Traditional Male Circumcision Among Young People - A Public Health Perspective in the Context of HIV Prevention

Male circumcision is increasingly being incorporated as a key component of comprehensive HIV prevention strategies in national responses to AIDS. Under the leadership of the World Health Organization (WHO), efforts are being made by UN bodies such as UNFPA, UNICEF, and the UNAIDS Secretariat, along with international NGOS and funding organizations, to assist countries in making evidence-based policy and programme decisions with a view to increasing the availability, accessibility and safety of male circumcision services for HIV prevention. Priority countries for the scale-up of male circumcision for HIV prevention have high HIV prevalence and low levels of male circumcision. In many African societies, and among certain ethnic groups in other geographical regions, male circumcision is carried out for cultural reasons, as an initiation ritual and a rite of passage into manhood. In general the countries and communities where traditional male circumcision is performed are not those with high HIV prevalence and low levels of male circumcision. However, for a number of reasons, including concerns about the safety of the procedure carried out by providers without any formal training, traditional male circumcision is receiving increasing attention. Since most countries in sub-Saharan Africa practice traditional circumcision to some extent, it will be increasingly important for Ministries of Health to have a clear position on traditional male circumcision when rolling out male circumcision programmes for HIV prevention and developing related national policies, standards and guidelines. In addition, there is growing interest in the opportunity that male circumcision programmes might provide for making contact with adolescents and young men, in order to move beyond HIV prevention and to include broader sexual and reproductive health and gender issues. Traditionally, an educational component is included in the cultural practices surrounding male circumcision as an initiation into manhood. Since they are often knowledgeable about the determinants affecting the lives of the adolescents in their communities, traditional circumcisers and other community members traditionally involved with the ritual of male circumcision may have the potential to contribute not only to HIV prevention but also to improving other aspects of young people’s sexual and reproductive health. The aim of this review is to assess the available literature on traditional male circumcision among adolescents, defined as male circumcision for cultural (non-religious) reasons by a provider without any formal training. The review focuses mainly on East and Southern Africa.The following topics are addressed. - The prevalence of traditional male circumcision, and the ages at which it is performed (Section 4.1). - Traditional male circumcision as part of the larger context of initiation into manhood: how is circumcision performed, how much foreskin is removed, and what takes place before, during and after the male circumcision procedure? (Sections 4.2 and 5.2.3) - Trends in traditional circumcision: what aspects of the practice are changing, including attitudes of young men and parents, and links with clinical practice? (Section 4.4) - What are the problems associated with traditional male circumcision, including safety, and what are the consequences of particular practices around traditional male circumcision which may have implications for HIV prevention? (Sections 5 and 6) - What attempts to work with traditional circumcisers are reported in the literature, including experiences from efforts to train traditional providers of male circumcision? What lessons have been learnt from programmes that have capitalized on traditional male circumcision practices as an entry point for addressing adolescents’ sexual and reproductive health? (Section 7)