Initiation deaths can be stopped

Nearly 80 boys and young men have died, 30 over a single weekend, and close to 300 have been hospitalized this year in South Africa from injuries sustained during traditional circumcision procedures — known as initiation.

Circumcision is just one component of the full initiation ritual, during which young men of the Xhosa and Ndebele communities enter manhood. The particulars of the ritual vary with region and community, but it is universally a sacred tradition shrouded in secrecy. Details are not readily discussed in public and the tradition is regarded with the utmost respect.

It is expected that every boy will eventually attend initiation school. A 19-year-old former initiate, Siviwe Mnana, says young men who are not initiated are mocked. “You are considered [to be] a coward and young boys will not respect you.” Not being initiated, then, is not a realistic option for those who wish to be deemed men by their communities. Moreover, said Mnana, initiation is necessary if a boy is to be “accepted as a real man by [his] ancestors in the Xhosa culture.”

Although circumcision forms a major part of other cultures, many Xhosa and Ndebele regard the full initiation ritual as essential to being a man. Siphelo Gqoboza, a 21-year-old former initiate, explained that this idea of identity was central to his decision to attend initiation school. “Initiation is part of my culture and it helps us as Africans to differentiate between the diverse cultures we have in this country. Apart from the fact that it is customary, I decided to participate in the initiation process as I wanted to show people who I am,” he said.

According to a World Health Organization (WHO) study of traditional male circumcision among Xhosa communities, young men are put through a series of “survival tests” to “prove” that they are ready to enter manhood. Besides being forced to undergo the circumcision procedure without anaesthetic, the young men are challenged over the course of the initiation process to confront pain and discomfort as proper men.

These tests often include isolation, exposure to harsh elements, and strict dietary restrictions that prohibit water and heartier foods such as meat during the seven days following the circumcision. Initiates who are hospitalized for medical issues other than botched circumcision are often treated for dehydration or hypothermia. Other practices around initiation persist behind closed doors; they are not to be shared with outsiders, women, or uncircumcised men.

Gqoboza believes such secrecy is important as it is essential to keep the initiation process culturally pure. “People from other cultural backgrounds cannot imitate the things that we do, as Xhosa people,” he said. “Some of these schools are under the authority of men who are not from the same cultural background as us [Xhosas] and often this leads to lots of complications to the initiation process.”

But this year’s especially tragic death toll has prevented the practice from proceeding with its usual secrecy. During any given year, approximately 20,000 boys attend initiation school in the Eastern Cape, one of the three provinces where initiation is most common. Though statistics for deaths and injuries associated with initiation are not fully documented and available, already hundreds of boys and young men have been admitted to the hospital with grave and, sometimes, fatal injuries. And there is still another circumcision season left to go this year.

Of the hundreds of boys and young men rescued from initiation schools over the past two months, most were admitted with septic wounds, extreme dehydration, and gangrene. The latter has led to many victims suffering from partial or full amputation of the genitals. The alarming number of young men’s lives being permanently scarred by their experiences in initiation schools has drawn international media attention, and government officials and social activists alike are calling for meaningful action.

The medical community is disturbed by this season’s rates of injury and death. Dr. Dino Rech, one of the founders of the Center for HIV and AIDS Prevention Studies (CHAPS), explained that one of the major issues taken by medical professionals is that deaths and lasting injuries associated with male circumcision are wholly preventable. “We know that, generally, medical circumcision is very safe,” said Rech. “Deaths are very uncommon for what we regard as a minor procedure, so much of the medical frustration and confusion around this practice is why these men actually die.”

Clinical trials have shown that medical circumcision reduces the risk of heterosexual men contracting HIV. The World Health Organisation recommends medical circumcision in areas with large HIV epidemics.

CHAPS runs the Boipelo Clinic in Orange Farm, south of Johannesburg, where over 50,000 boys and men have been circumcised by trained medical professionals in a safe clinical environment. When performed by trained officials, the procedure takes less than 10 minutes and does not subject patients to major pain or discomfort. Rech confirms, “We’ve reached out to local traditional providers and had great success, specifically in the Orange Farm area.”

Ikosi NJ Mahlangu, a member of the Mpumalanga Provincial House of Traditional Leaders, added his support. “The House of Traditional Leaders is in full agreement with the involvement of the medical practitioners in the surgical part of the initiation schools,” said Mahlangu. “Their involvement has been accepted by traditional leaders since 1993.”

Complications arise from improper use of surgical instruments. One study found that as many as a dozen initiates may be circumcised by a single unwashed and unsterilized blade. Lack of sterilization can lead to infected wounds and the spread of sexually transmitted infections. Some circumcisions are also performed with dangerously blunt instruments, which cause crude incisions.

Experienced traditional surgeons, called ingcibi, are well-versed in the necessity of sterilization and frequently use natural forms of sterilization like herbs to ensure safe surgery. Rech agrees that the deaths and injuries associated with this and other circumcision seasons are not at the hands of trained traditional healers. “Traditional providers can do it safely. In controlled environments, traditional providers can perform safe procedures. The deaths are at the hands of rogue criminal agents,” he said.

Fly-by-night initiation schools have emerged increasingly in recent years. Driven purely by monetary desires, these fraudulent nurses and surgeons set up schools and perform circumcisions without the sanction of their communities and traditional councils.

Circumcision is a large source of income in poverty-stricken communities where unemployment is high. Families are willing to pay large sums to send their boys off to become men, but this willingness to pay is too often exploited and leads, as this season has shown, to disturbingly high rates of injury and death.

These fly-by-night institutions often target underage initiates, who sometimes run away to gain passage into adulthood early. Boys are typically supposed to be 18 when they enter initiation schools but these illegal schools frequently enroll younger boys, some as young as 13 to increase profits. There have also been reports of younger boys being kidnapped from their homes and communities by illegal initiation school leaders.

Gqoboza, who was 19 when he attended initiation school in the Eastern Cape, attributes the tragedies this season to the fact that many initiates in illegal settings are underage. “I am aware of the initiates who were injured and some who died while following their culture at initiation schools in the Eastern Cape. I think the main reason why such horrid things have been happening is because, boys as young as 15 are sent to initiation school … These young boys are not strong enough to endure the difficult and harsh circumstances that come with going to initiation school.”

Gontsana also blames fake institutions, and is embarrassed by the effect that media attention skewed towards fly-by-night schools has on his culture. “A lot of unsafe things could happen [at an illegal school] and you could die. Then its going to make the ones that are legal look bad because people will think it’s the same school.”

21-year-old Mbulelo Nkhaphe, who plans to go to initiation school later this year during the second circumcision season, admits that the cases of circumcision accidents in illegal schools have made him nervous about the process, though he still looks forward to completing the tradition. “Seeing such stuff in the media really affects my thinking towards the circumcision because it makes me a bit scared to go there, but, for my sake, I am willing to go.” Nkhaphe said it is “easy to be attracted to an illegal school”, especially if a boy’s parent or guardian is not fully involved in the process.

Gqoboza hopes that the government will step in and make regular visits to initiation campuses to ensure they are being run correctly and safely. “Some of them [initiates at fake schools] are not even well taken care of when they are there.”

Minister of Health Aaron Motsoaledi said at a press conference on July 7th that fly-by-night schools have turned initiation “into something criminal and no longer has anything to do with culture”. Illegal initiation school leaders were destroying young boys’ lives and disrespecting culture. The answer is not the complete eradication of a long-practiced cultural tradition, but stricter regulation and monitoring to identify and shut down illegal institutions.

Since 2000, more than 500 boys have died in the Eastern Cape, alone, from injuries sustained during initiation rituals, and it is nearly impossible to determine how many cases ever reached official judicial closure. This year is no different. Only five arrests have been made in the Eastern Cape this season.

Both Gontsana and Gqoboza are adamant that police need to aggressively pursue those parties responsible for the deaths of young boys and men under the guise of honoring culture.

Mahlangu says that though many arrests are still pending “there has been a positive cooperation with the police and investigations are still [underway], regarding illegal schools.” He has faith in the police.

With the winter circumcision season coming to an end, activists, government, and active medical experts can take a few months before the next initiation period to think seriously about the future of the initiation tradition. There are already calls for the development of task-forces and committees.

As more lives are painfully altered or cut short, the urgency behind the move to successfully improve the nature of initiation in South Africa is only heightened. Rech believes that progress will come only if illegal and harmful actions, rather than culture are put on trial. “The government could help by bringing [traditional leaders and medical professionals] all around the same table to answer the question: how do we safeguard culture and human lives?”