What should MoH do?
University of Bergen
It is unquestionable! Ministry of Health is committed to implement Safe Male Circumcision (SMC) since its introduction in 2009.It is also unquestionable! The men of Botswana are willing to circumcise. Yet the two are in disagreement on the same at different levels: traditions, myths, beliefs, the painful surgery, HIV testing, and behaviours. Cultural standards and public views about the surgery contribute to men’s resistance to circumcise. Part of my PhD research between 2012 and 2016 was to explore cultural relevance in the implementation of SMC. The research that I have done with over 300 participants shows that genuine consultation with the communities and engaging their full participation before starting the intervention is key to the success of health programs.
The study gathered data directly and indirectly from communities with contrasting cultures; several communities with a historical tradition of initiation and still practicing it, and one that never practiced initiation and circumcision. Mochudi, community that still practices initiation was directly researched at different levels. Ramotswa and one of the Herero communities were referenced by my study participants. Hukuntsi, with a non-circumcising culture was directly researched.
Ministry of Health did consult the communities to implement SMC. But it seems this was superficially done hence frustrations from the service providers and service recipients. Excited about a new intervention that seemingly fitted well in their culture Mochudi community initially agreed that their cohorts of initiates, mophato, could participate in the program in 2009. Disappointments followed when the men, especially the ELDERS, realised that women were doing the surgery in the public clinics. In the mophato initiation tradition for men, this is a taboo – women are not allowed. The Ramotswa community responded the same way – allowed that the SMC teams circumcise their initiates out in the wilderness but abhorred it when the health providers expressed contemplations to advertise it in the media. Initiation is a male domain. All that happens there is not for public consumption.
Despite these strong protests, to protect their cultures the leaders of the community expressed the good of the program and wished that the health service providers could fit the activities timely with their mophato initiation activities, which are commonly scheduled every two years and in the winter. Meanwhile the leaders in Goodhope recruited their men to register for initiation before they could uptake SMC, opposing SMC campaigns that were targeting individual men to circumcise – against the culture of collectivism, doing it together. Ministry of Health finds itself torn in between two powers. On the one hand Ministry of Health embraces, understands and respects the importance of such cultural practices. On the other hand it faces pressure from the World Health Organisation (WHO) and international donors who support the program and demand numbers, that the target of circumcising 100, 000 men a year be reached every year. Botswana is known to excel in HIV intervention programs. On SMC, it faces a challenge of resistance. The question still remains. Is it the SMC leaders’ fault? Is it the fault of community leaders? Is the WHO’s fault?
There were other types of resistance from the communities. When SMC was first introduced in Hukuntsi, some community members resented the intervention feeling that Ministry of Health was enforcing another culture into their culture. It took time and elaborate explanations for some to embrace this. The Herero community did not openly declare their stand about SMC nor guide health officers on the best way to deal with them, but instead, practiced their initiation and circumcising ceremonies in silence. They ignored the SMC campaigns and continued carrying out their privatised cultural circumcision for boys, sometimes ordering circumcisers from their fellow Hereroes from Namibia. This is one culture that was difficult for Ministry of Health to penetrate… their practice of circumcision being a complete secrecy.
The communities believe that SMC is a good HIV intervention strategy but some elders detested its advertisements and marketing approaches. The circumcising cultures were against the use of initiation terms for SMC, for example ‘go rupa.’ This was argued even by the house of chiefs as wrong. Ministry of Health had no choice but to respect this and change the advertisement phrase to ‘go kgaola letlalo la banna,’ which does not carry the full meaning of SMC. Community elders of the initiating cultures treat circumcision with secrecy and view it as a man’s space. Therefore, public discussions about the subject of circumcision and the penis as a male private organ were not appreciated. Ba a e tlatsa tlatsa, one elder emphasised. Public discussions and activities that were regarded as breaching secrecy included research like mine – conducted by a woman, the MOVE advertisements on circumcision, the SMC celebrity’s campaigns, circumcision procedures performed by women in public clinics. The elders said even among the initiates hidden secretive language is used. For example ‘mpa ke bone lengole’ is a statement used when a fellow man wants to check if the other is circumcised, instead of bluntly saying ‘let me see your penis.’ The public adverts about SMC brought generational clashes in the community, breaching cultural silence about issues surrounding the penis. ‘You see children hear these things in the radios and ask us to explain, how can I talk to my grandson about private organs?’ one elder said. Furthermore, some men – representative of all ages, traditional leaders, professionals and uneducated men had a general view that the language used in the advertisements was sexualized. Phrases like ‘you are cool’ … ‘you will enjoy sex more’ were seen as more to attract men towards the intervention than educate them on the benefits of medical circumcision. Some men in the initiating culture actually said SMC weakens men’s sexual performance while traditional initiation strengthened it. The secret of how this is done was kept to themselves.
Mixed responses from younger modernised men
There were mixed responses about SMC in all the communities, even among the targeted age group, 15-49-year-old men. Some men resisted circumcising for fear of pain after surgery, abstinence for a period after circumcision, missing work and losing wages, and HIV testing – fear to get HIV positive results after testing. Some of the men who had already circumcised said it was the best decision they have ever made about their health and listed the benefits like enjoyment of sex and cleanliness. However, some reported numbness in their penis after circumcising. My research participants said this scared away many others to circumcise, especially after reading ‘horror experience stories’ in the media. There were other counter-productive myths mentioned around SMC: that the foreskins were being sold to the western world to make perfumes; and that sex would never be as enjoyable as before. SMC also carried risk behaviours where some men believed that it was a natural condom and that one could just be promiscuous, and not use condom after they have circumcised. Among the participants, a few with Christian background believed circumcision was not necessary since Christian moral standards encourage faithfulness and sticking to one partner. Some Christians viewed SMC as a way that leads to unfaithfulness in sexual relationships. Other Christians said the bible that they believe in states that circumcision is of the spirit, not of the body, therefore they will not act against God’s commands. Some women on the other hand preferred circumcised men – reported circumcised men to be ‘sexually good in bed and just cool.’ Some men believed that this conviction makes women promiscuous, wanting to test the best man among the circumcised and the uncircumcised.
Based on these finding the Ministry of Health has an opportunity to bridge these controversies and myths, and consult the communities again, now in a more in-depth participatory way to negotiate for strategies that can work for them and help get more men for circumcision. Open negotiations with WHO on the challenges could bring an understanding between aspirations on the high set target and realities.
NB: Published articles on the topic, by the same author – easily accessible through google scholar.