Traditional male circumcision

The majority of male circumcisions worldwide are performed for religious or traditional reasons. Such procedures generally take place outside of formal medical settings and are performed by providers who may have special training but who are normally not health professionals.

Traditional male circumcision is usually associated with a religious or cultural ceremony. The primary global determinant is religion, and almost all Muslim and Jewish males are circumcised.1,2 Muslim boys may be circumcised at any age between birth and puberty. A Jewish male infant is traditionally circumcised on his eighth day.

When male circumcision is performed on adolescents and young adults, it usually marks a transition from boyhood to manhood. In many traditional circumcision ceremonies, boys and men are educated about their responsibilities and duties as an adult member of the community. The precise details of what is taught are not well documented and are frequently considered confidential or secret. These ceremonies often involve demonstrations of bravery and manhood to confirm that the initiate is ready and worthy to become an adult member of the community. The actual cutting of the foreskin, while a pivotal moment in the circumcision ceremony, is a small component of the whole process. The limited data available on the safety of traditional male circumcision point to high rates of complications and adverse events.3,4,5,6,7

There are several important differences between traditional procedures and the clinical procedures adopted in the randomised controlled trials of male circumcision for HIV prevention. These include variations in the equipment used and the counselling provided to the men before and after surgery, as well as the overall context for and meaning of the surgery (for HIV prevention and health, compared with a rite of passage to manhood).

Another important difference is how much of the foreskin is removed. Some traditional circumcisions involve only a small cut to the foreskin or partial removal. The carefully standardised procedures used in the three randomised controlled trials that demonstrated the protective effect of male circumcision left, at most, a few millimetres of the inner aspect of the foreskin. They all removed sufficient foreskin that the glans remained fully exposed even on a non-erect penis.

While it is not known exactly how much foreskin must be removed in order to reduce the risk of HIV infection in men, complete removal is thought to be necessary. Thus, the practice of partial removal of the foreskin may help explain why some cultures that practice traditional male circumcision still have high rates of HIV prevalence. It is important to document and understand variations in the amount of foreskin removed by traditional circumcisers so that the benefits of male circumcision for HIV prevention can be maximised.

Despite these important differences in procedures, there are many ways that clinical and traditional circumcision services can work together. Traditional and clinical providers can collaborate to improve the safety and acceptability of male circumcision, reduce complications, enhance the health education content of civic education and rituals, and improve the sexual and reproductive health of men and women, while preserving the sociocultural importance of the male circumcision process. Examples of such collaboration include:

  • Training traditional providers in anatomy, aseptic technique, control of blood loss, and wound closure;

  • Ensuring supply of necessary instruments and dressings to reduce complications from circumcision;

  • Cooperating on the information provided and training given to circumcision initiates to maximise good health outcomes for the participants and their current or future partners and family members;

  • Ensuring a smooth and rapid transfer to, or intervention by, clinical services if a medical complication associated with the circumcision arises;

  • Developing models by which clinical and traditional providers can cooperate and share responsibility for the tasks involved in the circumcision process, while respecting the different skills that each contributes; and

  • Understanding more about the cultural and social significance of circumcisions performed by traditional providers according to the setting and age of the initiate.

References

  1. Rizvi, SA, Naqvi SA, Hussain M, et al. Religious circumcision: a Muslim view. BJU Int 1999;83(Suppl 1):13-16.​

  2. Steinberg, A. Halperin, M. A Jewish view: religion and education for HIV/AIDS prevention. Prospects: quarterly review of comparative education (UNESCO) 2002;32(2):225-236.

  3. Peltzer K, Nqeketo A, Petros G, et al. Traditional circumcision during manhood initiation rituals in the Eastern Cape, South Africa: a pre-post intervention evaluationBMC Public Health 2008;8:64.

  4. Bailey RC, Egesah O, Rosenberg S. Male circumcision for HIV prevention: a prospective study of complications in clinical and traditional settings in Bungoma, Kenya. Bull WHO 2008;86(9):669-677.

  5. Ahmed A, Mbibi NH, Dawam D, et al. (Abstract only) Complications of traditional male circumcisionAnn Trop Paediatr 1999;19(1):113-117.​

  6. Mayatula V, Mavundia TR. (Abstract only) A review on male circumcision procedures among South African blacksCurationis 1997;20(3):16-20.

  7. Naude JH. Reconstructive urology in the tropical and developing world: a personal perspective. BJU Int 2002;89(Suppl. 1):31-36.

Resources

 
Traditional Male Circumcision Among Young People

A literature review on traditional male circumcision in eastern and southern Africa offers recommendations for improving traditional practices and increasing men’ options for circumcision.

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Male Adolescent Circumcision for HIV Prevention and as an Entry Point for Sexual and Reproductive Health

This meeting report includes a statement the participants produced on the role of faith-based organisations in providing safe male circumcision services.

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South Africa

Male Circumcision Policy, Practices and Services in the Eastern Cape Province of South Africa: Case Study

This case study explores the practice of, and policies governing, traditional male circumcision in the Eastern Cape Province of South Africa.

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Tanzania

Challenges and Opportunities for Involvement of Traditional Practitioners for MC

A report on a study in Tanzania presents findings and evidence-based recommendations on involving traditional circumcisers in scaling up safe male circumcision for HIV prevention.

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Uganda

Formative Research to Inform Rollout of MC

This report summarises the findings, conclusions, and recommendation from formative research conducted in Uganda to guide the introduction of voluntary medical male circumcision.

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