The BBC reported on Friday that elders of Kenya's Luo ethnic group have refused to endorse a government plan to promote male circumcision to prevent HIV, saying that the practice is "against the community's culture." The Luo, who comprise 2.5 million of Kenya's 32 million people, do not traditionally practice circumcision. The elders, while acknowledging that circumcision is an individual decision, cited concerns about behavioral disinhibition following circumcision and the efficacy of the surgery in reducing the risk of HIV transmission. The BBC notes that the council of elders holds substantial sway among Luo, a fact that is likely to herald problems for the government's efforts to take medical circumcision services to scale. A similar situation is currently playing out in Lesotho, where traditional circumcizers have reportedly blocked efforts to launch a national circumcision initiative.
At the end of the day, is male circumcision really so different from any other health service that we promote? Maybe. In many of the cultures where it is traditionally practiced, circumcision signifies the transition from boyhood to manhood. Circumcision status is, in some settings, intimately connected to conceptions of masculinity, as well beliefs about sexuality, sexual prowess, and pleasure. Circumcision has traditionally been an important ethnic identifier, a point of belonging not only in terms of the physical act itself, but the many rituals that often accompany it. So can we really reduce all this to an individual decision about a surgical procedure? Again, the answer is maybe - but with due analysis of and consideration for the broader context.
PSI's male circumcision initiatives have chosen to address the question of culture in a variety of ways. In Zambia, a substantial minority of men undergo traditional circumcision, participating in camps where they are circumcized and instructed about adult life. Men need not belong to one of the groups that traditionally circumcise to attend the camps, and young men have the option of being circumcized in a medical setting but attending the camp for purposes of instruction. Rates of adverse events from circumcisions performed in the camps are apparently relatively low. PSI's formative research indicated that the medicalization of circumcision (and awareness of the surgery's potential health benefits) meant that many men no longer viewed it as a tradition linked to specific ethnic groups. Program staff reached out to traditional circumcizers, who were invited to visit PSI facilities and offer input on the initiative. Those were participated were generally supportive of the launch of medical circumcision services, and opportunities for further coordination and/or collaboration are being discussed.
In South Africa, where PSI provides communication support to the Bophelo Pele male circumcision pilot at Orange Farm, a very different conclusion has been reached. There, circumcision is strongly associated with certain ethnic groups and is still considered a key marker of ethnic identity. Moreover, the existence of amateur circumcizers (not to be confused with trained traditional circumcizers, many of whom are highly skilled professionals) has resulted in a number of grisly adverse events, inspiring a certain amount of anxiety around the procedure. Given this context, project partners concluded that addressing culture or tradition in any way was likely to be perceived as divisive or off-putting to potential clients.
So, how best to proceed when planning and implementing medical circumcision interventions? Carefully, and with the knowledge that it's rarely simple after all.