Traditional male circumcision-related fatalities in the Mthatha area of South Africa

Introduction

Male circumcision is one of the oldest traditions observed by many societies. The ritual is performed at specific periods in life with the main purpose of integrating the male child into the society according to cultural norms. Recently, especially in the Eastern Cape, many initiates have died or have had to face life with mutilated genitals following this ritual. Traditional male circumcision is still widely practiced by the Xhosa population throughout South Africa. Male circumcision is carried out mainly during summer and winter seasons. It involves traditional surgeons, traditional nurses, the parents of initiates and the initiates themselves. The circumcisions take place in initiation schools where they are performed by traditional practitioners. ¹

Unfortunately, during the past few years inexperienced traditional surgeons have been conducting the ritual. They do not conduct the procedure under aseptic conditions and the use of a single blade on many initiates can cause cross-infection. The ritual includes gratuitous beatings and other forms of physical abuse, extreme exposure to the elements, nutritional deprivation, and withholding of medicines from the chronically ill. The initiates are also significantly dehydrated during their two-week period of seclusion in the belief that this reduces the weeping of the wound. ²

No particular age is specified for these rites, and it is usually boys between the ages of 15 and 25 years who undergo initiation. This means that initiation is not linked to physical development and maturity, but is a socially significant act, resulting in integration into the community and assurance of acceptance and respect from other community members. ³

Due to high rates of morbidity and mortality associated with traditional male circumcision, there is widespread criticism from media, governmental and non-governmental organizations. Substandard circumcisions are a public health hazard and lead to tragic mutilation and deaths. The purpose of this study is to highlight the problem of circumcision-related deaths in the Mthatha area of South Africa.

Method and cases

This is a retrospective descriptive study. The male circumcision-related deaths at Mthatha (Umtata) General Hospital mortuary over the period 1 January 2005 to 31 December 2006 were reviewed. Mthatha General Hospital is the teaching hospital of Walter Sisulu University Medical School. The mortuary is type ‘M’ which conducts about 1200 autopsies every year and caters to about 400,000 people of this area. The deceased were brought to this mortuary from Mthatha, Ngqeleni, Libode, Tsolo, Mquanduli, Port St Johns and Mount Frere areas. Personal details such as name, address and age of the deceased were recorded in the register as well as the cause of death. The results were analysed with the help of the SPSS program.

Results

There were 25 traditional male circumcision-related deaths between 1 January 2005 and 31 December 2006. Of these, eight deaths were in 2005 and 17 in 2006. Deaths were highest in the summers of 2005 and 2006 (total 17 deaths; 68%). Four (16%) of these deaths occurred in July 2005 and 13 (52%) in July 2006 (Table 1). The common causes of death were septicaemia (9; 36%), pneumonia (5; 20%), dehydration (3; 12%), assault by fellow initiates (3; 12%), thromboembolism (2; 8%), gangrene (2; 8%) and congestive heart failure (1; 4%) (Table 2). The highest number of deaths (7; 28%) occurred in Libode, followed by Mthatha (6; 24%), Ngqeleni (5; 20%) and Tsolo (3; 12%) (Table 3). The youngest victim was a 12-year-old boy and the oldest was aged 32 years. All the fatalities were black Africans with a median age of 17.56 (SD = 2.56) years (Table 4).

Discussion

The issue of circumcision-related deaths is a recurring problem despite the Act passed in the Provincial Government of the Eastern Cape to curb the practice. There seems to be an increase in circumcision-related deaths; whether this is due to a real increase or an increase in reporting since the dawn of democracy is difficult to assess. Deaths rose from eight in 2005 to 17 in 2006 (Table 1). This doubling of deaths in a year is alarming and calls for immediate intervention. Since 1995, more than 6000 boys have been admitted to Eastern Cape hospitals and more than 300 have died. ⁴

There are several ethnic groups in Southern Africa who practise circumcision as part of a ritual of admitting boys to manhood. Recently, this ritual has been tarnished by serious complications that have occurred, leading to amputations of the penis and even death of initiates. ⁵ The Eastern Cape Provincial Department of Health recorded 1748 hospital admissions, 177 (10.1%) deaths and 107 (6.1%) genital amputations due to traditional circumcisions between June 2001 and June 2006. ⁶ The Eastern Cape has an average of 39 deaths per annum related to traditional male circumcision and most of them (56.5%) are from the O R Tambo District Municipality. ¹

Twenty-five deaths occurred in this area in 2005/2006 (Table 1). As with any medical procedure, it is possible for minor complications to occur, even in experienced hands, but deaths should not occur. The anecdotal evidence is that despite the evident dangers of the practice, young Xhosa men are today no less eager to be circumcised in a traditional way. Some 10,000 Xhosa men are circumcised annually in the Eastern Cape. Xhosa boys are aware from a young age that initiation is regarded as an inevitable part of life. In Xhosa custom, ritual circumcision is performed most commonly on men between 15 and 25 years. ⁷

Traditionally a man could not marry until he had been initiated. Initiation conferred socially approved status and with it marriage ability. In present day Xhosa tradition, initiation has remained a ritual transition from boyhood to manhood indicating the youth's incorporation into full membership of the community. On initiation, the man obtains greater rights and responsibilities and gains higher standing in society. Traditional male circumcision is also a gateway to sex, which attracts young men to participate in the circumcision ceremony. ⁸ Sometimes, young boys can be victims of this kind of ritual. The majority were aged 15–23 years (Table 4). The youngest of the deceased, a 12-year-old boy, had participated without his parents' knowledge.

The traditional practice is much like modern military training, hard but intended to nurture. It is performed by experienced operators, overseen by traditional leaders and healers who serve as teachers and sources of wisdom. They are also responsible for providing the herbs used as dressings and are expected to follow a professional code in order to minimize the risks to the initiates and to prevent fatalities. The practice has degenerated into unprofessional conduct due to the use of non-sterile instruments, using the same blade on multiple initiates, and doing so without necessary experience. This has resulted in the deaths of initiates by septicaemia (9; 36%) and pneumonia (5; 20%) in this study (Table 2). Three initiates died of dehydration. Negligence and lack of accountability lie at the root of the problem. Three died because of injuries following assault, which amounts to murder (Table 2). In short many of the so-called ‘circumcision schools’ of today are fake and deadly. They have very little to do with the traditional ethos and practice of this ancient ritual, and something must be done to stop them. ⁹

There were two deaths related to gangrene of the penis. Gangrene per se is not usually a cause of death but can lead to fatal septicaemia and renal failure (Table 2). It is difficult to estimate the extent of disability among initiates because many of them are not willing to seek the help of health professionals as it is considered very private information. Therefore, it is hard to gauge the extent of medical problems brought about by circumcision as it is not recorded. Similar horrifying circumcision outcomes have been observed every year, with reports of the deaths and mutilations being beamed across the world by all the major news services. No one understands why we as a country or as communities have seemingly stood by and done little or nothing as these deaths rock the country year after year. Anywhere else in the world, this kind of mayhem would have evoked community outrage and led to urgent and drastic action to prevent it. ⁹

Circumcision-related deaths continue to occur in the Xhosa community, which means that these laws are not effectively implemented or are not adhered to by traditional practitioners. According to one study, 67% of the population was unaware of any risk associated with traditional male circumcision and 63% of the subjects were in favour of traditional surgeons in the Mthatha area of the Eastern Cape. ⁵ Death due to ritual circumcision largely occurs in the impoverished and faceless rural and peri-urban communities. The people themselves have perhaps come to accept these occurrences as a part of their fate. Middle-class families from circumcision backgrounds ensure that their sons are circumcised in safe and nurturing environments. Unless these elite are moved and inspired to do something about the circumcision-related deaths among the less privileged, it seems unlikely that anything will change. ⁹

Conclusion

Deaths related to traditional male circumcisions in the Mthatha area of South Africa could be avoided by the training and monitoring of traditional surgeons by family physicians in the designated area, together with enforcement of the law.