In-depth: At the Cutting edge - male circumcision and HIV

MOZAMBIQUE: Parting with the prepuce is central to becoming a man

Waiting for his turn
Pemba, 19 July 2007 (IRIN In-Depth) - Silvestre João has good and not-so-good memories of his circumcision. "Let's go eat honey in the bush," his father told the nine-year-old. There was honey aplenty, and more: kumbi, the ritual initiation of the Makhuwa people of Mozambique's northern coast.

The boy spent six months in the bush with a group of other kids and adults, all male. He parted with his foreskin and learned about his culture.

The bad memories were "the horrible pain during the first day; I had an infection that took two months to heal"; the good ones were "playing naked in the bush, picking coconuts, swimming in the lagoon, learning songs and legends from the elders".

His padrinho, a male relative who acts as a sponsor and does not go home or have sex until the boy has healed, stayed with him throughout, shooing the flies from the wound. When João returned home, family and neighbours celebrated, and bought him books and pens for school. Now he belonged: as a Makhuwa - the largest ethnic group in northern Mozambique - a Muslim and a man.

That was in 1972. João, now 44, became a nurse and lives in Pemba, capital of Cabo Delgado Province. From October to February, the traditional months for kumbi, he is much in demand to perform circumcisions, but more safely than his was done.

"The value of circumcision persists," he told IRIN/PlusNews. Today's initiates may spend less time in the bush or have a town doctor do the cutting, but the triple layer of meaning - ethnicity, religion and masculinity - still makes male circumcision very special here."

Layered meaning

Rafael da Conceição, an anthropologist at the University Eduardo Mondlane, in the capital, Maputo, and author of a book on cultural identities in northern Mozambique, said circumcision was central to masculinity.

An uncircumcised man is forbidden to take part in key cultural activities reserved for men, such as burials and ancestor rites. "This means he will be vulnerable to aggression from evil spirits or from angry ancestors," said Conceição. "He will not be fully integrated into the male world."

Women from Northern Mozambique like their men cut. "An uncircumcised penis is not good. The prepuce smells, no matter how much the man washes, and women here don't want to have sex with uncircumcised men," said Marta Januario Licuco, a women's rights activist and a Muslim.

If a local girl dates a man from the south, her grandmother will alert her to the possibility that he may be uncircumcised. A campaign to persuade the young man to be circumcised will follow. It may take years, even after marriage, but the pressure will be on, subtly, relentlessly.

"The uncircumcised man is ashamed to remove his clothes, he will turn off the lights before getting into bed, he fees abnormal" Licuco said.

Licuco wears a bright turquoise headscarf and ankle-length dress; Marisia Jacinto, 20, wears tight jeans and a tank top, yet both share the same feelings about uncut men. "I would not accept such a man - I'd take him to the doctor," said Jacinto.

Cabo Delgado is overwhelmingly Muslim and Islam mandates male circumcision, so the kumbi ritual initiation overlaps with religion. Sheik Muhamade Abdulai Cheba, provincial director of the madrassas or Islamic schools, sees many advantages in circumcision: "It prevents disease and lesions; it improves marriage because both partners feel more and sex is healthy."

Making it safe

Kumbi has advantages - and dangers. The nekangas (circumcision masters) may use one blade for several boys without sterilising it. If there are medical complications, the nekangas use traditional medicines.

"The herbs sometimes work, and sometimes make things worse," said Dr Egidio Langa, director of the Central Hospital in Pemba, a town with around 100,000 inhabitants. Post-circumcision complications are more frequent in district and peri-urban health posts than in urban centres.

In 2006, Langa was the health director of Montepuez District, 170km inland from Pemba, when community leaders, worried about the safety of kumbi, approached him. "They spoke of haemorrhages, fevers, even deaths," he said.

He dispatched teams of nurses across the district. During the next two months, they trained the nekangas in hygiene, provided medical material, requested lists of boys due for the ceremony, and asked that they be brought to the nearest health post, where trained nurses performed the surgery on 50 to 60 boys aged seven to 13 every day.

Traditional rites, modern world
Photo: Mercedes Sayagues/PlusNewsClick to enlarge image
PEMBA - I learned how to circumcise from an old nekanga [master] in Nangade, in the north of Cabo Delgado Province, in Mozambique. It was 1983, before AIDS. Full report
"The experience was well received," said Langa. "With a small budget we reduced a big risk, increased protection against sexually transmitted diseases and made circumcision safe."

Building on this success, the provincial council against AIDS plans to train nekangas in HIV prevention between July and September. "Kumbi is a time of intense cultural transmission but, until now, our prevention messages have not made use of this channel," said council chairman, Toles Manuel Jemuce.

A correlation?

According to government data, 56 percent of males in the country are circumcised. In the mainly Muslim provinces of Nampula, Cabo Delgado and Niassa, where the Makhuwa live, it is nearly universal. The Chope and Bitonga ethnic groups, in the mainly Christian Inhambane Province, also practice it.

Langa, who is from Inhambane and was circumcised as a child, said the practice was spreading as people intermarried.

Recent studies in Uganda and South Africa have indicated that male circumcision could offer up to 60 percent protection against HIV, and experts have pointed out that the Mozambican provinces with lower seroprevalence coincided with areas of high male circumcision.

However, the lower alcohol consumption and stricter social controls separating the sexes among Muslims could also be a factor.

Pros and cons

Elias Cossa, a press officer with the national council against AIDS, said Mozambique would define its national policy on male circumcision before the end of the year, and this would be followed by a feasibility assessment.

Some activists argue that rolling out circumcision would divert scarce human and financial resources from a public health system already overburdened by AIDS, in a country with fewer than ten surgeons and even fewer urologists.

"[Antiretroviral] treatment is the priority. To treat a person is more important than to circumcise, because a healthy person will be able to provide for his family and protect them from HIV," said Julio Ramos Mujojo, executive secretary of the national association of people living with HIV (Rensida).

Others worry about cultural and ethnical implications of rolling out circumcision. "It could be perceived as forcing people to change their religion," said Antoninho Cheia Inglês, coordinator of FOCADE, an umbrella body for non-governmental organisations in Cabo Delgado.

Going strong

Thirty years after João´s kumbi, it was the turn of Buane Chande, 11. He, too, has good and not-so-good memories of his three months in the bush in 2001.

The bad memories are "the pain, until it went away, being away from my mother, and mosquitoes"; the nice memories are "playing, swimming in the river, listening to the elders' songs and stories".

When Chande returned home, "every one was so happy": the women ululated, a chicken was killed, a party followed. "Without kumbi, men don't know how to face life," he told IRIN/PlusNews. "A classmate who has not gone through kumbi is not really accepted. He remains a child, even if he is 18."

Chande is now 17 and finishing high school in Pemba. Having children is still in the distant future, but he has no doubts that his sons will undergo kumbi.

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