There is compelling scientific evidence that Voluntary Male Medical Circumcision (VMMC) is both safe and significantly reduces a man's risk of becoming infected with HIV. While there can also be some protection from traditional circumcision, the protective effect of medical circumcision is thought to be much greater. The World Health Organization (WHO) has recommended medical circumcision for HIV prevention since 2007.
Circumcision rates in South Africa have increased dramatically over the last decade. According to estimates from Thembisa, the leading mathematical model of HIV in South Africa, 62.5% of males aged 15 to 49 were circumcised as of 2022. In 2012, this number stood at 38.8%. Experts ascribe some of the reduction in the country's rate of new HIV infections to the massive circumcision drive over the last decade.
But the choice between medical, traditional, or no circumcision is often about much more than HIV risk. For one thing, traditional circumcision has great cultural meaning for some groups.
62.5% of males aged 15 to 49 were circumcised as of 2022. In 2012, this number stood at 38.8%.
'From boyhood to manhood'
Spotlight visited Lwazi Mfeka* at his ibhoma (traditional hut) during his last week at an initiate school in the Eastern Cape this winter. The first-year Walter Sisulu University student asked to remain anonymous for fear of victimisation, as talking openly about initiation is taboo in many rural communities.
He said leaving his ibhoma on the last day of his tenure as an initiate is a moment that will forever be etched in his mind. Not only did this signal the end of a "challenging" three-week period at the school, but it was also a symbolic moment where he says he has graduated from boyhood to manhood.
Experts ascribe some of the reduction in the country's rate of new HIV infections to the massive circumcision drive over the last decade.
Mfeka said he was supposed to have undergone the ritual in December last year, but due to a bereavement in his family, he couldn't. "At varsity, I was often mocked and isolated because I was still a 'boy'. This bothered me a lot and I couldn't wait to come here (to the mountain) and finally become a man," he said.
He admits he was gripped by fear in the months leading up to his initiation.
"For starters, many young boys die while undergoing the custom and I didn't want to add to the numbers. But, fortunately, my dad chose an ingcibi (traditional surgeon) with a good track record. I first had to go and get tested by a doctor for chronic illnesses such as HIV and TB as I had to present a medical certificate to the ingcibi before being circumcised. At the initiation school, everything was done according to the rules. After each cut, the spear gets sanitised to avoid any spread of infections," Mfeka said.
In the 2022 winter initiation season, 11 of 10 794 boys who underwent traditional circumcision in the province [EC] died, while in the summer initiation season, 23 of 51 601 died.
Botched circumcisions
Mfeka's fears are not without merit. In recent years, traditional male circumcision has often made headlines for all the wrong reasons, with the lives of young men lost due to botched or unhygienic circumcisions.
According to Mamnkeli Ngam, spokesperson for the Eastern Cape Department of Cooperative Governance and Traditional Affairs, in the 2022 winter initiation season, 11 of 10 794 boys who underwent traditional circumcision in the province died, while in the summer initiation season, 23 of 51 601 died. Ngam says around 20 000 boys went into the mountains to undergo traditional circumcision this winter (2023).
He told Spotlight that some fly-by-night ingcibis, desperate to make a quick buck, are the ones giving the custom a bad name. He says that assisted by the local chiefs and the police, they have been clamping down on illegal initiation schools and arresting bogus traditional surgeons.
"During the period between 1 June to 20 July, nine bogus traditional surgeons have been arrested in the Eastern Cape," Ngam said." We have been conducting safety campaigns ahead of the winter circumcision season to educate communities. Circumcising boys without parental consent [and] not having undergone medical examination to perform the procedure is against the law."
Nkosi Mpumalanga Gwadiso, the Eastern Cape House of Traditional and Khoisan Leaders' chair, told Spotlight that parents need to be involved throughout the process. "Often, parents leave everything to the amakhankatha (traditional nurses). That's where things go wrong. As chiefs, we always emphasise the importance of parental involvement from day one until the initiates come back home safely. Some traditional nurses are the reason things go wrong because they neglect the initiates and go drinking. It is therefore the responsibility of the fathers to ensure that they visit the initiation schools regularly and monitor everything," Gwadiso said.
While numbers vary widely and we haven't been able to get a full picture, we understand that initiation schools can admit around 100 initiates during each of the winter and summer circumcision seasons. Our informal survey of several initiation camps in the former Transkei suggests the cost is typically around R300.
The medical alternative
While medical male circumcision is a generally available alternative to traditional circumcision, its provision in the Eastern Cape is influenced by cultural factors. For example, according to Eastern Cape Provincial Health Department spokesperson, Yonela Dekeda, the department does not conduct open marketing or demand creation in the communities/public "due to cultural dynamics within the province".
"Medical Male Circumcision services are actually confined within the health facility level. Therefore, intake depends on the walk-ins, not on demand creation or promoting of the MMC services," Dekeda said. "MMC is the choice of individual families. However, as the department, we are ensuring that all the designated MMC sites are well equipped with necessary MMC equipment, including training of clinicians such as medical doctors, clinical associates, and professional nurses to provide quality voluntary medical male circumcision services."
Despite the lack of promotion, some young men, such as Bandile Macetywa*, have opted to go the medical route. He asked that we not use his real name for fear of victimisation from people who disapprove of his decision not to be circumcised in the traditional manner.
Speaking to Spotlight, the 20-year-old from Cofimvaba in the Eastern Cape said he pleaded with his parents, who are staunch traditionalists, to do the custom the medical way. "I know I disappointed my parents, especially my father, but at the end of the day, it was about my safety. I was happy when they respected my decision," he said.
However, Mecatywa says he is all too aware of the discrimination that awaits him in society. "There are already naysayers. But I'm just glad the whole process went well. For Pete's sake, we are in 2023. People are free to choose where they get circumcised. Some people had the guts to tell me to my face that I deserved to be abducted and circumcised again the traditional way?" he said.
Mecetywa believes many lives will be saved if rural communities can be educated to accept medical male circumcision. "It is much safer with [fewer] risks of getting infected while undergoing it. I am not saying traditional male circumcision is wrong. But why do initiates continue to die or have botched operations if things are done the right way," he asked.
While the department does not actively promote medical circumcision, and while Mecetywa is clearly very aware of being in a minority, there are in fact significant numbers of medical circumcisions being conducted in the Eastern Cape. According to Dekeda, 14 637 were performed in the province in 2022, while 14 300 have been performed so far this year.
Medical male circumcision is an elective procedure that is widely available in the public sector, often provided via NGOs. The process typically involves counselling, a pre-assessment to check for anything that may hamper a client's ability to be circumcised, post-operative care, and follow-up visits. Clients will typically also be offered an HIV test.
VMMC in the Western Cape
Meanwhile, in the Western Cape, the Department of Health and Wellness in collaboration with the City of Cape Town and the Department of Cultural Affairs and Sport has implemented an initiation consent form as a mechanism to uphold ethics. It includes medical screening that helps minimise and mitigate potential risks.
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Western Cape Department of Health spokesman Mark Van der Heever told Spotlight, "The initiation consent form is further reviewed to enable alignment to developments as these emerge. Training and capacitation of traditional surgeons is a key element to strengthening partnership following a whole of government and whole of society approach."
Van der Heever says since 2020, 274 circumcisions were performed by a Medical Officer invited by the traditional healers to perform the circumcisions. A total of 131 977 medical male circumcisions, according to Van der Heever, were performed at the Western Cape health facilities since 2013, with 13 105 performed just last year.
The rest of the stats are as follows:
2013 - 12 581
2014 - 15 990
2015 - 14 131
2016 - 11 982
2017 - 15 127
2018 - 14 557
2019 - 18 000
2020 - 5 750 (COVID)
2021 - 10 754 (COVID)
2022 - 13 105
Van der Heever adds that between April and March 2023, Medical Male Circumcision was reported at 130 public health sites and a total of 12 259 circumcisions were performed across the province.
"The province also has two Men's Health Clinics (in Karl Bremer and Elsies River). With the intention of increasing access to services, we are in discussions to upskill clinicians to enable service provision at health facilities. Current service provision is based on roving teams in both the metro and rural districts, which limit access to availability of the team."
