ARTICLES

 

Policy shortcomings affecting traditional male circumcision (TMC) in the Eastern Cape Province

 

 

Thanduxolo Nomngcoyiya; Simon M. Kang'ethe

Department of Social Work/Social Development, University of Fort Hare, Alice. South Africa. TNomngcoyiya@ufh.ac.za; SKangethe@ufh.ac.za

 

 

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ABSTRACT

The study took the form of a qualitative empirical case study in order to carry out a critical analysis of the shortcomings of existing policy pertaining to traditional male circumcision (TMC) in the Eastern Cape province of South Africa. Interview guides were developed to conduct in-depth interviews and focus group discussions with 28 participants. Among the principal conclusions from the findings were evidence of a lack of clarity on performing TMC operations, diverging perceptions of policy pertaining to TMC, unclear selection criteria for practitioners, and a lack of enforcement of policies which have been formulated. Recommendations are offered on the basis of the conclusions.

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AIM OF THF STUDY

This article is based on a study which was conducted from 2014 to 2015 with the principal objective of investigating the psychosocial consequences associated with the practice of traditional male circumcision, drawing on the subjective experiences of newly initiated men in a case study of Lusikisiki in the Eastern Cape province in South Africa. The study entailed a critical analysis to identify the respects in which the policies which apply to TMC at present fail to uphold the fundamental human rights of initiates and ensure their wellbeing and safety.

 

INTRODUCTION

South Africa has been internationally acclaimed since it attained democracy for embracing human rights and making a commitment to upholding human dignity. So it is a cause of great concern that the country should find itself at the centre of controversy for violating the same values and human rights which its Constitution pledges to defend (Douglas & Nyembezi, 2015). Whether the perceived failure to uphold these values in the case of TMC is the result of the deliberate flouting of the provisions of the Bill of Rights in the Constitution, or of failing to take them adequately into account, represents the crucial question which this study set out to answer. Due consideration should be given to the provisions which guarantee cultural rights in sections 30 and 31 of the Constitution of the Republic of South Africa and also those in the International Covenant on Economic, Social and Cultural Rights (Gudani, 2011; Mpateni, 2017). In addition, as cultural mores and values have also long been recognised as playing a pivotal role in maintaining social order and social cohesion, a cogent case can be made for retaining the practice of traditional male circumcision (Nyoka, 2017). Accordingly, cultural obligations have been incorporated into regional and international pieces of legislation, which are binding for South Africa and other signatories. These treaties include the African Charter on Human and Peoples' Rights (1989), the International Covenant on Economic, Social and Cultural Rights (ICESCR), and the Universal Declaration of Human Rights of 1948 (Ntombana, 2011). Nyembezi (2016) contends that although all of the rights which are enshrined in the various treaties and pieces of legislation are fundamental and held in high esteem in societies throughout the world, the degrees to which they are emphasised tend to vary from country to country and some categories appear to be more universally recognised than others.

As some human rights are generally perceived to play a more decisive role than others in determining quality of life, cultural rights need to accord with fundamental human rights. The right to life is the most fundamental right which is enshrined in the Bill of Rights in the Constitution of the Republic of South Africa (1996). Section 11 emphasises the right to life of everyone, while Article 4 of the African Charter on Human and Peoples' Rights (1989) requires all countries which are signatories to uphold and respect the right to life and integrity of all human beings. In addition, section 7 (2) of the Constitution enshrines the universal right to health in order to ensure the wellbeing of people and to uphold their right to healthcare (Fuzile & Feni, 2015). There can be no doubt that all of the rights which have been cited apply no less to young men whom cultural mores require to undergo traditional male circumcision than they do to any other citizens (Abrahams, 2017).

Sub-section 8(a) of Chapter 2 of the Children's Amendment Act No. 41 of 2007 prohibits children below the age of 16 years from undergoing circumcision and being subjected to conditions which compromise their wellbeing. In addition, it states that only a qualified medical practitioner or a properly trained person who has sufficient knowledge of the social or cultural practices of the communities of the young men who are to be circumcised is permitted by law to perform circumcisions. The provision has also been incorporated into relevant provincial legislation to regulate the practice of traditional circumcision and safeguard the wellbeing of initiates in South Africa; such legislation includes the Northern Province Circumcision Schools Act No. 6 of 1996, the Application of Health Standards in Traditional Circumcision Act No. 6 of 2001 of the Eastern Cape province, and the Initiation School Health Act No. 1 of 2004 of the Free State province (Nyoka, 2017).

The agencies of the South African criminal justice system which would be responsible for prosecuting cases of botched circumcisions resulting from the practice of traditional male circumcision appear to be particularly reluctant to fulfil their legal obligations, despite escalating rates of penile amputations and incidences of assault and torture of initiates, which in some cases have resulted in disability and even death (South African Broadcasting Corporation (SABC), 2017). It has also been alleged that in July 2014 the Deputy Minister of Cooperative Governance and Traditional Affairs admitted that the legislation and policies which are in effect at present do not enable perpetrators to be brought to book (Feni, 2014: 1).

 

PROBLEM STATEMENT

The reputation of post-apartheid South Africa as a country that champions human rights is threatened, both regionally and internationally, by its perceived failure to ensure the protection of young boys during traditional male circumcision rites in the Eastern Cape and other parts of the country (Nyembezi, 2016). The failure could stem partly from inconsistent interpretations of the policies which apply to the practice of traditional male circumcision by many of the people who are responsible for running initiation schools and performing circumcisions. It is apparent to the authors of this paper that many may not be fully aware of the implications of the policy environment in which traditional male circumcision is required to be carried out in post-apartheid South Africa. In many cases they are either insufficiently acquainted with the procedures by means of which policy is interpreted and implemented, or their ability to understand the nature of official policy is limited. It is quite conceivable that some may have little or no knowledge of the policy environment pertaining to traditional male circumcision. Consequently, it is entirely possible that there is a great deal of confusion about the policies that guide the carrying out of traditional male circumcisions, particularly in the light of the large numbers of deaths of initiates each year in the Eastern Cape. Policies pertaining to the selection criteria that apply to traditional surgeons and nurses in some cases appear to be unclear or insufficiently rigorously defined; furthermore, in some instances an apparent indecisiveness or reluctance has been discerned in relation to prosecuting bogus traditional practitioners who run illegal initiation schools. The nature of the problem makes it imperative to determine the specific shortcomings of the policies that are in force at present in order to arrive at an appropriate solution which harmonises the need to preserve and respect cultural traditions and values with the need to uphold the fundamental human rights of initiates. It is to be hoped that a comprehensive and accurate analysis of the shortcomings of present policies and their implementation would enable cultural imperatives to be fulfilled in a way that accords with the rights which have now been enshrined in the Constitution after centuries of racial discrimination.

 

RESEARCH METHODOLOGY AND THE SETTING IN WHICH THE STUDY WAS CONDUCTED

Research design

A qualitative approach was adopted in order to develop the research methodology, while the research design took the form of a case study. The study was exploratory in nature and made use of descriptive data, as the researchers endeavoured to conduct an in-depth investigation of, and to describe in detail, the perceptions, attitudes, beliefs and opinions of a diverse range of stakeholders concerning the policy environment in which traditional male circumcision is required to be carried out in South Africa. As Marlow (2011) explains, the qualitative paradigm places a premium on subjectivity, value judgements, individual voices, inductive reasoning and epistemology. Accordingly, it provided a viable basis for obtaining data from close interactions with the participants in the study in order to evaluate their perceptions, beliefs, opinions and attitudes in relation to shortcomings of the policy environment which governs the carrying out of traditional male circumcisions in the Eastern Cape (Creswell, 2014).

Methods employed to collect data

According to Salkind (2012), collecting data in qualitative research studies entails a precise and systematic process in which data can be obtained through procedures such as interviews, observations of participants, focus group discussions and narratives. In the study upon which this paper is based, one-on-one in-depth interviews were conducted with newly initiated men and members of their families and focus group discussions, which included members of their communities and traditional nurses (Marlow, 2011; Creswell, 2014). The findings were also corroborated by the responses of a few key informants who were believed to be particularly knowledgeable concerning the research topic.

Sampling procedure and techniques

The research sample was selected through the use of purposive non-probability sampling. The approach was adopted because the researchers intended to include in the sample only people who had direct experience of TMC or could be considered to be key informants. Purposive sampling ensured that the researchers obtained sufficiently richly detailed data to enable them to provide answers to the research questions from which the conclusions of the study could be drawn (Babbie & Mouton, 2012).

Selection criteria for the research sample

Selection criteria for the research sample included criteria for both inclusion and exclusion. Criteria for inclusion required participants to be:

• Men who had undergone traditional circumcision between 2012 and 2014, or members of families in which initiates had suffered from adverse consequences as a result of having undergone traditional circumcision between 2012 and 2014;

• Residents of the Ingquza Hill Local Municipality in Lusikisiki, which falls under the OR Tambo District Municipality in the Eastern Cape province.

In the case of initiates, they had to be between the ages of 17 and 25 years.

The following categories of potential participants were excluded from selection:

• Initiates who lived in Lusikisiki who were over the age 25 years;

• Members of families in which initiates had suffered from adverse consequences as a result of having undergone traditional circumcision before 2012;

• Government officials who did not serve the Lusikisiki region.

Unit of analysis and sample size

The unit of analysis was comprised of 28 participants who represented a number of different categories, namely:

• Six men between the ages of 17 and 25 years who had undergone traditional circumcision between 2012 and 2014;

• Five members of the families of men who had undergone traditional circumcision between 2012 and 2014;

• Five members of their communities;

• Seven traditional nurses;

• Five key informants, namely one education official, one circumcision monitoring team official, one committee leader, and two traditional leaders who held the position of either chief or headman.

Research instruments

Interview guides consisting of unstructured questions were used to steer the in-depth interviews and focus group discussions. In order to meet the scientific criteria of validity and reliability, the instruments were tested and refined during a pilot study which was conducted before the study was commenced. The in-depth one-on-one interviews with the key informants and the other interviewees and the focus group discussions enabled data to be corroborated and also permitted the researchers to evaluate a diverse range of perceptions, beliefs, and opinions pertaining to the research topic (Neuman, 2011; Rubin & Babbie, 2011).

The processes of data collection

The study was a cross-sectional one in that the data were collected on one occasion only, from January to February of 2015. Creswell (2014) explains that cross-sectional studies entail collecting data during a single period, as opposed to the longitudinal processes which are used to conduct ethnographic studies in which data are collected from the same groups of respondents at regular intervals. In order to put all of the participants at their ease and to enable them to express themselves in their home languages, the interviews and focus group discussions were conducted in isiXhosa, isiZulu, or English, in accordance with their preferences.

Analysis of the data

Thematic analysis was used to analyse the data by organising the raw data in a manner which enabled patterns to be discerned and themes to emerge from common threads of information. In this study thematic analysis entailed writing memoranda, recording keywords and comments, giving themes provisional names, using analogies, and jotting down notes to provide relevant cues for analysing the data (Creswell, 2014). The four sets of raw data which were obtained from the interviews with men who had undergone traditional circumcision, members of the families of initiates, traditional nurses and key informants were initially captured on audio tape by means of a recorder and then transcribed. From the transcriptions the large quantities of raw data were sorted, rearranged and reduced to manageable categories, which enabled themes to emerge and be appropriately coded (De Vos, Strydom, Fouché, & Delport, 2011). Scrupulous attention to detail during the laborious process provided a sound basis for performing an accurate analysis of the data.

Location of the study and justification for choosing it

The researchers considered that Lusikisiki would be an appropriate location for conducting the study because there has been a consistent spate of initiation deaths each circumcision season for several years. The phenomenon of deaths during traditional circumcision had become a grave concern for the government, the parents and families of initiates, their communities and many others, including the researchers, who had become aware of the magnitude of the problem. The numbers of deaths attracted the attention of both local and international media, with many reports suggesting that the cultural requirement of traditional male circumcision violated both the fundamental human rights and the right to health of initiates.

Ethical considerations

The ethical standards which apply to all research in the social sciences were rigorously adhered to at all times during this study. Particular emphasis was placed upon ensuring that the information which the participants provided was treated as strictly confidential and that they consented to participate in the study on the basis of informed decisions. After prospective participants had been briefed concerning the objectives of the study, those who agreed to participate were required to sign consent forms which confirmed that they agreed to do so completely voluntarily. In the cases of participants who were below the age of 18 years, parents or legal guardians were required to sign consent forms on their behalf.

The researchers ensured that all of the requisite research protocols of the university were also followed rigorously. Following these procedures ensured that the study was conducted in a manner which complied with all relevant ethical, administrative and moral standards. The principal research investigator was required to sign a form in which the nature of objectives of the study were declared as well as a sworn declaration that the study did not entail any conflicts of interest. In addition, it was necessary to obtain clearance from the University Research Ethics Committee (UREC), in order for the study to be granted a clearance certificate. Care was taken to conceal the identities of the participants by ensuring that they remained anonymous. The names of participants and the institutions or organisations by which some of them were employed, or with which some were associated, were disguised through the use of pseudonyms. In addition, codes were assigned in order to maintain their anonymity in relation to other people in the communities, schools or organisations in which they were known and to conceal their identities from members of the general public who read the research paper (De Vos ét al, 2011).

 

FINDINGS OF THE STUDY

Demographic information pertaining to the participants in the study

Details of the demographic profiles of the participants, such as their marital and socioeconomic statuses, were not considered to be relevant to the study, as it was concerned specifically with their subjective perceptions, beliefs and opinions in relation to traditional male circumcision and the respects in which they considered that the policy which is implemented at present fails to respect and uphold the rights of initiates. Other demographic details such as age, gender and the levels of education which they had attained were considered to be highly relevant, as they had a direct bearing upon how they perceived the initiation of males and the measures which they believed should be implemented in order to protect initiates. Although all of the male participants who had been selected because they had undergone traditional circumcision between 2012 and 2014 fell into the age range of 17 to 35 years, two were below the age at which the Constitution would define them as belonging to the youth of South Africa (i.e. 18 to 35 years). In the considered opinion of the authors of this paper, young men of 17 years or younger would be both legally under-age in terms of the Children's Amendment Act No. 41 of 2007 and also not sufficiently mature to assume the responsibilities and to withstand the privations which undergoing the rite of passage entails. From a similar standpoint and also from a cultural perspective, as the ages between 18 and 35 years define South African citizens as belonging to the youth of the country, the age range cannot be considered to represent an ideal for providing care to initiates in initiation schools after they have been circumcised. It was not considered insignificant that all but one of the traditional nurses in the research sample could be classified as youths.

In terms of the levels of education which the participants had attained, a total of eight had either never been to school or had not progressed beyond Grade 7 at the primary school level. Eighteen had received some secondary education and some had matriculated, while only two had received tertiary education. The generally low levels of education could reflect the high rates of unemployment in the region. It could also be suggested that uneducated people may be particularly likely to be unaware of the legal requirements pertaining to traditional male circumcision and unable to differentiate between bogus traditional practitioners and officially accredited ones. The low levels of education could also indicate cultural stubbornness and a high probability of encountering difficulties in inculcating changes in beliefs and values with respect to traditional cultural practices and also in relation to creating an awareness of the pressing need for socioeconomic development in rural areas.

The themes which emerged from the data are summarised in Table 2.

A lack of clarity concerning the rules which apply to traditional male circumcision and the operations by means of which it is to be performed

The participants complained that there was little clarity concerning rules which applied to traditional male circumcision and the operations by means of which it was to be performed. They maintained that there were discrepancies in the rules of practice for operations in that those who were ostensibly responsible for managing the rite either routinely failed to adhere to the relevant legislation, or were unsure of their roles and the course which the processes should follow. The participants in both the one-on-one interviews and the focus group discussions believed that the procedures which were required to be followed to perform circumcision operations needed to be more rigorous, thorough and stringent than they were at present. They also believed that not only did the policies need to become more binding than they were at present, but also that there needed to be increased emphasis on the roles of village chiefs in traditional male circumcision. They expressed disappointment with the weaknesses and the inadequacy of the procedures which were intended to guide the circumcision process, complaining that policies were either non-existent or could not be enforced. There was a general consensus that, although some policies had been formulated and procedures had been laid down, those who were tasked with their implementation tended to be ignorant of them, to ignore them deliberately, or not to understand them adequately. The excerpts which follow are representative of the perceptions of almost all of the participants.

"The laws regarding the carrying out of traditional male circumcision need to be strengthened. "

"It is apparent that there is either a lack of knowledge of the policies on the part of the cultural custodians or that they have abdicated their responsibilities and accountability. "

"The policy in relation to who should participate in the rite is both in doubt and questionable. "

"In my view, the policies are not effective. In other words, there are no policies because the circumcision ritual is still under the control of children. "

The findings suggest that as the officially sanctioned circumcision procedures and policy environment appear to have little bearing on actual practice at present, the cultural value of the circumcision rite may be fatally compromised. This assessment accords with the findings of Ngcukana (2014) and Abrahams (2017), who concluded that policies pertaining to TMC may be inadequate and, in some contexts, prone to manifesting grey areas, as pockets of traditional nurses and surgeons appear to redefine the legal prescripts of the circumcision rite and undermine the orderly conducting of initiation rituals by flouting existing regulations. Accordingly, it could be concluded that traditional leaders and the government, in the form of the Department of Traditional Affairs, have abdicated their responsibility of ensuring that the rite is performed in a culturally and ethically acceptable manner and that the rights of the initiates are adequately safeguarded.

Diverging perceptions of the policy environment which governs the carrying out of traditional circumcisions between the government and the custodians of traditional practices

The findings which emerged from the responses of the various categories of participants appeared to be characterised by a tendency to apportion blame for the alarming numbers of deaths of initiates to categories other than their own. Participants who represented government agencies attributed the deaths to a failure on the part of parents, traditional practitioners and community leaders to follow laid-down procedures and policies with respect to the carrying out of traditional circumcisions. They believed that it was highly probable that the categories of culprits whom they identified were either completely ignorant of the procedures and policies or else were not sufficiently conversant with them. By contrast, parents, traditional practitioners and cultural custodians believed that the ignorance and lack of awareness of the appropriate operational environment stemmed from poor administration and management of the circumcision process. They contended that the relevant government agencies and traditional leaders had failed to perform their roles and to fulfil their responsibilities. It emerged from the focus group discussions, which consisted of members of the communities of the initiates, that it was generally held that an inadequate policy environment had been a decisive contributory factor in the large numbers of injuries and deaths each initiation season. Some explained that sometimes circumcisions were performed without any necessary documentation or consent from the parents of initiates, while other initiates were not medically screened in accordance with the legislation which applies to traditional male circumcision. They also believed that the blame for the dramatic increase in the numbers of botched circumcisions lay with the cultural custodians, the parents of initiates, the Department of Traditional Affairs, and the government as a whole. They contended that all had contributed to a cultural rite that had once been venerated falling into disrepute, because it now threatened the health and the lives of initiates. The excerpts which follow are typical of the assessments which were made by the participants.

"I am not saying there are no policies, but in my experience I am not fully aware of them and perhaps the players are either ignorant of them or do not adhere to them completely. How can one adhere to a policy or follow a procedure of which one is not sufficiently aware? "

"There could be policies, but suppose those who are supposed to enforce them are ignorant. Then the policies will never be followed. "

"We do not know why the government has dragged its feet over the policy environment after the perennial deaths of initiates in the area. "

"Some of these young men undergo the circumcision ritual without signing consent papers, while others do not even go through a proper medical assessment before circumcision. "

It is evident that the circumcision process is frequently carried out without chiefs or the parents of initiates giving due consideration to the official procedures which have been laid down and the policies which are in force, such as the requirements that initiates should be screened by healthcare workers prior to undergoing circumcision and written consent should be obtained from both the parents of initiates and the traditional leaders of the villages in which they reside. This finding accords with the assessment of Feni (2014) that the parents of initiates and traditional leaders were to blame for the disastrous consequences of botched circumcisions, as they had allowed criminals who masqueraded as accredited practitioners to circumcise their children. It was also learnt that both parents and traditional leaders often denied healthcare workers access to initiates, thereby preventing them from carrying out the examinations which are required by law. In one instance an initiate died a day after undergoing circumcision because his father had refused to allow him to be examined by a healthcare worker, as he was opposed to what he perceived to amount to interference in traditional initiations by practitioners of modern medicine (Fuzile & Feni, 2015; Nyembezi, 2016). The account of the incident provides a succinct explanation for the proliferation of injuries and deaths to initiates each initiation season. It should also serve to underscore the pressing need for the government to ensure that policies and procedures are known, followed and enforced by all stakeholders.

Unclear or undefined policy pertaining to selection criteria for traditional surgeons and nurses

The participants lamented a lack of appropriate policies and the existence of poor policies with respect to selection criteria for appointing traditional surgeons and nurses. They believed that the traditional practitioners who occupied the positions at present lacked both the cultural and professional knowledge and skills which are needed to perform their tasks competently. In addition, they were unanimous in the belief that the lives of initiates could be safeguarded only by developing appropriate selection and recruitment criteria for traditional practitioners such as surgeons and nurses. They agreed that the standards according to which traditional male circumcisions were carried out had deteriorated to such an extent that the circumcision houses appeared to have been hijacked by opportunists who lacked both commitment to traditional culture and the technical skills which were needed to perform safe and hygienic circumcisions. The excerpts which follow reflect the assessments of the participants of the degree to which the standards which have applied to the carrying out of traditional circumcisions appear to have declined in recent years.

"I believe that the circumcision laws in the region are not really strict. Even our chiefs have failed dismally to provide leadership because we have mature men who are able to act as traditional nurses, instead of these young boys who control the ritual at present. "

"The custodians of culture have failed to maintain control of the ritual and have left it to be hijacked by bogus practitioners. "

"Seemingly, there are no selection criteria for traditional surgeons and nurses or they are not applied. "

"One thing that we need to realise as parents is that if we continue to let young people look after the lives of others in the circumcision schools, these mishaps will continue to occur and our young men will continue to die. "

The findings suggest that the survival of the traditional circumcision ritual is threatened by an inability to apply appropriate criteria to select and recruit traditional practitioners such as surgeons and nurses who are able to perform their functions in a manner which ensures the safety and wellbeing of initiates. There appears to be a general consensus in the relevant literature pertaining to cultural practices that the undesirable consequences of traditional male circumcision, such as the deaths of initiates and debilitating injuries, have been caused largely by immature and inexperienced traditional practitioners, with more blame being apportioned to traditional nurses than surgeons (Ntombana, 2011; Feni, 2014; Mpateni, 2017). According to Kheswa, Nomngcoyiya, Adonis and Ngeleka (2014), the recent epidemic of circumcision-related deaths and injuries stem directly from a lack of adequate screening of both traditional surgeons and nurses, which has enabled immature and incompetent practitioners to perform the rite and the dignity which was formerly associated with it has been compromised as a consequence. The findings could also suggest that the cultural custodians of the area may be inadequately equipped with the knowledge and experience that are needed to select and recruit traditional surgeons and nurses who possess the necessary experience and competence to perform circumcisions in accordance with generally accepted medical standards.

A lack of state machinery to enforce the policies of the state pertaining to traditional male circumcision

Most of the participants, in both the interviews and the focus group discussions, expressed their disappointment about the ineffectual performance of state machinery and the criminal justice system in prosecuting people who undermined the implementation of the policies that are intended to guide the carrying out of traditional male circumcisions by posing as qualified practitioners. They also believed that existing policies were either inadequate or adequate but effectively unenforceable by organs of the state, thereby exposing initiates to high risks of injury and even death as a result of undergoing traditional male circumcision. The participants also maintained that despite the procedures and policies that were officially required to be followed, practitioners either intentionally ignored them or did not have an adequate understanding of them, while the criminal justice system appeared to be reluctant to prosecute unqualified practitioners. They emphasised that the procedures and policies of the State with respect to the performing of traditional male circumcisions contained loopholes which enabled almost anyone to take advantage of the ambiguity which prevailed at present. The excerpts of the responses of the participants in the interviews and focus group discussions which follow are representative of their perceptions.

"Yes, it is clear that policies exist, but they are not followed and there are no mechanisms to enforce them. Practitioners simply undermine them. This is why the culture of traditional male circumcision is deteriorating and causing untold misery to initiates. "

"The government needs to enforce all of the policies pertaining to the rite strictly. "

The findings could suggest that the criminal justice system lacks the will to bring to justice those who flout the regulations pertaining to traditional male circumcision. Ludidi (2014) makes a similar assessment by maintaining that bogus traditional practitioners appear to enjoy immunity from the laws of South Africa for their illegal circumcision practices in initiation schools. This apparent state of affairs could suggest that not only are the procedures and policies which apply to traditional circumcision at present ineffectual, but also that the justice system allows bogus practitioners to act with complete impunity (Nyoka, 2017). Consequently, it is imperative that traditional leaders and relevant authorities in the criminal justice system should re-evaluate the legislation pertaining to the traditional male circumcision process and ensure that the procedures and policies which apply to the practice are enforced.

Unlawful and unprofessional conduct by practitioners of traditional male circumcision

Most of the participants expressed doubts concerning the cultural and professional credentials of traditional nurses with respect to their being sufficiently competent to perform the tasks which were required of them. The participants who had undergone traditional circumcision between 2012 and 2014 as well as those who were members of the families of the men who had been initiated during this period believed that incompetence represented one of the principal causes of the accidents and deaths which occurred each initiation season. They held that since some practitioners were too young and inexperienced to assume the responsibilities which are required of traditional nurses, they should be prevented from attending, controlling and taking part in the operations of initiation schools. The excerpts which follow are typical of the responses of the participants.

"Traditional circumcision today is a process of either you come back, or you die, or you come back without your manhood. "

"The problem is a lack of professionalism and skills among the present crop of traditional nurses. 1 was brutally abused in the circumcision lodge, my manhood was constricted to the point at which 1 could not even urinate, and 1 could feel that 1 was not well at all. When 1 informed the traditional nurses that 1 was really not feeling well, they told me to keep quiet and leave them to perform their duties. After only a few days, I saw that my penis was drying up like a dry stick and when they realised that, they told me they won't be able touch me anymore. I lost my penis through the unprofessional conduct of bogus traditional nurses. "

"The process of the rite is excruciatingly painful and leaves one physically, socially and psychologically injured. It has become both an abusive process and entails facing death, or, if one is lucky to come back half alive, facing losing one's penis. It is like a death chamber and chances of survival are very slim indeed."

The findings revealed the painful experiences which are associated with traditional male circumcision at present in an environment which is so fraught with unprofessional conduct that debilitating injuries and even deaths have become commonplace. The relevant literature pertaining to cultural practices and traditional male circumcision is replete with assessments that incompetence, inappropriate treatment, negligence and para-professionalism on the part of traditional practitioners represent some of the principal factors which are responsible for the recent spate of circumcision-related deaths and severe injuries (Seloana, 2011; Mpateni, 2017). Ngcukana (2014) also emphasises that many of the accidents and deaths which have occurred in circumcision schools have resulted from the proliferation of immature, incompetent and inexperienced practitioners, particularly traditional nurses. As long as unqualified people are permitted to act as traditional practitioners, no end can realistically be envisaged to the accidents and deaths which have tarnished the dignity which has been associated with traditional male circumcision for centuries.

 

DISCUSSION OF THE FINDINGS

The profiles of the participants which are provided in Table 1 reveal that the men who had undergone initiation between 2012 and 2014 were between the ages of 17 and 25 years and that the traditional nurses were between the ages of 18 and 37 years. The finding that some of the men would have undergone the rite of passage when they were under the age of 18 years suggests a lack of adherence to both cultural expectations and the legislation which applies to traditional male circumcision. According to both the Children's Amendment Act 41 of 2007 and the Eastern Cape Province Application of Health Standards in Traditional Circumcision Act No.6 of 2001 (Children's Amendment Act 41 of 2007, 2011; Mpateni, 2017), the statutory age for traditional male circumcision is 18 years. Both legislative frameworks also contain provisions for traditional surgeons and nurses, and the processes and procedures which are to be followed during initiation rituals, the stipulated ages of prospective initiates, and the obligation of parents and guardians to consent to the performing of the rite on their children.

From a cultural perspective, although the age profile is based upon a social contract, great emphasis is usually placed upon aspects of fitness, such as the physical, psychological and mental strengths of prospective initiates (Mpateni, 2017). Emphasis is undoubtedly placed upon fitness in order to ensure that initiates possess the physical, mental and emotional strength to endure hunger, thirst and other privations which are associated with traditional circumcision, and also to ensure that they have the cognitive capacity to understand the intentions and the ultimate purpose of the practice (Mavundla, Netswera, Toth, Bottoman, & Tenge 2010; Kheswa et al, 2014). The findings concerning the ages of the participants when they underwent traditional circumcision were a cause for concern and it is entirely plausible that their capacities for withstanding pain and other arduous conditions which accompany traditional male circumcision could have been diminished as a consequence. It is also possible that owing to their young age, some may not even have sufficiently understood the significance of traditional circumcision, or why their parents had given their consent to permit them to undergo the rite of passage. In addition, the finding also reveals the professional and cultural shortcomings of the culture custodians upon whom society has bestowed the responsibility of ensuring that only sufficiently mature candidates are allowed to enter initiation schools. The finding that most of the traditional nurses in the research sample were younger than 30 years of age also suggested that traditional culture may not be well served by sufficiently experienced practitioners.

The findings also revealed generally low levels of education among the participants. Eight had either never attended school or not progressed beyond primary school. A further 18 (64%) had received some secondary education, although only a few had matriculated. Only two (7%) had received tertiary education. It has been suggested that a lack of education could explain why communities in which traditional male circumcision is a venerated custom are easily deceived by unqualified practitioners who illegally masquerade as traditional surgeons and nurses (Feni, 2014). The necessity for formal education has never been greater than it is at present and it is indisputable that education holds the key to ensuring the welfare of all people throughout the world (The United Nations Educational, Scientific, and Cultural Organisation (UNESCO), 2005). Old cultural beliefs tend to die hard among uneducated people, who are particularly likely to rely upon culture custodians as authoritative sources of knowledge and information. Consequently, when cultural custodians fail to adhere strictly to cultural practices as a result of either ignorance or a lack of integrity, the value of the cultural practices will inevitably decline. A strong case could be made for applying this assessment to the present state of traditional male circumcision in many parts of South Africa (Mpateni, 2017).

Participants who fell into three different categories voiced complaints concerning a perceived lack of clarity in relation to the rules and procedures which ostensibly guide the performing of traditional male circumcisions. Representatives of all three groups identified inadequate policies, legislation and procedural guidelines as factors which contributed to the proliferation of deaths and injuries which bedevilled the practice at present. The assessment has been shared by a number of researchers, who have emphasised the need to pass culturally relevant legislation specifically to guide cultural practices such as traditional male circumcision (Mukhuthu, 2014: 2). In this respect, the findings echo comments which have been made by several lawmakers in the government of South Africa, such as those by the Deputy Minister of Cooperative Governance and Traditional Affairs in the address during the opening of the initiation season in Mthata in July of 2014, which confirmed that at present there are no provisions in the legislation pertaining to circumcision which require the prosecution of those who contravene the law, such as unqualified traditional practitioners who operate illegal initiation schools (Feni, 2014: 1).

The lack of appropriate provisions stands in particularly stark contrast to the reputation which South Africa enjoys for its commitment to crafting robust and comprehensive policy environments which are informed by and benchmarked in accordance with international standards (Kheswa et al, 2014; Nyembezi, 2016). Empirical evidence suggests that existing policies pertaining to traditional male circumcision may be inadequate and that in some instances there may be grey areas (Ngcukana, 2014). Abrahams (2017) found that there were pockets of traditional nurses and surgeons who appeared to be determined to undermine the orderly conducting of initiation rites by acting as if there were no need to abide by the provisions of any legal or policy frameworks whatsoever, thereby delegitimising the practice of traditional male circumcision and threatening its future. It is evident that a culture of impunity has entrenched itself to the extent that an environment in which cultural custodians can be held accountable for their conduct and actions is almost impossible to establish or sustain. There can be little doubt that the absence of punitive consequences has encouraged unqualified traditional practitioners to take full advantage of the lack of control over the performing of the rite, often with tragic consequences for communities whose members wish to retain traditional values and customs (Fuzile & Feni, 2015), which have manifested themselves in the grave hazards which have become associated with traditional circumcision in recent years (Nomngcoyiya & Kang'ethe, 2017; Mpateni, 2017).

Some of the principal findings of the study suggested that there was a significant divergence between the perceptions of participants who represented government agencies and those of cultural custodians in relation to the policy environment which is intended to regulate the carrying out of traditional male circumcisions. This conclusion has been widely confirmed by informants who are members of several different categories of stakeholders in relation to traditional male circumcision throughout South Africa. It appears that an environment which is characterised by mutual misunderstandings and recriminations has emerged as a consequence, with cultural custodians complaining that the government makes decisions concerning matters pertaining to interpretations of culture without consulting them in their custodial capacities (Kang'ethe & Nomngcoyiya, 2016). A great deal of the relevant literature pertaining to traditional male circumcision suggests that although cultural custodians appear to be aware of the hazards which are associated with the rite, there is little consensus among them concerning how the health and wellbeing of initiates should be safeguarded (Ngcukana, 2014). In the light of the spate of accidents and deaths, upholding the rights of initiates becomes a matter of public concern, as opposed to one which should concern cultural custodians only (Fuzile & Feni, 2015). Consequently, it is incumbent on the government to ensure that the Department of Traditional Affairs assumes full responsibility for ensuring the safety of initiates, which could entail advocating the adoption of other methods for performing male circumcisions (Nyembezi, 2016). It is the considered opinion of the authors of this paper that the inability of cultural custodians to ensure the safety of initiates requires decisive action on the part of the government, as people cannot be obliged to continue to have their fundamental human rights trampled upon in the name of fulfilling cultural requirements. No justification which accords with universally accepted definitions of human rights could permit cultural imperatives to take precedence over the rights of South African citizens to health, as these rights are enshrined in the Constitution and the Bill of Rights (Abrahams, 2107). It could be advanced, with considerable justification, that the injurious and often deadly consequences of the cultural practice of traditional male circumcision serve to delegitimise the authority of cultural custodians, the culture whose survival they purport to ensure, and the Indigenous Knowledge System (IKS) which prescribes traditional male circumcision (Kang'ethe, 2014; Nomngcoyiya & Kang'ethe, 2017).

There can be no doubt that the future of the cultural practice is threatened by the confusion and anxiety which have been generated by the widely publicised deaths and injuries which occur each initiation season (SABC, 2017). Traditional male circumcision represents one of the only remaining African cultural practices which has resisted succumbing to the combined influences of colonisation, globalisation, civilisation and Westernisation (Nomngcoyiya, 2015). Consequently, it is imperative to resolve the malaise which prevails at present in order to avail future generations of the social capital which is accumulated through adherence to venerated traditions (Kang'ethe, 2014; Ntombana, 2017). If traditional circumcisions cannot be performed in a manner which accords with the respecting and upholding of the rights of initiates, increased pressure on the state to introduce medical male circumcision could result in the phasing out of one of the few remaining enduring indigenous cultural practices.

The findings revealed a generally perceived lack of clarity concerning the policies which determine the selection criteria for traditional surgeons and nurses to perform traditional male circumcisions. From the accounts of the participants, selection processes appear often to have been carried out on an ad hoc basis and to have been generally bereft of stringently applied criteria in terms of skills and experience.

Tt was generally held that many accidents and deaths occurred in circumcision schools owing to a preponderance of immature, incompetent and inexperienced traditional practitioners, with more blame being apportioned to traditional nurses than surgeons (Ngcukana, 2014). It was also apparent that both parents and cultural custodians had to a large extent abdicated their responsibility to ensure that stringent standards were applied to the selection of traditional surgeons and nurses (Feni, 2014:1). From this standpoint, the actions of younger men taking control of the performing of the rite could be justified in the absence of older and more experienced men accepting their responsibility as bona fide custodians of the practice (Ludidi, 2014:1). The reluctance of many people to assume the necessary roles and responsibilities to ensure the survival of traditional cultural practices could also account, at least in part, for the decline of many cultural practices in Africa and the cultural decay which appears to be eroding many traditional African cultures (Kang'ethe, 2014). The phenomenon could also partially explain the increasing rates at which cultures undergo change as they adapt to an increasingly globalised world (Kang'ethe, 2013, 2014).

The authors of this paper firmly believe that the recruitment of culturally and medically qualified cultural practitioners holds the key not only to ensuring the safety and wellbeing of initiates, but also to restoring the dignity which has traditionally been associated with male circumcision rituals in many African societies (Kang'ethe, 2015). A commitment to ensuring that these criteria are rigorously adhered to could mark the beginning of a process of renewing the cultural values and norms of a long-venerated tradition (Ntombana, 2017).

The participants expressed a strong belief that the machinery of the state inadequately enforced the policies which have been formulated to ensure the safety of initiates. It emerged from the interviews and focus group discussions that many perceived that the criminal justice system of South Africa appeared to be reluctant to deal decisively with culprits whose lack of skills and knowledge had resulted in many botched circumcisions (Ludidi, 2014). The reports in the media concerning consequences such as penile amputations and assault and torture, which in some instances have resulted in disability and even in the death of initiates, have brought the practice into international, national and regional disrepute (Seloana, 2011; Nomngcoyiya & Kang'ethe, 2017). It is apparent that the government is aware of the need to take appropriate action. At the launch of the initiation season in July of 2014 in Mthatha, the Deputy Minister of Cooperative Governance and Traditional Affairs, Obed Bapela, explained that the government was in the process of developing legislation which was intended to curb illegal circumcisions and illegal initiation schools (Feni, 2014:1). He admitted, with regret, that present legislation and policies contained no legal provisions for prosecuting and arresting people who carry out illegal circumcisions and operate illegal initiation schools. The absence of appropriate and effective legislation and policies at present makes it imperative for the government to formulate and enact legislation which successfully eradicates all illegal circumcision practices. In the absence of effective action, the tragic consequences of illegal circumcisions which ravage South African communities in which the rite is practised will continue unabated.

The findings revealed that many practitioners of traditional male circumcision were considered to be insufficiently competent, owing to the large numbers of traditional nurses who were too young and did not possess the knowledge and skills that were needed to treat initiates after they had been circumcised. In this respect, the findings are corroborated by those of several other researchers who have conducted studies pertaining to traditional male circumcision and concluded that incompetence, negligence and para-professionalism represented the principal contributory factors to the spate of injuries and deaths which have plagued initiation seasons in many regions of South Africa (Seloana, 2011; Mpateni, 2017). The lack of provisions in present legislation for protecting the rights of initiates by prosecuting illegal practitioners contrasts particularly starkly with the advances which have been made to promote a culture of human rights since the attainment of democracy in 1994. Although the social injustices which are inherent in the abuse which has been inflicted upon initiates run completely contrary to the human rights which are enshrined in the Bill of Rights in the Constitution, in many quarters they appear to have been accepted as inevitable, thereby normalising a state of affairs in which the lives of black people are once again threatened by the caprices of authorities whose legitimacy could not withstand scrutiny against any generally accepted legislation pertaining to human rights (Nyembezi, 2016). According to Fuzile and Feni (2015), communities in which traditional male circumcision is practised are faced with the dilemma which arises when insisting that the initiation of young males should comply with the law of the country or allowing cultural imperatives to supersede all others and accepting the injuries and fatalities which result from the practice as the price which must be paid for diligent adherence to tradition. Communities are faced with these choices because questions pertaining to the failure of the state to honour its commitment to upholding human rights by prosecuting illegal practitioners or developing an alternative means of preventing injuries and deaths tend to be deflected by the mantra that the National Policy Framework on the Cultural Practice of Initiation has been formulated in order to take appropriate action against perpetrators (Zuzile, 2014; Kheswa et al, 2014).

 

IMPLICATIONS OF THE FINDINGS AND RECOMMENDATIONS FOR SOCIAL WORK PRACTICE

The social work profession plays a central role in educating and empowering individual people, groups and communities, not only by providing psychosocial therapeutic services such as counselling, but also by disseminating information which promotes the overall health and wellbeing of communities, such as information to prevent the spread of HIV and AIDS. Consequently, the roles of social workers need to be extended and integrated into the processes according to which traditional male circumcision is performed. Doing so would enable social workers to educate communities on the value of maintaining their cultural practices within the ambit of the human rights and rights to health as they are articulated in the Constitution after fundamental human rights had been denied to indigenous peoples for centuries.

There is an urgent need to empower and educate young men, their families and their communities concerning the dangers of undergoing traditional male circumcision without first ensuring that it is to be performed in accordance with the professional standards which are stipulated by both national and international protocols and legal frameworks. There is also a great need to inform the members of communities in a manner which is understandable to them of the psychosocial implications and consequences of traditional male circumcision and their rights in relation to the practice, in order to enable them to make informed choices with respect to attending registered circumcision schools. In addition, social workers, as mediators in psychosocial interventions to ensure the wellbeing of communities, should play a proactive role by providing counselling services and ensuring that the privations to which initiates are subjected during the course of the rite of passage do not compromise their health and wellbeing during adulthood in any way.

 

RECOMMENDATIONS

• The government in its capacity as the lawmaker for the people of South Africa needs to consider the wishes of the people. If the majority wish to continue practising the cultural rite of traditional male circumcision, their cultural rights need to be upheld in accordance with the Constitution and the Bill of Rights.

• The machinery of the state needs to be used effectively to ensure that the injuries and deaths which have marred adherence to the cultural practice are avoided. Although medically performed male circumcisions may ensure the health and survival of initiates, the social capital which is inherent in adherence to traditional practices would inevitably be lost if medical circumcision were to replace traditional male circumcision.

• It is essential that cultural custodians in collaboration with the government should develop appropriate mechanisms to ensure that only qualified traditional surgeons and nurses are permitted to practise, and that young and immature traditional nurses be barred from circumcision schools.

• All who participate in or are affected by the cultural practice of traditional male circumcision have vital roles to play in ensuring that the practice is able to regain the venerated status which it had for centuries as a crucial rite of passage in an enduring African culture. Consequently, all categories of role players need to be represented in the selection of mature, skilled, knowledgeable, experienced, highly professional and competent traditional surgeons and nurses.

• It is imperative that women should be integrated in an appropriate manner into the practice. The suggestion does not imply that women should supplant the men to whom specific traditional tasks in the practice are assigned, but rather that they should perform appropriate complementary roles to ensure that the practice is perpetuated in a manner which strengthens the bonds among all members of societies which continue to hold traditional cultural values.

• Parents and other cultural custodians need to work towards reclaiming the functions which cultural practices performed in traditional societies in terms of the social capital which they generated by instilling moral values and ethical standards in initiates. From this standpoint, adherence to traditional cultural values could contribute to instilling the values of citizenship in modern societies.

 

CONCLUSION

South African society needs to acknowledge the failures of both policy and legislation which have resulted in the cultural practice of traditional male circumcision drawing widespread opprobrium, owing to the numbers of accidents, penile amputations, disabilities, and even deaths of initiates which have marred each initiation season in recent years. By formulating, implementing, and enforcing appropriate and effective policies to guide the carrying out of traditional male circumcisions, it is possible for traditional South African cultural values and practices to be retained while actively pursuing socioeconomic development. The successful integration of traditional cultural values and practices into a dynamic and growing modern economy would dispel all of the negative stereotypes and myths which portray African cultures as retrogressive and unable to promote development. Consequently, it is imperative that the practice of traditional male circumcision should be modernised in the sense of complying with the standards of modern medicine, which are respected and applicable in all countries and societies throughout the world, while its essential character and cultural function remain unchanged. Achieving an optimal balance would enable African cultural practices to be acknowledged as a means not only of ensuring cultural permanency, but also of promoting socioeconomic development.

 

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