Traditional male circumcision remains a dangerous business

Male circumcision using traditional methods is a dangerous, even life-threatening, rite of passage. In presumably the fi rst study to test the feasibility of an intervention for safe traditional circumcision among the Xhosa in the Eastern Cape, Karl Peltzer et al found weak support for encouraging this practice.

Circumcisions carried out under non-clinical conditions have significant risks of serious adverse events, including death. Among the Xhosa in South Africa, an unsterilised, unwashed blade may be used on a dozen or more initiates in a single session. Initiates are also significantly dehydrated during their two-week period of seclusion in the belief that this reduces weeping of the wound. And after-care may be in the hands of a traditional attendant with no basic medical training.

The combination of dehydration and septicaemia can result in acute renal failure, gangrene, tetanus or even death. The Eastern Cape provincial Department of Health recorded 2 262 hospital admissions, 115 deaths and 208 genital amputations for circumcisions between 2001 and 2006.

To address this, traditional surgeons are now required by law to be officially recognised and registered with the provincial department of health. The Eastern Cape Legislature promulgated a law, the Application of Health Standards in Traditional Circumcision Act No. 6 of 2001, which regulates traditional male circumcision.

Approach to the intervention study

In this study, traditional surgeons and nurses registered with the health department were trained over fi ve days on ten modules, including safe circumcision, infection control, anatomy, postoperative care, detection, early management of complications and sexual health education. Initiates from initiation schools of the trained surgeons and nurses were examined and interviewed on the second, fourth, seventh and fourteenth day after circumcision.

Traditional surgeons were provided with a tool box, containing surgical blades (scalpels), scalpel handles, latex hand gloves, sterilisation instruments and paper towel rolls. Traditional nurses also received a tool box containing latex hand gloves, sterilisation instruments, and paper towel rolls.

The research protocol was reviewed and approved by the ethics committee of the HSRC, and the provincial health department, the district health offi ce and traditional authorities in the study areas approved the study  As for the initiates, all agreed to participate in the study. They were fi rst informed about the study when undergoing medical examinations for circumcision. On the second day after circumcision the designated medical offi cer, the clinical research nurse, and an HSRC researcher visited the initiation school to introduce the study and to get individual formal consent from the initiates to undergo physical examinations and to do an interview with the research nurse and HSRC researchers.

Results show high rates of complication

Of the 192 initiates examined on the fourteenth day after circumcision by a trained clinical nurse, the rates of complications were high: 40 (20.8%) had mild delayed wound healing, 31 (16.2%) had mild wound infections, 22 (10.5%) had mild pain and 20 (10.4%) had insufficient skin removed. Whereas most traditional surgeons and nurses wore gloves during the operation and care, they did not use the recommended circumcision instrument.

Seven days after the circumcision, initiates were asked about the circumcision procedures. Most,(85%) indicated that the traditional surgeon had been wearing gloves when performing the procedure, and two-thirds (69%) of the traditional nurses wore gloves when caring. Further, 53% of the initiates reported that they had been circumcised with an assegai (spear) and 47% indicated that they had been circumcised with a surgical blade or knife.

Expectations about traditional male Circumcision

When participants were asked about their perceptions about traditional circumcision, most respondents 126 (70%) felt that they expected some complication following male circumcision; and 57.8% expected to stay in the bush for a month, 40% less than a month and 11.1% for more than a month.

Participants were asked questions relating to their body, satisfaction and the outcomes. The level of satisfaction among all participants was high; 72.9% reported that they were extremely satisfi ed, 18.8% reported that they were quite satisfied, and 5.6% reported their dissatisfaction with the appearance of their sex organs (see Table 1).

 Sexual behaviour and HIV risk of initiates

Sexual behaviour and HIV risk

From the interviews it is clear that the majority of initiates engage in risky sex, exposing them to HIV infection. Most initiates (88%) had sexual intercourse before circumcision. The mean age of fi rst sex was 14.8 years, ranging from 10 to 25 years; 55% had been sexually active in the past 12 months; 29% reported that they had sexual intercourse with two partners; and 24 (15%) had sexual intercourse with three and more sex partners in their life time.

Only 38% indicated that they had used a condom with their last sexual partner, 9% were diagnosed with a sexually transmitted disease in the past 12 months, 15% used alcohol in the past week and 10% indicated that they had sex under the infl uence of alcohol. Almost all had received AIDS training; and although most felt knowledgeable about HIV, they did not feel susceptible to HIV.

In this study delayed wound healing was found among 21% initiates 14 days post-operation. Most young men (88%) were found to be sexually active prior to circumcision and such a long period for healing could expose them to elevated risk for HIV infection through an open wound.

Training and more training

It appears that a five-day training for traditional surgeons and nurses is not sufficient and that more training is needed in the surgical procedure, the control of sepsis, post-operative wound care, recognition of complications, and when to refer patients to hospital. Further supportive training may be the most effective way to promote cognitive, attitudinal, and behavioural change.

The use of the appropriate surgical instruments and wound care needs to be emphasised by traditional leaders. In order to improve timely and appropriate monitoring of initiates by designated medical offi cers, initiation schools should only be established in more central and easily accessible locations.

Post-operation counselling with initiates should include HIV risk reduction, reproductive, HIV pre-testing and manhood counselling. Traditional surgeons and nurses need to be appropriately registered and fulfi l all criteria stipulated in the male circumcision act.

Still, one should emphasise the danger of the procedure, even with an intervention of additional training. Improving the quality of male circumcision services could reduce healing times and thus reduce the risk of HIV infection in those who resume sexual activity soon after circumcision.

Counselling males not to engage in sex until they are fully healed must be included in post-operation instructions. Circumcision cannot be a stand alone procedure; it must be integrated with behavioural and reproductive health counselling in order to minimise both complications and risk of HIV infections.

This article is based on a paper published in BMC Public Health 2008, titled Traditional circumcision during manhood initiation rituals in the Eastern Cape, South Africa: a pre-post intervention evaluation, by Karl Peltzer et al. Professor Karl Peltzer is a director in the Social Aspects of HIV/AIDS and Health research programme at the HSRC.