ADULT CIRCUMCISION PRACTICES OF TRADITIONAL SURGEONS ANDNURSES IN RELATION TO THE INITIATES’ HEALTH OUTCOMES/MORBIDITY

IN THE EASTERN CAPE.

by

SIYAMTHEMBA DALASA

A dissertation submitted in fulfilment of the requirements for the degree of

MAGISTER CURATIONIS

DEPARTMENT OF NURSING SCIENCE

FACULTY OF HEALTH SCIENCES

UNIVERSITY OF FORT HARE

Supervisor: Prof DT Goon

April 2019

i

DECLARATION

I, Siyamthemba Dalasa, hereby declare that the study on, “Adult circumcision

practices of traditional surgeons and nurses in relation to the initiates’ health

outcomes/morbidity in the eastern cape” is my original work. This study has not been

submitted to any other University for the completion of any degree purposes. The

researcher has revealed and acknowledged all the citations used or quoted from

other people’s work by means of complete referencing.

Name: Siyamthemba Dalasa

Signature: …………………………………..

Date: …………………………………………

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DECLARATION ON PLAGIARISM

I, Siyamthemba Dalasa, student number 200902505, confirm that the content

contained in this document is my own work, is not copied from any other author’s

work. I know that plagiarism is wrong and is against the University of Fort Hare’s

policy on plagiarism. In any case where other people’s work has been used in this

document, appropriate citations and references have been provided. I have not

permitted, and I will not consent to anyone copying my work with the aim of making it

their own work.

Signature:……………………….

iii

CERTIFICATION

This study was completed under the guidance and supervision of Professor DT

Goon at the University of Fort Hare, East London.

Supervisor: Professor DT Goon (University of Fort Hare, Department of Nursing

Science, Faculty Sciences)

Signature:…………………………………..

Date:………………………………………...

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ACKNOWLEGEMENTS

My sincerest gratitude goes to my supervisor Professor DT Goon, (University of Fort

Hare).

I would to thank the people of the OR Tambo District (KSD, Nyandeni and Qawukeni

municipalities), for allowing me, the opportunity to collect data in order to complete

my research study at the University of Fort Hare. I further thank Mr. Merile, acting on

behalf of the Eastern Cape Department of Health and to Chief Tyhali, representing

the Eastern Cape house of traditional leaders in O.R. Tambo for providing me with

the opportunity to proceed with the collection of data in the district.

I highly appreciate Dr I. Ajayi (University of Fort Hare) for his dedicated help,

guidance, support and mentoring during the process of completing my paper.

To my cousin brother, Sinekhaya Xibiya, and my younger brothers, I thank you for

the help you offered in accompanying me to all those hard-to-reach areas of the

Nyandeni and Qawukeni municipalities.

A very special word of thanks goes to Dr. Yako who, while she was still working for

the University of Fort Hare, helped me to initiate this research process. I deeply

appreciate the assistance I received from all other parties involved, including Ms. N.

Rala (University of Fort Hare,) who helped me when I desperately needed help.

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LIST OF ACRONYMS

COGTA - Co-operative Governance and Traditional Affairs

DoH - Department of Health

EC DoH - Eastern Cape Department Of Health

HIV - Human Immunodeficiency Virus

KSD - King Sabatha Dalindyebo (municipality)

LRC - Lusikisiki Rescue Centre

MEC - Member of the Executive Council

MMC - Male Medical Circumcision

PIDAC - Provincial Infectious Diseases Advisory Committee.

TMC - Traditional Male Circumcision

UNAIDS - Joint United Nations Programme on HIV and AIDS

WHO - World Health Organisation

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ABSTRACT

BACKGROUND

Despite the adverse outcomes associated with traditional male circumcision, the

practice remains prevalent, especially in the Eastern Cape, South, Africa. This study

seeks to assess the practices of traditional surgeons and nurses in relation to the

prevention and control of infections and their understanding of human physiological

mechanisms during circumcision processes.

METHOD

This study has adopted a qualitative design, which involved conducting 115 semi-

structured interviews among traditional surgeons, traditional nurses and traditionally

circumcised men, and one focus group discussion among traditional nurses. The

data generated were transcribed and subjected to thematic content analysis.

RESULTS

The analysis revealed that both traditional surgeons and nurses demonstrated both

poor aseptic techniques and a lack of knowledge of how the human body functions.

Their lack of knowledge of basic human physiology meant that they trivialised sepsis

in the penile wound. In addition, the seclusion lodges for circumcision and initiates

living were unclean and uninhabitable.

CONCLUSION

The poor aseptic techniques of traditional surgeons and nurses, as well as the

uncleanliness of their environment during traditional male circumcision procedures,

could expose initiates to infections and morbidity. Environmental health officers

should regularly supervise traditional surgeons and nurses in order to prevent the

adverse health outcomes associated with the traditional male circumcision practice.

KEY WORDS: Aseptic Technique, Traditional Male Circumcision, Initiates,

Traditional Surgeons and Nurses.

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TABLE OF CONTENTS

DECLARATION.........................................................................................................................i

DECLARATION ON PLAGIARISM....................................................................................... ii

CERTIFICATION.....................................................................................................................iii

ACKNOWLEGEMENTS........................................................................................................ iv

LIST OF ACRONYMS.............................................................................................................v

ABSTRACT..............................................................................................................................vi

TABLE OF CONTENTS................................................................................................vii

LIST OF TABLES........................................................................................................... xi

LIST OF FIGURES........................................................................................................ xii

CHAPTER ONE.......................................................................................................................1

1. 1 INTRODUCTION AND BACKGROUND OF THE STUDY............................... 1

1.2 PROBLEM STATEMENT........................................................................................7

1.3PURPOSE OF THE STUDY....................................................................................8

1.4 OBJECTIVES.....................................................................................................8

1.5 RESEARCH QUESTIONS......................................................................................9

1.6SIGNIFICANCE OF THE STUDY........................................................................... 9

1.7DELIMITATIONS OF THE STUDY.......................................................................10

1.8 THEORETICAL FRAMEWORK........................................................................... 10

1.9DEFINITION OF TERMS....................................................................................... 14

1.10OUTLINE OF THE DISSERTATION..................................................................16

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CHAPTER TWO....................................................................................................................18

LITERATURE REVIEW................................................................................................18

2.1 INTRODUCTION...................................................................................................18

2.2 CULTURAL AND SOCIAL SIGNIFICANCE OF “ULWALUKO”

(CIRCUMCISION). 18

2.3 TRADITIONAL LEGAL CONSIDERATIONS OF ‘’ULWALUKO”

(CIRCUMCISION).........................................................................................................19

2.4SECRECY OF MALE CIRCUMCISION...............................................................21

2.5 FOOD TABOOS...................................................................................................22

2.6HEALING MEDICINE..............................................................................................23

2.7CONTROL AND PREVENTION OF INFECTION.............................................. 23

2.8COMPLICATIONS OF “ULWALUKO” (CIRCUMCISION)................................ 24

2.9RISKS OF CONTRACTING HUMAN IMMUNODEFICIENCY VIRUS............25

2.10 SUMMARY...................................................................................................28

CHAPTER THREE............................................................................................................... 29

RESEARCH METHODS.............................................................................................. 29

3.1 INTRODUCTION...................................................................................................29

3.2 RESEARCH DESIGN............................................................................................ 29

3.3 POPULATION...................................................................................................29

3.4SAMPLE AND SAMPLING PROCEDURE..........................................................29

3.4.1Inclusion and exclusion criteria..................................................................30

3.5MEASUREMENT INSTRUMENT........................................................................ 30

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3.6DATA COLLECTION...............................................................................................31

3.7TRUSTWORTHINESS........................................................................................... 32

3.7.1 Credibility..................................................................................... 32

3.7.2 Confirmability..................................................................................... 32

3.7.3 Transferability..................................................................................... 33

3.7.4 Dependability..................................................................................... 33

3.8ETHICAL CONSIDERATIONS..............................................................................33

3.8.1The principle of respect for persons..........................................................34

3.8.2Principle of no harm to subjects.................................................................34

3.8.3 Principle of justice..................................................................................... 34

3.8.4The principle of anonymity and confidentiality.........................................35

3.8.5 Informed consent..................................................................................... 35

3.9 DATA ANALYSIS...................................................................................................35

CHAPTER FOUR..................................................................................................................37

PRESENTATION OF FINDINGS............................................................................... 37

4.1 INTRODUCTION...................................................................................................37

4.2DEMOGRAPHIC CHARACTERISTICS OF STUDY PARTICIPANTS........... 37

4.3ASSESSMENT OF ASEPTIC TECHNIQUES USED BY TRADITIONAL

SURGEONS AND NURSES DURING TRADITIONAL CIRCUMCISION

PROCESSES 39

4.3.1Use of surgical gloves................................................................................. 39

4.3.2Cleanliness and sterilisation of circumcision instrument........................39

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4.3.3Cleanliness of the seclusion lodge............................................................40

4.3.4 Wound dressings..................................................................................... 41

4.3.5Treatment of penile wound......................................................................... 42

4.3.6Experience of purulent penile wound........................................................43

4.4 Summary..................................................................................................................43

CHAPTER 5...........................................................................................................................44

DISCUSSION OF FINDINGS, CONCLUSION AND RECOMMENDATIONS.....44

5.1 INTRODUCTION...................................................................................................44

5.2DISCUSSION OF FINDINGS................................................................................ 44

5.3STUDY LIMITATIONS............................................................................................ 47

5.4 CONCLUSION...................................................................................................48

5.5RECOMMENDATIONS.......................................................................................... 48

REFERENCES.............................................................................................................. 50

APPENDIX A: Letter of approval from the University of Fort Hare ethics

committee.......................................................................................................................58

APPENDIX B: Letter of approval from the Eastern Cape Department of Health60

APPENDIX C: Letter of approval from the sub-district house of traditional

leaders in Mthatha.........................................................................................................61

APPENDIX D: Informed Consent by participant/parent/guardian......................... 62

APPENDIX E: Letter for ethical clearance to the University of Fort Hare...........65

APPENDIX F: Researcher’s declaration and conflict of interest declaration.......66

APPENDIX G: Questionnaire guide...........................................................................70

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LIST OF TABLES

Table 1.1: Death toll of initiates in the Eastern Cape associated with circumcision

from 2006-2013.

Table 4.1. Demographic characteristics of the participants.

xii

LIST OF FIGURES

Figure 1.1: The Health Belief Model

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CHAPTER ONE

1. 1 INTRODUCTION AND BACKGROUND OF THE STUDY

According to the World Health Organisation and Joint United Nations Programme

(2007), globally, roughly 30% of males are circumcised, of whom about two thirds

are Muslim. Some common factors of male circumcision are ethnicity, observed

health and sexual fulfilment and the preference to fit into social norms (WHO &

UNAIDS, 2007). Neonatal circumcision is commonly practised in the following

countries: Israel, the United States of America, Canada, Australia and New Zealand

and in the greater part of the Middle East, Central Asia and West Africa (WHO &

UNAIDS, 2007). However, it is less common in East and Southern Africa, where the

average age of circumcision differs from boyhood to the late teens or twenties (WHO

& UNAIDS, 2007).

In several countries, the prevalence of non-religious circumcision has undergone

both rapid increases and decreases, revealing cultural mixing and varying

perceptions of health and sexual benefits (WHO & UNAIDS, 2007). It is also claimed

that male circumcision protects against several diseases that include urinary tract

infections, syphilis, chancroid, invasive penile cancer, and HIV (WHO & UNAIDS,

2007). However, as with any surgical procedure, there are potential risks entailed,

such as cross infection, complete removal of the foreskin or even glans penis.

The benefits of male circumcision are well documented (Connolly et al., 2008; Auvert

et al., 2013; Tobian et al., 2014; Kripke et al., 2016). Available evidence suggests

that male circumcision is protective against the acquisition of HIV and other sexually

transmitted diseases (Connolly et al., 2008; Auvert et al., 2013; Tobian et al., 2014;

Kripke et al., 2016). According to the WHO and UNAIDS (2011), 22% of HIV

infections between 2011 and 2025 among the 14 priority countries of eastern and

southern Africa could be averted if 80% of males between the ages of 15 and 49

years were to be circumcised by 2015. South Africa has a heavy burden of HIV, and

the HIV prevalence rate is disproportionately high among young people. However,

the rate of male circumcision is low in the country (Govender et al., 2013/14; Shisana

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et al., 2014) and in parts of South Africa where the rate is high, most of the male

circumcisions are done after sexual debuts (Peltzer et al., 2008b; Peltzer & Kanta,

2009; Maughan-Brown et al., 2011). Consequently, the South African Government

introduced voluntary medical male circumcision as one of the methods of preventing

HIV (SANAC, 2012).

The issue of male circumcision continues to generate attention among policy makers

and scholars. In the South African context, the debate about male circumcision is

two-fold, arising from the cultural divergence in the country. In the Kwa-Zulu Natal

province, and in other provinces, where culturally males are not circumcised, the

priority remains on how to scale up voluntary medical male circumcision (Scott,

Weiss & Viljoen, 2005: 305; Naidoo, Dawood, Driver, Narainsamy, Ndlovu & Ndlovu,

2012). However, in provinces where traditional male circumcision is prevalent, the

need to make the process medically safe overrides the promotion of voluntary

medical male circumcision, which is often resisted by custodians of traditions

(Vincent, 2008b; Kepe, 2010). Among the AmaXhosa people of South Africa (the

majority of whom live in the country's Eastern Cape province), traditional male

circumcision symbolises the “rite of passage of boys to manhood” (Mavundla et al.,

2009). It is viewed as an important process of socialisation, necessary for

maintaining social order and the organisation of groups into hierarchies, renewing

group unity and a means for the transmission of values across generations (Vincent,

2008b; Vincent, 2008a).

Over the past two decades, following the traditional male circumcision ritual,

thousands of young men have been admitted to hospitals, hundreds have undergone

penile amputations and, consequently, died (Kepe, 2010). For instance, a study

conducted in the Mthatha area of South Africa shows that 25 deaths related to

traditional circumcisions were recorded at the Mthatha General Hospital during 2005

and 2006. Another study which assesses the extent of circumcision-related

complications and fatalities in the Eastern Cape shows that the incidence rate

remain unchanged (Meissner & Buso, 2007).

Despite the adverse outcomes associated with traditional male circumcision, the

practice still remains prevalent (Mark et al., 2012). This could be attributable to a

number of factors such as fear of stigmatisation (Mavundla et al., 2010, Peltzer &

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Kanta, 2009; Mshana et al., 2011), religion/culture, notions of manhood, and social

disapproval (Mark et al., 2012; Kepe, 2010). Meissner & Buso (2007) assert that

unqualified traditional surgeons, negligent traditional nurses, irresponsible parents

and youth medically unfit for the hardships of initiation school contribute to the tragic

outcomes. Anecdotally, the ritual circumcision-related deaths are attributable to poor

hygiene at the initiation schools and failure to adopt proper aseptic techniques. The

South African Regulation 328 of 2007 gives the environmental health practitioners

(EHPs) an ethical opportunity and supremacy to enter every premise,

accommodation or structure for the purpose of health inspections. However,

available evidence suggests that initiation schools are not regularly inspected for

safety due to fear of interference with the traditional value systems (Rathebe, 2018).

Training of traditional nurses and surgeons has been suggested as a means of

reducing the adverse health outcomes associated with traditional male circumcision.

However, the results of studies assessing its effectiveness are mixed (Peltzer et al.,

2008b; Peltzer et al., 2008a). The political will to address the traditional circumcision

related-deaths and complications is lacking; however, the importance of providing

compelling scientific evidence demonstrating the need to make changes cannot be

overemphasised. This study thus seeks to assess the adult circumcision practices of

traditional surgeons and nurses in relation to the initiates’ health outcomes/morbidity

in the Eastern Cape.

In South Africa, more especially in the Eastern Cape, as is often shown on television

news and newspapers, in particular during the winter and summer seasons, when e

the practice of initiation schools normally takes place, it seems that traditional male

circumcision has become a crisis of morbidity and death. The number of deaths of

the initiates associated with circumcision each year has been on the increase (Table

1.1).

4

Table 1.1: Death toll of initiates in the Eastern Cape associated withcircumcision from 2006-2013.

YEAR NUMBER OF DEATHS PER YEAR

2006 58

2007 32

2008 34

2009 91

2010 62

2011 62

2012 74

2013 86

Total 499

Source: Daily Dispatch (Feni, 2014b: 01).

A 16-year-old initiate was interviewed in the Nelson Mandela Academic Hospital

after he was visited by The Daily Dispatch. He explained that he had been

pressurised by from peers and had been tortured by his seniors in the practice and

was attacked by so-called friends. The young man told The Daily Dispatch that as

initiates, they were made to sing all day long, denied water to drink for eight days

and did not eat for two days. They were given food after two days of starvation and

were only given a half-cooked stiff pap. In addition, they were beaten and mocked

when they cried. They were told that they were not real men, but as weak as women.

This explains why some initiates die from dehydration, heart failure and septicaemia.

They are not permitted normal daily diets and emotional, psychological and social

support is denied them. There is no sense of love, kindness or care. Rather, they

5

are judged and tortured, as well as being deprived of the general living conditions

normal for human beings. Even plants cannot survive without water, necessary

nutrients and need suitable environmental conditions to survive. Then how much

more so for human beings? Thus, the focus of this study is to examine the

circumcision practices of traditional surgeons and nurses in relation to the initiates’

health outcomes/morbidity in the Eastern Cape.

In the AmaXhosa tradition, the “abakhwetha” (initiates) are placed away from view

of the public in a temporary lodge called “ibhuma”, which is made from tree branches

and layered with grass to shelter the house of the “abakhweta”. In the middle of the

lodge, there is usually a tall straight pole either from the tree, named in isiXhosa,

“umthathi” or “umnquma”. This is believed to be symbolically linked to the ancestors,

and so provide protection to the “abakhwetha” (initiates). The lodge is generally

located in a wooded area near to water to provide favourable conditions for the

initiates (Dold & Cocks, 2012: 94).

However, urbanisation and environmental factors have precipitated certain changes

in the practice of the traditional circumcision in association with the health conditions

that the ‘’abakhwetha’’ are prone to contract in the process of ‘’ulwaluko’’, for

example, HIV and pneumonia. This is often because resources are scarce in the

urban settlements with the result that the lodge is covered with plastic sheets instead

of grass. However, the central pole from “umnquma” or “umthathi” is still used for the

protection of the ancestors (Dold et al., 2012: 93).

The day before AmaXhosa boys undergo traditional circumcision a goat is

slaughtered and traditional beer is made for clansmen attending the ritual called

“ukubingelelwa” (a greeting ceremony). Only men are allowed to attend this

ceremony in a barn where seating arrangements are in order of seniority. This is

crucial in the AmaXhosa tradition, for example, those who initiated first are senior to

those who initiated later, hence, and the sequence starts from the left, next to the

exit extending towards the junior men. This ritual is performed to request blessings

from the ancestors before the initiates go to the temporary seclusion lodge (Dold et

al., 2012: 93).

The boys eat only the meat from the forelegs which is temporally placed on fire

made from trees called ‘’umthathi (sneezewood)’’ or ‘’umnquma’’. These trees give

6

off a bitter taste, which is symbolic - to strengthen the boys in preparation of the ritual

to follow the next day. The initiates’ hair is remove and burnt to avoid reuse by the

sorcerers. The regrowth of the hair of the initiates symbolises the “rebirth” of

someone in the AmaXhosa tradition (Dold et al., 2012: 96).

Before the sacrifice begins, the initiates perform a dance called “umguyo”. In the past,

the dance costume was made from palm tree leaves and the boys painted their

bodies with clay and ochre. However, nowadays, traditional initiates in the

AmaXhosa culture wear an old shirt and hat that have been cut into many long

ribbons to draw attention to the dance (Dold et al., 2012: 96).

In the hours of the morning on the day of “ulwaluko” (circumcision), following the day

of the sacrifice, the initiates go to the nearest water stream in which they wash

themselves to purify themselves from the ritual uncleanliness called “ubunqalathi” in

AmaXhosa. Physiologically, the cold water helps constrict the blood vessels,

reducing the lowering blood flow to the site of the operation during circumcision, thus

minimising bleeding.

The vital phase of the ritual is that boys run to the nearest stream to wash. On return,

each boy is given an “intambo yabakhwetha” (charm necklace), which is believed to

protect initiates from the evil spirits of the sorcerers, and an “ityeba” (strap) (Dold et

al., 2012: 96). Both of these are made from “uluzi” (a string made from the roots of

fig veld tree) by either the parents or the guardians of each boy, using forest material

(Dold et al., 2012: 96). After the initiates have been given the “intambo yabakhwetha”,

they immediately leave the home and go to the forest where the “ibhuma” has

already been built to shelter the initiates (Dold et al., 2012: 96).

As the initiates invade the forest, they are led by the young boys, called

‘’amanqalath”, of around ten years of age who stay with the initiates during the

period of seclusion and do run odd jobs for the initiates. Following these boys is the

“Ingcibi” (Surgeon), the “Ikhankatha” (traditional nurse), fathers and the elders of the

clan (Dold et al., 2012: 97).

All females are strictly forbidden to attend this phase of the ritual. However, all family

members (including both genders of any age, except the very young who might not

understand what is about to happen) of the clan of each initiate do know that one or

7

more of their family sons is a few hours away from changing from boyhood to

manhood (Dold et al., 2012: 97).

Even though the women and daughters left at home do not attend the ritual in the

forest, they do have mixed emotions of ‘’happiness’’ and ‘’sadness’’ because their

boy children are now going to be groomed into manhood. It makes them happy on

one hand, but on the other, the fact that their child is going to be away from home

for a certain period of time with no idea of what really happens in the ‘’forest’’

(‘’ebhomeni’’) brings them sadness. During this time, the women enjoy themselves

with their traditional songs and playing drums to rejoice in the proceedings of the

ritual in the forest (Dold et al., 2012: 97). Immediately after the surgeon has finished

the operation, the young boys on top of the mountains make the noises of whistling

and shouting, to inform the women at home that their sons are no longer boys (Dold

et al., 2012: 97).

1.2 PROBLEM STATEMENT

Over the past years, a rise in the death of initiates has been noted, especially in the

Eastern Cape. Between 2006 and 2013 about 499 initiates died (table 1.1). There is

no clarity as to whether the initiates’ ill-health and deaths could be attributed to

traditional surgeons’ and nurses’ failure to do their job properly. Initiate deaths are an

ongoing crisis. It was reported by the Social Development MEC that the main focus

in the department is to prioritise the initiative to offer emotional support to young men,

some of whom have had their penises amputated. The report indicated that 19

initiates had died and 134 had been rescued from illegal initiation schools for

hospitalisation. Among those initiates, 11 were from Mount Ayliff, two from Lusikisiki

and the rest from Bizana in the Pondoland region. They were taken to the Lusikisiki

Rescue Centre (LRC). Government statistics from Bisho reveal that 437 initiates

have died, some having lost their penises and thousands more have been

hospitalised. Most of initiate deaths occurred in the O R Tambo region/ district (Nini,

2014: 04).

8

There have also been cases of initiates’ deaths in Mthatha. A 17 -year old initiate

from Qweqwe village died of septicaemia and hypothermia on 23 June 2014. Yet,

another 18-year old initiate from Ncise village died of septicaemia and heart failure

on 30 June 2014 (Feni, 2014a: 05).

The problem of deaths of initiates is exacerbated by the way in which the traditional

surgeons and nurses perform their duties, as well as by the conditions of the

environment in which initiates cared for. It is therefore imperative to investigate the

circumcision practices of traditional surgeons and nurses in relation to the initiates’

health outcomes/morbidity in the Eastern Cape. There is little information in this

regard.

1.3 PURPOSE OF THE STUDY

The aim of this study is to investigate the circumcision practices of traditional

surgeons and nurses in relation to the initiates’ health outcomes/morbidity in the

Eastern Cape, in order to unravel the factors associated with the negative health

outcomes of many initiates.

1.4 OBJECTIVES

The objectives of the study are to:

Determine the sterile procedures, to prevent infection, by traditional surgeons

and nurses before, during and after circumcision..

Assess the human physiological and anatomical knowledge of the traditional

surgeons and nurses in relation to male circumcision and its complications.

Determine the environmental conditions under which the circumcision takes

place.

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1.5 RESEARCH QUESTIONS

The following research questions have been posed:

What sterile procedures, to prevent infection, do traditional surgeons and

nurses use before, during and after circumcision?

Are the traditional surgeons and nurses knowledgeable about human

physiology and anatomy in relation to male circumcision and its

complications?

Is the environment in which the circumcisions take place hygienically safe

for the circumcisions?

1.6 SIGNIFICANCE OF THE STUDY

Young boys are at risk of losing their gender identity, or even of death, during

traditional circumcision. Thus, this study will benefit the youth, especially those

young males who are still considered boys since they have not yet been circumcised.

With proper research findings, analysis, recommendations and implementation the

young males are more likely to survive the circumcision ceremony without

permanent physical damage or ill health. Further, pre-education of young males

prior to circumcision or initiation school will empower them by teaching them about

what to expect in the process that they are about to undertake.

In addition, this study will benefit the family members through providing

recommendations that could successfully prevent or reduce the morbidity of initiates

from the initiation schools. Hence, the families will be relieved of the unnecessary

loss of their loved ones and the financial stresses of the burial services.

Community members will benefit through the centralisation of circumcision or

initiation schools and they will know to choose right person to circumcise their

children, who will take good care of them. This study will promote community

solidarity to ensure safe circumcision and to eradicate the illegal practices of unsafe

circumcision.

10

The findings and recommendations of the study will help the Eastern Cape

Department of Health (DoH) in the implementation of new strategies to help save the

lives of initiates.

1.7 DELIMITATIONS OF THE STUDY

This study examines the role of traditional surgeons and nurses and their practice

based on what they do to control infections, it assesses the knowledge based of the

physiology l and anatomy of the human body, linked to the practice and its

complications. Further, it assesses the suitability of the environment for the survival

of initiates in which the practice takes place.

1.8 THEORETICAL FRAMEWORK

This study is guided by Hochbaum’s (1958) framework participation in medical

screening programmes. This framework comprises major elements of perception

such as perceived threat, perceived benefits of an action, perceived barriers to an

action and cues to an action (stimulus). Perceived threat is formed by two more

elements, perceived susceptibility and perceived seriousness of the condition.

Perceived susceptibility is defined as one’s judgement or belief whether one is

vulnerable to contracting a condition (Hochbaum, 1958: 09; Glanz, Rimer & Lewis,

2002: 48). According to Hochbaum (1958: 10), a person may believe that he or she

is prone to contracting a disease or may have it without noticing symptoms However,,

the person may not believe in the benefits of early diagnosis. For example, there is

the likelihood that traditional surgeons and nurses might believe that initiates are

prone to certain conditions but, due to socio-cultural stereotypical values, attitudes

and norms or other social influences, they do not consider ways to prevent such

conditions.

Moreover, with education-based knowledge and prioritising the health of the initiates

as a human being, rather than focusing on the social and cultural influences behind

the practice, the boys or their parents would probably opt for other safer means of

circumcision.

11

The perceived seriousness of a condition refers to the extent of severity of the

condition based on biological or physical changes and its impact on socio-economic

engagements (Hochbaum 1958: 12; Glanz et al., 2002: 48).This is, for instance,

evident in the case of initiates who develop sepsis while in the lodge and there is no

consideration of early medical help to prevent complications. Some of those initiates

might end up having their penises amputated, resulting in social stigma, low self-

esteem, inability to meet sexual needs, changes in urine passage. This may result in

psychological stress that could be suicidal in nature.

Glanz et al. (2002:47) define perceived benefits as the belief in the effectiveness of

the proposed action to reduce the risk or seriousness of impact. When public

communities are made aware of crises, they make sound decisions. Social

influences from friends, neighbours and co-workers might play a role in the choice of

circumcision practices, be it in a positive or negative manner (Hochbaum, 1958: 18-

19).

Evidence-based knowledge can be obtained through reading newspapers, watching

television news, attending official awareness programmes in the community, and

reading research articles about the practices of “ulwaluko” (circumcision).

Perceived barriers to an action are generally one’s perception or judgement about

the extent of the difficulty of the set of various factors that may interfere with the

achievement of certain proposed behaviours. For example, when knowledge is

minimal or absent about professionally trained traditional surgeons and nurses, and

social stigma dominates in those who undergo a certain method of circumcision, it

may block bringing changes to healthy behavioural practices. Glanz et al. (2002:47)

define this element as the belief about the physical and psychological costs of the

advised action.

However, Glanz et al. (2002) does not consider the socio-economical aspect in his

definition. Some barriers might be socially or financially related, or sometimes the

culture might be personal to the individual himself. For example, someone might opt

to undergo traditional male circumcision, not because he likes the aspect of it, but

because of his fear that he will be regarded as a boy if he were to undergo medical

12

male circumcision, or else he might be from a remote area where health care centres

are not easily accessed.

Hochbaum’s cues to action or the stimulus refers to an individual’s motivation when

he or she realises that there is a benefit to the action he or she is about to take.

Actual change mostly occurs when an external or internal cue generate an action.

Two types of cues to action have been identified: (a) physical changes noticed by the

individual and (b) cues from the external situation, such as posters, articles,

television and radio programmes (Hochbaum, 1958: 10). Cues to action trigger

‘readiness’ (Glanz et al., 2002:49).

The degree of the required stimulus to activate an action would be determined by the

levels of motivation to change, together with the perceived benefits weighed against

the costs. Change is more likely to happen with improved education in communities

as a way to motivate youth and to advantage traditional surgeons and traditional

nurses who have undergone a proper training about the practice. They are more

likely to practise in a safer way, understanding the social, psychological and

biological changes in the human body and the impact of poor practices of

circumcision and caring for initiates’ wounds in the lodge. In addition, they would

have a better understanding of the physiological and pathological mechanisms

behind the development of certain conditions that at times lead to disability or even

death.

Self-efficacy is defined shortly as confidence in one’s potential to take action (Glanz

et al., 2002: 48).

As based on the framework of this study, the perceived threat of disease with the

help of cues to an action, such as raised awareness, can motivate communities to

consider other ways of preventing complications and deaths of initiates. However,

the likelihood of individuals in the communities considering recommended health

actions may depend on the benefits weighed against the barriers to action and

modifying factors such as age, level of education, personality, social class,

knowledge about the disease and related experiences of that disease. Therefore,

this theoretical framework is focuses more on prevention and bringing about a

13

change in health behavioural practices in communities and in health-care related

settings.

Perceived

susceptibility to

disease

Perceived

seriousness of the

disease

CUES TO ACTION

1. Raised awareness - for example,

mass media campaigns,

newspapers etc.

2. Personal advice - for instance a

reminder from a health

professional.

3. Personal symptoms

4. Illness of a friend or family

member

Perceived benefits of

taking action against

barriers to action

14

Figure 1.1: The health belief model (Hochbaum 1958: 09-19; Glanz 2002: 49).

1.9 DEFINITION OF TERMS

Adverse outcomes

In this study, adverse outcomes refer to ill-health, loss of genital organs or death,

resulting from surgical removal of the foreskin and poor post-surgery management of

circumcision in a traditional setting.

“Unintended injuries caused by medical management rather than the disease

process” (Vincent, Neale, Woloshynowych, 2001).

Circumcision

The surgical removal of the prepuce by a surgeon usually for medical or cultural

reasons. In AmaXhosa tradition, circumcision refers to a ritual that is routinely

performed to mark the boy’s maturity, and it indicates a rite of passage for the

adolescent male from boyhood to manhood (Mogotlane, Ntlangulela & Ogunbanjo,

2004: 60).

Control and prevention of infection

Control and prevention of infection depends on a knowledge-based approach and

applicable methods planned to prevent damage caused by an infection to initiates

and those who take care of them (WHO, 2019).

“Evidence based practices and procedures that, when applied consistently in health

care settings, can prevent or reduce the risk of infection in clients/patients/residents,

health care providers and visitors” (PIDAC, 2009).

15

Infection

The invasion of an organism’s body tissues by disease caused by either bacterial or

viral agents.

“The entry and multiplication of an infectious agent in the tissues of the host”(PIDAC,

2009).

Prevalent

Refers to something that is widespread or existing commonly in a certain area at a

specific time (Smith, 2000).

Traditional male circumcision

The surgical removal of the male’s foreskin out of a hospital environment, by a non-

medically trained surgeon for traditional reasons.

Meissner and Buso (2007) define traditional male circumcision as “a rite of passage

that prepares the initiate for transition to manhood”.

Traditional Nurse

A male person who is usually selected by the community members to look after

initiates. A traditional nurse performs wound dressings and regularly monitors the

progress of wound healing. Mogotlane, Ntlangulela and Ogunbanjo (2004) refer to

traditional nurses as “traditional attendants”.

Traditional Surgeon

A traditional surgeon is someone who performs the surgical removal of the foreskin

in fulfilment of the ritual without having a formal education qualification.

16

According to WHO (2010), a traditional surgeon is a traditional provider who

performs traditional male circumcision in a non-clinical setting for cultural reasons

without any formal medical training.

Traditionally Circumcised Men

These men have undergone traditional circumcision as a rite of passage from

boyhood to manhood. They are meant to take above average social responsibilities,

make sound decisions, respect the elderly, bring order in family disagreements and

do away with childish behaviour (Vincent, 2008a: 438).

“Ulwaluko”

Ulwaluko is the isiXhosa term used to describe traditional male circumcision. It is

defined as an initiation into manhood and is an ancient initiation rite of passage from

boyhood to manhood. This ritual is traditionally intended to teach and prepare young

males for the responsibilities of manhood (Rijken & Dakwa, 2013: 01).

“Umdlanga”

“Umdlanga” refers to the spear that is used by traditional surgeons to cut the foreskin

from an uncircumcised male for traditional reasons. Mogotlane, Ntlangulela &

Ogunbanjo (2004) describe “umdlanga” as the “traditional spear”.

1.10 OUTLINE OF THE DISSERTATION

Chapter One provides an introduction and gives the background of the study, the

problem statement, purpose of the study, objectives, research questions,

significance of the study, delimitations, theoretical framework, definition of key

functional terms and an outline of the study.

17

Chapter Two presents the literature review of the study. Under the review of

literature the cultural significance of traditional male circumcision, traditional legal

considerations of circumcision, the secrecy of traditional male circumcision, food

restrictions, traditional medicine used for wound healing, prevention and control of

infections, complications of circumcision and the risks of contracting HIV in the

process of circumcision are discussed.

Chapter Three - the research methodology of the study is described in this chapter.

The research design, target population, sample, and sampling procedure,

measurement or instrument, data collection, trustworthiness, ethical considerations

and data analysis are provided.

Chapter Four discusses the divergent responses concerning aseptic techniques and

the extent of knowledge of traditional surgeons and nurses about human anatomy

and the physiological process during circumcision.

Chapter Five presents and discusses the findings emerging from the study. It then

draws the conclusion, based on the study findings.

18

CHAPTER TWO

LITERATURE REVIEW

2.1 INTRODUCTIONThe review of literature for this study focuses on investigations of traditional

surgeons’ and amakhankathas’ (traditional nurses’) practices and their impact on the

outcomes or morbidity during circumcision in the initiation schools in the Eastern

Cape. The literature review critically discusses previous studies under the following

subheadings: (1) cultural and social aspects of “ulwaluko” (circumcision); (2) legal

considerations of ulwaluko; (3) secrecy of “ulwaluko”;. (4) food “taboos”; (5) healing

medicine; (6) control of infection by traditional surgeons and nurses (7)

Complications of “ulwaluko”; and (8) the risk of contracting HIV.

2.2 CULTURAL AND SOCIAL SIGNIFICANCE OF “ULWALUKO”(CIRCUMCISION).

Culturally and socially, male circumcision is assumed to signify the rite of passage

from boyhood into manhood, the gaining of social status, the right to take certain

responsibilities at home and in the community. It is believed to be a mark of identity.

For example, a man who has not undergone traditional male circumcision in the

AmaXhosa culture, is less likely to inherit his father’s possessions.

Traditional male circumcision is mainly performed by experienced traditional

surgeons who, the community believes, is good at his job. It is traditionally believed

that AmaXhosa men do not have to be attended to by female nurses in hospitals.

The initiates are not allowed to be seen by women of the community, understandably,

because in AmaXhosa tradition, male circumcision is a secret ritual (Dold & Cocks,

2012: 97).

However, the tradition seems to be ignorant of the prevalent complications and

morbidity associated with “ulwaluko”. Ironically, the complications that occur from

the traditional circumcision practice are eventually more likely to result in the initiates

being attended to by clinical nurses and clinical surgeons. This suggests that

19

working together with trained clinical surgeons and nurses at an early stage could

reduce the common complications and deaths.

According to the study conducted at St Lucy’s Hospital by Anike, Govender,

Ndimand & Tumbo (2013/14: 05), genital sepsis is the most common complication

among the initiates who are hospitalised; and there is a need for traditional surgeons

to be trained on safe techniques and the use of hygienic practices to reduce

complications commonly identified in the study.

2.3 TRADITIONAL LEGAL CONSIDERATIONS OF ‘’ULWALUKO”(CIRCUMCISION).

Originally, traditional surgeons were individuals who were recognised by the

communities as experienced surgeons in the practice of traditional circumcision.

However, the prevalence of complications and deaths of young boys undergoing

traditional male circumcisions among the AmaXhosa has resulted in government

intervening in the process. This has led to some conflict between the government

and the traditional leaders who complain that they were not part of the conclusions

reached by the government, based on traditional circumcision changes (Kepe, 2010:

732). One example of changes government has made, is that traditional surgeons

must be registered with the Department of Health in order to perform traditional male

circumcision. The same author further states that those who illegally perform the

surgical practice of male circumcision should be arrested and illegal initiation schools

should be shut down. Hospitalisation of initiates has increased in numbers, most

probably because initiates found with illnesses resulting from illegal initiation schools

are taken to hospital by the health monitors of the Department of Health (Kepe, 2010:

732; WHO, 2008: 28).

However, there still seem to be illegal practices of traditional male circumcision. For

example, 20 initiates died in Mpumalanga Province in 2013 and the causes of death

were haemorrhage, and hypothermia, which are preventable conditions (Sapa, 2013:

01). Moreover, health workers are still not fully involved in the traditional male

circumcision. The increase in number of initiation schools is linked to financial

benefits to those who claim to be traditional surgeons. It is well known that

20

traditional circumcision is taken care of by traditional leaders, but some misuse the

word “culture” and led the health minister to pronounce these surgeons

“culturepreneurs” because they profit from the practice (Sapa, 2013: 01).

Further, it was stated by the COGTA deputy minister, Obed Bapela, that there is

currently no legislative provision enabling the state to prosecute illegal circumcision.

However, the government is working to develop legislation that will deal with illegal

circumcision and initiation schools (Feketha, 2014: 05).

The age at which young boys are legally permitted to undergo male circumcision is

16 or older with the signed consent of a legal guardian or parent or with the relevant

religious or medical reasons. However, a boy of 18 or more was given the legal right

to sign consent for himself (WHO, 2010: 11). The same author states that it is

recommended in the policy, that those who are about to undergo the process of

circumcision should first undergo a physical examination by an authorised physician

to ensure that his health is good enough for him to be circumcised.

However, there seems to be no clarity on specific medical conditions that might

exclude an individual from the ritual. It is also not clear whether the choice remains

with the client or his parents, in the case of minors, to undergo the circumcision

regardless of his health status as per the medical examination.

According to Deacon and Thomson (2012: 13), some boys are forced to undergo

traditional circumcision at puberty, even though they might prefer a medical

circumcision. This violates the South African Children’s Right Charter that stipulates

children have the right to freedom to practise their own culture, religion and beliefs

without fear.

According to Deacon et al. (2012); The Sunday Times, 27 Jan (2008); and Huisman

(2009) an 18 year-old boy was forced by his father to go for traditional male

circumcision. The boy maintained that his Christian religion did not allow any

procedure involving blood in association with the ancestors (The Sunday Times, 27

Jan 2008). This is basically the violation of the young man’s rights to freely perform

his religious and cultural practices without being interfered with. In this instance, the

case was open by the boy against his father (The Sunday Times, 27 Jan 2008). It is

also stated that traditional leaders themselves did not acknowledge that a child has

21

the right to decide on the type of circumcision he wants to follow. Those who refuse

to undergo traditional circumcision are often totally exorcised by their community

(Huisman, 2009). This is clearly in contradiction of the South African Children’s Right

Charter.

2.4 SECRECY OF MALE CIRCUMCISION

The ritual teachings are not shared with the uncircumcised or with men who have

undergone male medical circumcision (MMC). They are excluded from the important

gatherings of men about the initiation schools and other important cultural practices.

AmaXhosa traditional male circumcision is sacred and there is much secrecy that it

is respected by those who practise it. There are limitations imposed within the

context of traditional male circumcision practice among the isiXhosa speaking tribe.

These include the involvement of women, uncircumcised males and medically

circumcised males. Male medical circumcision practice is stigmatised because it

involves anaesthesia and is assumed to be performed in the presence of female

nurses and female doctors.

It is for instance, believed that women are associated with uncleanliness (“umlaza”)

and in association with this statement, men who have recently been involved in

sexual practice are not allowed to attend the initiates because they carry those

impurities from their female partners (Kepe, 2010: 732).

However, Kepe (2010) continues with the argument that, “the very concepts of

tradition and ritual imply that there is a history to the practice, yet it would be foolish

to assume that traditions and rituals do not change as societies change”.

This indicates that traditional circumcision should go along with the present research

to improve the practice of health- based care to avoid putting initiates at risk of

infections, complications and morbidity.

22

2.5 FOOD TABOOS

Initiates are traditionally forbidden to consume salty foods and water for the first eight

days post circumcision. Only hard food is allowed because it is believed that water

causes painful micturition and more bleeding (ukucobela) from the operation site

(Casement, 2018; Bullock, 2015). This evidence shows that lack of education is

having other influences based on the practice of traditional male circumcision. In

their study, Mogotlane, Ntlangulela & Ogunbanjo (2004) report that initiates

verbalised the restrictions on drinking water and eating salty foods, including meat.

Unfortunately, in some regions, initiates are restricted from eating eggs and meat,

which are scientifically proven sources of protein which facilitate the healing process

of wounds. According to the WHO (2008: 29), traditional surgeons and nurses

ignore the anatomical significance of the procedure, wound dressing techniques,

food that is richer in protein to facilitate wound healing, and arising health conditions

are not taken seriously as medical conditions that need urgent medical attention. As

a result, initiates die every year. For example, a 15-year-old initiate from East

London (Duncan Village) died at the Gompo Initiation School after complaining of

severe chest pain and respiratory problems. The traditional surgeon called the father.

However, when the father came to the lodge the initiate told him that he was feeling

much better. Then after a while, the pain and the difficulty in breathing became

worse and the ambulance and police were called in, but when they arrived at the

scene, the initiate has already passed on. This is likely to instil psychological trauma

to the parents as well as fellow initiates, who had to watch their friend dying and

being taken away from them as a corpse (Mukhuthu, 2014: 02).

Despite common practice, the policy of male circumcision in the Eastern Cape,

states that it is illegal to deprive “abakhwetha” (initiates) of water to drink as one of

the common complications among the initiates is dehydration (WHO, 2008: 13).

23

2.6 HEALING MEDICINE

In traditional circumcision, medicinal plants called isichwe (everlasting) are used as

an anti-septic and ishwadi (sore eye flower) is used to heal the wounds of initiates.

The ishwadi plant, which is used to stop bleeding, is normally gathered by a

traditional nurse a month before the circumcision and is left to dry out in the kraal in

readiness for use (Dold & Cocks, 2012: 96).

2.7 CONTROL AND PREVENTION OF INFECTION

In a traditional male circumcision, it is probable that sterility is not maintained. This

might include the use of sterile gloves during the procedure and the use of a sterile

cutting object called ‘’umdlanga”. The changing of wound dressings by one

traditional nurse from the first initiate to the last, without washing his hands can

introduce infection through contamination, the repeated use of ‘’ityeba’’ (bandage)

that has been washed with ordinary soap can also expose initiates to infection of the

circumcision wound. However, there is no scientific evidence to support or criticise

whether traditional surgeons and nurses apply aseptic techniques during the wound

care of initiates.

The assumption that one “umdlanga”(knife or assegai) is used by traditional surgeon

to circumcise many different initiates without its being sterilised is more likely to

expose the boys to infectious diseases, in particular HIV, Hepatitis C Virus (HCV)

and HBV. (Sedar, Derek, Unic, Marijancevic, Markovic, Primorac & Petrovecki, 2013:

150).

Moreover, the unwillingness to use medical equipment and the lack of education,

knowledge and the reluctance of traditional surgeons to work together with the

Department of Health, as well as the scarcity of resources, is likely to interfere with

the control of infection in the AmaXhosa traditional circumcision practice.

Interestingly, the study conducted by Peltzer, Nqeketo, Petros and Kanta (2008a)

reports that most traditional surgeons and nurses who were trained on ten modules

(safe circumcision, infection control, sexual health education, detection and early

24

management of complications, anatomy and post-operative care) over five days

wore gloves during operations and care but did not use the recommended

instruments. High rates of complications were found in this study and as a result, it

showed little support of the benefits of traditional male circumcision.

Currently, no studies showing evidence of the acknowledgement of the importance

of hand hygiene by traditional surgeons and nurses before and after they attend to

initiates. Peltzer et al. (2008a) report that only some of the surgeons and nurses

wore gloves but they did not clarify whether the gloves were changed between

initiates. It was not clear whether the gloves used were sterile or not. The routine

according to which bandages were changed during wound dressings was not

mentioned to their study. The use of dirty bandages can introduce infection to the

initiates’ wounds. The nature of the cutting objects used was different from one

initiate to another. However, it was not clear whether these objects were used

repeatedly on different initiates. Lastly, there is no clarity as to whether the

instruments used were sterile or not.

2.8 COMPLICATIONS OF “ULWALUKO” (CIRCUMCISION)

Traditional surgeons do not usually undergo any formal training to perform their job.

They use their own traditional skills and circumcision techniques. This may result in

initiates’ lives being at risk because of the traditional surgeons’ lack of knowledge

about the anatomical and physiological aspects of the procedure, its complications

and their management.

The extent in which the ‘’ityeba” (bandage) is tightly applied around the penis is likely

to interfere with the blood circulation to the glans penis by severely constricting blood

vessels. As a result, gangrenous penile tissue may form from insufficient

oxygenation.

Wilcken, Keil and Dick (2010: 908) claim that four of the 45 admitted patients lost

the glans of the penis and two patients lost the entire penis. “In this study, 93% of

the 45 subjects presented with some form of penile injury resulting, not necessarily

from the circumcision procedure itself, but from poor post-operative wound care”

25

(Wilcken et al., 2010: 908). Other complications are linked to the poor practice of

traditional surgeons, for instance, excessive bleeding is more likely to be witnessed

when the penile shaft skin is excessively removed or the glans penis is cut off by

surgeon (Wilcken et al., 2010: 908; WHO, 2008: 29).

In AmaXhosa traditional male circumcision fluid intake is normally restricted to

minimal amounts because it is traditionally believed that fluid intake causes more

“icobelo”(bleeding) from the operation site. Based on this belief, initiates may

become dehydrated and eventually die. According to Wilcken et al. (2010: 908)

dehydration was found to be a common cause of death.

2.9 RISKS OF CONTRACTING HUMAN IMMUNODEFICIENCY VIRUS

The Brown, Venkataramani, Nattrass, Phil, Seekings and Whiteside (2011) study

argues that there is more risk of contracting HIV amongst individuals whose

foreskins have not been removed at all and amongst those with partially removed

foreskins. However, complete removal of the foreskin proved to be more important in

the reduction of HIV among males. They further maintain that partial removal of the

foreskin is more common among young men who have experienced traditional male

circumcision. Consequently, medical male circumcision was considered a more

protective and safer practice in reducing the chances of HIV infection among

circumcised men. According to Vincent (2008a), the cutting of the foreskin

contributes to the reduction of HIV infection by removing cells that are particularly

susceptible to contracting HIV. The same authors further state that there is an

impression that the circumcised penis develops a thicker layer of skin, which is

resistant to HIV infection.

The younger the age of the person undergoing male circumcision, the lower the

chances of contracting HIV (Brown et al., 2011: 503). The results of this study, as

indicated above encourages medical male circumcision (MMC) at very young age,

for example, the circumcision of infants is regarded as a more advantageous

practice than those who are circumcised during adolescence.

26

Most men who were traditionally circumcised prefer TMC over male medical

circumcision (Brown et al., 2011: 501). However, with the knowledge of the benefits

of MMC, a few traditionally circumcised men have indicated a preference for

MMC(Brown et al., 2011: 501).

It seems that despite the on-going research knowledge and the existing laws about

circumcision, there are still challenges resulting from traditional male circumcision.

For example, the fact that there are still complications resulting from circumcision

malpractices and unauthorised surgeons circumcise boys as young as eight,

suggests that enforced parental education about the route that they should follow

when their children are about to undergo circumcision is needed to protect their

children against these surgeons. In addition, the children themselves should be

warned (Sapa, 2013: 01).

“Last year, around 400 000 initiates underwent the rites of passage, with just over

20 000 being illegal initiates who were either under age or had no permission from

parents or traditional leaders. Over 80 initiates died, while 31 had their penises

amputated. A further 670 were admitted to hospital and four initiates lost their lives in

East London Hospitals and Qawukeni. The death of initiates was largely caused by

septicaemia, dehydration, gangrene, kidney problems and abuse, according to the

EC DoH” (Ludidi, 2014: 01). Children and communities also need to be empowered

because the lives of the children are at risk of illegal circumcision that might result in

these young boys dying, while measures to prevent these deaths are believed to be

available.

For example, the provincial health spokesperson said that there was a case where

the Department of Health officials were doing random checks and were denied

access by the parents to one of the illegal initiation schools. As a result one initiate

died the following day (Feni, 2014b: 01). These people should be held liable and the

law should take its course to punish them because they are costing the lives of

young men.

In one of the initiation schools at kwa-Dosi village, close to Mthatha, traditional

nurses were found drunk and could hardly manage to move (Feni, 2014b: 01). This

suggests an urgent need for professionally trained traditional nurse to look after

initiates with regulations to guide their practice. No one dealing with life and death

27

situations should be caught drunk at the workplace. These people are not mentally

or physically fit to take care of the initiates.

There also seems to be difficulty in implementing health strategies for the prevention

of infections that occur in the practice of traditional male circumcision. This might be

because of the cultural differences between the Department of Health and the

communities that practise traditional male circumcision as a rite of passage from

boyhood to manhood. Some of the differences may arise a result of the fact that the

ritual is sacred and there is secrecy behind its practice (Nkosi, 2013:126).

Traditional male circumcision should be formalised and centralised to ensure

identifiable initiation school locations. Traditional surgeons and traditional nurses

should undergo proper formal training. The training should be long enough to allow

enough time for both theoretical training and practical exposure to ensure that

initiates will be safe from complications and death related to the traditional practice.

It was stated in The Daily Dispatch newspaper that the government is being urged to

include into policy the availability of first-aid training and kits for traditional surgeons,

traditional healers and clean running water points at circumcision sites and tap water

for nurses who help initiates (Feketha, 2014: 05).

Most of the studies seem to focus on the prevalence of specific conditions that

initiates tend to acquire rather than looking at the major causative factors regarding

the practice of traditional surgeons and nurses. They do not specify the procedures

and curricula, which the training of traditional surgeons and nurses should be

focusing on. Furthermore, it is not clear what practical changes could be made in the

environment where contagious practices are evident. For example, from a medical

perspective, when wound dressing is carried out, a sterile field is normally

considered important to prevent contamination from unsterile objects. Few studies

specify significant physiological mechanisms behind the development of the sepsis

and other complications.

However, bringing change in the traditional circumcision practice among the

AmaXhosa population is not easy. This is because they have been practising this

ritual since the times of their ancestors and the male traditional circumcision is still

considered a valuable practice in AmaXhosa tradition.

28

According to Burns and Grove (1993: 683), within the social system there are forces

that promote social stability as well as forces that resist change.

2.10 SUMMARY

In this chapter, literature was reviewed, and the cultural and social aspects of

circumcision have been discussed, as well as the legal considerations of

circumcision, the secrecy of TMC, food restrictions, healing medicines, control of

infection by traditional surgeons and nurses, medical and surgical complications of

TMC and the risk of contracting HIV was also considered. The design and the

methodology of this study are discussed in the following chapter.

29

CHAPTER THREE

RESEARCH METHODS

3.1 INTRODUCTION

This chapter describes the methodology and design utilised in this study. It further

describes the research design, population, sample and sampling procedure,

instrument of measurement, collection of data, trustworthiness, ethical

considerations and an analysis of the data.

3.2 RESEARCH DESIGN

The study uses a qualitative method and an exploratory research design. Semi-

structured interviews of traditional surgeons, nurses and traditionally circumcised

men, with one focus group interview in the study area, were conducted.

3.3 POPULATION

The target population was both traditional surgeons and nurses aged between 18

and 90, as well as traditionally circumcised males aged between 16 and 35.

3.4 SAMPLE AND SAMPLING PROCEDURE

This study has adopted purposive and snowballing sampling techniques. A

purposive sampling method was used to select 47 traditionally circumcised men.

Purposive sampling was adopted because the researcher wanted to target the most

knowledgeable participants about Male Traditional Circumcision (MTC). Access to

the traditional nurses and surgeons was limited and, given the sensitivity of the topic,

the researcher adopted a snowballing sampling technique to reach this group of

study participants. Thirty traditional surgeons were selected using this technique.

The researcher was able to identify a traditional surgeon in the community after

30

discussion with the community elders. At the end of the interview, this traditional

surgeon was asked to refer the researcher to other traditional surgeons. Every

traditional surgeon was asked to refer the researcher to another traditional surgeon

until the sample size of 30 was reached. The snowballing sampling technique was

also used to select 45 traditional nurses. Data collection ceased when data

saturation was reached.

3.4.1 Inclusion and exclusion criteria

Participants were included in the study if they were registered traditional surgeons

aged between 18 and 90; traditional nurses aged between 18 and 90, and

traditionally circumcised men aged between 16 and 35. Non- circumcised males;

medically circumcised males; non-registered traditional surgeons; women or females

and children; and mentally challenged individuals were excluded from the study.

3.5 MEASUREMENT INSTRUMENT

Focus group interviews and semi-structured interviews with video tapes were used.

The researcher developed interview guides to guide the focus group interview and

the semi-structured interviews. The following questions were asked:

What measures do traditional surgeons use to sterilise their surgical instruments

for circumcision?

What do you do to prevent excessive bleeding?

Do traditional surgeons tighten the bandage around the penis?

Do traditional nurses tighten the bandage during wound dressings?

Are the initiates allowed to drink water?

How would you describe the conditions under which the traditional surgeons

perform circumcision?

31

What measures do traditional nurses used to sterilise their surgical instruments

for circumcision?

What measures are taken to safeguard the health of the initiates after

circumcision?

How would you describe the conditions of the lodge where the initiates are kept

after circumcision?

3.6 DATA COLLECTION

Data was collected through one focus group interview of seven traditional nurses

and 115 semi-structured interviews of 45 traditional nurses, 30 traditional surgeons

and 47 traditionally circumcised men were conducted in a quiet, private setting. The

researcher asked permission from the participants prior to the commencement of

each interview session. The interviews were facilitated by the researcher. During

data collection the researcher asked open-ended questions using a self-structured

questionnaire –interview guide. The questionnaire was written in English, which

meant that the researcher had to translate what was written in the questionnaire for

the participants in order for them to clearly understand the content. The focus group

interview with the traditional nurses lasted for 21 minutes 48 seconds. The semi-

structured interviews with traditional surgeons, nurses and traditionally circumcised

men lasted between 07:37 and 23: 06 minutes per session. Participants were free to

ask questions; share their experiences, views, emotions and wishes about the topic

under investigation without fear of intimidation. Instead of taking notes, the

researcher used video tapes and recording software to record the information from

the participants, but no participants’ images were captured in the process.

The researcher asked the participants about the use of surgical gloves during

surgical removal of the foreskin and wound dressings. He also investigated whether

the circumcision instruments were sterile and whether one circumcision instrument

was used to circumcise more than one initiate without its being sterilised. The

researcher asked about the cleanliness of the environment in which the circumcision

32

process took place. In assessing the level of understanding of human physiological

processes, the participants were requested to explain whether the bandage was

tightly applied around the penis, and if the initiates were free to drink clean water.

3.7 TRUSTWORTHINESS

Ensuring data quality in a qualitative study is very important. The researcher

established credibility, confirmability, dependability and transferability of this study

in the following ways:

3.7.1 Credibility

Long lasting engagement: data was collected until there was no more new

information from the participants (data saturation reached). Also, the researcher

established rapport with the participants, which made the interview atmosphere more

relaxed.

Negative case analysis: the researcher ensured that the analysis was done in sucha way that all voices were represented. Both positive and divergent views were

captured in the analysis.

Referral adequacy: the researcher continued to ask for referrals from participants

until the data saturation was reached.

Constant observation was maintained by continually interpreting data in different

ways to determine what added up and what did not.

Peer debriefing: Throughout the period of data collection, the researcher kept in

touch with the supervisor to discuss challenges and to gain insight. Through this, the

researcher modified his techniques and styles of questioning to ensure accurate data

were gathered.

Member checks. The researcher assessed the intentionality of participants torectify noticeable errors and provide additional information.

3.7.2 Confirmability

The idea of confirmability is the qualitative researcher’s comparable concern to

neutrality (Shenton, 2004). The researcher ensured that bias was eliminated from

33

the study by excluding his own ideas about the topic under investigation. Both

positive and negative contributions of ideas from the interviews of participants were

documented without compromising either. The data were collected from participants

with experience and knowledge of the phenomenon under study.

3.7.3 Transferability

According to Lincoln and Guba (1985), transferability is a way of achieving external

validity in qualitative research. The authors explain that by describing a

phenomenon in sufficient detail one can begin to evaluate the extent to which the

conclusions drawn are transferable to other times, settings, situations and people.

To enhance transferability in this study, the researcher provided a full description of

the research context and the assumptions about the phenomenon being studied.

3.7.4 Dependability

According to Shenton (2004), dependability entails the researcher’s applying

techniques that, if the study was to be done once again, in the same setting, using

the same methods, and with similar participants’ comparable results would be

achieved. “External audits involve having a researcher not involved in the research

process examine both the process and product of the research study. The purpose

is to evaluate the accuracy and evaluate whether or not the findings, interpretations

and conclusions are supported by the data” (Lincoln & Guba, 1985).

In this study, dependability was ensured through regular checks for possible errors

that might have occurred during the process of transcription. It was ensured that the

content of transcription did not lose the actual meaning of the original themes. The

researcher also ensured consistency in the presentation of such themes.

3.8 ETHICAL CONSIDERATIONS

The rights of the participants were protected, and the ethical standards were

adhered to. The University of Fort Hare Ethical Review Committee granted ethical

approval (GOO011SDAL01) for the study. All participants signed a written informed

consent form to indicate their willingness to participate in the study. The rights of

34

participants to privacy, anonymity and confidentiality, to be treated fairly, to self-

determination and the right to protection from discomfort and harm were ensured

(Brink, Van Der Walt & Rensburg, 2013: 34).

3.8.1 The principle of respect for persons

The individual participants were aware that their decisions whether to take part in the

study or not carried no risk of punishment or harmful treatment.

The researcher respected the participants’ right to withdraw from the study at any

time in the process or to refuse to provide information or to ask for clarity about the

aim of the study. The participants voluntarily decided whether to participate in the

study or not.

In some rural African communities and religious groups, individuals may not be

regarded as independent, and the researcher had to respect this traditional practice

without ignoring the human rights of vulnerable participants (Brink et al., 2013: 35).

In keeping with the University’s reputation, the researcher treated every participant

with respect and kindness to avoid any negative attitude from the participants

towards the researcher which might eventually impact on the University (Brink et al.,

2013: 35).

3.8.2 Principle of no harm to subjects

The physical, social, emotional or psychological well-being of all the participants was

secured by the researcher to ensure that there was no harm or discomfort to any of

them. This principle was ensured by protecting the image of persons through the use

of voice recordings and temporary names, instead of cameras showing the identity of

persons and using real names. The interviews were conducted in isolation from

peers to allow ease of communication and safety from social criticism and judgement.

3.8.3 Principle of justice

The selection of the participants by the researcher was directly based on individuals

who were able to provide information related to the research problem. There were no

participants taken advantage of just because they could be easily manipulated to be

35

part of the study. The researcher treated each one of the participants in the same

way without any judgements or favours to benefit certain individual participants.

3.8.4 The principle of anonymity and confidentiality

The right to privacy and confidentiality of the participants was adhered to. For

example, in the case where a participant verbally stated the extent to which the

information he gave could be shared, the researcher respected this right. The

researcher explained to the participants that the information received from them

would remain anonymous (nameless or private) and confidential. This was ensured

by using temporary names for each participant with their matching codes to protect

their real names; the list of real names was destroyed. No photographs or video

footage showing faces were used in the process of data collection to protect the

image of the participants. If it happened that a video camera or recordings were used,

then the researcher had to take the responsibility to keep them in a secure place.

During the data discussions temporary names were used to identify the participants

(Brink et al., 2013:36). The researcher kept all the recorded information in a safe

locker to which no one had access without the permission of the participants or the

researcher.

3.8.5 Informed consent

The researcher read and verbally clarified to the participants what was written in the

consent form, with a second official person to witness whether the participant had

understood and agreed to what was explained to him before signing the consent

form. Hence, written consent was obtained from all the participants in this study.

3.9 DATA ANALYSIS

Data were transcribed and translated to English verbatim. To ensure validity, two

independent qualitative researchers assessed the translations to ensure their

accuracy. Thematic content analysis was used for data analysis. All responses were

read for familiarisation with the data. At this stage, codes and themes had not yet

been developed. Two of the authors independently coded the data after reading the

responses. The research team then met to review the codes and themes before

36

agreeing on the themes. Content analysis was used to ensure that all relevant

information was grouped and coded appropriately.

37

CHAPTER FOUR

PRESENTATION OF FINDINGS

4.1 INTRODUCTION

In the previous chapter, the research methodology of the study was discussed. This

chapter presents the findings of the study derived from the data analysis. The

findings use verbatim quotes relating to the study objectives. The demographic

information of the participants is presented first in order to provide a background for

the subsequent findings.

4.2 DEMOGRAPHIC CHARACTERISTICS OF STUDY PARTICIPANTS

Table 4.1. Demographic characteristics of the participants in the qualitativestudy.Variables Initiat

esn=47

TraditionalSurgeonn=30

Traditional Nursesn=45

Sampledpopulation(n)

Age (years)16-20 13 1 1 15

21-30 26 2 27 55

31-40 2 14 17 32

41-50 1 9 0 10

51-60 0 0 0 0

61-70 0 1 0 1

81-90 0 3 0 2

Black race 47 30 45 122

MunicipalityMthatha 4 11 1 16

Libode 25 9 21 55

Lusikisiki 18 9 23 50

38

Level of educationTertiary 8 2 2 12

Grade 12-11 22 6 12 40

Grade 11-10 7 6 9 22

Grade 10-9 8 8 4 19

Grade 9-8 1 2 4 7

Grade 8-7 0 1 3 4

Grade 7-6 0 2 2 3

Grade 6-5 0 0 2 2

Grade 4-3 1 1 0 2

Grade 2-1 0 2 0 2

Did you stay in a shelterwithin the community?

No 31 23 30 84

Yes 13 5 15 33

Did you stay in a hut inthe bush?

No 11 5 9 25

Yes 33 25 29 87

TOTAL n=122

Table 4.1 presents the demographic characteristics of the participants. A total of 122

participants took part in the study; 47 traditionally circumcised men, 30 traditional

surgeons and 45 traditional nurses. Of the 47 traditionally circumcised men, 44 were

between the ages of 16 and 30; 32 had a grade 9 to 12 level of education; and 35

lived in a bush hut during the period of circumcision. Pertaining to the traditional

surgeons, most (22) of them were between the ages of 31 and 50 and 25 lived in a

hut in the bush. Half of the traditional surgeons had a grade 3-4 level of education.

Slightly more than half of the traditional nurses were between the ages of 21 and 30.

A significant majority of the 29 traditional nurses lived in a hut in the bush and all of

them had at least a grade 5 level of education.

39

Amongst the 116 interviews conducted during the study, 115 were semi-structured

interviews with 30 traditional surgeons, 47 traditionally circumcised men, 38

traditional nurses and one interview of seven participants was conducted as a focus

group interview of traditional nurses. All participants were of black South African

origin from the O. R. Tambo region in the Eastern Cape.

4.3 ASSESSMENT OF ASEPTIC TECHNIQUES USED BY TRADITIONALSURGEONS AND NURSES DURING TRADITIONAL CIRCUMCISION

PROCESSES

4.3.1 Use of surgical gloves

Most traditional surgeons stated that they used gloves, and that they changed them

for every initiate they attended. However, the majority of the traditionally circumcised

men disagreed that the traditional surgeons had used gloves. Most of them stated

that those who happened to use gloves did not change them between initiates. One

traditionally circumcised man only realised at the time of the interview that the

traditional surgeon who circumcised him had not used gloves, and he stated that:

“He never used gloves, it is only now that I see that traditional surgeon was stupid,

he was drunk” (In-depth interview, traditional circumcised man, Participant 5).

In contrast, the majority of of both traditionally circumcised men and traditional

nurses maintained that traditional nurses did not use gloves, and the few who

happened to use them, did not change them between initiates attended to during

wound dressings.

4.3.2 Cleanliness and sterilisation of circumcision instrument

When asked whether they sterilised their instruments, most traditional surgeons

claimed that they sterilised their assegai. The traditional surgeons’ responses

confirmed that they cleaned their assegais after use. This is evident from the

response of an old traditional surgeon who had been practising since 1972:

“I clean my assegais using spirit and a soap that I got from health department but I

do not know its name” (In-depth interview, traditional surgeon, participant 1).

40

However, most traditionally circumcised men were of the opinion that the

circumcision instruments were unclean and unsterilised.

4.3.3 Cleanliness of the seclusion lodge

The results generally showed that the temporary seclusion lodge was dirty and not fit

for habitation. One traditionally circumcised man explained that they were made to

sit and sleep on the ground and that insects bit them. Others simply stated that the

environment was dirty. Another traditionally circumcised man described the

environment as unclean. He said that he did not think that a professional doctor

would approve of any human beings staying in the temporary seclusion lodges. This

is because initiates excreted urine inside the lodge. Despite urinating in the seclusion

lodge, their food was served and eaten in the dirty environment. Moreover, the

processes such as wound dressings and caring for the initiates goes on concurrently

in the same place. This, according to the participant, would indicate to anyone that

the place itself was not a hygienic place because some individuals used the place to

smoke, rest and to sleep over night. He maintained that when people are all sleeping

in one place, it becomes foul-smelling. In addition, the traditional nurses stayed there

without bathing, which further indicates that it was not fitting place for anyone to stay.

“I don’t think a doctor would agree with the way people live there because you will

remember that initiates excrete urine there inside, eating is done there and all that

process of looking after initiates, the dressing of wounds of initiates, everything is

done there inside and that tells you that it should not be a neat place where

everything is done in one place because others are smoking, others are staying

there and others are sleeping. You will remember that when people are sleeping

there is too much odours and the traditional nurses are staying there and they do not

bath, everything which informs you that if there would be a visit from the people who

are experts, they would tell you that it is not a proper place for anyone to stay” (In-

depth interview, traditionally circumcised man, participant 2).

However, one participant, who was initiated covertly, stated that he made an effort to

clean the environment using cow dung before he was circumcised. According to

him, the once-off use of the cow dung kept the place clean for the entire two weeks

of his stay in the lodge. He went further to describe the further improvements made

to the lodge after his initiation by stating that the floor had been cemented in order to

41

store the maize and it became even neater (In-depth interview; traditional

circumcised man participant 1).

In the focus group discussion interview among traditional nurses, it was emphatically

stated that the seclusion lodge was not clean because there was no sweeping of the

floor. While some supported this statement, one traditional nurse stated on behalf of

the group that:

“Oowh! It is dirty, it is dirty, it is dirty in the seclusion lodge so that is clear that there

is work done! There is no sweeping of the floor in there you too know about that,

they said while laughing. One of them returning the question, “Was yours got

cleaned up?” The researcher laughed without responding. They continued

confirming, ‘It is dirty in the lodge, there is no cleaning done’. Laughing throughout.

They repeatedly asked the researcher the same question and laughing at the same

time, “Wait, was yours getting cleaned up?”( Focus group interview, traditional

nurses, participant 3).”

On the other hand, one among the traditionally circumcised men, participant 5, said

that his place was cleaned up before he entered as a newly circumcised initiate.

However, there was no clarity on continuous cleaning of the lodge during his period

of stay.

4.3.4 Wound dressings

Wound dressing is the main duty of the traditional nurses. In terms of the cleanliness

of the environment where wound dressing is performed, over half of the traditionally

circumcised men and traditional nurses indicated that the environment in which

traditional nurses work is not hygienically prepared prior to wound dressing. However,

the traditional surgeons stated that the main surgery of traditional male circumcision

is done in a clean environment. Most traditionally circumcised men corroborated this

view. A vast majority of the traditional surgeons and traditional nurses claimed that

the bandages are not tightly applied. However, when water appears from the penile

wound, the water is squeezed out from underneath the penis (where the wound is)

by tightening of the bandage known as ‘ityeba’ (Semi structured interview, traditional

surgeon 1).

42

In contrast, most traditionally circumcised men responded that the bandage was

tightly applied. This was confirmed repeatedly during the interviews. In describing

the effect of the tightening of the bandage, one traditionally circumcised man said:

The bandage is tightly tied around the penile wound and often make the wound to

get very sore (Semi-Structured Interview, Traditionally circumcised man, participant

3).

The tightening of the bandage often leads to the initiate experiencing pain, as

described by one of the participants: While you urinating yes it is fine and then after

traditional bandage is applied it is painful but it goes away with time and also when it

is painful on urination it gets fixed and you get better (Semi-Structured Interview,

Traditionally circumcised man, participant 4)

Likewise, participant 5 revealed that during the first two days of the seclusion period,

t felt normal, however, from the third to the eighth day, things got worse as the

bandage was tightly applied, a process he described as “ukutyanywa”.

You can feel that it is painful and some tend to consider loosening their own

bandages and therefore it becomes difficult even to pass urine because you have to

be tightly dressed with the traditional bandage (Semi structured interview,

traditionally circumcised man, participant 5).

4.3.5 Treatment of penile wound

In order to facilitate healing of septic wounds, all participants stated that there were

traditional medicines or leaves that are used; among which are ‘isichwe’ (traditional

leaf), ‘ishwadi’ (traditional medicine) and ‘ityeba’ (traditional bandage). The traditional

bandages are made from used, old clothes, cut into small strips of bandage. The

leaves and the often-used traditional bandages are not sterilised. This poses the risk

of exposure to infection. In trying to heal the wounds, the importance of aseptic

techniques is ignored by the traditional surgeons and nurses. This is possibly due to

a lack of knowledge.

“To eliminate the pus, there is one thing that is usually used within the Xhosa tribe

which is ‘isichwe’ (traditional medicinal leaf) to mention one that is used to drain the

pus completely” (In-depth interview, traditionally circumcised man, participant 2).

43

In addition, one traditionally circumcised man added that cotton wool, surgical

bandages and betadine were not used in the bush.

“There are certain leaves that are used which we cannot mention my honourable

chairperson. Yes things that are meant for treatment in accordance with the tradition.

Surgical bandages, cotton wools and beta-dines are not used there”(In-depth

interview, traditionally circumcised man, participant 5).

4.3.6 Experience of purulent penile wound

Most traditionally circumcised men stated that they had had purulent penile wounds

when they were circumcised. To some, the presence of pus in the wounds of the

initiates was taken lightly as it is perceived as an expectation of traditional

AmaXhosa male circumcision.

“Yes there was pus (ubugqutsu) and we will have to understand that it is expected

when you are there inside, more especially when you circumcised in AmaXhosa

tradition” (In-depth interview, traditionally circumcised man, participant 2).

Another participant stated that it is a must to have an infected penile wound while in

the initiation school. This indicates how lightly the presence of infection is viewed in

the tradition of AmaXhosa male circumcision.

Laughing, “It is a must that there is a pus while you are there” (In-depth interview,

traditionally circumcised man, participant 5).

4.4 SummaryThe demographic characteristics of the participants are presented in this chapter, as

well as the findings of the study, using verbatim quotes. The next chapter discusses

the findings and offers a conclusion and recommendations resulting from the study.

44

CHAPTER 5

DISCUSSION OF FINDINGS, CONCLUSION AND RECOMMENDATIONS

5.1 INTRODUCTION

The study results were interpreted in the previous chapter. The discussion of the

findings, the limitations of the study, conclusion and the study recommendations are

presented in this chapter.

5.2 DISCUSSION OF FINDINGS

This study assesses the aseptic techniques of traditional surgeons and nurses and

the cleanliness of the circumcision environment. The study has produced mixed

results. While traditional surgeons described their environment and instruments as

clean, the traditionally circumcised men disagreed. Further, the traditional surgeons

claimed that they used surgical gloves and changed the gloves for each initiate.

However, the traditionally circumcised men disagreed and often maintained that they

did not use gloves. An intervention study, which trained traditional surgeons and

nurses in the Eastern Cape on safe circumcision, infection control, anatomy, post-

operative care, detection and early management of complications and sexual health,

reveals that most traditional surgeons and nurses wore gloves during operation and

care, but did not use the recommended circumcision instruments (Peltzer, Nqeketo,

Petros & Kanta., 2008b). It is possible that many of the above-mentioned traditional

surgeons and nurses gave the response they felt was socially desirable in view of

the fact that they had been trained on the importance of using surgical gloves. The

traditionally circumcised men had no reason to misrepresent the facts considering

that they had nothing to lose, unlike the traditional surgeons. For this reason, there is

a need for proper inspection of the traditional circumcision process in the study

settings. Many circumcision-related deaths and complications could be prevented

with the proper use of gloves and a clean environment.

45

The majority of both traditionally circumcised men and traditional nurses stated that

traditional nurses did not use surgical gloves, and the few who did use them, did not

change the gloves between initiates. Rijken and Dakwa (2013) also found, in their

study of ulwaluko, that traditional nurses in Pondoland did not use gloves, and did

not wash their hands prior to circumcision. This posed the risk of infection to the

initiates. The application of universal precautions and aseptic techniques play a vital

role in the prevention of cross infections by reducing the microbial load on the wound

surface (Orsted et al., 2018).

It is strongly recommended that, when carrying out any procedures that involve the

presence of bodily fluids, such as blood, purulence, exudate, excretions and invasive

procedures, attendants wear surgical gloves to reduce the risks of acquiring

infections from either the patients or transmitting them to the patients. Surgical

gloves are a way of preventing hands from being in direct contact with the sterile

sites (Brooker & Waugh, 2013). When dressing wounds, surgical gloves must be

worn, changed and hands must be washed before and after each initiate attended to

by either traditional surgeon or nurse in order to prevent cross infections among the

initiates. This is applicable in both traditional settings and government or private

sectors that offer health care services of any kind that involve risks related to

bacterial or viral infections (Burns et al., 2006). Brooker & Waugh (2013) argue that it

is crucial to treat gloves as single use items, and then discard them immediately after

removal.

Most responses of traditional nurses and traditionally circumcised men in the study

clearly show that the temporary seclusion lodges were dirty, and that traditional

nurses and traditionally circumcised men stayed in the lodges for days without

bathing resulting in the lodges becoming foul smelling. None of the published

studies has reported on environmental cleanliness during traditional male

circumcision. According to Jill (1986), the reservoirs of environmental infections are

the air, direct contact and cross infection. This was further clarified in a hospital

setting where the air contains droplets from the nasal passages of patients, staff

personnel and visitors, as well as skin shed as they move around. When the wound

is not covered, it is exposed to microbial substances. When an occlusive dressing is

applied in a sterile environment, it helps by completely isolating the wound from the

environmental contaminants (Jill, 1986). However, there are further chances of

46

further infection through openings, such as drains, interference with the dressing or

moisture penetrating through the dressing (David, 1986).

Most traditional surgeons and traditional nurses claimed that the penile bandage was

not tightly applied and that it was only tightened when the wound was wet. However,

more than half of traditionally circumcised men responded that the bandage was

tightly applied. When muscle tissue is compressed, blood supply to the peripheral

tissues becomes diminished or they are completely deprived of oxygenation and

nutrient supply, requirements for healthy survival of such tissues (Copstead &

Banasik, 1995). Exposing muscle cells to such conditions can lead to either infection

or dry, shrunken and dark reddish to black tissue being affected. These may be

signs and symptoms of gangrene (Copstead & Banasik, 1995). Eventually the line of

separation might bring about complete separation followed by the total fall off the

gangrenous tissue, a process called auto-amputation. This happens when there is

no surgical intervention (Copstead & Banasik, 1995).

At least one study on ‘relative contributions of compression and hypoxia to

development of muscle tissue damage’ suggested that hypoxia does not evidentially

lead to cell death in a 22-hour period. Nevertheless, muscle tissue compression has

been tested further and found conclusively to cause prompt cell death which

worsened with time (Rijken & Dakwa, 2013). Dry gangrene is the result of chronic

ischemia without infection.

The results of the current study indicate that most traditionally circumcised men

developed wound sepsis while in the initiation school, and for some, it was perceived

to be a normal phase a wound had to undergo before healing.There is a delay in

wound healing and increased pain when sepsis develops. The oxygen needed for

the vital functioning of body cells is compromised for both body cells and the bacteria

present in the body; when the wound is infected, a rise in body temperature, redness

and inflammation and/or pain is normally manifested. This may also lead to extreme

anxiety, sorrow, ill health and the possibility of the patient’s death.. Furthermore, the

rendering of nursing care might be costly (Van Rooyen et al., 2009, Gethin, 2009:

05). Individuals with septic wounds experience more pain than those with non-septic

wounds (White, 2009). Hence, it is important to control infection to prevent infection

in active wounds.

47

Based on the findings of this study, close supervision of traditional surgeons and

nurses by environmental health officers and infection control personnel would be a

key factor in ensuring the use of surgical gloves and the adoption of aseptic

techniques during circumcision and post-surgery wound care. This would possibly

reduce the rate of morbidity and deaths in the process of circumcision.

A multiple-disciplinary team involved in the process of traditional male circumcision,

including environmental health officers and infection control personnel, needs to be

closely engaged in these processes. There is a need for legal seclusion lodges to be

built in places that are officially chosen by government officials. Notwithstanding,

these lodges would have to be in line with the general practices of traditional male

circumcision. Initiates should be looked after by well-trained staff, with appropriate

security measures. Strict rules on cleanliness are needed and the number of visitors

to the lodge should be limited to minimise avoidable infections.

Community leaders and government stakeholders need to encourage the public to

participate positively for such implementations to be made. It should be made clear

that the changes implemented are not meant to interfere with the processes of

traditional circumcision but to save the lives of the initiates.

5.3 STUDY LIMITATIONS

Even though this study makes an important contribution to the body of knowledge on

traditional circumcision, the findings should be interpreted within its limitations. First,

this study utilised a qualitative approach thus limiting the generalisability of the

findings. Qualitative studies are context specific, and as such, the findings of this

study may not reflect the practice of traditional surgeons throughout South Africa.

However, this study provides rich data on the aseptic techniques of traditional

surgeons and nurses in the Eastern Cape. Further, the responses are self-reported,

thus, social desirability bias cannot be ruled out in the responses of the traditional

nurses and surgeons. Nonetheless, the combination of responses of traditionally

circumcised men with that of traditional surgeons helps to mitigate this limitation.

48

Access to the community was not easy because traditional male circumcision is

secret amongst those who practise it and particularly among circumcised men.

5.4 CONCLUSION

This study has established that both traditional surgeons and nurses poorly maintain

aseptic techniques, thus, exposing initiates to infections, morbidity or death.

Concerning the issue of bandage tightening, the findings have shown mixed results.

Hence, this study concludes that instances of bandage tightening during wound

dressing be strongly discouraged.

Based on the findings of this study, it is evident that the environment in which

circumcision processes take place is exceptionally dirty. These results suggest that

the adverse outcomes resulting from traditional male circumcision are costly to both

the initiates and the government health services. Their cleanliness would benefit

both the government’s wastage of resources and the citizens’ vulnerable lives.

5.5 RECOMMENDATIONS

Traditional male circumcision stakeholders should work closely with government

departments to improve the conditions under which the traditional circumcision

practice is performed to meet acceptable standards of general health care settings.

This should, however, be done in a way that respects the tradition of male

circumcision among the AmaXhosa and AmaMpondo tribes in the Eastern Cape.

There is a need for professionally trained and knowledgeable individuals to take over

the performance of circumcision surgery and the continued nursing care of initiates

following the surgical removal of the prepuce. Traditional male circumcision should

be done in clean and well-ventilated, spacious and warm surroundings. A close

supervision of traditional surgeons and nurses by environmental health officers and

infection control personnel is therefore recommended.

49

The public of the Eastern Cape need to be convincingly educated about the current

risks of traditional male circumcisions and the significance of their threat to lives. The

pressures arising from the stereotypes of traditional male circumcision need to be

revealed. This could be achieved through health promotions and safety talk shows

on radios or through other relevant community stakeholders, such as churches,

schools and chief gatherings. The aim is to spread awareness so that young people

can make sound and independent decisions about their choice of circumcision,

without feeling pressured by either peers or family members or the community at

large.

Finally, Traditional Male Circumcision (TMC) should keep abreast of present

research to reduce the practice of health-based activities that put initiates at risk of

infections, complications or morbidity.

50

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APPENDIX A: Letter of approval from the University of Fort Hare ethicscommittee

59

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APPENDIX B: Letter of approval from the Eastern Cape Department of Health

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APPENDIX C: Letter of approval from the sub-district house of traditionalleaders in Mthatha

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APPENDIX D: Informed Consent by participant/parent/guardian

Ethics Research Confidentiality and Consent Form

Please note:

This form is to be completed by the researcher(s) as well as by the intervieweebefore the commencement of the research. Copies of the signed form must befiled and kept on record

(To be adapted for individual circumstances/needs)

Our University of Fort Hare / Department is asking people from your community /

sample / group to answer some questions, which we hope will benefit your

community and possibly other communities in the future.

I ---------------Master’s degree student at the University of Fort Hare, School of

Health Sciences, Department of Nursing Sciences is conducting research regarding

Research Project: -----We are carrying out this research to help improve the quality

of patient care. .

Please understand that you are not being forced to take part in this study and the

choice whether to participate or not is yours alone. However, we would really

appreciate it if you do share your thoughts with us. If you choose not take part in

answering these questions, you will not be affected in any way. If you agree to

participate, you may stop me at any time and tell me that you don’t want to go on

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with the interview. If you do this, there will also be no penalties and you will NOT be

prejudiced in ANY way. Confidentiality will be observed professionally.

I will not be recording your name anywhere on the questionnaire and no one will be

able to link you to the answers you give. Only the researchers will have access to the

unlinked information. The information will remain confidential and there will be no

“come-backs” from the answers you give.

The interview will last around (X?) minutes (this is to be tested through a pilot). I will

be asking you questions and ask that you are as open and honest as possible in

answering these questions. Some questions may be of a personal and/or sensitive

nature. I will be asking some questions that you may not have thought about before,

and which also involve thinking about the past or the future. We know that you

cannot be absolutely certain about the answers to these questions but we ask that

you try to think about these questions. When it comes to answering questions there

are no right and wrong answers. When we ask questions about the future we are not

interested in what you think the best thing would be to do, but what you think would

actually happen. (adapt for individual circumstances)

If possible, our organisation would like to come back to this area once we have

completed our study to inform you and your community of what the results are and

discuss our findings and proposals around the research and what this means for

people in this area.

CONSENT

I hereby agree to participate in research

regarding …………………………………………………. I understand that I am

participating freely and without being forced in any way to do so. I also understand

that I can stop this interview at any point should I not want to continue and that this

decision will not in any way affect me negatively.

I understand that this is a research project whose purpose is not necessarily to

benefit me personally.

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I have received the telephone number of a person to contact should I need to speak

about any issues which may arise in this interview.

I understand that this consent form will not be linked to the questionnaire, and that

my answers will remain confidential.

I understand that if at all possible, feedback will be given to my community on the

results of the completed research.

……………………………..

Signature of participant Date:…………………..

I hereby agree to the tape recording of my participation in the study

……………………………..

Signature of participant Date:…………………..

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APPENDIX E: Letter for ethical clearance to the University of Fort Hare

SECTION 1: DETAILS OF APPLICANT/PRINCIPAL INVESTIGATOR

Name:SIYAMTHEMBA

Surname:

DALASA

Professional Status:PROFESSIONAL NURSE

University Division / Faculty and Department: FACULTY OF SCIENCE AND

AGRICULTURE: NURSING

SCIENCES

Telephone No: 043 7092448 (w)

Fax No: Cell No: 0812188044

E-mail address: 200902505@UFH.AC.ZA

SECTION 2: TITLE OF STUDY

Title of Research Project:

ADULT CIRCUMCISION PRACTICES OF TRADITIONAL SURGEONS AND NURSES IN

RELATION TO THE INITIATES’ HEALTH OUTCOMES/MORBIDITY IN THE EASTERN

CAPE.

Sponsor’s Protocol No (if applicable)

Sponsor’s Details (if applicable)

SECTION 3: STUDY FOR DEGREE PURPOSES Not applicable

Name of Degree: MASTER OF CURATIONIS Supervisor: PROF. T. GOON

Division/Department: NURSING SCIENCES E-mail:

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APPENDIX F: Researcher’s declaration and conflict of interest declaration

RESEARCH ETHICS COMMITTEE

RESEARCHER'S DECLARATION AND CONFLICT OF INTERESTDECLARATION

(To be completed in typescript)

The principal investigator, as well as all sub- & co-investigators must each sign a

separate declaration.

A. RESEARCHER

Surname Initial TitlCapacity Principal X Sub- Co-Department Nursing SciencesPresent E-Telephone (w Ce Fa

B. PROJECT TITLE (MAXIMUM OF 250 CHARACTERS FOR DATABASE

PURPOSES)

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I, (Title, Full

name) …………………………………………………………………………………………

declare that:

I have read through the submitted version of the research protocol and allsupporting documents and am satisfied with their contents

I am suitably qualified and experienced to perform and/or supervise the above

research study.

I agree to conduct or supervise the described study personally in accordance withthe relevant, current protocol and will only change the protocol after approval by

the UREC, except when urgently necessary to protect the safety, rights, or welfareof subjects. In such a case, I am aware that I should notify the UREC without delay.

I agree to timeously report to the UREC serious adverse events that may occur

in the course of the investigation.

I agree to maintain adequate and accurate records and to make those records

available for inspection by the appropriate authorised agents when and if

necessary.

I agree to comply with all other requirements regarding the obligations of clinical

investigators and all other pertinent requirements in the Declaration of Helsinki, as

well as South African and ICH GCP Guidelines and the Ethical Guidelines of the

Department of Health as well as applicable regulations pertaining to health and

other research.

I agree to comply with all regulatory and monitoring requirements of the UREC.

I agree that I am conversant with the above guidelines.

I will ensure that every research subject or other involved persons, such as

relatives, shall at all times be treated in a dignified manner and with respect.

I will submit all required reports within the stipulated time frames.

Principal / Sub- / Co-investigator /Supervisor: …………………………………….……….………………

(print name)

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Signature :…………………………………….……….………………

Date :…………………………………….……….………………

CONFLICT OF INTEREST DECLARATION (OBLIGATORY)

The researcher is expected to declare to the University Research Ethics Committee(UREC) the presence of any potential or existing conflict of interest that maypotentially pose a threat to the scientific integrity and ethical conduct of any researchin the University.

The UREC will decide whether such conflicts are sufficient as to warrantconsideration of their impact on the ethical conduct of the study.

Disclosure of conflict of interest does not imply that a study will be deemed unethical,as the mere existence of a conflict of interest does not mean that a study cannot beconducted ethically. However, failure to declare to the UREC a conflict of interestknown to the researcher at the outset of the study

will be deemed to be unethical conduct.

Researchers are therefore expected to sign either of the two declarations below:

a) As the Principal Researcher in this study (name: )

I hereby declare that I am not aware of any potential conflict of interest which

may influence my ethical conduct of this study.

Signature: _____________________________ Date: ________________________

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b) As the Principal Researcher in this study (name: SIYAMTHEMBA DALASA)

I hereby declare that I am aware of potential conflicts of interest which

should be considered by the UREC:

Signature: _____________________________ Date:_________________________

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APPENDIX G: Questionnaire guide

Demographic Questions: Yes No

1.1. Are you a traditionally circumcised man?1.2. Are you a traditional nurse?1.3. Are you a traditional surgeon?1.4. Does your age range between

any of these?

(Indicate with ‘’X’’ next to the rightanswer under column ‘’YES’’).

16-20 years21-30 years31-40 years41-50 years51-60 years61-70 years71-80 years80-90 years

1.5. Choose your race. Are you: Black?White?Coloured?Indian?Asian?

1.6. Are you from: Mthatha(KSDmunicipality)Libode(Nyandenimunicipality)Lusikisiki(Qawukenimunicipality)

1.7. What is your level ofeducation:

Degree?Diploma?Standard 10-9?Standard 9-8?Standard 8-7?Standard 7-6?Standard 6-5?Standard 5-4?Standard 4-3?Standard 3-2?Standard 2-1?Standard B-A?

1.8. Did you stay in a shelter within the community?1.9. Did you stay in a hut in the bush?

Section B: Structured interview questions with further probing:

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What measures do traditional surgeons use to sterilise their surgical instruments

for circumcision?

What do you do to prevent excessive bleeding?

Do traditional surgeons tighten the bandage around the penis?

Do traditional nurses tighten the bandage during wound dressings?

Are the initiates allowed to drink water?

How would you describe the conditions under which the traditional surgeons

perform circumcision?

What measures do traditional nurses used to sterilise their surgical instruments

for circumcision?

What measures are taken to safeguard the health of the initiates after

circumcision?

How would you describe the conditions of the lodge where the initiates are kept

after circumcision?

Probed questionsPsychological counsellingDo initiates get psychological counselling about the conditions of the customduring and after seclusion period prior to circumcision?Support from the traditional surgeons (family, traditional surgeons, traditionalnurses); any form of maltreatment?

QuestionsDo traditional surgeons work in a neatly prepared environment prior tocircumcision procedure?The use of traditional surgeons use gloves; changing of the gloves before theyattend to the next initiate; the use of blades or knife to cut the foreskin; whethersealed blades; use of an assegai; the sterilisation of the assegai or the knife afteruse; use of the same blade, knives or assegai on more than one initiate?The traditional surgeons use new sealed bandages to cover the wound;application of ointment after the foreskin cut or when dressing out the wound;wound dressing; the neatness of the environment; use and changing of glovesbefore attending to the next initiate; use of new sealed bandages to cover thewound?

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Human physiological and anatomical knowledge of the traditional surgeonsabout male circumcision and its complications

Do traditional surgeons tightly apply the bandage around the penis? How are themeals cooked-well cooked or half done? Allow to drink water? Get enough rest?

Environmental conditions in which the circumcision takes placeThe state of the initiates lodge (cold hut, wet when raining, hot, dirty, small,overcrowded); mountainous setting?