Lessons from Swaziland: male circumcision
By Wilson Johwa
31 May 2010 | Government Policy | Circumcision | Prevention
We already know that male circumcision is the next biggest frontier in South Africa's fight against HIV-AIDS.
Enabling policy guidelines are still being finalised before the expected roll-out. This could be anytime soon, most definitely after the FIFA 2010 Soccer World Cup which, mind you, is expected to chew up an extra 1.5 billion condoms that the government is providing.
While doubts and counter arguments follow male circumcision, it is possible that South Africa can learn something from Swaziland. However, unlike South Africa which has a mixed experience regarding male circumcision, the Swazi kingdom has one of the lowest circumcision rates in the world, most of which are performed for medical reasons.
But the scale of the AIDS epidemic made it consider any intervention that would help reduce the scale of the AIDS epidemic. Swaziland has among the most acute HIV epidemics in the world, with HIV prevalence among pregnant women attending antenatal clinics estimated at 42% in 2008.
In July last year the country published its policy on male circumcision to prevent HIV. This followed the findings of three trials – Orange Farm, South Africa, in 2005; Kisumu, Kenya, in 2007 and Rakai District, Uganda, in 2007.
The outcome of the three studies have since been challenged by critics of medically-supervised male circumcision who argue that the studies were not conclusive. However, endorsement of male circumcision by WHO and UNAIDS provided Swaziland with enough reason to draw up its own policy.
The thinking is similar to that of authorities in SA who are considering offering male circumcision as part of a comprehensive package. This includes behaviour change communication, HIV testing and counseling and condom use.
Derek von Wissel, director of Swaziland’s National Emergency Research Council on HIV-AIDS, says male circumcision started with pilot programmes, encompassing “circumcision Saturdays”, that were meant to prepare for a mass roll-out. “We’re now reaching a level where we can say it’s an active programme,” he says. The target is 120 000 circumcisions over the next five years, targeting mainly 18-24 year olds.
Driving the intervention is the Swaziland Male Circumcision Task Force mandated to provide “technical guidance”. Among the members of the task force are health providers, policy makers, people living with HIV, the government’s partners in the health sector and even the media.
The policy says scaling up of male circumcision should be “sensitively handled, with respect shown for Swazi culture and gender implications.” It does not name these gender implications, or dwell on the likely cultural, social and sexual ramifications of male circumcision.
Instead it urges research into the “socio-cultural meanings and impacts of male circumcision” but also says “the need for ongoing consultation and social mobilisation should not hold back policy implementation.” Emphasis on a biomedical intervention is typical of the region’s response to HIV-AIDS.
The policy does not seem to sufficiently interrogate the possibility that support for male circumcision runs the risk of giving the impression that process makes condoms look like an unnecessary extra. This gap was no doubt left for counsellors to fill. Von Wissel says the messaging is strong on the point that male circumcision offers only 60% protection.
Swaziland’s policy on male circumcision came as the WHO and other agencies were already providing technical support to the Swazi government. For example, teams of Israeli surgeons — who circumcised thousands of adult men in keeping with religious traditions during the mass migration of Jews from the former Soviet Union in the early 1990s — had trained at least 10 Swazi doctors and backup staff on how to perform the operation quickly and safely with limited resources.
Inon Schenker, who coordinated the Israeli missions to Swaziland told the Associated Press in 2008 that his organization, the Jerusalem AIDS Project, had several dozen surgeons ready to help African countries scale up adult male circumcision by training local health workers in both surgical techniques and counseling.
As public policy scholars know, policy intentions and consequences barely ever amount to the same thing. South Africa would do well to closely study the Swazi experience before promoting male circumcision as a barrier against HIV. However, Von Wissel says each country must look at its own circumstances, providing for decentralisation and adequate human resources. He plays down the social effects of male circumcision, saying the process is not entirely new to the country. “Swaziland is a country that used to circumcise. The social aspects are not an impediment,” he says.
Wilson Johwa is an HIV/AIDS and the Media Project fellow.
Circumcision Season
By Melissa Meyer
27 July 2009 | Circumcision | The Media and HIV/AIDS
It is circumcision season again, and newspapers are telling stories of young Xhosa men who flock to the mountains where they subject themselves to mutilation and a certain risk of death.
The casualties have been dutifully tallied: towards the end of the June season, the Sunday Times reported 44 deaths, 270 maimed genitals and 13 penile amputations.
This has been a particularly gruesome initiation season and whilst there has been intelligent discussion in the media around issues of tradition and manhood, coupled with much-need exposure of illegally operating surgeons, the macabre stories of botched circumcisions seem to speak loudest.
A Sunday Times article, titled Circumcision Horror, quite graphically recounts the experience of young Zuko who lost his brother and his genitals during the initiation ritual. The article also tells of illegal traditional surgeons and careless elders. An accompanying article sets this against the broader context of circumcision as a business — generating large profits, attracting unethical practitioners and maiming young men.
Fortunately, some stories have been less about genitals and more about manhood (which one could argue, is the real issue at stake here). A Mail&Guardian article proposes that even circumcisions done in hospital (in this case on a gay man called Themba) can be an initiation into manhood. Compelling photographs of traditional circumcision initiates cleverly set Themba’s experience against that of young Xhosa men, suggesting that both experiences can be a part of ‘becoming a man’.
The star of this year’s circumcision drama, however, has been Thando Mgqolozana. In his debut novel A Man Who is Not a Man, Mgqolozana openly explores the repercussions of a botched ritual circumcision, which goes to the core of traditional notions of manhood. Fortunately for Mgqolozana, his book has generated as much publicity as it has outcry from traditional leaders.
Efforts like these to engage in meaningful dialogue around issues of ritual circumcision and manhood have made valuable headway in the debate around male circumcision. But is this enough?
Circumcision stories of another kind have been unfolding in South Africa, albeit rather quietly. They might not offer the enticing narrative of unfortunate genital amputations following treacherous journeys to the mountains, or an emancipating visit to a hospital, but they are equally, if not more pertinent.
Since January 2008 more than 9000 men have made their way to Orange Farm outside Johannesburg to be circumcised. Their journeys are not motivated by cultural norms or traditions but informed rather by scientific evidence that circumcised men are significantly less likely to contract or transmit HIV.
Macabre reports of botched ritual circumcision could easily discourage readers from getting “the snip” at a time when circumcision (in its medical sense) can be hugely beneficial to a country firmly in the clutches of a devastating AIDS epidemic. Whilst the Mail&Guardian article makes brief, though vague, mention of “the evidence about HIV and circumcision” the other articles discussed here fail to raise the issue at all.
Whilst it would be irresponsible to downplay the seriousness of botched traditional circumcisions, in the interest of HIV prevention, some distinction between the traditional and surgical procedure (and its benefits) is necessary.
Melissa Meyer is a researcher at the HIV/AIDS and the Media Project.
Peltzer, K. and Kanta, X. (2009) Medical circumcision and manhood initiation rituals in the Eastern Cape, South Africa: a post intervention evaluation.
Media must provide context when tradition and medicine collide
1 October 2005 | Government Policy | Circumcision | The Media and HIV/AIDS
Two traditions that bear an impact on HIV/AIDS prevention have caught the attention of the press over the last few weeks.
The National Council of Provinces (NCOP) is scheduled to hold public hearings on the Children's Rights Bill, which is stirring controversy amongst traditionalists because of its proposed outright ban on virginity testing. But it is not only traditional culture that is at stake, according to some, but also the HIV-prevention benefits of these practices.
Bongani Mthethwa's report in the Sunday Times on September 25 noted the challenge the Children's Rights Bill poses.
“Under a section on social, cultural and religious practices, the Bill condemns anyone who takes part in what it calls genital mutilation and calls for the prosecution of such people under criminal law.”
While some hail the benefits of virginity testing for HIV/AIDS prevention, others say human rights are violated by the practice.
“[Promoting virginity] is a good cause, given our current Aids pandemic, but we still need to take a stand as a country aspiring to be fully democratic. Like many parts of the developing world we face difficult choices and they are often choices that appear to be conflicts between tradition and modernity,” University of KwaZulu-Natal anthropologist Suzanne Leclerc-Madlala told the Sunday Times.
But according to the report, the Bill does not ban traditional male circumcision practiced by Xhosas, creating perceptions of double-standards and even tribal bias.
Male circumcision has hit the headlines for different reasons recently, with HIV/AIDS expert, Francois Venter, advocating circumcision as probably being the “ best available AIDS vaccine against the virus in the country”. In an Associated Press(AP)article, Venter, who is clinical director of the Reproductive Health Research Unit at the University of Witwatersrand, encouraged the TAC to promote circumcision as a prevention tool given that existing methods were “failing to slow the spread of the epidemic”.
Venter told a congress of health activists in the Treatment Action Campaign that a recent survey in Soweto indicated that circumcised men were 65 percent less likely to contract AIDS than those who had not been circumcised.
"We dream of a vaccine which has this efficacy," said Venter. "The results are phenomenal."
The APreport highlighted the dangers of traditional circumcision in terms of HIV/AIDS prevention. Some traditional communities in South Africa practice circumcision, but there have long been calls for tighter medical controls to limit health risks from blunt and contaminated instruments.
"We don't want our men to go to the chop shop but have medical circumcision," said prominent HIV/AIDS activist and head of the TAC, Zackie Achmat.
While using “blunt and contaminated instruments” is a concern in traditional male circumcision, the identification of virgins could pose another dilemma. Although promoting abstinence, virginity testing can also pinpoint likely victims for men who believe the myth that sex with a virgin will cure them of HIV/AIDS.
The Sunday Timesarticle presents a fairly well-rounded story; but one interesting aspect not explored in the article is what our own Health Minister, Manto Tshabalala-Msimang, thinks about these issues. What is her take on the various initiatives that people are taking to save their communities from the devastation of AIDS?
Unfortunately an extensive search revealed that Tshabalala-Msimang has been tip-toeing cautiously, being mindful of her every move. It appears she has not said anything publicly about either of the contentious issues of virginity testing or circumcision, preferring to stick to her familiar chant of “Garlic diet! Garlic diet!”
(Tshabalala-Msimang's medically unsubstantiated olive oil and garlic campaign diet has fuelled public confusion since it was first reported by the South African Press Association among others in 2003. But this needs to be the subject of another blog all on its own …)
Back to the Sunday Timesreport: it would've been interesting to hear what the Health Minister's stance is on a Bill that the article claims has taken on “tribalistic undertones”. The same Bill has many virginity testers in KwaZulu-Natal arguing that the government has double standards as it continues to protect male circumcision.
The media's role is vital, as it is with any other issue, but especially in this instance where two worlds seem to be at loggerheads with one another: the traditional versus the medical. Each side is arguing that their methods are the better option in AIDS prevention. In this context of confusion and contestation, it's imperative that the media provide clear, considered reporting for the many South Africans personally affected, and for the politicians currently designing new laws that will have a long-lasting impact on all of us. - Lunga Madlala
