License to cut and kill practice: a case report on botched circumcision in Mthatha region of South Africa

Abstract

The objective of this letter is to highlight the problem of deaths related with traditional circumcisions in the Mthatha region of South Africa. Mr. XY, a schoolboy, died as a result of traditional circumcision. He went to a traditional surgeon for circumcision, and paid him for doing it. At the autopsy, a ligature mark was visible in the gangrenous penis. The lungs were edematous, and pus was oozing out on compression of the lungs. Other internal organs were congested and edematous. The cause of death was septicemia as a result of gangrene of the penis. Death related with traditional circumcision is unacceptable and both the way it is practiced and legislation governing it need to be addressed urgently.

Keywords:

• initiation ceremony
• traditional circumcision
• Xhosa culture

To the Editor

Circumcision is one of the oldest surgical procedures performed in the world. The ritual of circumcision has been done in West Africa for over 5000 years, and in the Middle East for at least 3000 years.¹ It is a practice which carries with it a whole host of social meanings. Some of these meanings link to what it is to be a man, with circumcision taking place as a rite of passage into adulthood in several African and oceanic societies.²

Recently, this ritual has been tarnished by serious complications that have occurred, leading to amputation of the penis and even death of initiates.³ About 500 circumcision related deaths occurred in the Eastern Cape Province between 2006 and 2013.⁴ The author reported in 2010 that there were 25 deaths between 2005 and 2006 in the Mthatha region of the Eastern Cape. The common causes of deaths were septicaemia (36%), pneumonia (20%), dehydration (12%), assault (12%), thrombo-embolism (8%), gangrene (8%) and congestive heart failure (4%).⁵

Circumcision is a relatively safe procedure with a low rate of complication which ranges from 0.19% to 3.1%.⁶ The majority of complications are minor and treatable.⁷ Death from circumcision is an extremely rare occurrence. Cairns reported a case of a misplaced plastic bell ring, which caused complete meatal obstruction resulted in acute venous stasis and subsequent death from sepsis in 2007.⁸ The purpose of this report is to highlight the problem of botched circumcision in the Mthatha region of South Africa.

A teenager (Mr XY) died as a result of traditional circumcision. He was a schoolboy and wanted to get circumcised. Under the circumcision (Act) regulations require that no child (<16 years of age) should be allowed to go for circumcision. He went to a traditional surgeon for circumcision to whom he paid money for the operation. However, it is against the law for the surgeon to accept him for surgery. On autopsy, a blood-soaked dressing was removed from the penis. On careful inspection of the penis a demarcation zone was clearly visible at the middle of shaft of penis. This zone indicated that a tight bandage had been applied. Lungs were oedematous and pus was oozing out on compression of the lungs. Other internal organs were congested and oedematous. Cause of death was septicaemia as a result of gangrene of the penis.

It is difficult to accept a single death because of circumcision. It is such a minor procedure just to nip (prepuce) the skin when it is performed in a medical setting. A study conducted in Cape Town on Xhosa males showed that 92.5% of the men reported being circumcised, with 10.5% partially circumcised.⁹ It is worse for those who are surviving with an amputated penis. It is unacceptable for men to live without a penis. It may lead to a terrible psychological depression that could lead to suicide.

Traditional surgeons performing circumcision may not be caring during the procedure. This results in either injuring the glans penis or amputating the shaft of the penis. The penis is a very vascular structure. Its arterial blood supply is derived from the internal pudendal artery and the veinous drainage with which the cavernous spaces communicate carry blood either directly into the prostatic plexus or into the deep dorsal vein and so to the plexus.¹⁰ The cut in the glans penis or shaft of the penis leads to bleeding profusely. Traditional surgeons try to stop the bleeding by applying a tight bandage. This will help with immediate control of the bleeding, but sacrifices the penis. This is because these traditional surgeons do not have basic training. Firstly, they are not pulling the foreskin from the glans penis at the time of the nip. Secondly, they are unaware of the consequences of applying a tight bandage. They must be trained and undergo at least a certificate level of test, before being allow to perform a circumcision. Efforts should be made to encourage earlier circumcisions and to work with traditional surgeons to reduce the number of partial circumcisions. ⁹

There are always big statements and promises by the politicians, but no action. The traditional leaders allege that the government enacted legislation (Application of Health Standards in Traditional Circumcision Act of Eastern Cape, 6/2001) and other health measures are violation of cultural rights as enshrined in the constitution. It is a provincial statute, and not a national legislation, therefore the provincial government has a duty to implement the Act firmly. There is also violation of rights of children under the Children’s Act 38 of 2005, which is a national legislation and also applies to deaths related to circumcisions. Under this Act, regulations require that no child (<16 years of age) should be allowed to go for circumcision. The initiates are dying every season. There is no control on untrained traditional surgeons.

Notes

This Letter to the Editor was also published as a full case report: Meel B. Dangerous to mix: culture and politics in a traditional circumcision in South Africa. Afr Health Sci. 2015;15(1): 283–7. doi: 10.4314/ahs.v15i1.38.