“The most widespread form of bodily mutilation is male circumcision”.

Ritual circumcision is practised across many cultures in the world and is one of the “most resilient of all traditional African practices within [the] urban industrialised environment”. In South Africa, every year, young abakwetha (Xhosa: male initiates) are hospitalised or die from circumcision wounds undergone during traditional initiation rites. Ritual circumcision¹ under some circumstances can put young men at risk of contracting STDs, HIV/AIDS and other blood-borne infections. Countering this, new epidemiological research demonstrates that circumcised men carry a lower risk of contracting HIV than uncircumcised men. Merely from the above, it is indisputable that ritual male circumcision is a cultural issue that is complexly linked to public health.

¹Literature refers to circumcision in this cultural context as male circumcision, ritual circumcision , traditional circumcision or plainly circumcision. In that the act of circumcision is intricately involved in initiation rites, I have favoured the terminology ritual circumcision for purposes of this paper.

Society organises its members into certain hierarchies and groups with defined, distinctive roles. These organisational factors may be political, religious or economically determined and in turn, become guidelines that shape the practices and modes of living, ultimately contributing to a common cultural identity. Expanding on this, culture therefore directs and determines (all) aspects of human behaviour, interaction and belief systems, and is passed from one generation to the next, through articulated ritual, language and symbol.

Rituals are a means for society members to communicate values and ways of living, through psychological, social and symbolic interactions and teaching. Anthropologists categorise ritual in three specific ways:- those which are calendrical, those which address misfortune, and rites of passage . Male initiation rites fall into the latter, and illustrate the transition from boyhood (ubukhwenkwe) to manhood (ubudoda) . In this document, information is largely drawn from the initiation practices of Xhosa-speaking people for the sake of simplicity². No particular age is specified for these rites (boys between the ages of 15-25 undergo initiation), which illustrates that initiation is not linked to physical development and maturity, but is a socially significant act, resulting in the integration into the community and assurance of acceptance and respect from other community members. Initiation is an important social device in dealing with adolescence Ð the training and preparation provided at the initiation schools enables the shift from childhood behaviour to more complex behaviour expected in adulthood (Schlegal and Barry in).

²A review of the literature suggests that ritual circumcision is not exclusively practised by one cultural group (in South Africa). Historically, the Zulu circumcised, but the practice for ritual’s sake has largely been modified/abandoned. The Tswana and Sotho and Shangaan-Tsonga also circumcise. Not all Xhosa-speaking groups circumcise, for instance it is not practised amongst the Bhaca, Mpondo, Xesibe or Ntlangwini.

When viewing rites of passage as rituals associated with times of change and crisis in the lifecycle, the ritual becomes a means of re-fashioning a body “at war with itself”, with the healing being part of the transformation. Rites of transition involve the stages of separation, transition and incorporation (van Gennep in). Although ceremonies differ across different groups, certain commonalities exist, these including ritual sacrifice, seclusion (entering the bush and building temporary lodge), circumcision, and the painting of the skin with white clay, followed by the burning of the lodge and belongings at the close of the seclusion. Celebrations of the change in status accompany the incorporation of these men into the community.

A profound aspect of the initiation school is the acquisition of cultural knowledge. It is where young men receive instruction in courtship and marriage practices. Cultural expectations regarding social responsibilities and their conduct as men in the community are transmitted and following initiation, men are afforded numerous privileges associated with their status. “Men who’ve been through initiation are distinguishable by their social behaviour and a particular vocabulary they learn during their time in the bush”.

Helman describes that in terms of the physical, a person’s status may be inscribed onto their body. Physical symbols placed on or incorporated as part of the body illustrate the relationship of an individual to their social context to the extent that “the body is the tangible frame of selfhood in individual and collective experience”. Circumcision is one such example of permanent bodily alteration, which signifies membership to a particular group. Ritual circumcision becomes a health issue when certain problems/factors arise. These can be attributed to the following five factors.

1) The training and competence of the traditional surgeon (ingcibi) Inadequate training can lead to errors in surgical technique, and at times, surgeons have been found to be operating under the influence of alcohol.

2) The sterility and reuse of surgical instruments Traditionally an assegaai is used. Implements may be blunt or reused. This practice has been implicated in the spread of blood-borne infections, such as Tetanus, Hepatitis B and STDs, including HIV/AIDS. As yet, no study of HIV/AIDS in relation to ritual circumcision has been carried out, as youths presenting at hospitals are not routinely tested.

3) STDs Funani notes that traditionally, sex was proscribed before marriage, however, youth are becoming sexually active at an increasingly younger age and therefore there is a higher prevalence of STDs amongst initiates. This is transmitted through the use of equipment that is not sterilised between each use.

4) Aftercare Medical complications occur most frequently during the aftercare period of the initiate. A traditional attendant (ikhankatha) is ascribed to each initiate, and is responsible for bandaging the wound. Ischaemia (starvation of blood supply) or/and infection from the tight thong bandage wrapped around the wound, leads to penile sepsis and gangrene, with subsequent loss of penile tissue. Infection can spread throughout the body and ultimately, Septicaemia is the cause of most deaths from circumcision.

5) Another risk factor is severe dehydration, which is common in initiation schools, because initiates are discouraged from drinking fluid post circumcision. This is not only to prevent frequent urination, but is set as a test of endurance. This taboo, accompanied by climatic factors - initiation schools currently occur more often in the hot summer months, as opposed to autumn in the past - and the use of plastic building materials in lieu of traditional grass and leaves, contribute to a harsh environment that is not conducive to healing.

It is difficult to quantify the morbidity and mortality associated with ritual circumcision in South Africa, as actual numbers of youths partaking in these rites annually is indeterminable. This is largely due to the esoteric nature of the rite and as a consequence, data collection is scant. However, the issue may be illustrated in research carried out by Crowley and Kesner (1990), in which 45 youths presented with varying stages of septic circumcision at the Cecilia Makiwane Hospital (CMH), Ciskei between December 1988 and January 1989, resulting in a 9% mortality rate. Some presented with crush syndrome, indicating that they had been severely beaten, as result of heavy chastisement regarding adherence to the protocols of the school. Those who left the hospital alive, not only took with them penile deformity, but also lifelong psychological scars.

Members of the communities who practise initiation rites are aware of the associated health risks, and mothers in particular are concerned for their sons, yet their traditionally enforced social distancing from the ritual has resulted in a lack of influence on events. Meintjes found that in general, community members were not prepared to own the problem, and considered morbidity and mortality as par for the course. He elaborates that in interviews, people expressed that “deaths and injury were seen as a way of separating out those boys who were not fit to play the role of men in society.” Compounding this ‘natural selection’ technique, another popular belief is that if an initiate suffers medical complications, he has brought it upon himself through some form of wrong doing, and is therefore being punished.

With so much at stake, it is understandable that hospitalisation is strongly resisted by afflicted initiates, and those who do present themselves for medical treatment face the risk of stigmatisation, abandonment by their families and ostracisation by their communities, due to the indeterminable status of their manhood.

It is debatable as to whether health care systems are able to cope with the socio-cultural aspects of this issue. There are conflicting reports on the degree of sensitivity with which it is handled, for instance Meintjes suggested that some health care workers are derogatory and judgmental, sometimes delaying surgical procedures and prolonging suffering in order to let the case resolve naturally, as an unnecessary adherence to cultural expectations and outcome. However, there is a move towards a compromise between cultural and medical perspectives in an effort to improve morbidity and mortality associated with ritual circumcision. In the 1990s, a programme was started in Alice to change the practices of traditional surgeons, with the result of an increased use of surgical scalpels and new blades for each initiate. At the same time, the Eastern Cape Health Department set up the Circumcision Task Team, based at CMH, under the auspices of Charge Nurse Henderson Dweba. The Task Team is sensitive to the fact that for many initiates, it is impossible to leave the school to get medical assistance, so the team treats cases medically in the bush where needed. Apart from this, Dweba runs an education programme that attempts to address the behavioural changes needed to lessen the risks of ritual circumcision, whilst upholding cultural values. For instance, by reverting to earlier traditional practices of arranging schools in the winter months, initiates can avoid the warm and humid conditions that aggravate infections, and by teaching initiates about the stages of wound healing, they are better equipped to pre-empt infection.

Governmental health policy also attempts to provide some protection for initiates. In 2001, the South African Human Rights Commission (SAHRC) conducted preliminary investigations in an attempt to level cultural practice with the Constitution. Whilst acknowledging the positive role of initiation schools as cultural teaching institutions, it concerned itself with the investigation of several apparent human rights violations - for instance transgressions in the rights to life; human dignity; freedom and security of the person and health care, food and water. The Application of Health Standards in Traditional Circumcision Act (2001) attempts to regulate ritual circumcision practices by licensing initiation schools and subjecting them to regular checks by the Eastern Cape Health Department officials. Illegal schools face heavy fines for non-adherence. This attempt to work with traditional structures has provoked animosity amongst traditional leaders, who see it as interference, and the debate has yet to be resolved.

For Xhosa-speaking people who practice ritual circumcision as a cultural institution, alternatives are negligible to non-existent. Initiation is seen as the “formal incorporation of males into Xhosa religious and tribal life”, and before circumcision, a male cannot marry or start a family, inherit possessions, nor officiate in ritual ceremonies. Medical circumcisions, performed by health care professionals, who substitute traditional equipment and dressings for medical ones, are deemed meaningless. However, recent literature encourages the introduction of safe measures of circumcision as a “potential public health benefit” in the fight against the HIV/AIDS pandemic. Circumcision, particularly pre-pubertal circumcision, has been associated with lowered risk of STD and HIV transmission. Circumcision as a health care intervention is a low cost and once off procedure, and hence is an attractive option for lowering disease risk, and presents as a problem only in a ritual context when sepsis is a potential health risk. In a South African study conducted by Rain-Taljaard et al, when asked whether they were in favour of circumcision if it were to reduce their chance of contracting HIV and STDs, over half the respondents agreed. The study also suggests a weakening of the cultural significance of ritual circumcision and an increase in the demand for medical circumcision in recent times, however, this was based on research carried out in Nigeria. It would be simplistic to project into the future and wish for such a local trend, when the majority of ethnic groups see circumcision as an integral component of initiation rites {Kauffman, 2004 #33}. More conclusive research into this area of circumcision and HIV/AIDS needs to be done, and more importantly in the interim, health policy needs to do more to creatively address and reduce the mortality and morbidity associated with ritual circumcision, whose strong cultural basis continues to be at odds with Western medical methods.

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