The government’s long-awaited male circumcision campaign — aimed at reducing HIV infection — will be launched by the end of March next year, Yogan Pillay, the deputy director general of health said this week.
But the policy is being strenuously resisted by traditional leaders, who insist that circumcision is a customary, not a health, procedure and that “strangers” will not be allowed to oversee traditional practices.
Some insiders, who have seen the draft policy, believe health department implementation could happen as early as December this year.
Male circumcision can reduce a man’s risk of contracting HIV by 60%. The foreskin contains HIV target cells and is easily abraded during sex, which encourages infection.
The South African National Aids Control Council, headed by Deputy President Kgalema Motlanthe, has submitted a memorandum based on the draft policy for Cabinet review. Pillay expects a response within two weeks.
The policy recommends that the government launch male circumcision in KwaZulu-Natal — the province with the highest HIV infection, but also the lowest male circumcision rate. It will then be expanded to a further 17 districts.
However, Patekile Holomisa, acting chairperson of the Congress of Traditional Leaders (Contralesa), insisted that male circumcision was a “religious matter”.
“We can’t allow it to be used for other purposes such as a reduction of HIV infection rates,” he told the Mail & Guardian.
“For years the Western world has opposed our initiation and circumcision practices and now it wants to use it for its own ends.”
Holomisa was adamant that “strangers” would not be allowed to interfere with traditional practices. “We’ll only talk to government and medical officers who have been initiated,” he said.
Holomisa was outraged by Pillay’s involvement. “Who is this man? Is he a graduate or initiate? How can we talk to him about our practices if he’s not?”
Because of the use of unsterilised equipment, bare hands on wounds and surgeons’ lack of medical training, traditional circumcisions have resulted in at least 50 deaths and several penis amputations in the Eastern Cape this year.
A Human Sciences Research Council and University of the Free State study has found that in at least 10% of traditional circumcisions the entire foreskin is not removed. Researcher Xola Kanta said such circumcisions often pose a risk of HIV infection.
“We found that, after a five-day training of traditional surgeons in the Eastern Cape, when the use of surgical blades and gloves was explained and they were provided more than half the circumcisers still used spears for circumcision and a third did not wear gloves,” Kanta said.
Kanta and co-researcher Karl Peltzer established that often up to 50 initiates are circumcised with the same blade and “many traditional surgeons and nurses on training workshops have never seen a condom”.
In some cases, including that of Eastern Cape initiate Bonani Yamani (21), traditional surgeons reopen medical circumcision wounds to remove extra skin. Yamani is taking his parents to court for forcing him to undergo traditional circumcision after he was medically circumcised in hospital.
Kanta said the government’s challenge is how “to integrate traditional circumcisions into plans for medical circumcisions in its efforts to reduce the risk of HIV in South Africa”.
Although the government plans to consult traditional leaders widely before implementing its policy, many feel unrecognised.
“People seem to think our training for traditional circumcisers doesn’t matter,” said the Contralesa organiser, Kgoshi Thobejane.
“Experience and knowledge supersede medical training. Our circumcisers started to learn how to perform the procedure in childhood and don’t practise until they’ve attended ceremonies.”
Thobejane is convinced that a government curriculum for traditional circumcisers will not work.
“Eighty percent of government officials don’t understand traditional circumcision because they’ve never gone through it. Who’ll write the curriculum? What is needed is indigenous knowledge — not formal schools with books and texts.”
The only facility that performs male medical circumcisions in South Africa is the Bophela Pela circumcision centre in Orange Farm. After more than 8000 circumcisions the project has started to work with traditional circumcisers.
“The biggest challenge is that they aren’t happy with us using local anaesthetics. They strongly believe pain is necessary as part of a passage into manhood. We’re trying to find a way around that,” said project chief Dirk Taljaard.
The Zambian and Botswana governments have incorporated medical circumcision into their HIV-prevention policies.