Tribal Circumcision

1. Tribal Circumcision • Martin Mukeshimana • Andrew Krein • Angela Assad • Wendy Pereira • Fairoza Essak • Taryn Lewis-Thomas • Kiran Ranchod

2. Circumcision Initiates

3. B.Y. sues father and community leaders for apology and assurances

4. B.Y. – forced circumcision • December B.Y. circumcised Frere Hospital • Based on “conscience and religious belief” • 3 months later Parents call him home • Early morning abducted by father, family and community members • See he is circumcised but cut again and furthermore make him eat it. • Returns Frere to be diagnosed with infection of previously healed wound on right side of penis • Mother claims without consent “abomination” in Xhosa Culture • Father – “silly boy” and as long as under my roof…..

5. Ethical Question Arises • Mzimhle Popo, provincial manager of the Eastern Cape Human Rights Commission, said B.Y.’s human rights had been violated in multiple ways. • Eastern Cape House of Traditional Leaders deputy chairperson Zolile Burns-Ncamashe said traditional leaders appreciated individual rights but there were also communal rights which had to be respected and observed by individuals who lived in those communities

6. M.M. • 15 Years old • Teased and ostracized by peers • Insisted against mothers wishes • Let him go when threatened suicide • Circumcised on Friday by illegal surgeon • Dead by Sunday -Times Live Sep 1, 2009 Ziphezinhle Msimango

7. Case of Y.B. 18 year old - legal age • Victim 22 of 2008 Died of pneumonia consistent with hypothermia due to exposure • Family knew complications therefore prior hospital circumcision – same as brother • June 21 – 23 Initiates • Surgeon declares correctly already circumsised • Nurse (iikhankatha) pressure and then beat • Nurse performs circumcision in front of others • No blanket, no food, no water • Becomes weak and ill, refuse help • Tries to flee but caught and brought back • Uncle alerted weak later and find weak and in coma • Dies soon after

8. Tradition vs Human Rights • Does tribal law supercede bill of rights • What happens when knowingly break law • Who are individuals or groups to dictate to Government • Do we still live in Dark Ages where deaths can be ascribed to as “witchcraft” when foul play is obvious • License to kill at individuals discretion!!!!

9. Ritual Circumcision becomes health issue • Training and Competence of Surgeon (Ingcibi) inadequate • Inadequate and unhygienic tools • STD transmission due to unsterilised tools • Inadequate care by the nurse (Inkhankata) • Denial of food and water

10. There are 2 major points to be considered in Sokol’s 2nd quadrant: the patients mental capability and competence to make an informed decision regarding a medical procedure. • If not competent, his/her presumed wish. Mr B.Y an 18 year old: • His actions appear to be clearly thought out and rational. • He left the family home to avoid traditional circumcision. • Yet he went to hospital to have himself circumcised – indicating that he (a) did not wish to be ostracised from his community.(b) did not object to the procedure of circumcision. • His only objection to traditional circumcision was due to his religious belief. The only covenant he was in with Jesus Christ and not with his ancestors.

11. Does this sound like the actions of a person who lacks the mental competence to make an informed decision? I think not. If anything, I believe he is an extremely competent and rational young man who has the strength of character to stand up for what he believes in. Through his actions he tried to show respect for his culture (parents) and clearly did not want to be ostracised from the community.

12. Mr Y.B • There is not much to indicate whether he or not he had consented to medical circumcision. • It appears as though the whole family had been involved in the decision made in the best interest of their son. • The family respected their tradition but, out of concern for the health of their son, chose to have him circumcised in a hospital and then complete the ritual at a traditional initiation school. • His elder brother had gone this route and it appeared to be a good compromise so I assume that 18 year old YB did not object to going the same route.

13. Mr MM, a 15 year old youth • He chose to go to initiation school. • His reason: he was being mercilessly teased at school. • Could a young person who is under a lot of peer pressure capable of making a rational decision? • The Child Care Act (2007) states that it is illegal for children under 16 to undergo circumcision except for religious or medical reasons. • Application of Health Standards in Traditional Circumcision Act (2001) states that it is illegal to circumcise young men under the age of 18. • I am in full agreement with the above Law since I do feel that Mr MM was not mentally competent to make a rational decision and the law was there to protect him.

15. Taryn: Within Jewish Culture • Jewish males must be circumcised shortly after birth, during childhood or puberty as part of a rite of passage called a “Brit or Bris Milah”-which means ‘covenant of circumcision and it is done according to their religious & political beliefs based on the Torah. • The procedure is done on the 8th day after birth and it is only postponed in the case of threat to the infant’s life. • It is considered of such importance in their society that if a jewish man dies his body will be circumcised before burial if he hasn’t already been circumcised. • Although the majority of Jews follow this ancient tradition without question, there are nowadays many Jews who feel it is unethical because it has no medical or religious importance. • One Rabbi in particular, Dr Ronald Goldman, a researcher, has written a book, “Questioning Circumcision: A Jewish Perspective” documenting some of the more modern Jewish views on this procedure and he also runs the Jewish Circumcision Resource Centre in Boston for counselling parents and Jewish men or boys who are considering circumcision. • In his book Jews can learn everything they need to know about circumcision, it also covers recent research on infants and the effects of surgical procedures on them which has shown to have long-term effects lasting even into adulthood. With this information, Goldman hopes young and older Jewish men as well as expectant parents will be able to make an informed decision for themselves concerning the procedure. (Ref:http://www.jewishcircumcision.org/info.htm)

16. Taryn: In Islamic Culture • Some scholars state that it is recommended & others that it is obligatory. • There are no quotes from the Qur’an but according to their ‘Hadith’ text, circumcision is based on a covenant with Ibrahim and Muhammad. • Prophet Muhammad is reported to have said, “Five are the acts quite akin to fitrah: Circumcision, shaving the pubes, cutting the nails, plucking the hair under the armpits and clipping (or shaving) the moustache.” (Reported in all the six authentic collections of Hadith) • So those who follow the Islamic tradition and religion strictly adhere to this text taking it to mean that circumcision is a mandatory act. • The word ‘fitrah’ in the text is also said to 'imply an inner sense of cleanliness in man which is proof of his moral convictions and mental health.' • This statement shows the importance in Islam placed upon the performance of circumcision as one of the rules of cleanliness in Islam. • Thus they believe the performance of circumcision and the practice of the ‘hadith’ hygiene texts as recommended in Islam are medically beneficial and that this practice “reflects the wisdom of the Islamic statements.” • Even though many people of the Islamic faith endorse circumcision-it is not required for converting to Islam. (Ref: http://www.islamzine.com)

17. Taryn: In Christian Religions • Today circumcision is not a religious issue for Christian families. • Although where Christianity is the main religion, the majority of newborn baby boys are routinely circumcised after birth. • The practice, however, has nothing to do with religion and everything to do with social convention. • The majority of men these days are circumcised for non-religious reasons. • We now know there are differing opinions & practices – • Some christians opose circumcision as a Pagan ritual. • Catholics nowdays do not endorse nor do they mandate it as a requirement of their religion. • It is a customary practice within the Coptic, Etheopian & Entrean orthodox churches and others such as the Nomiya church in Kenya require it for christian membership. (Ref:http://www.bbc.co.uk/ethics/malecircumcision/social_1.shtml)

18. Taryn: In African Culture • Circumcision is not performed neonatally but from the ages of 15-25 years in young men - as a traditional & cultural ritual practice known as an ‘Initiatory Rite of Passage’ into adulthood or “warrior-status”. • Anthropologists describe a ritual as: a society’s method for members to communicate their ways of living through psychological, social & symbolic interactions and teachings. • The initiation is not directly linked to physical development and maturity but it is a socially significant device enabling a shift within the individual from childhood behaviours to the more complex behaviours expected from an adult and with this they gain the acceptance & respect from their fellow community members. (Ref:http://www.africanvoices.co.za/culture/circumcision.htm) • Martin will now speak in more detail about circumcision in African Culture.

19. Applying the ethical theories of Beneficience & Nonmaleficence • The term Beneficence refers to the practice of weighing up the beneficial good outcomes of an action in comparison to the possible harm or suffering that could come from an action. • It puts the emphasis on morally good actions being ones that bring benefits and reduce any risks of injuries. • This theory in relation to circumcision could prove to be a worthy theory to apply in the argument for a standardised practice of circumcision that makes it medically safer such as; supplying & using the correct tools, anaesthetics, emergency kit available for complications and an informed practitioner who is aware of the risks of HIV/AIDS as well as correct hygiene practices. • It would obviously be more beneficial and in alignment with the benefit of all to have a medical procedure such as circumcision done in a pain-free and safe way that minimizes risk of injuries or fatalities if it is going to be talking place at all. • Nonmaleficence relates to our oath as practitioners to “First, do no harm”. Yet in the circumcision procedure we are indirectly causing harm to many young babies and men of an age ready to enter into young adulthood - even though this is not the intention behind the reasons for the practice. • Instead the fatalities seem to arise mostly due to the lack of sterile tools, medical hygiene practices and the type of complications that can occur in rural settings so perhaps it would be best to focus at these areas for intervention strategies.

20. Contextual Features • ·Economic factors • What are the cost involve? • Long term cost? • ·Quality of life • Pain involved? • Should a professional or skilled person be doing this? • Should it be done in unhygienic condition? • Is what I want respected?

21. ·Religion and culture • Is there a difference between religion and cultural beliefs? • ·Confidentiality • Will other people know it was done? • Is my confidentiality respected? • ·Referances • http://www.info.gov.za/speeches/2008/08070310451001.htm • STATS http://www.ecdoh.gov.za/uploads/files/281107142127.pdf • http://www.southafricalogue.com/travel-tips/ritual-circumcision-claims-more-lives-in-eastern-cape.html

22. Ethical Considerations: Mr BY: From his actions it does appear as though he respected his cultural traditions in as far as it did not clash with his religious beliefs. -This is supported by his actions of having himself circumcised. - However, since the traditional belief of spilling of blood to form a covenant with/appease the ancestors is the one aspect of the custom of circumcision that, due to his religious convictions he could not support, he chose not to attend traditional initiation school. As a 18 year old, he has a right to agree to a medical procedure or not. Circumcision, whether done in a hospital or in the bush is a medical produce.

23. Rights thus violated: The constitution (Sect. 15 Bill of Rights) guarantees everyone freedom of conscience, religion, thought and belief. • All these freedoms were violated, because this was the basis of his objection to traditional circumcision. • The actions perpetuated against him was not only a form of physical abuse but mental abuse as well (imagine being woken in the early hours of the morning, tied and marched into the bush by the very person who is supposed to love and protect you- your father and then being forced to eat your own foreskin after being circumcised – again. This appears to be more serious than mental abuse – it enters the arena of mental torture.

24. Mr Y.B The parents chose to go the middle route whereby they (and their son) could have the best of both worlds. He could be safely circumcised and be initiated into the Xhosa culture by participation in the other rituals. • The family tried to follow the cultural traditions but, out of concern for their sons, they chose to compromise: a medical circumcision with a final bush initiation. • This has worked before (the brother) and appeared to be safer route. • However, the risk comes about at the initiation school. • For some practioners (in this case the nurses), culture over-rides the law and they seek to implement certain practices with no regard to human rights, legal prescriptions or even the express decree of Traditional leaders.

25. This becomes a dangerous practice where these people are no better than criminals since culture does not supersede the constitution of the country. • These practioners violate the rights of young men placed into their care by denying them the right to medical treatment when they need it. • They could be considered as cultural mafia who impose their view of what constitutions proper cultural traditions. • This is ethnically and morally reprehensible – especially when it violates the constitution of the country. • While one understands and can even sympathize with those who strive to preserve their cultural heritage in a rapidly changing world. • Is the death of young men in the prime of their lives ever justified in the name of culture and tradition? I think not. • The constitution of this country respects and protects cultural and religious belief but gives each person the right to choose.

26. Mr MM: • This case represents everything that is wrong with illegal initiation schools • Legally, as was mentioned earlier, he should never have been allowed to participate in the initiation process. • His mother claims he was so desperate to go he claimed he would kill himself if she said No. How many parents have heard this kind of dramatic threat before from their teenagers? • This leaves one to question the motivation behind these illegal schools. • Is it really tradition and culture as they claim or is it the pursuit of material (money) gain? • Parents also play a role in the perpetuation of these illegal schools - if there is no demand for them, they will not proliferate. • Research has shown that a large number of young men from single female headed households attend these illegal school. [Ndolvu, N, 2009]

27. This appears to be an attempt to be accepted within the community and a way of attaining some respect as a man. • Issues of abuse, intimidation and the role of power should be taken into account. • Often the practioners are respected men in their community and thus young boys are not willing to speak out about any forms of abuse (e.g. denying initiates water, medical attention). • One cannot underestimate the powerfully controlling role of culture and tradition in small rural villages where going against the norm is complete heresy. • The unnecessary death of a young person with their whole life ahead of them is not only tragic but unacceptable and no amount of rationalisation (witchcraft, ancestors, destiny, they weren’t strong enough) justifies the death.

28. Young men who are mutilated are almost destined to live their lives in the shadows- what support is there for these men who are not accepted by their culture as ‘real’ men since they have not completed the initiation process? • Research done by HSRC [Stinson, K: 2007] shows that many of these young men turn to gangsters where they find a sense of belonging and are given ‘respect’ by the community. • It is one thing to have a constitution that is as progressive and all encompassing of human rights as ours • However, if it does not impact on the lives of the people who are vulnerable and most in need of protection, the act is meaningless.

29. ACTS • We are opposed to the way circumcisions are performed: • disregard • non adherence • abuse • Of the laws of the Republic of South Africa

30. CHILDREN`S ACT Prohibits circumcision of male children under the age of 16, except :religious purposes : medical reasons Child has to consent if able Child has the right to refuse circumcisions Legal age for circumcisions in EC is 18. MM was 15years old Contravention of both Acts http:www.nocirc-sa.co.za

31. Universal Declaration of Human Rights, G.A.res 217 (III), U.N. Doc A/810 at 71 (1948) Article 1- all humans born free and equal Constitution of South Africa Chapter 1, Section 1:human dignity, equality, human rights and freeedom Section 2: Constitution highest law in country, binds everyone Chapter 2: BOR Section 7: affirms democratic values of human dignity, equality and freedom Section 9.1: Equal protection and and benefit of the law 9.3: Discrimination – ethnic, cultural,religion,health.

32. Section 10: Right to human dignity Section 11: Right to life -- also protected by Common Law Sectiion 12: Freedom and security Section 14: Right to privacy Section 15: Freedom of religion, belief and opinion Section 28: Children’s rights Section 31: Cultural, religious and linguistic communities Chapter 12: Traditiona l authorities- recognition of traditional leaders and and indigenous or customary law. Customary law cannot go against the Constitution. The Constitution establishes a National Council of Traditional Leaders and Provincial Councils of Traditional Leaders. http://www.paralegaladvice.org.za/docs/chap01/05.html

33. Council of Traditional Leaders Act (No. 10 of 1997 Section 7.1: Objects and functions of Council • Promote role of traditional leadership • Enhance unity and understanding We as South African enjoy many rights. Much ignorance about our rights and obligations, thus transgressions

34. RECOMMENDATIONS • Concerted effort to inform individuals about the BOR and the Constitution– active marketing, advertising, education in schools. The state needs to actively undertake adequate training of traditional surgeons by setting up legally registered circumcision schools and paying the practitioners and traditional nurses. • Parents must respect children’s rights (BY case) • Monitoring body to oversee that there are no transgression in initiation schools. (YB case) • Identify and shut down illegal initiations schools • Watchdog body to oversee and enforce individual rights as regards circumcisions • Awareness of age 18 before circumcision needs to be done(MM). • All circumcisors to be informed of their legal obligations and ethical boundaries • Training workshops for circumcision procedures, rights of individuals, informed consent, STD’s, analgesia , anaesthesia

35. Informing all circumcisors about their legal obligations and ethical boundaries as well as repercussions to these Beneficience- first do no harm Circumcisors to attend a Government run training programme for more that 5 days.(Prof Peltzer). All circumcisors to be taught correct procedures for pre-, and post treatment care Legal recourse of individuals Written and informed consent Consent forms to be recorded in a register All procedures to be performed in an environment approved by the body under which circumcisors fall Only circumcisors approved by Government to perform procedures. Must register with a body for circumcisors and a code of conduct must be enforced!

36. CONCLUSION The irony of all of the above is that all these recommendations were already gazetted in the Provincial Gazette of the Province of the Eastern Cape in 2001, This being the case these procedures are still being performed illegally. ONLY INCREASED AWARENESS AND EDUCATION OF INDIVIDUAL’S RIGHTS, WILL STOP THESE ILLEGAL PRACTICES AND THE UNNECESSARY PAIN, MUTILATION AND DEATH OF INNOCENT SUBJECTS !