Medically assisted circumcision: a safer option for initiation rites

Culturally sensitive integration of medical circumcision could avert adverse effects at traditional male initiation rites

In many traditional cultures, male initiation rites involve circumcision practices that can sometimes result in medical complications. In a recent incident in the Northern Territory, three young men required airlifting from their Borroloola initiation site to Darwin for medical assistance.1 The risk of permanent harm and potentially fatal outcomes could be decreased if safer options were available during initiation ceremonies. In this article, we report that it is possible to provide safe circumcision at male initiation rites.

In December 2013, a traditional initiation ceremony was conducted in Drekikier District, East Sepik Province, Papua New Guinea (PNG). During the 4-week ceremony, circumcision, considered vital for transition from boyhood to manhood, is conducted in the first week. Previously, young initiates suffered excruciating pain and severe blood loss when a carved cassowary bone was used to cut the penis and foreskin. On this occasion, at the invitation of community leaders, a medical team assembled at the site to provide safe male circumcision for 34 initiates.

The team consisted of a medical officer, two community health workers, an HIV counsellor and the provincial HIV response coordinator. Consistent with local cultural traditions, the entire team consisted of men originating from the local cultural group who also participated in cleansing rituals as part of the ceremony. Medical supplies, surgical instruments and a portable steriliser were brought to the initiation site deep in the forest. A specially built traditional dwelling stood in the middle of a small clearing. The few bush tracks that led into the site were carefully concealed to be completely segregated from other villagers, especially women and children.

A small shelter that stood immediately to the back of and continuous with the main ceremony house served as the operating theatre. It had an opening in the roof to allow sunlight in. Two beds and two tables were assembled in the centre of this structure. The beds served as operating tables and the tables were used for medical supplies and surgical instruments. The medical officer and one community health worker performed complete foreskin removals with assistance from other team members. Five to 10 mL of 1% lignocaine was infiltrated around the base of the penis and the procedure was conducted using sterile technique.

Five or six circumcisions were performed per day. Of the 32 initiates who were circumcised, only two experienced adverse events. The first had slight bleeding, rectified by reinforcing the gauze bandage and gentle continuous pressure for 1 minute. The second experienced heightened pain despite having two 500 mg paracetamol tablets after the procedure. This pain resolved after further regular doses of paracetamol.

Two initiates had previous penile modifications and were refused surgery. The injection of substances (such as cooking oil) or insertion of objects (such as ball bearings) under the skin of the penis can cause extensive scarring and disfigurement.2,3 For the safety of the initiates with previous penile modifications, arrangements were made for their circumcision to be done in the district hospital.

A number of challenges were encountered. Health workers needed to be re-deployed from existing programs and some supervisors were reluctant to allow staff to participate. Surgical instruments and medical supplies were sourced from provincial health facilities and were provided with a degree of reluctance. The makeshift operating theatre did not have a good light source, nor was it enclosed by flywire to keep insects out. Sterilisation was challenging, with forceps and tissue scissors washed in water collected from a nearby stream, placed in kidney dishes and sterilised in a pressurised portable steriliser heated over a fire for 30 minutes. This took 1 hour and limited the number of procedures per day.

Despite these challenges, the service proved successful. Of the 32 initiates circumcised, all had successful healing and fully participated in the remaining activities, including instruction on responsible living, family planning, wealth acquisition and respect for one another. All initiates completed the 4-week ceremony with a rousing celebration on 15 January 2014.

Improving the evidence base and increasing the availability of safe male circumcision procedures was a major recommendation from a recent national policy forum in PNG.4,5 Providing safe circumcision at the initiation site meant that some aspects of traditional circumcision were adjusted. Circumcision was delegated and performed entirely by the medical team, albeit a team of local cultural origin. Penile foreskins were completely removed, and medically contraindicated procedures such as urethral poking or scarification were not performed. However, chants and recitals continued in the main ceremony house as initiates were being circumcised.

This experience has shown that it is possible to provide medically assisted circumcision within initiation ceremonies in cultures that traditionally practise male circumcision in PNG. A similar approach may assist cultural groups in Australia to reduce the risk of adverse effects from male circumcision during traditional initiation ceremonies.