Tag: circumcision

A culture of dying

Originally published in the Daily Maverick

623156_314164Kabelo Mokgweetse ran away from his initiation school in Pampierstad in November last year, to look for food. He was tracked down and thrashed with a sjambok, before having his feet burnt as further punishment. Then, he was left for dead at the side of the road, where a passing motorist happened to spot him.

Initially only his toes were amputated, but the nerve damage eventually required further surgery, where his right foot was removed in its entirety, along with most of the left. The question that’s difficult to ask – never mind answer – is whether he might prefer to instead be one of the 23 youth who recently died as a result of initiation ceremonies in Mpumalanga.

Mokgweetse and thousands of boys like him are sent (and often willingly go) to initiation schools to mark the transition between boyhood and manhood, undergoing ritual circumcision and being instructed about their social responsibilities. And in most years, children die in the course of “becoming men”. It’s so typical, in fact, that a government news agency can use a headline like “Traditional leaders welcome no initiation deaths”.

That headline was for a story about Limpopo in particular, and dealt with the 2010 season, where attendance at initiation schools was reportedly down by 75% thanks to the World Cup. Limpopo does seem to be a province that has taken the health of initiates particularly seriously, with deaths in the low single-figures for the past few years.

The key question that arises for outsiders like myself is this: do the children who go to initiation schools, the parents who send them there, and the Ramophato (initiation school owner) think that this is a fair price for preserving these cultural practices? And if one death is a fair price, how many would be too costly?

Part of the reason for the continued survival of poorly regulated initiation schools is surely that they provide a narrative to life – a structure, and a reinforcement of community and communal values. But if those goods can be acquired at a lower price – and they undoubtedly can be – then the dozens of deaths we’ve seen so far this year are surely not only too many, but also reason for widespread outrage as well as legal action against those responsible.

Because this is a matter of culture, though, people prefer to tread lightly, tempering their criticisms with politically correct noises about tolerance and respect. But isn’t this in itself condescending, perhaps even racist? Could we instead wonder whether, if the average adolescent in Mpumalanga knew that they had a decent prospect of a good education, a good job and so forth, they’d rather be joining protests against such schools – opting for medical circumcision at the very least, if not entirely rejecting cultural instruction of this sort?

But it’s been – and will continue to be – a long wait for more people to have a better shot at a good life through adequate healthcare, education, and those goods many of us take for granted. And what we put in place as substitutes to give meaning to life – namely cultural practices such as these – result in initiation schools, genital mutilation, corrective rape, culturally embedded homophobia, sexism and so forth.

“Culture” is used as an excuse for all sorts of things (in South Africa, often as a simple vote-getter). But it’s only when you get to choose what your “culture” is – and not have it forced upon you – that it stands a chance of being respectable. And even then, it should never be a stand-alone justification for doing or believing something.

Culture can explain why we do things, even if they appear to be irrational to outsiders. Justification is a different matter, though – if not, how could we complain if a Eugene Terre’Blanche, for example, cites culture as a reason to keep black slaves? Culture cannot serve alone as a reason for doing something.

Equally, culture should not serve as a reason to avoid intervening when needless deaths can be avoided. Last week, a caller to Radio702 recounted his experience of an initiation school (where a close friend of his happened to have died). The caller, Sam, explained that deaths were common thanks to initiates being deprived of water until the last week of proceedings, and also poorly fed – meaning that they had few physical reserves to cope with the gruelling nature of the rituals.

Furthermore, they would also be less able to fight off infection, more common as a result of the lack of qualifications of many who perform the circumcisions. All of these factors can be managed, and to some extent have been managed in Limpopo. This is clearly not the case in Mpumalanga.

Interviewed on eNCA, the MEC for Health in Mpumalanga said that, as a woman, she couldn’t get involved. Her precise words were: “This is a tradition. This is a tradition. So in other tradition whether there are deaths or what but a woman can’t come closer to that”. A competing tradition here involves avoiding needless death, and doing your job. Someone who chooses the tradition of turning a blind eye to death deserves to lose her job, at the very least, and seems at least partly responsible for any future deaths.

Appeals to culture, tradition and the like have causality entirely back-to-front: things could become cultural norms because they are good norms; but the fact that something is a cultural norm has no bearing on whether it’s a good or respectable norm or not. And a cultural practice in which there is no age of consent, poor or no medical oversight, and wilful ignorance on the part of government officials is problematic, to say the least.

“Only God knows who’s going to die, when” was Msebenzi Masombuka’s (a representative of King Mabhoko) comment following the deaths in Mpumalanga. Even if one does believe that, we’d still present ourselves as candidates for earlier or later deaths, through our actions or inactions.

Or sometimes, it’s others we present as candidates for an earlier death. And we sacrifice them on the altar of “culture”. In May 2013, culture killed at least 23 boys – yet we should respect it, just … because.

Maiming, killing and dying for “culture”

Originally published on SkepticInk

Parts of a 17-year-old boy’s feet from Bonita Park, in Hartswater had to be amputated, after he ran away from an initiation school in Pampierstad in search of food.

After he was tracked down, he was thrashed with a sjambok, while his feet were burnt with fire. He was later abandoned along the side of the road, where he was left for dead, naked and bleeding, until a passing motorist noticed him and alerted the police.

Due to extensive nerve and muscle damage, his toes had to be surgically removed.

667532_612441This boy, and thousands like him, are sent (and often willingly go) to initiation schools to mark the transition between boyhood and manhood, “through ritual circumcision and cultural instruction regarding their social responsibilities and their conduct”. Ever year, children die in the course of “becoming men” – and in South African society, being a man correlates quite positively with thinking you can dictate the course of the lives of women.

Part of the reason for the continued survival of poorly regulated initiation schools, with poor hygiene and cultural instruction from previous centuries, is that they provide a narrative to life – a structure, and a community. If the average adolescent knew that they had a decent prospect of a good education, a good job and so forth, they’d probably be joining protests against such schools – opting for medical circumcision at the very least, if not entirely rejecting cultural indoctrination.

But it’s been – and will continue to be – a long wait for more people to have a better shot at a good life through adequate healthcare, education, and those goods many of us take for granted. And what we put in place as substitutes to give meaning to life – namely cultural practices such as these – result in initiation schools, genital mutilation, corrective rape, culturally embedded homophobia, sexism and so forth.

“Culture” is used as an excuse of all sorts of things (in South Africa, often as a simple vote-getter). But it’s only when you get to choose what your “culture” is – and not have it forced upon you – that it becomes remotely respectable. And even then, it should never be an explanation or justification for doing or believing something. As I tell students, appeals to culture, tradition and the like get the causality entirely backwards: things could become cultural norms because they are good norms; but the fact that something is a cultural norm has no bearing on whether it’s a good or respectable one or not.

The Cologne ruling on religious circumcision

Originally published in Daily Maverick

In June this year, a court in the German city of Cologne heard a case involving a four-year-old child from a Muslim family who was admitted to hospital with bleeding following a circumcision. The doctor who performed the circumcision did so at the request of the boy’s parents, and was acquitted of the charge of grievous bodily harm for this reason.

While this particular doctor was acquitted, the court made the general observation that circumcision violated a child’s “fundamental right to bodily integrity”, and that this right outweighed the rights of parents. While leaving room for circumcision to be permissible on medical grounds, the court, in other words, ruled that ritual circumcision amounts to impermissible bodily harm and also constituted a violation of the rights of children.

Contrary to the predictable cries of anti-Semitism that have resulted (and how convenient it is for critics that a German court made the ruling), this is a victory for freedom of religion. Yes, one element of one ritual is outlawed, namely that parents can no longer choose to cut flesh from the penis of their non-consenting child. But why should they ever have had that “right”?

The argument that religion, custom and culture – in and of themselves – are insufficient justification for a practice applies across the board, not simply to examples of such practices that are more anachronistic, bizarre or unfashionable than the ones that happen to still be mainstream in modern societies. We wouldn’t endorse foot-binding on grounds of culture, and we certainly don’t endorse female genital cutting.

Foot-binding would of course not be possible at a later age, or it would at least be far less effective. But you can be circumcised at any age, once you determine that you independently desire to identify with a certain culture or religion. That should be a choice, and not the choice of the parents – this is surely what freedom of religion means. An infant might have Muslim or Jewish parents, but we should wait to hear from the child itself before performing irreversible surgery on them.

Informed consent is a fundamental principle of modern medicine. Exceptions do of course exist, such as when consent cannot be given for whatever reason, and an intervention is held to have significant benefits for the patient. But it’s only contingently the case that we happen to accept male circumcision as exempt from this principle – it has a weight of history and privilege (the privilege that is accorded to religion generally) behind it.

If we were to instead engage in the thought experiment of enquiring whether – in the absence of that history and privilege – male circumcision would be considered permissible, the conversation would revolve around costs and benefits, and whether any benefits could be accrued at lower costs.

In the case of female genital mutilation, the answer is clear – the costs far outweigh very dubious benefits. In general, it’s therefore not very useful or justified to compare that practice with male circumcision (except as examples of cultural artefacts, as I do above. Or, if we were to follow the Jewish scholar Maimonides, we might think them comparable in that both are aimed at a “decrease in sexual intercourse and a weakening of the organ in question, so that this activity be diminished and the organ be in as quiet a state as possible”).

For male circumcision, the fact that it comes at a small physical cost (relative to most instances of female circumcision) is presented as part of the justification for why it should be permissible. But any cost is too great, if it doesn’t come with benefits that can’t be accrued more cheaply. What we should not do is make the mistake of asking adult circumcised men whether they think harm was done to them. They’re not in a position to entertain any counterfactuals – both in terms of their physical state, and also because the majority of them would have grown up in a culture where male genital cutting was acceptable. It would be unsurprising that they found it unproblematic, as it would be just as normal as being uncircumcised would be to other men.

The point is that by that time, the opportunity for choice has passed. A non-religious child has had non-essential surgery performed on it by a religious parent, on the assumption that the child will eventually choose to belong to that religion. And of course, they are more likely to make that choice after having (non-volitionally) embraced the commitment-device of circumcision.

How much stronger would their commitment be, one wonders, if they instead choose to get circumcised as a teen or adult? If circumcision involves a sacred covenant with God, that covenant seems strengthened through being voluntary – and parents should not be free to make that covenant on behalf of their infant in cases where doing so involves cutting the infant’s flesh.

Religious parents in the 21st century are surely aware of these concerns, and do appear to struggle to justify what is at least a prima facie rights violation. So, they sometimes turn to information that wouldn’t have been available to Maimonides – the purported health benefits of circumcision. While it’s repeated so frequently as to seem axiomatic, the evidence that circumcision reduces HIV infection is not as clear-cut (pdf) as many think it is.

Likewise, the claim that circumcision reduces cervical cancer is also more suspect than many realise, as the reported headline findings give little indication as to the dearth of quality data underlying those findings. The key trial held to justify that conclusion is a meta-analysis of 7 different studies in 5 countries, where none of the individual studies found any correlation between circumcision and cervical cancer.

That’s not necessarily a problem, as meta-analyses can sometimes reveal data that isn’t clear in individual trials. In this case, though, the meta-analysis only revealed a correlation with human papillomavirus (HPV), a factor in the development of around 90% of cases of cervical cancer. But while HPV is almost always a factor in cervical cancer, it doesn’t necessarily lead to cervical cancer.

You can of course show that it tends to do so, but note that we’re talking about two degrees of separation from circumcision here, so establishing a sufficiently strong correlation (to even suspect that there might be causation) between circumcision and cervical cancer would require a mountain of data. Instead, what we have in this meta-analysis  is a relatively small sample (for the control group), a suspect methodology, and virtually no controlling for other cervical cancer risk-factors, such as smoking or poverty.

In other words, the evidence of benefits from circumcision is not entirely clear. And against these possible benefits, we also need to weigh costs – for example, the cost of reduced penile sensitivity. Or, perhaps the cost of increased rather than decreased HIV infection, seeing as the South African National Communication Survey on HIV/AIDS in 2009 found that 15% of adults thought that circumcision eliminated the need to use condoms.

I don’t necessarily think that all ethical dilemmas can be resolved by empirical evidence, even if many of them can be. But even if circumcision does come with the benefits of reducing HIV infection or instances of cervical cancer, there’s no obstacle to men of a sexually-active age choosing to be circumcised. If the data were clear I’d happily endorse their doing so, because it’s sensible to reduce risk where possible, and where the reduction comes at an acceptable cost.

But it should be a choice. And while surgical interventions can sometimes be approved by someone other than the patient, this should never be the case for non-essential surgery. So to my mind, the Cologne court made what is unquestionably the correct decision on health grounds, and one which also happens to protect freedom of religion. That is, the freedom of the infant to later choose a religion, or to choose to not have one.

Also worth reading:
Religion is no excuse for mutilating your baby’s penis, by Brian D. Earp

And here’s a lunatic rant from Brendan O’Neill:
The rebranding of circumcision as ‘child abuse’ echoes the ugly anti-Semitism of medieval Europe