Integrating traditional circumcision

Randomised controlled trials have evaluated the effectiveness of circumcision by medical professionals. However, ‘ritual’ or ‘traditional’ circumcision is widespread in many cultures, and there are fears that in these circumstances, circumcision could do more harm than good.

Nonetheless, a 2007 study¹ suggested that traditional circumcision protects low-risk rural Kenyan men against HIV infection as effectively as doing it in a modern medical setting. The investigators, based in the town of Kericho, evaluated 1378 men aged 18 to 55 years over six months.

Circumcision status was identified at baseline (80% of the men were circumcised) and recorded as having been carried out by a healthcare worker, traditional circumciser, or other.

After two years of follow-up, there were 30 new HIV infections, 17 in circumcised and 13 in uncircumcised men. Two-year HIV-incidence rates were 0.79 for circumcised men and 2.48 for uncircumcised men, corresponding to a statistically significant hazard ratio of 0.31- in other words, a protective effect of 70% for circumcision, which persisted after adjusting for baseline sociodemographic and behavioural/HIV risks.

The majority of circumcised men (73.9%) had been circumcised by traditional circumcisers, while the rest had been circumcised by healthcare workers. The mean age at circumcision was 12.7 years, with a range of one to twenty-eight years.

The policy implications of the study were that attention to cultural practices and preferences such as circumcision have a place alongside safety and efficacy data from conventional RCTs in informing public health policies.

Another survey conducted in 2008 by the World Health Organization² found that, while traditional circumcision or medical circumcision conducted in the minimally resourced settings of Africa may be equally effective against HIV, it had major safety implications for patients.

This survey reported a rate of adverse events, infections and delayed healing described as ‘shocking’ and ‘unacceptable’ by the investigators, who included Robert Bailey, the principal investigator of the Kisumu RCT.

The rate of adverse events observed (35% in traditional circumcision and 18% in medically performed ones) are an order of magnitude above those seen in the RCTs of circumcision, and in medically supervised circumcision in the developed world. Six per cent of operations resulted in adverse events described as permanent and irreversible.

The survey results were a result of interviews with 1007 boys and young men who had undergone circumcision in the Bungoma district of western Kenya, 445 of them traditionally and 562 with some kind of medical supervision. The first 24 procedures were directly observed by the investigators and when it became clear that there was a very high rate of adverse events, the last 298 men and boys in the survey to be interviewed were also given a penile examination, an average of 45 to 90 days after circumcision.

Poorly performed circumcision represents a significant HIV risk in itself, as 6.3% of the young men circumcised traditionally and 3% of those circumcised medically had already engaged in sex a mean of 60 days after circumcision, even though in a quarter of the traditional cases and one-in-five medical cases the circumcision wound had still not healed properly by this time. In the subset of 24 directly observed procedures, no wound had properly healed by this time. In contrast, in the RCTs, all but 4% of circumcision wounds had healed by 30 days after the operation.

In 75% of medical circumcisions the wound was sutured, though often inadequately, whereas in traditional circumcision it was just left to heal. Not surprisingly, bleeding was a common adverse event with 8% of medical circumcisions featuring bleeding described as “profuse, requiring IV fluids”.

Infections, ranging from mild swelling and redness to life-threatening necrosis, were very common, even in the medical settings. Permanent adverse events included torsion (bending) of the penis, injuries to the glans, loss of penile sensitivity caused by scarring and erectile dysfunction.

The cost of a traditional circumcision was about $4.50, though additional payments were often required when there were complications, with the total sometimes costing more than medical procedures.

In many cases, especially in traditional circumcision, instruments were not sterilised between several operations, creating an infection and HIV-transmission risk.

No death was reported as directly due to circumcision, though the authors comment on one case in which, if the patient had not been taken to the district hospital by the investigators, he “would very likely have died.”

The authors comment that: “The levels of morbidity and mortality from circumstances documented as occurring in this study community are unacceptable. Our results…should serve as an alarm to ministries of health and the international health community that focus cannot only be on areas where circumcision is low…it must address the safety of circumcision in areas where it is already widely practised.”

They said that there is sufficient anecdotal evidence to indicate that Bungoma is not unique, especially in east and southern Africa where circumcision is performed on adolescents rather than infants.

They urged training for practitioners, the provision of low-cost kits of circumcision materials, and the integration of circumcision into a full complement of HIV-prevention and reproductive-health services, including a certification process for traditional and medical practitioners.

At a session at the 2008 International AIDS Conference,³ Fred Sawe of the Kenya Medical Research Institute, which conducted the Kericho study, reported on the feasibility and acceptability of integrating a) modern medical safety standards and b) HIV and sexual-health information into the traditional circumcision ceremonies performed by the other local ethnic groups. 

Boys in these groups are traditionally circumcised when they reach the age of 11 to 15. After the circumcision they enter a one-month period of seclusion in the bush during which they are instructed in tribal rules and norms by a mentor, usually a relative. 

The study worked with a group of trainers who in turn provided training for 222 of these mentors, alongside 70 of the boys’ parents and others, including provincial administrators and church leaders. Altogether, the programme reached 1345 adolescent boys.

Forty-five traditional circumcisers (the men who actually wield the knife) were also trained, of whom 58% had had some degree of medical training, largely as nurses or operating assistants. In the end, 72% of circumcisions were performed by a person with some medical training. Sawe commented that “a transition from a traditional to a pseudo-traditional/medical approach seems to be happening in Kenya’s southern Rift Valley Province.”

One study showed that when men say they have been traditionally ‘circumcised’, researchers should not take this at face value.

Bertan Auvert, principal investigator in the first RCT of circumcision at Orange Farm in South Africa, surveyed 1680 households (1201 men and 1399 women) in the area⁴ and asked them about circumcision status and willingness to be circumcised or for their partner to be circumcised. He also tested participants for HIV.

Almost 28% of male respondents said they were ‘circumcised’. But on further investigation – which meant showing interviewees photographs of circumcised and uncircumcised penises – 45% of men who said they were circumcised in fact were not and had intact foreskins.

It turned out that there was confusion between the terms for ‘initiation ceremony’ and ‘circumcision’. One astounded youth said, when shown a photo, “I went to an initiation school. I thought I was circumcised. I am really surprised!” Others had told relatives they were circumcised, but had in fact ducked out of the operation.

HIV prevalence was tied to true, rather than perceived, circumcision status; 20% of uncircumcised men had HIV, as did 18% of men who said they were circumcised but in fact were not, compared with 6% of men who actually were circumcised.

Auvert warned investigators to make sure that people truly understand what they are being asked and are not just trying to please investigators, and that in the case of circumcision, investigators should take photos with them to show what it meant.

At a symposium at the same conference,⁵ Mogomotsi Supreme Mafalapitsa, of the reproductive health organisation EngenderHealth, noted that circumcision is often imbued with religious and cultural meanings, and very often forms part of ceremonies that mark a transition from boyhood to manhood.

He warned that attempts to change practices around circumcision were fraught with difficulties. Health officials may prefer circumcision to take place at a different age, or under medical supervision in a sterile environment, but he said that “cultures who are already circumcising adolescent males do not take kindly to the possibility of alteration of their culture by medical circumcision and neonatal circumcision.” Circumcision performed in medical settings was not regarded as ‘proper’ circumcision, and, in particular, using anaesthesia was regarded as not performing the ceremony properly, as enduing the pain was part of the transition to becoming a man.