Research Traditional male circumcision in eastern and southern Africa: a systematic review of prevalence and complications Andrea Wilcken,a Thomas Keila & Bruce Dickb Objective To systematically review studies on the prevalence and complications of traditional male circumcision (i.e. circumcision by a traditional provider with no formal medical training), whose coverage and safety are unclear. Methods We systematically searched databases and reports for studies on the prevalence and complications of traditional male circumcision in youth 10–24 years of age in eastern and southern Africa, and also determined the ages at which traditional circumcision is most frequently performed. Findings Six studies reported the prevalence of traditional male circumcision, which had been practised in 25–90% of all circumcised male study participants. Most circumcisions were performed in boys 13–20 years of age. Only two of the six studies on complications reported overall complication rates (35% and 48%) following traditional male circumcision. The most common complications were infection, incomplete circumcision requiring re-circumcision and delayed wound healing. Infection was the most frequent cause of hospitalization. Mortality related to traditional male circumcision was 0.2%. Conclusion Published studies on traditional male circumcision in eastern and southern Africa are limited; thus, it is not possible to accurately assess the prevalence of complications following the procedure or the impact of different traditional practices on subsequent adverse events. Also, differences in research methods and the absence of a standard reporting format for complications make it difficult to compare studies. Research into traditional male circumcision procedures, practices and complication rates using standardized reporting formats is needed. الرتجمة العربية لهذه الخالصة يف نهاية النص الكامل لهذه املقالة. .Une traduction en français de ce résumé figure à la fin de l’article. Al final del artículo se facilita una traducción al español Introduction prevalence, the age at which the procedure is undertaken and the complications arising from it. Globally, 30% of men are circumcised, mostly for religious reasons.1 In many African societies, male circumcision is carried Methods out for cultural reasons, particularly as an initiation ritual and a rite of passage into manhood. The procedure herein referred to Search strategy as traditional male circumcision is usually performed in a non- clinical setting by a traditional provider with no formal medical An initial search of African Healthline and African Index Me- training. When carried out as a rite of passage into manhood, dicus using the terms “traditional circumcision” and “traditional traditional male circumcision is mainly performed on adolescents circumcisers” brought up no studies; we therefore excluded or young men. The self-reported prevalence of traditional male these databases from the subsequent search. We searched for circumcision varies greatly between eastern and southern Africa, primary studies in MEDLINE, Web of Science, Popline and from 20% in Uganda and southern African countries to more African Journals OnLine using the terms “male circumcision than 80% in Kenya.2 AND traditional”, “traditional circumcisers”, “male circumcision AND anthropology”, “male circumcision AND complications”, Randomized controlled trials have shown a substantial “male circumcision AND history”, “male circumcision AND protective effect of male circumcision with respect to female–to– 3–5 manhood/masculinity/rite of passage”. The search was limited male transmission of human immunodeficiency virus (HIV). to the period from January 1980 to February 2008 and covered In these studies, complications following male circumcision articles published in any language. Additional reports were ranged from 1.7% to 7.6% and were mostly of minor clinical 6,7 provided by key researchers and members of the Joint United significance. However, serious complications and even deaths Nations Programme on HIV/AIDS Working Group on Male have been reported from traditional male circumcision carried 8,9 Circumcision, and the East and Southern Africa Inter-Agency out on adolescents. While medical male circumcision is in- Task Team on Male Circumcision. We also searched all the ref- creasingly being incorporated in comprehensive strategies for erences listed in the articles identified during the initial search. the prevention of HIV infection10, traditional providers will continue to be an important source of circumcision for many Selection criteria males in eastern and southern Africa and will not easily be re- placed by male circumcision performed in a clinical setting for To be included in the review, articles had to describe original re- reasons that are both cultural and linked to health service capac- search studies from eastern and southern Africa that reported on ity. Our aim in this systematic review was to evaluate traditional the prevalence or complications of traditional male circumcision male circumcision in eastern and southern Africa in terms of its (as defined in the introduction) performed on youth 10–24 years a Institute for Social Medicine, Epidemiology and Health Economics, Charité University Medical Centre, Berlin, Germany. b Department of Child and Adolescent Health, World Health Organization, Geneva, Switzerland. Correspondence to Andrea Wilcken (e-mail: [email protected]). (Submitted: 2 October 2009 – Revised version received: 31 May 2010 – Accepted: 1 June 2010 – Published online: 29 October 2010 ) Bull World Health Organ 2010;88:907–914 | doi:10.2471/BLT.09.072975 907 Research Traditional male circumcision in eastern and southern Africa Andrea Wilcken et al. in Kenya (83% for 12 directly observed Fig. 1. Study selection in systematic review of the literature on traditional male 18 circumcision in eastern and southern Africa study participants) and 48% in South Africa (Table 2).14 1639 citations retrieved from search, titles and/or abstracts screened Types of complications 1559 citations excluded for the following reasons: Two studies used direct observation to - duplicates assess complications after traditional male - not relevant for research topic circumcision.17,18 Infection and delayed - not meeting any criteria of inclusion wound healing were the most common 80 full text articles retrieved and screened complications. No severe bleeding oc- curred in the Kenyan (n = 12),18 and the 69 articles excluded for the following reasons: South African study (n = 192).17 Excessive - not on traditional male circumcision (n = 17) - not on prevalence, age, complications (n = 19) circumcision was reported as a primary - age group not between 10–24 years (n = 13) complication after traditional male cir- - study setting not eastern or southern Africa (n = 16) cumcision in the South African study17 - narrative article (n = 15) and as a secondary result of incomplete - review (n = 6) initial circumcision in the Kenyan study.18 11 articles included Re-circumcision resulted in excessive re- moval of skin and a deepened wound with of age, either specifically or in the context level.11–14,16 The percentage of men report- prolonged wound healing, excessive scar- of a larger study. For assessing prevalence edly circumcised varied from 52% in an ring and loss of penile sensitivity. Delayed and age, we included cross-sectional, cohort urban setting in Mbale district, Uganda,13 to wound healing and keloid scarring were and register studies; for assessing complica- 80% in rural areas of the Southern Rift Val- also associated with the use of a powder tions, we also included intervention studies. ley in Kenya,11 and 99% in rural and urban containing penicillin and talc that is used Studies reporting on male circumcision areas of Tarime district, in the United Re- for wound care by traditional providers provided through medical facilities were public of Tanzania.16 Rates of circumcision in Kenya.18 Fatalities did not occur in excluded, as were studies focusing on new- performed by traditional circumcisers in the South African study17 and one death born and infant circumcision. districts where male circumcision is widely was prevented by the research team in the practised were up to 90% in Uganda,13 Kenyan study.18 Evaluation of studies 74% in Kenya11 and 63% in the United One study assessed complications Republic of Tanzania.16 In the townships 14 Two medically trained reviewers (AW, based on recall by participants (n = 108). of the Gauteng province of South Africa, TK) independently evaluated identi- In contrast to results from direct obser- 10% of males aged 14–24 years and 22% fied studies in terms of methods, study vation, bleeding (26%) and severe pain of those aged 19–29 years were report- design and representativeness of the (43%) were reported as being major edly circumcised, in 58–65% of cases by study population. The reviewers then adverse results, whereas delayed wound traditional circumcisers.12,14 The choice of healing was not mentioned and local extracted the data relating to prevalence, providers depended on the affiliation to age and complications of traditional male infections were reported in only 4% of different ethnic groups; for example, 86% cases.14 circumcision. Any discrepancies in the of Xhosa participants were circumcised by evaluation were resolved by consensus. According to hospital admission traditional providers compared with only records, infection was the most common 37% of Tswana men.12 Results