Honourable chair,
Traditional and religious circumcision is practiced in many communities in South Africa, with infant circumcision being widely practiced in Jewish and Muslim communities, and young adult circumcision being practiced amongst different language groups, particularly in the Eastern Cape, Limpopo and Mpumalanga.
Circumcision in these groups includes cultural initiation of young men into adulthood, called ulwaluko, which involves “going to the bush or to the mountain” for several weeks, usually in July or December, where young men stay isolated from their families in a traditional hut or ibhoma. The circumcision is performed by a traditional surgeon, or ingcibi and traditional nurses (amakhankatha), often a male relative or family friend will look after and care for the initiates or abakhwetha, until the circumcision wound has healed.
Why are we debating traditional adult circumcision and the role of traditional leaders in overseeing traditional circumcisions today? It is because something is going horribly wrong with traditional circumcisions and, instead of being a joyful celebration of young men entering adulthood, it has become a practice that is associated with fear, mourning, and shame.
Tragically, every year, dozens of otherwise healthy young men will die; and this is but the tip of the iceberg. A much larger number – nearly ten times as many – will develop injuries and infections that will require hospitalisation and will lead to auto-amputations of their penises, or cause permanent disfigurement, sexual dysfunction, and lifelong psychological scars.
What is behind these awful complications, why do initiates die and what can be done about it?
I have personally looked after young men with complications of circumcisions as a doctor working in the rural Eastern Cape. My experiences and those of colleagues all over the Eastern Cape, as well as a review of the literature shows that the main causes of complications appear to be inexperienced or untrained traditional surgeons, who use incorrect circumcision techniques, including a lack of sterility, and who provide incorrect wound care afterwards, including applying dressings too tightly, which compromises blood supply and can lead to infection and gangrene.
The main causes of death at hospitals in the Eastern Cape, which is the province with the highest mortality rate, are all associated with either poor circumcision techniques, poor care behaviours by amakhankatha or delays for initiates accessing medical care. The top three causes of death are:
- Generalised sepsis – infection that has seeded from the circumcision wound into the blood circulation, and sometimes also the joints and onto heart valves;
- Renal failure due to dehydration which is often due to young initiates not being allowed to drink water;
- Crush syndrome – which, horrifically is due to some initiates being brutally beaten with sjamboks by their carers for a variety of reasons, including wanting to get care.
What can be done to prevent deaths and mutilation from traditions circumcisions?
- At the time of their medical check-up before going to the bush, initiates and families must be informed that any initiation school which denies initiates water or food at any time are acting in contravention of the Customary Initiation Act, 2021, and should report this to authorities. Such schools should be closed down and traditional attendants and leaders should be criminally charged.
- The House of Traditional Leaders need to work much more closely with the DoH so that every single traditional circumcision surgeon should be trained or certified under the auspices of the DoH to ensure that circumcisions are performed, correctly, safely, and in a sterile manner, and that wound care is practiced safely. Traditional surgeons must further be provided with one sterile blade per initiate.
- All amakhankatha and iincgibi must be encouraged to bring any initiates who they are concerned about to medical facilities early, to prevent severe complications from developing, and should not be penalised for doing so.
- Traditional circumcision’s age limit must be raised to 18 years – and the loophole of allowing boys of 16 or 17 years to attend to go to the bush if they have parental consent must be closed.
- Finally, the cause of every single death and every penile auto-amputation needs to be thoroughly investigated, by a combined team from the DoH and the House of Traditional Leaders, and the circumcision school where severe complications occur must be closed, and the traditional surgeons and carers must be held responsible.
- The payment of amakhankatha with alcohol must be made illegal.
- Finally, unregistered and illegal circumcision schools must be found and shut down.
And if the number of deaths and severe complications are not drastically reduced in the next five years, government needs to seriously consider putting a moratorium on all circumcision schools until measures are put in place that will eradicate deaths and severe complication. One mutilated or amputated penis is one too much.