enshrined in the United Nations Convention on the Rights of the Child, to which South Africa is a state signatory.
National Organisation of Circumcision Information Resource Centres – South Africa
National Organisation of Restoring Men – South Africa
Dean Ferris – National Coordinator
Ethical and medical considerations
Dr. D. Sidler, paediatric surgeon
Female circumcision reduces risk of HIV infection in womenFemale circumcision and HIV infection in Tanzania: for better or for worse?
Stallings R.Y. (1), Karugendo E. (2)
Abstract from paper given at Brazil conference
(1) ORC Macro, Calverton Maryland, United States of America, (2) National Bureau of Statistics, Dar es Salaam, United Republic of Tanzania
It has been postulated that female circumcision might increase the risk of HIV infection either directly, through the use of unsterile equipment, or indirectly, through an increase in genital lacerations or the substitution of anal intercourse. The authors sought to explain an unanticipated significant crude association of lower HIV risk among circumcised women [RR=0.51; 95% CI 0.38,0.70] in a recent survey by examining other factors which might confound this crude association.
Capillary blood was collected onto filter paper cards from a nationally representative sample of women age 15 to 49 during the 2004 Tanzania Health Information Survey. Eighty-four percent of eligible women gave consent for their blood to be anonymously tested for HIV antibody. Interview data was linked via barcodes to final test results for 5753 women. The chi-square test of association was used to examine the bivariate relationships between potential HIV risk factors with both circumcision and HIV status. Restricting further analyses to the 5297 women who had ever had sexual intercourse, logistic regression models were then used to adjust circumcision status for other factors found to be significant.
By self-report, 17.7 percent of women were circumcised. Circumcision status varied significantly by region, household wealth, age, education, years resident, religion, years sexually active, union status, polygamy, number of recent and lifetime sex partners, recent injection or abnormal discharge, use of alcohol and ability to say no to sex. In the final logistic model, circumcision remained highly significant [OR=0.60; 95% CI 0.41,0.88] while adjusted for region, household wealth, age, lifetime partners, union status, and recent ulcer.
A lowered risk of HIV infection among circumcised women was not attributable to confounding with another risk factor in these data. Anthropological insights on female circumcision as practiced in Tanzania may shed light on this conundrum.
UNAIDS cautious on quick surgical fixesDespite the media hype celebrating the latest amazing news from Africa (driven as much by the desire to keep circumcision going in the USA as to control AIDS in the Third World), the United Nations AIDS organization and the World Health organization have adopted a cautious and, indeed, sceptical attitude towards suggestions that mass circumcision should be introduced as a significant weapon in the battle against HIV infection.
In the latest Epidemic Update report (December 2005), in a document of hundreds of pages, this is all they have to say:
Male circumcisionA recent study in South Africa found that circumcised men were at least 60% less likely to become infected than uncircumcised men. These promising results must be confirmed in ongoing studies in Kenya and Uganda before male circumcision can be promoted as a specific HIV prevention tool. If proven effective, male circumcision may help increase available proven options for HIV prevention, but should not cause the abandonment of existing effective strategies such as correct and consistent condom use, behavioural change and voluntary testing and counselling. Male circumcision does not eliminate the risk of HIV for men and the effects of male circumcision on women’s risk of HIV are not known. It also remains to be demonstrated whether and to what degree circumcision could reduce HIV transmission in cultures where it is not currently practised.
UNAIDS/WHO, AIDS Epidemic Update: December 2005, p. 40
AIDS now spreading fast in (largely circumcised) Middle EastWhatever the US media may claim, there are increasing reports that AIDS is making rapid headway in the Middle East – that is, among Moslem populations where most of the males are circumcised. A recent report by Nicholas Eberstadt and Laura M. Kelly in the US journal Foreign Policy suggests that denial of the problem (leading to failure to take action), repressive attitudes to sexuality and lack of attention to counselling in safe sex practices are more important factors in the spread of the disease than normal (or even abnormal) human anatomy.
Full text of article here.