Exploring factors influencing integration of traditional and medical male circumcision methods at Ingquza Hill Local Municipality, Eastern Cape: A socio-ecological perspective.

BACKGROUND:  Medical male circumcision (MMC) and traditional male circumcision (TMC) are reportedly having negative and positive outcomes in the Eastern Cape province. Researchers show contradictory remedies; some advocate for abolishment of TMC and others call for the integration of both methods. AIM:  This study aimed to explore factors influencing the integration of TMC and MMC at different socio-ecological levels. SETTING:  The study was conducted at Ingquza Hill Local Municipality in the Eastern Cape province. METHODS:  An explorative qualitative study design, using in-depth interviews (IDIs) and focus group discussions (FGDs), was employed in this study. Purposive sampling was used to select the participants. A framework analysis approach was used to analyse the data, and the themes were developed in line with the socio-ecological model. RESULTS:  Four main themes emerged from the data as important in influencing the integration of TMC and MMC methods. These included: (1) individual factors, related to circumcision age eligibility and post-circumcision behaviour; (2) microsystem factors, related to alcohol and drug abuse, peer pressure, abuse of initiates, and family influence; (3) exosystem factors, related to financial gains associated with circumcision and the role of community forums; and (4) macrosystem factors, related to stigma and discrimination, and male youth dominance in circumcision practices. CONCLUSION:  Male circumcision in this area is influenced by complex factors at multiple social levels. Interventions directed at all of these levels are urgently needed to facilitate integration of the TMC and MMC methods.

The Notion of Manhood Embedment in the Practice of Traditional Male Circumcision in Ngove Village, Limpopo, South Africa.

Traditional male circumcision (TMC) is a cultural ritual that involves the removal of the penile foreskin of a male person undertaken as part of a rite of passage from childhood into adulthood. The aim of the study was to determine the notions of manhood in TMC by African adolescent boys in Ngove Village, Limpopo Province. This was a qualitative study that sampled a total of 20 adolescent boys through purposive sampling. Data were collected using semistructured interviews and analyzed through interpretive phenomenological analysis (IPA). Five main themes emerged from this study, namely: (a) TMC as a passage to manhood, (b) the role of TMC in role modeling, (C) fearlessness and aggressiveness as qualities of manhood in TMC, (d) TMC as indicating readiness for heterosexual relationships, and (e) the decline in the practice of TMC. The study concludes with discussion and recommendation of integration of both traditional male circumcision and medical male circumcision (MMC) with specific tactfulness and respect of the notion of manhood value embedment in the process to gain cooperation of the local community members affected.

Safe male circumcision in Botswana: tension between traditional practices and biomedical marketing.

Botswana has been running Safe Male Circumcision (SMC) since 2009 and has not yet met its target. Donors like the US Centers for Disease Control and Prevention and Africa Comprehensive HIV/AIDS Partnership (funded by the Gates Foundation) in collaboration with Botswana's Ministry of Health have invested much to encourage HIV-negative men to circumcise. Demand creation strategies make use of media and celebrities. The objective of this paper is to explore responses to SMC in relation to circumcision as part of traditional initiation practices. More specifically, we present the views of two communities in Botswana on SMC consultation processes, implementation procedures and campaign strategies. The methods used include participant observation, in-depth interviews with key stakeholders (donors, implementers and Ministry officials), community leaders and men in the community. We observe that consultation with traditional leaders was done in a seemingly superficial, non-participatory manner. While SMC implementers reported pressure to deliver numbers to the World Health Organization, traditional leaders promoted circumcision through their routine traditional initiation ceremonies at breaks of two-year intervals. There were conflicting views on public SMC demand creation campaigns in relation to the traditional secrecy of circumcision. In conclusion, initial cooperation of local chiefs and elders turned into resistance.

Barriers and facilitators to the uptake of voluntary medical male circumcision (VMMC) among adolescent boys in KwaZulu-Natal, South Africa.

Epidemiological modelling has concluded that if voluntary medical male circumcision (VMMC) is scaled up in high HIV prevalence settings it would lead to a significant reduction in HIV incidence rates. Following the adoption of this evidence by the WHO, South Africa has embarked on an ambitious VMMC programme. However, South Africa still falls short of meeting VMMC targets, particularly in KwaZulu-Natal, the epicentre of the HIV/AIDS epidemic. A qualitative study was conducted in a high HIV prevalence district in KwaZulu-Natal to identify barriers and facilitators to the uptake of VMMC amongst adolescent boys. Focus group discussions with both circumcised and uncircumcised boys were conducted in 2012 and 2013. Analysis of the data was done using the framework approach and was guided by the Social Cognitive Theory focussing on both individual and interpersonal factors influencing VMMC uptake. Individual cognitive factors facilitating uptake included the belief that VMMC reduced the risk of HIV infection, led to better hygiene and improvement in sexual desirability and performance. Cognitive barriers related to the fear of HIV testing (and the subsequent result and stigmas), which preceded VMMC. Further barriers related to the pain associated with the procedure and adverse events. The need to abstain from sex during the six-week healing period was a further prohibiting factor for boys. Timing was crucial, as boys were reluctant to get circumcised when involved in sporting activities and during exam periods. Targeting adolescents for VMMC is successful when coupled with the correct messaging. Service providers need to take heed that demand creation activities need to focus on the benefits of VMMC for HIV risk reduction, as well as other non-HIV benefits. Timing of VMMC interventions needs to be considered when targeting school-going boys.

Making the cut: evidence-based lessons for improving the informed consent process for voluntary medical male circumcision in Swaziland and Zambia.

The informed consent (IC) process for voluntary medical male circumcision (VMMC) was evaluated in Zambia and Swaziland as VMMC programs scaled up. In-depth interviews (IDIs) were conducted with clients 1 week after surgery to explore understanding of IC and gauge how expectations of MC surgery compared to actual experiences. In Zambia, key opinion leaders (KOLs) were also interviewed. Some clients equated written IC with releasing the clinic from liability. Most clients felt well prepared for the procedure, although many were surprised by the level of pain experienced during anesthesia and postsurgery. Clients were highly motivated to adhere to wound care, but some were overwhelmed by extensive instructions. Adolescents described barriers to accessing follow-up care and the need for support in overcoming adult gatekeepers. KOLs indicated that IC is not well understood in poorly educated communities. Results led to concrete programmatic changes, including revised patient education materials and more effective anesthesia for longer-lasting pain relief.

Knowledge, attitude and behaviour of boys and parents about circumcision.

AIM: To determine the knowledge, attitude and behaviour of parents and previously circumcised early adolescent boys about circumcision. METHODS: Half of the boys attending the sixth class of the primary school in our city centre and their parents were included in this cross-sectional, descriptive study. Questionnaires were prepared by the authors, which include 38 questions for parents and 25 questions for boys. RESULTS: Sixty-six per cent of the students were circumcised at the age of 7 years and above, 26% between three and 6 years and 8% below 3 years of age. Forty-two per cent of boys were circumcised by a traditional circumciser and 64% were circumcised at home. Main reasons of circumcision for parents were religious purposes (79%) and health issues (51%). When the boys were asked about their thoughts during circumcision, they mostly stated that 'it was necessary to become a man' (58%) and 'it would hurt much' (50%). Thirty-eight per cent of boys were frightened during circumcision and 46% were worried. Boys circumcised in the 7 years and above age group were most content about their age of circumcision. CONCLUSIONS: We consider that it is reasonable to wait up to an age at which the child could understand and participate in the decision of the concept and timing of circumcision.

Understanding the partial protection of male circumcision for HIV prevention among women in Iringa Region, Tanzania: an ethnomedical model.

Communicating the partial efficacy of male circumcision for HIV prevention is challenging. Understanding how people conceptualize risk can help programs communicate messages in a way that is understandable to local communities. This article explores women's ethnomedical model of disease transmission related to male circumcision in Iringa Region, Tanzania. We conducted in-depth interviews (IDIs) with 32 female partners of male circumcision clients and focus group discussions (FGDs) with married (n=3) and unmarried (n=3) women from November 2011 to February 2012. Interviews were digitally recorded, transcribed, and translated into English, and codes were developed based on emerging themes. While women understand that circumcised men are still at risk of HIV, risk is perceived to be low as long as both partners avoid abrasions during sexual intercourse and the man's penis is kept clean. Women said that HIV transmission only occurs when both partners have abrasions on their genitalia and mixing of blood occurs. Abrasions are thought to be the result of friction from fast or dry sex and are more likely to occur with uncircumcised men; thus, HIV can be prevented if a man is circumcised and couples have gentle, lubricated sex. In addition, women reported that the foreskin traps particles of sexually transmitted infections (STIs) including HIV, which can easily be passed on to female partners. In contrast, circumcised men are viewed as being able to clean themselves of disease particles and, therefore, do not easily acquire diseases or transmit them to female partners. These findings align with the scientific understanding of increased HIV risk associated with abrasions or microflora in the foreskin; however, the ethnomedical model differs from scientific understanding in that disease transmission can in fact occur without either of these conditions. Programs can build upon these findings to better convey risks along with the benefits of male circumcision.

"There's evidence that this really works and anything that works is good": views on the introduction of medical male circumcision for HIV prevention in South Africa.

Three clinical trials have demonstrated the partial efficacy (40-60%) of surgically conducted medical male circumcision (MMC) in preventing HIV transmission to circumcised men. This research formed part of a larger study exploring the importance of integration of sexual and reproductive health with HIV services. The objective was to elicit key informant views on the introduction of MMC for HIV prevention in South Africa. Twenty-one key informants representing the South African Health Department, local and international NGOs and universities, were asked, via semi-structured interviews about their views on introducing MMC as an HIV prevention strategy in South Africa. Interviews were transcribed and all discussions on MMC were coded for analysis using NVivo 8. The majority of the key informants were knowledgeable about MMC for HIV prevention and felt that making MMC available in South Africa was a good idea, with some recommending immediate introduction. Others felt that MMC should be introduced with caution. Various factors were recommended for consideration, including culture, the impact of circumcision on women, possible increase in sexual risk behaviour from behavioural disinhibition and that MMC may become another vertical health service programme. Most felt that MMC should be undertaken in neonates, however, acknowledged concerns about cultural responses to this. Recommendations on the implementation of MMC ranged from integrating services at primary health care level, to provision by private medical practitioners. In conclusion, MMC is viewed as a key HIV prevention strategy. However, there are numerous factors which could hinder introduction and uptake in South Africa and in the region. It is important to explore and understand these factors and for these to be aligned in the national MMC policy.

Circumcision in boys: time for doctors to reconsider.

The Convention of the Rights of the Child from 1989 states in Article 19 that States "shall take all appropriate legislative, administrative, social and educational measures to protect the child from all forms of physical or mental violation, injury or abuse..." Article 24.3 urges all States "to take all effective and appropriate measures with a view to abolishing traditional practices prejudical to the health of children". Article 37 states that "no child shall be subjected to torture or other cruel, inhuman or degrading treatment...". In the UNICEF Implementation Handbook for the Convention (1998) it is stated in relation to Article 24.3 that a review is to be undertaken regarding "all forms of genital mutilation and circumcision". Other traditional practices which are to be reviewed include "binding, scarring, burning, branding, forced holding under water..." and similar cruel treatment of children. No doubt it is time to act! Apparently no such action has been taken and the Convention is not applied in any country as regards circumcision of boys--let alone regarding mutilation of girls (which is done by the hundreds of thousands every year).

Female circumcision: understanding special needs.

The article discusses the provision of appropriate care that is sensitive to the special physical and psychosocial needs of the circumcised client seeking midwifery services in Australia. Aspects addressed include prevalence of the practice globally; potential problems for the prenatal, intrapartum, and postnatal periods; and implications for the midwife caring for the woman during these periods. Appropriate strategies for management include gaining an awareness of individual, cultural, and personal needs; provision of appropriate education in the prenatal and postnatal periods; establishment of positive working relationships with the family as a whole; and provision of adequate pain relief at all times. Health care policy can affect the ability of midwives and other health professionals to provide for culturally specific health needs.

When cultural practices are health risks: the dilemma of female circumcision.

The circumcision of young women and girls is widespread in African countries as well as in other parts of the world and clearly places them at risk for serious health consequences. Plans to eradicate the practice must recognize the cultural underpinnings that have maintained it. This article discusses the types of female circumcision and the concomitant short- and long-term health risks. The cultural aspects and origins of the procedure are described and a simple model of risk-taking based on control, information, and time is used to explain the complexity of issues that may be involved in the decision of women to consent to the procedure.

PIP: This article, which provides basic information about female genital mutilation (FGM) and its cultural relevance and offers a risk-taking model that helps explain the complexity of issues involved in the decision to continue the practice, opens with a section that describes the three main types of FGM, its prevalence and the geographic region where it is practiced, the age of the victims, immediate and long-term complications, and the increased risk of HIV transmission association with the procedure. The article then draws three variables from risk theory on business decision-making (control, information, and time) to explain individual decision-making that may place a person at risk of an untoward outcome. In this model, control is dependent upon information and time, information is dependent upon time, and time is the foundation. After detailing the significance of each of these variables, the article considers the cultural context of FGM, reviews the arguments of the proponents of the procedure, suggests reasons why it is continued, and identifies the primary commonalities of practicing cultures. Finally, the article integrates some of this cultural information into the proposed model and proposes that women may achieve more control over their decisions about perpetrating FGM if they have increased access to resources such as education, economic opportunities, training in self-reliance, and support groups. Time should be used effectively to provide individuals with the information they need to gain control and make appropriate decisions about FGM.

Female circumcision in Somalia and women's motives.

Two hundred and ninety Somalian women have participated in a study. They responded adequately to the questionnaire administered. One hundred percent of these women were circumcised, despite their relatively high socio-economic status as shown by their educational level. Eighty-eight percent of them had been circumcised with excision and infibulation, 6.5% were circumcised with clitoridectomy and the remaining 5.5% with Sunna. The majority of these women justified the practice of female circumcision with religious reasons and all were willing to circumcise their daughters. Fifty-two percent of the respondents had been operated on by medically untrained persons, usually traditional birth attendants and the majority were operated on at home.

PIP: 290 Somalian women participated in a study where they responded adequately to a questionnaire. 100% of these women were circumcised, despite their relatively high socioeconomic status as shown by their educational level. 88% had been circumcised with excision and infibulation. 6.5% were circumcised with clitoridectomy and the remaining 5.5% with Sunna. The majority of these women justified the practice of female circumcision with religious reasons and all were willing to circumcise their daughters. 52% of the respondents had been operated on by medically untrained persons, usually traditional birth attendants, and the majority were operated on at home.

Behavioral effects of circumcision with and without anesthesia.

The behavior of full-term neonates undergoing circumcision with and without local anesthesia was examined using the Brazelton Neonatal Assessment Scale (BNAS). Evaluations were done blindly pre-and postcircumcision and on the day following the procedure. Infants receiving lidocaine in a dorsal penile nerve block (DPNB) remained more attentive to animate and inanimate stimuli following circumcision and demonstrated a greater ability to quiet themselves when disturbed. The smoothness and maturity of motor behaviors showed the expected rate of improvement or recovery curve in the anesthetized group, while the control group's behavior did not. Behavioral differences were still evident on the day following the procedure. This report adds to the growing body of data that indicate that circumcision is a painful procedure that disrupts the course of behavioral recovery following birth. These disruptions can be lessened by the use of local anesthesia to relieve pain and stress during the procedure without any additional morbidity. These data support the use of DPNB during anesthesia for routine neonatal circumcisions still requested by the majority of parents in the country.

The circumcision controversy: an update.

One constructive feature has come out of all of the circumcision controversy. It has made us aware that neonatal circumcision is not a simple procedure and that it should not be regarded as "routine." It is a surgical procedure and it should be taught as one. The authors of this article wrote a review article on circumcision in 1981 and Dr. Grossman has recently published a book designed to teach proper circumcision technique, and to familiarize the operator with the common congenital anomalies as well as the prevention and treatment of the complications of circumcision. The advocacy of neonatal circumcision cannot be considered as a cut and dried issue. For some, it has an absolute religious indication, which transcends current medical logic. For others the available facts still allow for a decision based on one's perception of those facts. If one has the perception that there is value in improving local hygiene, or that the loss of the prepuce will allow for an earlier discovery of a penile lesion, or that circumcision actually does cause a decrease in the incidence of penile or cervical cancer, or group conformity is important, then one might well advocate neonatal circumcision. If, however, one sees the potential values as insignificant in light of the lack of hard data relating circumcision to penile or cervical cancer, and that if one is concerned with the "rape of the phallus," then one is against routine neonatal circumcision. But, this individual must be aware that a small percentage of males will need a circumcision at a later time in life, when technical and psychological problems may lead to an increased morbidity. The decision of the physician, and the advice given to the new parents, at present, appears to be more subjective than the advice concerning RhoGAM, or DPT immunization, although it occasionally is given with as much certainty. We are dealing with the art of medicine rather than science. On this basis, rather than deride each other for positions taken, and religious considerations aside, we would do much better to develop better scientific studies to answer the scientific questions. Today's tendency to make decisions on evaluation of the risk:benefit ratio is clearly difficult if both are not adequately quantitated. Until these are available the decision of whether or not to circumcise must result from an objective discussion between the doctor and the parents of newborn males.(ABSTRACT TRUNCATED AT 400 WORDS)