The purpose of this study was to develop an intervention health promotion programme to prevent circumcision related health problem such as sepsis, botched circumcision, dehydration, penile amputation and reduce the number of deaths. The intervention programme was aimed at promoting a safe male circumcision practice affecting boys aged 12-18 years at Libode rural communities in Eastern Cape Province of South Africa. This was achieved through a mixed method design using both quantitative and qualitative approaches utilizing sequential transformative strategy to allow for the convergence of multiple perspectives of the traditional male circumcision in Libode. The study was conducted in 22 schools of the rural communities of Libode because most of the participants are still attending school. Frequencies and percentages were used to analyse the quantitative data, utilizing the Statistical Package for Social Sciences (SPSS). A total of 1036 participants, AmaXhosa circumcised young men (abafana) and uncircumcised boys (amakhwenkwe) participated in the cross-sectional survey, quantitative phase of the study. Qualitative phase of this study was composed of 7 focus group discussions with a total of 84 circumcised and uncircumcised male participants and 10 key informants’ interviews were conducted. In analysis qualitative data, the researcher found the most descriptive words for each topic and turned them into categories or sub-themes. Topics that related to each other were then grouped in order to reduce the number of categories and to create themes. The similar categories of data were grouped and analysed using Tesch’s method. Findings indicated that traditional circumcision is performed during winter and summer holidays in order to cater for the boys who are attending schools. The circumcision age at Libode ranges from 12 and 18 years of age which is against the Health Standards in Traditional Circumcision Act (Act No. 6 of 2001). Although the participants were aware of the complications of male circumcision in Libode, there was a high preference for traditional circumcision (92.3% of participants) to hospital circumcision. The participants were of the view that the benefits of traditional circumcision outweigh the complications or challenges related to traditional circumcision. They wanted to be socially accepted and wanted to learn about manhood values in the traditional circumcision which are values that cannot be achieved through the hospital based circumcision. As male circumcision initiation is seasonal and the intervention programme needed to be approved by different stakeholders, the testing of intervention programme could not happen before the programme was approved by all the stakeholders.

In 2012 the American Academy of Pediatrics (AAP) revised its recommendations regarding neonatal male circumcision, transitioning from a recommendation against it to endorsing the practice. The current recommendations are based on the findings of three studies performed in Sub-Saharan Africa. In those studies, the researchers suggested that circumcision may result is reduced rates of Human Immunodeficiency Virus (HIV) transmission via heterosexual intercourse. In addition to the above studies there are several studies suggesting that circumcision can have benefits in reducing the rates of penile cancer, human papilloma virus transmission, and urinary tract infections. Based on the AAP recommendations some third-party payers have revised their policies regarding reimbursement procedures. While circumcision practices are a topic of debate in the United States, non-therapeutic circumcision is not recommended by the European Academy of Paediatrics and is not reimbursed by third-party payers. For instance, the National Health Service in Great Britain discontinued the practice of routine non-therapeutic circumcision in the mid twentieth century. This presentation will give a thorough review of the existing body of knowledge regarding the practices of non-therapeutic male infant circumcision. Existing studies regarding HIV risk reduction will be discussed in detail. At the same time, the generalizability and transferability of the above studies to the US health care system will be discussed. Finally, third-party reimbursement practices, costs associated with circumcision, and ethical issues related to this issue will be discussed.

Submitted in partial fulfilment of the requirements for The Degree of Doctor of Philosophy (Community Psychology) Faculty of Arts University of Zululand, 2010. / The lives of individuals in all societies are a series of passages from one age to another and from one occupation to the other. Among the Vhavenda, there are fine distinctions among age or occupational groups and progression from one group to the next is accompanied by special rituals enveloped in ceremonies which involve actions that are clearly regulated and guarded so that the entire society suffer no discomfort or injury. The research explores and describes the lived experiences of Vha-Venda initiated women in the rural areas of Mashau, Mashawana and Shayandima village in Limpopo Province, South Africa. The perception that transition practices, otherwise known as initiation rituals or rites of passage, are only practiced in the ‘traditional’ societies because it is believed to be where the culture is embedded. This study draws on qualitative research principles based on the ethnographic approach. This research explores and describes the lived experiences of initiation of Venda women that is practiced and currently being implemented in the three villages that is, Mashau, Mashawana and Shayandima village in Limpopo Province, South Africa. As a result, this study is informed by the qualitative data gathered during the initial stages of the research with the assistance of research guides. The core material in this study emerges from in depth, semi-structured interviews conducted during individual interviews and focus group interviews with fifteen initiated women and two research guides between the age of thirty and sixty. The research guides, with special knowledge of the culture assisted the researcher on the process and activities of the initiation and also informed the researcher about the venues where certain rituals take place and also assisted in translation of certain phrases for clarification. In compliance with research ethics, the identities of the respondents remain confidential through the use of pseudonyms. The research concludes that the lived experiences of women initiation are private and one is strictly prohibited to talk about them, especially with uninitiated women. The aim is to portray the traditional social and cultural ritual proposed to be learnt and preserved. In this study, the researcher’s findings are that: Conformity, compliance and obedience with the initiation rituals can save a person from embarrassment in Limpopo Province where initiation is practiced. Participants reported that women are silenced and forbidden to talk about initiation outside ‘dombani’ with the uninitiated women. They reported that the initiation ritual is secret and thus a taboo to talk about it. Initiates are prohibited to disclose what happens during the initiation process. In contrast, uninitiated women viewed the ritual as barbaric and promiscuous. The initiated indicated that they were forced to attend because of fear of rejection, discrimination and isolation by the community. Other participants agreed to have attended for the sake of acceptance, though they believed to have gained knowledge about understanding womanhood. Most of the women mentioned that although it was some years that they had attended the initiation school, they still carried the burden of anger, shame, humiliation, frustration, low-self esteem, sense of helplessness and lack confidence and still find it hard to share their experiences or talk about them. The researcher concurs with the participants and Stayt (1968) that initiated women are denied freedom of expression. It is sticky prohibited to talk or share the initiation experiences with the non- initiated let alone discuss it outside dombani. Thereby, the aim, and its concomitant 4 objectives, have been thoroughly explored and achieved.

Allegations by the Canadian media that the Canadian-Somali population has been continuing its traditional practice of Female Circumcision (FC) or Female Genital Mutilation (FGM) in Canada despite its illegality was questioned in this thesis. Through qualitative interviews undertaken with fourteen members of the Somali community in Southern Ontario, it was discovered that the respondents do not believe the practice is being continued in Canada. Their views concur with those of the Ministry of Health -Canada which claims that to date, not a single case ofFC/FGM being performed in Canada has been substantiated. The respondents credit their voluntary abandonment of the practice primarily to anti-FGM campaigns that were supported in the urban regions of Somalia from the 1970s until the onset of the Somali civil war in the late 1980s. A secondary deterrent is the fact that the practice is illegal in Canada. Present anti-FGM programs in Canada were deemed necessary by the respondents to reach the minority of individuals who might seek to continue the practice in Canada. Such programs, however, also serve to provide support to circumcised women living in Canada, as well as to provide education about health care in general. Non-FC/FGM related health concerns were deemed more pressing to the Canadian-Somali community, namely, lack of employment, overcrowded living conditions, and inability to access proper health care. Consequently, the respondents were critical of the Canadian media's approach to FC/FGM since the media has neglected to consider other, and in their view, more immediate health concerns faced by the Canadian-Somali community. / Thesis / Master of Arts (MA)

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Thesis (MPhil)--Stellenbosch University, 2014. / ENGLISH ABSTRACT: In efforts to combat the global HIV/AIDS pandemic, the WHO/UNAIDS published the Joint Strategic Action Framework to Accelerate the Scale-up of Voluntary Medical Male Circumcision for HIV Prevention in Eastern and Southern Africa which outlines the aim of a VMMC (voluntary medical male circumcision) prevalence of 80% among males 15-49 year old in 14 countries by 2016 (WHO/UNAIDS, 2011). In line with this directive, South Africa has launched a national VMMC campaign. However, a lot of ethical issues remain unaddressed surrounding VMMC. These can be categorised as individual considerations (autonomy and informed consent; non-maleficence and unintentional, unforeseen harm; risk compensation in circumcised men; risk of undermining current HIV prevention strategies; age of circumcision), community considerations (cultural considerations; justice: the gender divide and female subjugation; distributive justice; social stigmatisation as a result of VMMC), national considerations (adverse events and complications on a macro level; cost saving and unforeseen expenditure of VMMC; the implications of international funding for VMMC; the public health ethics of VMMC; risks of “de-medicalisation” of a surgical procedure; the ever present danger of corruption), global considerations (female genital mutilation; non-sexual HIV transmission; a dangerous shift in focus) and other considerations (a statistical perspective on VMMC; circumcision technique; lack of ethical awareness; dealing with medical uncertainty). Finally, I shall consider neonatal circumcision, which is in itself a contentious issue, and has no role to play in VMMC. The unresolved issues raised by these ethical considerations cast doubt on the moral status of VMMC and I conclude that the VMMC campaign as it stands in South Africa currently is morally indefensible. There is, undeniably, a pressing need for HIV/AIDS prevention strategies in South Africa and other developing countries but the role of circumcision has been overemphasised to the detriment of more holistic approaches. While there are no easy answers to any of the ethical dilemmas presented in this thesis, it is imperative to raise ethical awareness surrounding VMMC. / AFRIKAANSE OPSOMMING: In ‘n poging om die globale MIV/VIGS-pandemie te bekamp, het die WHO/UNAIDS in 2007 die Joint Strategic Action Framework to Accelerate the Scale-up of Voluntary Medical Male Circumcision for HIV Prevention in Eastern and Southern Africa gepubliseer wat ‘n aksie-plan is wat poog om ‘n voorkoms van VMMC (vrywillige mediese manlike besnyding) van 80% in 14 lande onder 15-49 jaar oue mans in 2016 (WHO/UNAIDS, 2011) te bewekstellig. In ooreenstemming met dié riglyn, het Suid-Afrika 'n nasionale VMMC veldtog geinnisiëer. Maar baie van die etiese kwessies verbonde aan VMMC is nie bevredigend aangespreek nie. Hierdie kwessies kan geklassifiseer word onder individuele oorwegings (outonomie en ingeligte toestemming; nie-kwaadwilligheid en onbedoelde, onvoorsiene skade; risiko vergoeding in mans wat besny is; VMMC ondermyn die huidige MIV-voorkoming strategieë; ouderdom van besnyding), gemeenskap oorwegings (kulturele oorwegings; geregtigheid: die oorweging van die geslag verdeel en vroulike onderdanigheid; distributiewe geregtigheid; sosiale stigmatisering as gevolg van VMMC), nasionale oorwegings (newe-effekte en komplikasies op 'n makro-vlak; kostebesparing en onvoorsiene uitgawes van VMMC; die implikasies van internasionale befondsing vir VMMC; die openbare gesondheid etiek van VMMC; risiko's van "de-medikalisering" van 'n chirurgiese procedure; die alomteenwoordige gevaar van korrupsie), globale oorwegings (vroulike genitale verminking; nie-seksuele oordrag van MIV; 'n gevaarlike verskuiwing in fokus) en ander oorwegings ('n statistiese perspektief op VMMC; besnyding tegniek; die gebrek aan bewustheid van hierdie etiese kwessies; die hantering van mediese onsekerheid) bespreek. Ten slotte, sal ek neonatale besnyding ondersoek, wat op sigself 'n omstrede kwessie is, en geen rol behoort te speel in VMMC nie. Die onopgeloste kwessies wat deur hierdie etiese oorwegings aan die lig gebring word veroorsaak twyfel oor die morele status van VMMC. Ek lei dus af dat die VMMC veldtog soos dit tans bestaan in Suid-Afrika moreel onverdedigbaar is. Daar is ongetwyfeld 'n dringende behoefte vir MIV/VIGS- voorkoming strategieë in Suid-Afrika en ander ontwikkelende lande, maar die rol van besnydenis word oorbeklemtoon ten koste van ‘n meer holistiese benadering. Hoewel daar geen maklike antwoorde op enige van die etiese dilemmas wat in hierdie skripsie verken is nie, is dit noodsaaklik dat etiese bewustheid rondom VMMC verhoog word.

A research report submitted to the Faculty of Humanities, School of Social Sciences, University of the Witwatersrand, Johannesburg, in partial fulfilment of the requirements for the degree of Master of Arts in the field of Demography and Population Studies. November 2016. / Introduction: South African men practice both traditional and voluntary medical male circumcision. Voluntary Medical Male Circumcision (VMMC) was introduced as a health intervention strategy against HIV/AIDS. On the other hand, traditional male circumcision (TMC) is a ritual that marks the rite of passage into manhood. TMC has been identified as a public health hazard associated with high numbers of complications and even deaths. The South African government has launched and promotes the VMMC programme. The programme aims to reach a target of 80% coverage in order to effectively reduce HIV infections in the country. However, TMC remains a popular practice. In 2009, the National HIV Community Survey reported that 67% of men were traditionally circumcised, while 33% had been circumcised medically. This study aims to identify factors associated with VMMC, in order to inform the current programme. Furthermore, this study will add to the body of knowledge regarding VMMC and TMC, as previous literature has focused on identifying factors associated with circumcision status rather than the choice of circumcision type (VMMC vs TMC). Objective: The aim of this study was to the identify levels of circumcision status and circumcision types (VMMC vs TMC). Furthermore, this study aimed to examine the relationship between demographic, socio-economic, cognitive and environmental factors associated with VMMC and TMC in South Africa. Methodology: The study used data from the Third National HIV Communication Survey, 2012. The study sample is 6 828 473 males aged 16-55 years who underwent VMMC or TMC. The first step of the analysis was descriptive, using cross tabulations and graphs. Finally, multivariate analysis was employed using binary logistic to examine the relationship between VMMC and TMC with demographic, socio-economic, cognitive and environmental factors. Results Fifty-one percent (51%) of circumcised males were circumcised medically, while 49% were traditionally circumcised. As expected; ethnic groups known to practice TMC were less likely to choose VMMC. In terms of socioeconomic variables, education was significantly associated with whether males were medically circumcised (p<0.05; CI1.66=5.11). Availability of VMMC at the health facility significantly influenced the males choice of selecting VMMC as the type of circumcision to undergo (p<0.05; CI 0.43=0.79). / GR2017