How safe is traditional circumcision?

When Steve Matlhabela, 16, left his home on a chilly June morning to visit some relatives in a village not far from his in the rolling hills outside the town of Tzaneen, in South Africa's Limpopo Province, he didn't expect that it would be a month before he returned.

At his relative's village Steve met a boy he knew, who invited him to go see a movie. Steve agreed and they walked for some distance before reaching a remote camp where it soon became clear there would be no movies.

"I wasn't scared at first because there were many other boys there," Steve told IRIN/PlusNews, "but then they told me to take off my clothes." Steve's clothes were delivered to his mother by the same boy who had taken him to the camp. "Your son has gone to initiation," he told her.

Steve's cousin, Thabang, who had been in the family's care since his mother died from an AIDS-related illness in February, was also at the initiation "school". The family was informed that the fee for both of them would be R1,420 (US$192), a significant sum considering their only source of income is two child support grants totalling R420 (US$57) a month.

"We felt there was nothing we could do," said Steve's grandmother, Rosinah Matlhabela. Going to the police was not an option, she said, because the school was run a local police captain. Eventually, they took out a loan to pay the fees.

Steve was circumcised by a traditional practitioner soon after arriving at the school. No anaesthetic was administered; bearing the pain of the cutting is considered vital to the process of becoming a man. A disposable blade was used, but the wound was not bandaged; the only protection against infection was the application of some traditional medicine.

More than a month after being cut, Steve said the wound still caused him pain but he would not to go to a doctor. "They told me if I go to the doctor I'm not a real man."

Traditional circumcision overlooked

Since three randomised trials in 2005 and 2006 demonstrated that circumcision could reduce the risk of HIV infection among men by up to 60 percent, international NGOs, donors and even some African governments have been channelling resources into creating a demand for medical male circumcision, and increasing the capacity of hospitals and clinics to meet it.

Meanwhile, some public health experts have complained that making traditional circumcisions safer has received considerably less attention or funding.

Limpopo has had legislation in place governing the conduct of the province's more than 200 initiation schools since 1996, but the cultural taboos that prevent initiates from talking about their experiences, and the involvement of local officials in running the schools has made the law difficult to enforce.

In 2007 five boys died while attending initiation schools in the province, and the same number died during this year's initiation season, from June to July.

A number of sources IRIN/PlusNews spoke to said it was common for boys much younger than Steve to be tricked or coerced into entering an initiation school without the knowledge or permission of the adult responsible for them.

''The ones who attend this year, by next year they're taking the other ones because the school owners promise them money''

"The ones who attend this year, by next year they're taking the other ones because the school owners promise them money," said Eddy Hlongwini, chairperson of a local association of traditional healers. "They tell them it's a nice place, that they're eating nice [food], and once they're there they have no chance to run away."

Khosi Vusani Netshimbupfe, chairperson of an initiation school task team overseen by the province's House of Traditional Leaders, explained that in terms of the legislation, boys must be over 12 and have permission from their parents to enter the schools. A medical professional must also certify them fit to undergo the procedure and to spend a month at a remote mountain camp in the middle of winter, wearing nothing more than a blanket.

Some boys sneak into the schools without either, Netshimbupfe admitted. "If they're caught before they see what is going on there, they can be turned away. But the problem is if they've gone in and they've seen something; according to custom after you've seen the secret you can't be turned away."

When Promise Mhangwana, 9, ran away from his grandmother's home to join his 12-year-old uncle at an initiation school, no one stopped him from entering the camp. By the time he returned home, he was walking with difficulty, but refused to show his grandmother where he had been cut. Finally, he allowed a nurse at a local clinic to dress the infected wound.

"We have these kind of children every winter," the nurse, who asked not to be named, told IRIN/PlusNews. "For now, there are about eight coming for regular dressings, but most of them won't allow a woman to see that area, so when they come home they don't tell the mothers there's a problem."

Photo: MujahidSafodien/IRIN
In 2007, a total of 243 initiation schools were registered in Limpopo Province and 32,300 boys were initiated

The regulations stipulate that initiation schools charge no more than R350 (US$48), but some schools charge more than twice that amount. Increasingly, families prefer to send their sons to hospitals to be circumcised for the considerably lower fee of R150 (US$21), but this does not protect the boys from being ridiculed by their peers.

"They laugh at them, they side-line them, especially leading up to the [initiation] season," said the nurse. "My nephew used to go and stay in town with my daughter to avoid it, but this year he went [to the school]; he said he was tired of hiding."

Morris* sent his three sons to the hospital to be circumcised. "I didn't want them to go to the mountain, it's not safe," he said. He was particularly keen to protect his youngest son, Lucky*, 15, who suffers from asthma.

But Lucky was lured to a school last month by some boys who promised him a party with food and drink. Morris had to raise R650 (US$89) from relatives to pay the school fee and his son returned sick. "It was cold, and he can't stay in the cold," he said.

Lack of oversight

Local police are reluctant to get involved in what they describe as a "traditional issue". "You must talk to the chiefs," Ngoveni Khazamula, Tzaneen's police commissioner told IRIN/PlusNews. "This is not a matter for the police."

Traditional surgeons have to be registered with the department of health after undergoing training, but permits for initiation schools to operate legally are issued by local chiefs.

Some chiefs "take it to be a business", said a local headman, who declined to be named. "I tell my people not to go to initiation schools; I think it's a waste of time. In our tradition there are good things and bad things, and in my place I discard the bad things," he said.

Local traditional healer Eddy Hlongwini said having a permit and registered surgeons did not guarantee that a school would prioritise the safety of initiates. "Some are registered but I don't think it means anything; in the past year many accidents have happened," he said. "Once they have permission, they might run six schools in one year, which means they can't look after all the boys."

Netshimbupfe admitted, "It does happen that some people who run these things see it as a money-making scheme," but disputed the idea that cracking down on illegal initiation schools was a matter only for the chiefs. "If somebody goes against the regulations they can be fined in a court of law," he pointed out.

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Khazamula said his station had not received any complaints about initiation schools, but one of the families interviewed by IRIN/PlusNews said they had asked the police to help them retrieve their child from a school.

"We phoned the police to ask us to help go get him from the mountain, but they said they were afraid to go," said the boy's grandmother.

*Not their real names