In Swaziland, about one-quarter of all people between the
ages of 15 and 49 are estimated to be living with HIV. With the world’s highest
HIV-prevalence rate, Swaziland was an early adopter of WHO recommendations. In
2009, the country developed plans to circumcise 150,000 males within two years.
But by 2011, the
country had only met about 12% of this target, according to Alfred Khehla
Adams of the Universiteit van Amsterdam.
To find out why circumcision had been so unpopular among
Swazi men, Adams interviewed men in the Kwaluseni district of Manzini,
Swaziland through a mix of focus group discussions and interviews. He found
that because men feared reduced sexual pleasure and possible adverse effects,
Swazi men felt the procedure threatened their notions of manhood.
“A real Swazi man is defined as someone who has a wife and
children, and is able to take care of family,” Adams told the conference. “In
order to have a wife and children, a man has to be sexually functional – the
issue of circumcision introduced a threat to this.”
Nonetheless, the three large randomised clinical trials found
that only a small percentage, between 1.5 and 3.8%, of circumcisions resulted
in complications such as wounds or swelling.
Men also reported that they did not see the value in medical
male circumcision when continued condom use was still advised following the
“They tell you to circumcise and also use condoms, why?”
said one uncircumcised man during a focus group. “This thing is not 100% effective
so why don’t you just leave the circumcision thing and condomise?”
Research from Botswana also points to lingering
acceptability issues in the country, which in 2009 committed to medically
circumcise 100,000 men each year. In 2012, the country was able to circumcise
about 40,000 men, falling short of the targets that it is under pressure from
the World Health Organization to meet, according to Masego Thamuku of the
University of Bergen.
Conducting research in Mochudi, Botswana, Thamuku found that
national circumcision campaigns that were initially well received by
traditional leaders and communities had fallen out of favour. This was largely
due to the way campaigns have been publicised and carried out among Tswana
communities that already practice traditional circumcision via traditional
Public campaigns breached notions of privacy and secrecy attached to traditional circumcision
“In 2009, three cohorts of initiation schools were brought
into the clinic to be circumcised,” said Thamuku during her presentation at the
Paris conference. “In 2011, everything turned all around – the public campaigns
had breached traditional privacy.”
Not only had campaigns using radio and public events, as
well as female nurses, breached notions of privacy and secrecy attached to
traditional circumcision, but also they were seen to have eroded the kind of
kinship fostered by traditional schools in which men learned the rules of
manhood as part of a rite of passage. Following from this, Thamuku’s interviews
with men and implementers of circumcision revealed that there were doubts in
the community as to whether medically circumcised men could be seen as “real
men” alongside those who had been traditionally cut.
Justin Parkhurst of the London School of Hygiene and
Tropical Medicine suggested that the government of Malawi had actively resisted
international pressure to implement a prevention method imposed on it by donors.
While medical male circumcision is usually framed as a
technical issue, Parkhurst said that it could be deeply political. In Malawi,
information about circumcision was understood in the context of tensions
between Christians and Muslims. Local knowledge – such as higher HIV prevalence
in regions with high traditional circumcision rates – was privileged and the
findings of international researchers questioned. Resistance to circumcision
became part of a broader challenge to the country’s dependence on Western aid.