We briefly debated the potential benefit of including men from outside the Xhosa culture but decided against it since our specific interest in Male Circumcision is related to the traditional use of circumcision as initiation into manhood by Xhosas.
To widen the scope would have been expensive in terms of time and work! It would require questions aimed at men circumcised outside the Xhosa tradition which includes a very diverse and wide group.
I have also received and incorporated feedback from a group of research specialists experienced in surveys about VCT and MC.
Thank you so much for your input! I believe it has sharpened our instrument considerably and will ease our analysis process after the fieldwork.
Dean also sent me the article in the lancet which he co-authored, some interesting facts arising!
Have a look at www.thelancet.com volume 369 feb 2007
I also include the email which has interesting facts about circumcision increasing risk of HIV infection.
Written by Dean Peacock:
A report by Brewer et al in the Annals of Epidemiology just released indicates that, in Lesotho, Kenya and Tanzania, "HIV transmission may occur through circumcision related blood exposures in eastern and southern Africa" with significantly higher HIV infection rates for self reported virgins. According to the report: "Circumcised male and female virgins were substantially more likely to be HIV infected than uncircumcised virgins (Kenyan females: 3.2% vs. 1.4%, odds ratio [OR] = 2.38; Kenyan males: 1.8% vs. 0%, OR undefined; Lesothoan males: 6.1% vs. 1.9%, OR 3.36; Tanzanian males: 2.9% vs. 1.0%, OR 2.99; weighted mean phi correlation = .07, 95% confidence interval .03 to .11)."
I put together the following response and would love your feedback on it.
Working with traditional leaders and circumcisors critical to effective role out of male circumcision as an HIV prevention strategy.
Dean Peacock and Bafana Khumalo[1]
This week, the prestigious British public health journal, the Lancet, features a number of articles on male circumcision as an HIV prevention strategy. Summarising research done by Wiliams et al a team from the University of California Los Angeles, Columbia University and South African NGO Sonke Gender Justice write “that large-scale implementation of male circumcision has the potential to avert about 2 million new HIV infections and 300 000 deaths over the next 10 years. Over the subsequent 10 years, an additional 3·7 million HIV infections and 2·7 million deaths could be averted.”[i]
Sawires et al go on to say, “Male circumcision is the most compelling evidence-based prevention strategy to emerge since the results from mother-to-child transmission clinical trials. We encourage multilateral, bilateral, and government agencies, along with non-governmental organisations, to make this life-saving strategy affordable and safely available to relevant populations bearing the heaviest burden of HIV infection”.
In discussions following the release of the Kenya and Uganda circumcision trials, not enough attention has been paid to the role of traditional circumcision providers.
Where growing demand already outstrips the ability of health systems to provide clinical circumcision, it seems likely that people will turn to traditional providers in greater numbers rather than wait many months for a public sector procedure or pay large amounts in the private sector. IrinPlus reports that "requests for male circumcision have tripled in western Kenya since studies found the procedure reduces the risk of contracting HIV by more than half[ii] ." Health personnel in Lesotho and Swaziland confirm similar increases in demand there and report that there are now waiting lists as long as 6 months in some government facilities.
Recently released research on traditional circumcision in Tanzania, Kenya and Lesotho, however, shows that traditional circumcision practices are related to increased rates of HIV infection.
A report by Brewer et al in the Annals of Epidemiology just released indicates that, in Lesotho, Kenya and Tanzania, "HIV transmission may occur through circumcision related blood exposures in eastern and southern Africa" with significantly higher HIV infection rates for self reported virgins. According to the report: "Circumcised male and female virgins were substantially more likely to be HIV infected than uncircumcised virgins.”[iii]
The implications of this require urgent action from government and civil society to make sure that traditional circumcision is made as safe as possible and that capacity within the public health sector to provide MC be rapidly expanded.
Given this, and given the relative lack of attention paid to the role of traditional circumcisors by international bodies following the randomized controlled trial findings, it seems critical that government and civil society put in place strategies to educate, monitor and where necessary hold accountable traditional providers.
As a starting point, in South Africa research should be conducted to determine whether relevant legislation intended to promote safe traditional circumcisions is being used. Of particular relevance here are three pieces of legislation: the Northern Province Circumcision Schools Act No. 6 of 1996; Application of Health Standards in Traditional Circumcision Act No. 6 of 2001 (Eastern Cape); the Free State Initiation School Health Act No. 1 of 2004.
According to the British Medical Journal (BMJ 2001;323:1090), the Application of Health Standards in Traditional Circumcision Act: "provides for the observation of health standards in traditional circumcisions with penalties of up to 10 000 rands (about £800; $1200) and 10 years in jail." The BMJ article describes the ambit of the act: 'It provides for the regulation of people qualified to perform the ritual and regulates the circumcision "schools." The law makes it compulsory for parents or guardians to give permission and requires that in all but exceptional circumstances the young men cannot be younger than 18. Only recognised traditional practitioners may perform the operation, and they must have the permission of a medical officer designated in the area who also has to give permission for each circumcision school.'
At the time of its passage, the Application of Health Standards in Traditional Circumcision Act was roundly condemned by the Congress of Traditional Leaders (Contralesa), who called the law "an insult to our tradition." Chief Nonkonyana derided it as a "load of rubbish and we reject it with the contempt it deserves."
Despite frequently made assumptions about the inflexibility of traditionalists, it would appear that the conversation has since moved on and that at least some traditional leaders now hold more nuanced positions.
At a recent conference on traditional circumcisions jointly convened by the Human Rights Commission and the Commission for the Rights of Cultural, Religious and Linguistic Communities held in Johannesburg in October 2006, 'Prince Zukisile Makaula, a senior royal member of AmaBacha was the first to criticise opportunists who have introduced a moneymaking practice by charging a price – money and two goats. “Strangely only one goat would be needed”, he said. However, it turned out that the opportunists take the second goat to their own flocks[iv] .’
Similarly, at a speech by the Eastern Cape Minister of Health, at the 2nd Initiation Schools Conference held in October 2006, Nomsa Jajula spoke critically of the ways in which circumcision as a cultural practice is being abused by people intent on making money from it, "the infestation of our people by greed has drawn this great practice to be used for self enrichment, which is very much against our cultural roots"[v] .
At the Traditional Initiation Schools Conference held in Johannesburg in May of 2004, Minister of Provincial and Local Government Sidney Mufamadi indicated that action had been taken in the Eastern Cape to enforce the Application of Health Standards in Traditional Circumcision Act. He reported that: "42 traditional surgeons and nurses have been arrested since the Traditional Circumcision Act was introduced. Of these, 18 were convicted" and went on to say that "20 Pondoland initiation schools closed down and approximately 150 boys rescued from these schools and referred to hospitals in the region"[vi] .
While Government has put in place legislative frameworks intended to make traditional circumcisions safer and to curb the use of traditional circumcision as a money making venture, statistics released by the Eastern Cape MEC of Health suggest that not enough has changed.
In June 2002 there were 291 admissions to health facilities due to complications, 14 mutilations and 33 deaths. In June 2006, there were 283 admissions, 5 mutilations and 23 deaths[vii] .
The report by Brewer et al that traditional circumcision is associated with higher levels of HIV infection amongst young men who have not yet had sex should increase the urgency of our efforts to ensure that traditional circumcision is safe and that relevant legislation requiring this is rigorously enforced.
The coming months are likely to see demand increase for male circumcision in South African and across the region. Governments, civil society groups and multilateral bodies such as UNAIDS and the World Health Organisation have a responsibility to address the reality of widespread traditional circumcision practices--which research now shows can increase. Research is needed to understand the impediments to the application of existing legislation on traditional circumcision.
Traditional practices are often assumed to be far more inflexible than they turn out to be. Indeed resistance from traditional leaders is very often not about tradition itself but instead about a perceived lack of genuine consultation or respect. There is already evidence that traditional leaders are eager to ensure the safety of traditional circumcision practices. It’s worth reiterating the point we made in the Lancet, “Male circumcision offers the opportunity to re-engage with religious and ethnic groups in HIV prevention
Our collective task is now to make sure that circumcision is made available as part of an HIV prevention package and that it is offered in a manner that is safe. This is the task of AIDS activists, health personnel, civil society organisations, governments, donors and of traditional leaders. This will require visible advocacy, rigorous research, strong political leadership and an unwavering commitment to implementation from all groups involved.

[1] Dean Peacock and Bafana Khumalo are Co-Directors of Sonke Gender Justice, a South African NGO focused on gender equality, HIV/AIDS and human rights. Dean Peacock is co-author of a February 24 Lancet article entitled Male circumcision and HIV/AIDS: challenges and opportunities. Both authors have attended WHO and UNAIDS global and regional consultations and are involved in research on male circumcision.

[i] Sharif R Sawires, Shari L Dworkin, Agnès Fiamma, Dean Peacock, Greg Szekeres, Thomas J Coates (2007) Male circumcision and HIV/AIDS: challenges and opportunities; The Lancet, Vol 369 February 24, 2007
[ii] Circumcision Demand Increases, But Guidance Crucial. UN Integrated Regional Information Networks February 23, 2007. http://allafrica.com/stories/200702230859.html
[iii] Brewer, D. D., Potterat, J. J., Roberts, J. M., Jr., & Brody, S. (2007). Male and female circumcision associated with prevalent HIV infection in virgins and adolescents in Kenya, Lesotho, and Tanzania. Annals of Epidemiology, 17: 217-226.
[iv] Human Rights Commission report, “Anger at public hearings on koma/ulwaluko/lebollo (initiation schools)”, Oct 3, 2006 http://www.sahrc.org.za/sahrc_cms/publish/article_225.shtml).
[v] Speech by MEC for Eastern Cape Department of Health, Ms Nomsa Jajula at the 2nd Initiation Schools Conference held at Griffiths Mxenge College of Education, Zwelitsha from 24 - 27 October 2006
[vi] Opening address by Minister FS Mufamadi, Minister for Provincial and Local Government, at the Traditional Initiation Schools Conference, Fourways, Johannesburg 24 May 2004 retrieved from http://www.thedplg.gov.za/index.php?option=com_content&task=view&id=120&Itemid=36
[vii] Speech by MEC for Eastern Cape Department of Health, Ms Nomsa Jajula at the 2nd Initiation Schools Conference held at Griffiths Mxenge College of Education, Zwelitsha from 24 - 27 October 2006.
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