CORRESPONDENCE

Traditional circumcision - the unkindest cut of all

'What kind of ritual is this that it now is killing our children?'
(mother of a male Xhosa initiate)¹

To the Editor: Twenty years ago two Eastern Cape urological surgeons documented their experience with treating initiates of umkhwetha, the ancient custom of ritual circumcision practised by the amaXhosa people of southern Africa. Crowley and Kesner followed up 45 consecutive patients and documented a mortality rate of 9%.² Recent press reports from the Eastern Cape claim an annual death rate of more than 70 per year.³ The death toll for the 2010 winter initiation period stood at 40 at the time of writing.⁴ These statistics not only point to the fact that little has changed, but suggest that the situation may in fact be deteriorating.

While the deaths write headlines, the misery goes much further; 150 youths are said to be attending hospitals in Eastern Cape for 'botched circumcisions',⁴ with results ranging from wound infections to gangrene to total penile loss. Twenty-two young men are reported to have suffered 'penile amputations'.⁴

Much academic socio-medical research has been done to understand and explain the complex circumstances leading to these deaths and mutilations.^1,5 In addition to this important research, countless programmes have attempted to sanitise the practice. Yet if progress is counted in lives, the efforts appear to have been wasted.

Kepe has eloquently mapped the terrain of the current crisis into two distinct components.⁵ Firstly a 'public health nightmare' exists, created by the morbidity and mortality caused by ritual circumcision among the amaXhosa. Secondly, there is mounting tension between traditional leaders and government. Traditional leaders cite interference and violation of cultural rights, while the government has instituted prevention programmes and in 2001 promulgated the Circumcision Act in the Eastern Cape.

Dan Ncayiyana, editor of the SAMJ, has campaigned for changes to circumcision practice. He has labelled the circumcision schools as 'deadly' and their claims of offering a genuine rite of passage as fake.⁶ He sees solutions in certified training of traditional surgeons, a registry of accredited schools, and regular inspection of the schools.

Considering what little progress the many initiatives by government and health care providers have made, is it not time to recognise that the root of the problem lies with traditional leaders? Until government finds the courage to prosecute in court traditional leaders in whose name the circumcision schools are run, no progress can be achieved in the fight against this preventable loss of life.

John Lazarus
Division of Urology
Groote Schuur Hospital and
University of Cape Town
j.lazarus@uct.ac.za

1. Peltzer K, Nqeketo A, Petros G, Kanta X. Traditional circumcision during manhood initiation rituals in the Eastern Cape, South Africa: a pre-post intervention. BMC Public Health 2008; 8: 64.         [ Links ]

2. Crowley IP, Kesner KM. Ritual circumcision (Umkhwetha) amongst the Xhosa of the Ciskei. Br J Urol 1990; 66(3): 318-321.         [ Links ]

3. Times Live. http://www.timeslive.co.za/local/article522833.ece/DA--Circumcisions-must-be-done-in-hospitals (accessed 28 June 2010).         [ Links ]

4. City ensures circumcision schools are safe. Cape Times 1 July 2010, p. 4.         [ Links ]

5. Kepe T. 'Secrets' that kill: Crisis, custodianship and responsibility in ritual male circumcision in the Eastern Cape Province, South Africa. Social Science & Medicine 2010; 70: 729-735.         [ Links ]

6. Ncayiyana DJ. Astonishing indifference to deaths due to botched ritual circumcision (From the Editor). S Afr Med J 2003; 93: 546        [ Links ]