Doctors and health workers in Pondoland in the former Transkei have put together six medical teams to be on standby for the upcoming initiation season during the Christmas period. They are convinced that this initiative represents the closest the Eastern Cape has come so far to integrating medical male circumcision with traditional initiation.

The TB/HIV Care Association formed the teams, and each group consists of a doctor, three nurses and two HIV counsellors.

The action follows 39 initiation-related deaths, 26 of them in Pondoland, according to the provincial health department, during the June/July initiation season. In addition to this, hundreds of initiates suffered penile injuries and at least 25 men lost either their entire penis, or part thereof, said Dingeman Rikjen, who was a doctor at Holy Cross Hospital near Flagstaff at the time and treated several of the injured.  

"The 25 amputees [men who lost their penises or part thereof] is a figure that we recorded at eight of the ten hospitals in Pondoland," he said. "There might be more from the other two hospitals and also a few that never came to hospital that we just don't know of." 

Rijken said that most of the amputations and deaths could be ascribed to untrained traditional nurses applying penile bandages too tightly, which results in the blood supply to the penis being cut off.

According to Eastern Pondoland's royal spokesperson, Sonwabile Sihlobo, Queen MaSobuzha Sigcau or her representative will formally reinstate initiation, or ulwaluko, among the amaMpondo next month. The ritual, which serves as a passage to manhood, was abolished in the 1820s because the king at the time believed it weakened his warriors during the Xhosa war with the Zulus. 

The royal house, however, never officially reinstated the practice when it re-emerged during the late 1970s, resulting in it being unable to institute formal rules for initiation schools, which are also known as bomas.   

Negotiations
For the past two months, Rijken and his team, as well as the TB/HIV Care Association, which performs medical male circumcision, have been negotiating with Eastern and Western Pondoland's two kings' councils to find ways to incorporate medical circumcision, performed by doctors, into traditional initiation ceremonies to make circumcision safer. 

The association's Carlos Orte said all indications were that "traditional chiefs will be allowed to choose, in consultation with the community, whether medical or traditional circumcision will be practised in their respective areas. For those who choose medical circumcision, TB/HIV Care will provide free medical teams to perform the procedure and we'll also be available to handle injuries and provide training for traditional circumcisers and nurses in areas that have chosen to go the traditional route."  

According to several health workers in the area, many chiefs are planning to go the medical route.

During medical circumcision, a doctor surgically removes the foreskin of the penis and uses stitches to close the wound. It is also possible to use nonsurgical devices for the procedure, but these are not yet used widely in South Africa. 

The national health department said medical male circumcision in the country had so far been injury free. It said it had carried out more than a million circumcisions since April 2010 without any "major reported injuries" as part of an HIV prevention campaign. 

Several studies have shown that medical circumcision reduces the chance of heterosexual men contracting HIV by more than half. 

In the case of traditional circumcision, the entire foreskin of the penis is often not removed, eliminating the potential HIV-prevention benefit that comes with circumcision. Traditional circumcisers and nurses also don't stitch the wounds, using only penile bandages. Wounds are treated with herbs rather than with clinical medicine.

Orte said his organisation had made arrangements to acquire generators over December, should the doctors need to perform medical circumcisions in tents without electricity, as some of the equipment used for the procedure required power.  

"We've also agreed that each chief will host a super-boma [a single location where all bomas or initiation camps will be based] in his or her area, which will make the monitoring of bomas considerably easier as all initiates will also have to register with the chief," said Rijken. 

Sihlobo confirmed this arrangement, saying: "As custodians of the customs and norms of the culture, we have decided that one common initiation event in each area is better and safer."  

Final decision up to the ama-Mpondo
Sihlobo emphasised, however, that the "final decision" about whether medical or traditional circumcision would occur would be the ama-Mpondo's choice, and whether the chiefs would have "autonomy" over that choice in their respective areas would be announced closer to the initiation season. 

"We must be highly secretive at this stage because we're dealing with something that has implications for many people, and for our culture, which is very important to us," he said. 

"We can't disqualify medical circumcision or traditional circumcision at this stage. What I know is that the method or methods we eventually choose must prevent injury and death."  

Several senior community members and other sources close to the king's council said the queen and her family were extremely supportive of medical circumcision. One said: "They are pushing for it for the sake of their people." 

According to sources close to the Eastern Pondoland king's council, it has several "concerns" and "demands" regarding the issue and the forthcoming season. These include the requirement that doctors performing medical circumcision should be exclusively Xhosa men who have gone through initiation themselves. 

A source with inside knowledge of a recent council meeting said some chiefs on the council had suggested that "an area that had a high amount of injuries" during the winter initiation period be selected to "launch" medical circumcision in the region. "The suggestion, then, is that this specific area be a guinea pig, to see how medical circumcision goes and if it is accepted."  

Meetings to take final decisions on the issue for both Eastern and Western Pondoland have been scheduled for next week, although the negotiations with Eastern Pondoland are more advanced than those with King Ndamase's Western Pondoland, a community member said. 

"One of our biggest challenges in the Eastern Cape has been to get people to use our services, as it's often seen as being in conflict with traditional culture," Orte said. 

Said Zolani Barnes, TB/HIV Care's advocacy co-ordinator: "It's important to remember that circumcision is only a small part of initiation, which is a passage to manhood. I'm Xhosa and have gone through initiation myself, but I'm considering sending my sons for medical circumcision. 

"Things have changed; there are too many injuries and deaths now. All of us need to make a mind set shift and realise that our culture is about creating better and stronger men, not killing or mutilating men. 

"For that to happen, we might have to become open to allowing medical help in traditional ceremonies." 

                                                                               Medical male circumcision at Orange Farm (Delwyn Verasamy)

M&G story helps to bridge divide between medicine and tradition

A Mail & Guardian/Bhekisisa article on the victims of botched traditional circumcisions in Pondoland in the former Transkei has played a pivotal role in creating partnerships between medical doctors and traditional leaders to promote safer circumcision during initiation ceremonies. 

"The boys who lost their manhood" (August 16) resulted in the health organisation TB/HIV Care contacting Dingeman Rijken, a doctor at the Holy Cross Hospital near Flagstaff at the time. He was quoted in the article. 

"After reading the story, I googled Dr Rijken's contact details and got in touch with him," said Carlos Orte from TB/HIV Care. 

"I thought there must be a way to collaborate, as we have been conducting medical male circumcisions in the Eastern Cape for quite some time. We have, however, had serious problems with the uptake of our services, as medical circumcision is often not acceptable from a traditional point of view."  

"The experiences of Dr Rijken's patients who had lost their penises because of botched circumcisions were very similar to what we had seen in the areas where we work." 

According to Rijken, the story led to a solid collaboration. "Because I had strong relationships with traditional leaders and the royal house in Eastern Pondoland, I was able to put TB/HIV Care in touch with them, and together we presented a proposal to the royal house on how we could work with them. 

"TB/HIV Care has several doctors' teams who will conduct medical circumcisions for free at initiation camps in areas where chiefs are open to it, with the king's council's blessing." 

Rijken said the article has also led to royal house representatives, particularly the head of Eastern Pondoland, Queen MaSobuzha Sigcau, who read the M&G piece, "becoming more open" to partnerships with doctors. 

"The terribly messed-up lives of boys described in the article, who now live with either no or half a penis as a result of circumcisions gone wrong, shocked the leadership into speeding up their efforts to come up with a plan to make circumcisions safer," he said. 

"It has also helped to increase awareness of the issue among provincial and national government leaders and is also partly why Health Minister Aaron Motsoaledi has asked me and Community Development Foundation director Nkululeko Nxesi to write an advisory report for him with suggestions on how to solve this appalling situation in Pondoland."