Every year botched traditional circumcisions in the Eastern Cape make headlines as some young men are badly injured and in some cases die.

The provincial legislature in 2016 passed the Eastern Cape Customary Male Initiation Practice Act in an attempt to ensure that initiates come back home healthy and alive. The legislature is now reviewing the act to further tighten provisions to protect initiates better.

However, despite the legislation, and other efforts at improving safety, some initiates still die while undergoing the ritual. The traditional circumcision season in the province usually takes place twice a year, in summer and winter. 

Thirteen initiates died in the Eastern Cape during the 2020 summer circumcision season. In 2020, the government suspended initiations in May and temporarily lifted the suspension in December for the summer initiation season.

‘Dying with my boots on’

Dr Mbuyiselo Madiba, a urologist at the Nelson Mandela Academic Hospital in Mthatha, believes that voluntary medical male circumcision (VMMC) would help to stem the death toll. 

But not everyone agrees.

Teenagers Aviwe Qeqe and his best friend Aphelele Loro from Motherwell in Nelson Mandela Bay metro are preparing to undergo initiation in the next summer season. They believe in the traditional way of circumcision and tell Spotlight they can’t wait for their turn. They say the ritual will change their lives and status as they mature into men. 

“I’m mentally prepared to take the ride and to become an upstanding man in my community,” says Aviwe. “It is the norm that Xhosa boys have to go through traditional circumcision to be recognised as men. In order for my community to take me seriously, I have to undergo the traditional way, as opposed to VMMC. I never heard of a case in my family of a person who underwent a VMMC, so I don’t want to be the first one. I will rather die with my boots on than take the western culture.”

Just like Aviwe, 19-year-old Aphelele believes traditional circumcision is the right way to become an “authentic Xhosa man”. 

“Last year December I was supposed to go to initiation school, but because of Covid-19, I was unable to go. I hope this coming summer circumcision season I will be able to fulfil my dreams of becoming a man.” Aphelele says reports of botched circumcisions do not scare him. “As far as I know in Nelson Mandela Bay, I don’t remember hearing anything about deaths or hospitalisation of initiates.” 

Deaths and injuries are preventable

Madiba says these deaths and injuries are preventable. He acknowledges in areas such as OR Tambo and Alfred Nzo districts young men who opted for VMMC are often not recognised in their communities. “But the transition from boyhood to manhood is about more than a surgical procedure,” he says.

“For those who still believe the traditional circumcision is the way to go, our urology department has about 12 urologists who are trained and are ready to help in any areas when there is a problem. Early this year, we proposed to traditional leaders that we volunteer our time to train traditional surgeons and place ourselves as backup to avoid any further deaths. We took this initiative because we know all the botched circumcision complications end up coming to us for treatment. Currently, what is happening in circumcision schools is a mess resulting in preventable injuries and unnecessary deaths,” Madiba says.

“Urologists need to be part of the teams that work with traditional surgeons; this does not undermine the efforts of other medical practitioners. But we are of the view that the process of pre-clinical examination is very important because as urologists we know how to prevent complications and the effects of a botched circumcision.” 

Madiba says botched circumcision impacts not only one person once, but also impacts their close friends, relatives, and the entire community. “Imagine an 18-year-old teenager who had his entire penis amputated.” 

Madiba says it affects that person’s whole life. “What is the reason for preparing boys to become men and yet they don’t reach that stage at all?” he asks.

Safeguards

According to Madiba, they made a presentation to the House of Traditional leaders in Bhisho early this year.

“We proposed to volunteer our time and skill for free to train traditional surgeons. The training would be ongoing, it is not specific. But during the training, we will equip surgeons with the necessary skills to deal with any eventuality and to provide basic medical attention during initiation. The training also includes pre-counselling about what it means to be a man.

“The House of Traditional Leaders took a keen interest in our proposal and promised to come back to us,” Madiba says. “We are waiting for them. By working together with them, we are not taking away the culture or custom but want young men undergoing traditional initiation to be safe.”

Spokesperson for the Eastern Cape Department of Cooperative Governance and Traditional Affairs (Cogta), Mamkeli Ngam, says all registered traditional surgeons who have received a written recommendation from their traditional leader or initiation working committee, attend workshops organised by the provincial health department to prevent and identify infection.

“The Department of Health is working with Cogta to support safe circumcision in initiation schools. They are also providing pre-initiation health screenings to initiates, and medical supplies to traditional surgeons.

“Nevertheless the House of Traditional Leaders is still considering the proposal made by Dr Madiba and his team of urologists and would make a decision in due course,” says Ngam.

Reviewing the Initiation Practice Act

According to Ngam, the provincial government is now also reviewing the Eastern Cape Customary Initiation Practice Act to close all the loopholes in the law to curb the injuries and deaths of initiates due to bogus initiation schools. 

“There are gaps in the act that need to be reviewed in order to make life better for future initiates and make this traditional practice more efficient. One of the grey areas is an issue of age because the act recommends that under no circumstances should a person under the age of 18 years be allowed to be circumcised. But it also allows prospective initiates who have not yet reached 18 years of age to be circumcised, if a parent or guardian gives consent.

“This age issue is a source of frustration for stakeholders. A boy aged below 18 years of age is not an adult and is not supposed to be circumcised hence we’re reviewing the act in order to prevent the deaths and injuries of initiates. We believe once the act is reviewed it will assist in curbing the casualties and underage illegal schools.”

Meanwhile, another piece of legislation, the Customary Initiations Bill, was passed in Parliament in March this year and now awaits the president’s signature. Once enacted, the act will regulate and monitor all initiation schools in the country.

Reopening of winter initiation schools 

Acting chairperson of the Eastern Cape House of Traditional Leaders, Nkosi Langa Mavuso, says the Provincial Initiation Coordinating Committee has submitted their proposal to reopen winter initiation schools under Covid-19 restrictions. 

“We will be guided by the provincial government about when the season should start. In accordance with our proposal that we presented to government, we encourage ingcibi (the man responsible for the circumcision) and ikhankatha (the guardian of the initiates) to operate within the Covid-19 protocols.

“All initiates must first undergo medical and Covid-19 tests to ensure they are fit before they go through the traditional rite of passage. The check-ups are good for health and help to detect any problems that might occur in the initiation school. Those are some of the things that will ensure that there is compliance in our initiation schools,” he says.

“Our risk adjustment plan for the initiation practice last season was critical in paving the way for the formulation of a roadmap towards a safe rite of passage. In December, we recorded 13 initiation school fatalities — three were shot during an alleged fighting. It is alleged they were not part of the initiates. This is our lowest record ever hence we emphasised cooperation of all stakeholders in verifying the legitimacy of initiation schools,” Mavuso says.

VMMC back ‘up and running’ 

VMMC is a key part of South Africa’s HIV prevention efforts and is thought to have contributed to reductions in HIV incidence over the last decade. Men who undergo VMMC are at a much lower risk of contracting HIV than uncircumcised men. Traditional circumcision does not offer the same level of protection as VMMC.

National Director of Medical Male Circumcision Collen Bonnecwe, said the national Department of Health recorded an unprecedented drop of numbers for the VMMC programme due to Covid-19 as the services were suspended from April to September last year. 

“The programme is up and running again but not at the original pace due to Covid-19 risk containment measures. The uptake is lower as men are afraid of Covid-19-related risks and therefore performance of the programme is negatively affected. Fewer circumcisions are conducted per day due to social distancing,” Bonnecwe said.

According to Bonnecwe, the VMMC target is 600,000 per year and in the 2019/20 financial year, the department recorded 413,057 medical male circumcisions. During the 2020/2021 financial year, the numbers dropped to 177,134 due to six months of inactivity because the country was in lockdown and most MMC sites were converted into Covid-19 sites. 

“After lifting the suspension last year summer, Project 300,000 (Project 300K) was implemented and led by [the] national department of health and funded by the US President’s Emergency Plan for AIDS Relief (Pepfar). The project entailed vigorous demand creation activities and outreach mobile services were implemented with targets monitored weekly, followed by remedial action. These activities have seen the programme performance gradually improving,” he said.

According to the most recent estimates from the Thembisa Model, the leading mathematical model of HIV in South Africa, around 64% of men aged 15 to 49 in the Eastern Cape have been circumcised. This is slightly higher than the national level of around 60%. DM/MC

This article was produced by Spotlight – health journalism in the public interest.