Circumcision and the Community

**3**

**Chapter 1**

**Abstract**

of children's rights.

**1. Introduction**

the medical literature [2, 3].

Phoenicians, Hittites, and Ethiopians.

The Relationship between Female

Scholars of Arabic use the word "îzâr," which means defect, and the word "hafd," which means reducing and shrinking to express circumcision. Besides these, the words tahûr and tahâre are also used to express circumcision. European languages use the common expression female genital mutilation or circumcision to refer to circumcision. However, observations of some female mummies in Egypt and the description of circumcision on ancient Egyptian wall paintings supports the opinion that this tradition dates back very long and that it has continued for many years. The historian Herodotus states that circumcision was practiced by the Phoenicians, Hittites, and Ethiopians. Information obtained shows that circumcision is also practiced in the tropical regions of Africa, the Philippines, and by the tribes of the Upper Amazon and the women of the Australian Arunta tribe. The tradition of female circumcision that is originally a concept of the religions of African tribes has been associated with the religion Islam even though there is no reference to female circumcision at all in the Quran. Female circumcision is a violation of human rights. There is no legal explanation or excuse for persecuting women at young ages with various agendas like religion (!), customs and tradition or health in an area that affects their entire lives. This violation of women's rights can also be interpreted as a violation

**Keywords:** female circumcision, Africa, women's rights, religion, women's health

There is very little information about the origin of female circumcision. However, observations of some female mummies in Egypt and the description of circumcision on ancient Egyptian wall paintings supports the opinion that this

tradition dates back very long and that it has continued for many years. The historian Herodotus states that circumcision was practiced by the

Female circumcision or female genital mutilation has been defined by the world health organization as "all procedures that involve partial or complete removal of the external female genitalia, or other injury to the female genital organs for nonmedical reasons" [1]. Although the procedure is called female circumcision in the countries that perform it, its negative physical and psychological effects have led to the use of the Latin term "mutylatio" that means to maim, to cut off (mutilation) in

Circumcision and the Religion

*Özer Birge and Aliye Nigar Serin*

## **Chapter 1**

## The Relationship between Female Circumcision and the Religion

*Özer Birge and Aliye Nigar Serin*

## **Abstract**

Scholars of Arabic use the word "îzâr," which means defect, and the word "hafd," which means reducing and shrinking to express circumcision. Besides these, the words tahûr and tahâre are also used to express circumcision. European languages use the common expression female genital mutilation or circumcision to refer to circumcision. However, observations of some female mummies in Egypt and the description of circumcision on ancient Egyptian wall paintings supports the opinion that this tradition dates back very long and that it has continued for many years. The historian Herodotus states that circumcision was practiced by the Phoenicians, Hittites, and Ethiopians. Information obtained shows that circumcision is also practiced in the tropical regions of Africa, the Philippines, and by the tribes of the Upper Amazon and the women of the Australian Arunta tribe. The tradition of female circumcision that is originally a concept of the religions of African tribes has been associated with the religion Islam even though there is no reference to female circumcision at all in the Quran. Female circumcision is a violation of human rights. There is no legal explanation or excuse for persecuting women at young ages with various agendas like religion (!), customs and tradition or health in an area that affects their entire lives. This violation of women's rights can also be interpreted as a violation of children's rights.

**Keywords:** female circumcision, Africa, women's rights, religion, women's health

## **1. Introduction**

Female circumcision or female genital mutilation has been defined by the world health organization as "all procedures that involve partial or complete removal of the external female genitalia, or other injury to the female genital organs for nonmedical reasons" [1]. Although the procedure is called female circumcision in the countries that perform it, its negative physical and psychological effects have led to the use of the Latin term "mutylatio" that means to maim, to cut off (mutilation) in the medical literature [2, 3].

There is very little information about the origin of female circumcision. However, observations of some female mummies in Egypt and the description of circumcision on ancient Egyptian wall paintings supports the opinion that this tradition dates back very long and that it has continued for many years.

The historian Herodotus states that circumcision was practiced by the Phoenicians, Hittites, and Ethiopians.

In addition to this, information obtained has revealed that circumcision is also practiced in the tropical areas of Africa, the Philippines and by the tribes of the upper amazon and the women of the Arunta tribe in Australia [4]. The practice of circumcision is also called "tahara" in Arabic which means the procedure of cleaning. About the relationship between cleanliness and circumcision, the historian Herodotus asks, "where did the ancient Egyptians learn this, when the reproductive organs of all peoples on earth are remaining the same?". It has also been pointed out that cleanliness came before beauty for the ancient Egyptians [5].

The world health organization has classified circumcision into four different groups [2, 3, 6]:

Type I: partial or complete removal of the preputium and/or clitoris (Sunna). Type 2: excision of the clitoris together with the partial or total excision of the labia minora (excision).

Type 3: cutting nearly all of the labia minora and majora together with the clitoris and preputium and sowing the edges of the open wound together leaving only a small orifice for urine and menstruation blood to pass (infibulation).

Type 4: is an unclassified group and comprises other mutilating practices (piercing, pricking, tattooing, scraping, cauterization).

Many applications have been carried out in unhygienic conditions without anesthesia and mixtures of plants, cow dung and butter have been used for wound healing [5]. Severe pain, bleeding, urinary retention, ulcers in genetical area, adjacent organ injury, sepsis and even death can be seen following procedures with scissors, part of glass, blade, bark, plant thorn performed by persons who do not medical professional training [7].

Infections, keloids, genital tract infections, sexual inherited diseases, especially genital herpes, increasing HIV infection risk, labor complications, sexual disorders and post-traumatic stress disorder can be listed among late period complications. Also, cases with Type 3 female genital mutilation are more risky since complaints such as requirement of deinfibulation, frequent recurrence, re-requirement of surgery, urinary retention, menstrual problems and painful sexual intercourse are frequently seen [8].

The symptoms of lower urinary system are frequently seen in females with Type 2 and 3 female genital mutilations [9]. Decreasing in urinary flow rate depending on infibulation causes urinary stasis and therefore causes repetitive urinary infections. Consequently, formation of urinary or vaginal stone can be seen [10]. In these cases, recommended treatment method is the deinfibulation. Urethral strictures or fistulas can be seen depending on urethral trauma during mutilation. In our case, urinary retention depending on adherences secondarily developed with mutilation was thought. It was observed that case urinated easily after deinfibulation operation. Cases with inability to have a sexual intercourse and therefore dyspareunia depending on improved vulvovaginal laceration and adherences in genital region after female genital mutilation performed in unhygienic conditions was reported [11]. It has been thought that genital mutilation applications increase infertility by causing sexual disorders (dyspareunia, apareunia) and genital infections. In case control study, it was stated that there was a relationship between primary infertility and female mutilation [12]. It was reported that psychological disorders such as secondary anxiety disorder and posttraumatic stress disorder against female genital mutilation could be seen [13].

Mutilation is still practiced in 30 countries in Africa, a few countries in the Arabian Peninsula, in some societies in southeastern Asia and secretly in ethnic groups that have migrated to Europe, America or Australia from these countries [2, 14]. Although the historical origin of this traditional practice is not entirely

**5**

*The Relationship between Female Circumcision and the Religion*

understood, there is evidence that it has existed since the ancient Egyptian civilization [15]. According to the reports of the World Health Organization, approximately 100–150 million women alive have been subjected to these practices, 6000 African girls between the ages 4 and 12 are subjected to these practices every day,

In earlier studies it has been identified that FGM is performed as part of the culture and tradition (like an initiation rite into womanhood) or religion, to make finding a spouse easier, or for reasons like chastity, genital hygiene, high morality or virginity [16]. It is known that circumcision is performed by Muslim, Christian, Jewish and also irreligious societies in Africa. In addition, no relationship was identified between religion and the prevalence of circumcision [17]. The prevalence of circumcision in Muslim countries Egypt, Sudan, Somalia and some middle-eastern countries has led to the emergence of an opinion that circumcision is a recommendation and a requirement of Islam. Sudan is an Islamic Republic that applies Islamic rules in social life and government procedures. Thus, religious rules and principles have an important role in the lives of the Sudanese people. The sayings and deeds of religious opinion leaders and imams hold a significant value in the eyes of the public. The expression circumcision that is the subject of this study refers only to female circumcision. The tradition of female circumcision that is originally a concept of the religions of African tribes has been associated with the religion Islam even though there is no reference to female circumcision at all in the Quran. The differences between religious systems in countries that practice female circumcision show that circumcision exists as a cultural phenomenon in other non-Islamic cultures. In this respect, it is believed that the tradition of female circumcision in Islamic African countries originates from African tribes. The highest levels of the tradition of female circumcision practiced by some African Animist groups in the pre-Islamic era have been encountered in the Yoruba and Bakango tribes. In addition to this, it is known that it was practiced widely in the era of the Kingdom of Kush ruled by Black pharaohs in Nubia in Upper Egypt during the time of the 18th dynasty. While Islam was spreading among the Animist tribes of Africa, the tradition of female circumcision influenced some schools of Islam through mutual interactions. Leaders of African tribes that converted to Islam and wanted to continue the practices of female circumcision associated it with Islam. Consequently, a belief that this

The practice of female circumcision differs by country and can be performed at any time starting from babyhood until the ages of 13–14 [7, 8]. In half of the countries circumcision is performed in, it is done before the age of 5 by a woman called a "daya," usually without numbing the genital area and by using non-sterile tools like knives, razor blades, sharp pieces of glass or sharp edges of tin. Acacia thorns, bone nails, needles, strings made from animal hair or leather are used to close the wound, and then the girl's legs are tied together tightly from the knee to the hip in an upright position. The circumcised girl lies without moving for a few weeks and is helped to urinate and defecate where she lies. During the circumcision, apart from the daya, other women gathered around the girl hold the girls' arms and legs tightly, some press her shoulders down to prevent her from moving. To prevent the girl from swallowing or biting her tongue a cloth or stick is placed in her mouth, and the other women play the tambourine and sing songs loudly to

and 2 million new procedures are performed annually worldwide [1, 14].

*DOI: http://dx.doi.org/10.5772/intechopen.86657*

practice is a requirement of Islam emerged [18].

**2. History and methods**

mask the screaming [4, 9, 10].

#### *The Relationship between Female Circumcision and the Religion DOI: http://dx.doi.org/10.5772/intechopen.86657*

*Circumcision and the Community*

groups [2, 3, 6]:

labia minora (excision).

medical professional training [7].

frequently seen [8].

mutilation could be seen [13].

In addition to this, information obtained has revealed that circumcision is also practiced in the tropical areas of Africa, the Philippines and by the tribes of the upper amazon and the women of the Arunta tribe in Australia [4]. The practice of circumcision is also called "tahara" in Arabic which means the procedure of cleaning. About the relationship between cleanliness and circumcision, the historian Herodotus asks, "where did the ancient Egyptians learn this, when the reproductive organs of all peoples on earth are remaining the same?". It has also been pointed out

The world health organization has classified circumcision into four different

Type I: partial or complete removal of the preputium and/or clitoris (Sunna). Type 2: excision of the clitoris together with the partial or total excision of the

Type 3: cutting nearly all of the labia minora and majora together with the clitoris and preputium and sowing the edges of the open wound together leaving only a

Type 4: is an unclassified group and comprises other mutilating practices (pierc-

Infections, keloids, genital tract infections, sexual inherited diseases, especially genital herpes, increasing HIV infection risk, labor complications, sexual disorders and post-traumatic stress disorder can be listed among late period complications. Also, cases with Type 3 female genital mutilation are more risky since complaints such as requirement of deinfibulation, frequent recurrence, re-requirement of surgery, urinary retention, menstrual problems and painful sexual intercourse are

The symptoms of lower urinary system are frequently seen in females with Type 2 and 3 female genital mutilations [9]. Decreasing in urinary flow rate depending on infibulation causes urinary stasis and therefore causes repetitive urinary infections. Consequently, formation of urinary or vaginal stone can be seen [10]. In these cases, recommended treatment method is the deinfibulation. Urethral strictures or fistulas can be seen depending on urethral trauma during mutilation. In our case, urinary retention depending on adherences secondarily developed with mutilation was thought. It was observed that case urinated easily after deinfibulation operation. Cases with inability to have a sexual intercourse and therefore dyspareunia depending on improved vulvovaginal laceration and adherences in genital region after female genital mutilation performed in unhygienic conditions was reported [11]. It has been thought that genital mutilation applications increase infertility by causing sexual disorders (dyspareunia, apareunia) and genital infections. In case control study, it was stated that there was a relationship between primary infertility and female mutilation [12]. It was reported that psychological disorders such as secondary anxiety disorder and posttraumatic stress disorder against female genital

Mutilation is still practiced in 30 countries in Africa, a few countries in the Arabian Peninsula, in some societies in southeastern Asia and secretly in ethnic groups that have migrated to Europe, America or Australia from these countries [2, 14]. Although the historical origin of this traditional practice is not entirely

Many applications have been carried out in unhygienic conditions without anesthesia and mixtures of plants, cow dung and butter have been used for wound healing [5]. Severe pain, bleeding, urinary retention, ulcers in genetical area, adjacent organ injury, sepsis and even death can be seen following procedures with scissors, part of glass, blade, bark, plant thorn performed by persons who do not

that cleanliness came before beauty for the ancient Egyptians [5].

small orifice for urine and menstruation blood to pass (infibulation).

ing, pricking, tattooing, scraping, cauterization).

**4**

understood, there is evidence that it has existed since the ancient Egyptian civilization [15]. According to the reports of the World Health Organization, approximately 100–150 million women alive have been subjected to these practices, 6000 African girls between the ages 4 and 12 are subjected to these practices every day, and 2 million new procedures are performed annually worldwide [1, 14].

In earlier studies it has been identified that FGM is performed as part of the culture and tradition (like an initiation rite into womanhood) or religion, to make finding a spouse easier, or for reasons like chastity, genital hygiene, high morality or virginity [16]. It is known that circumcision is performed by Muslim, Christian, Jewish and also irreligious societies in Africa. In addition, no relationship was identified between religion and the prevalence of circumcision [17]. The prevalence of circumcision in Muslim countries Egypt, Sudan, Somalia and some middle-eastern countries has led to the emergence of an opinion that circumcision is a recommendation and a requirement of Islam. Sudan is an Islamic Republic that applies Islamic rules in social life and government procedures. Thus, religious rules and principles have an important role in the lives of the Sudanese people. The sayings and deeds of religious opinion leaders and imams hold a significant value in the eyes of the public.

The expression circumcision that is the subject of this study refers only to female circumcision. The tradition of female circumcision that is originally a concept of the religions of African tribes has been associated with the religion Islam even though there is no reference to female circumcision at all in the Quran. The differences between religious systems in countries that practice female circumcision show that circumcision exists as a cultural phenomenon in other non-Islamic cultures. In this respect, it is believed that the tradition of female circumcision in Islamic African countries originates from African tribes. The highest levels of the tradition of female circumcision practiced by some African Animist groups in the pre-Islamic era have been encountered in the Yoruba and Bakango tribes. In addition to this, it is known that it was practiced widely in the era of the Kingdom of Kush ruled by Black pharaohs in Nubia in Upper Egypt during the time of the 18th dynasty. While Islam was spreading among the Animist tribes of Africa, the tradition of female circumcision influenced some schools of Islam through mutual interactions. Leaders of African tribes that converted to Islam and wanted to continue the practices of female circumcision associated it with Islam. Consequently, a belief that this practice is a requirement of Islam emerged [18].

## **2. History and methods**

The practice of female circumcision differs by country and can be performed at any time starting from babyhood until the ages of 13–14 [7, 8]. In half of the countries circumcision is performed in, it is done before the age of 5 by a woman called a "daya," usually without numbing the genital area and by using non-sterile tools like knives, razor blades, sharp pieces of glass or sharp edges of tin. Acacia thorns, bone nails, needles, strings made from animal hair or leather are used to close the wound, and then the girl's legs are tied together tightly from the knee to the hip in an upright position. The circumcised girl lies without moving for a few weeks and is helped to urinate and defecate where she lies. During the circumcision, apart from the daya, other women gathered around the girl hold the girls' arms and legs tightly, some press her shoulders down to prevent her from moving. To prevent the girl from swallowing or biting her tongue a cloth or stick is placed in her mouth, and the other women play the tambourine and sing songs loudly to mask the screaming [4, 9, 10].

According to the UNICEF report, around 125 million women have been circumcised to this day, and nearly 30 million girls are in danger of circumcision. Girls between the ages of 3 and 10 are subjected to this torture every year. Egypt (most prominently), Sudan, Ethiopia, Nigeria, Kenya, Indonesia, Malaysia, and Somali are among the countries where the tradition of female circumcision is practiced. It is rarer in Syria, Iraq and Iran and is also seen in Europe, Canada, America and Australia as a result of migration [9, 10, 12].

Our research revealed that female genital mutilation was used in past to treat some female disorders like hysteria, epilepsy, masturbation, lesbianism, sex addiction and mental disorders in the United States of America and west Europe [4, 13].

The social scientists studying this topic have separate views that support each other. Among these, there are opinions that female circumcision dates back to the Neolithic era, that the Egyptians used circumcision to prevent their relatives and slaves from getting pregnant and that it was also prevalent in the Arabian Peninsula before Islam [19].

Another aspect of the origin and spread of the tradition of female circumcision is the economic and geographic background. Harsh climate changes between Africa and the inner parts of Asia accelerated the replacement of the democratic and peaceful matriarchal society with a patriarchal society. As Nevâl es-Sa'dâvî has also stated, during the era of the pharaohs Egyptian women held important positions in the field of governing as well as religion. Research conducted supports the opinion that ancient pagan gods were also female. However, the period of goddesses dates further back than the origin of patriarchal societies and feudalism. Women in ancient agricultural societies succeeded to preserve their social and political positions. However, the advancements in agriculture and its evolution into a means of living led to the birth of private ownership. The rise of class discrimination and the developments disrupted the position of women and made them lose their prior prestige and reputation. They were pushed towards the lower levels in all of the hierarchic systems [20].

The works of Nevâl es-Sa'dâvî and Esma ed-Darîr on this subject have enabled access to first-hand reliable information and have facilitated raising awareness at a global level. Besides this, apprehension has increased with the development of feminist awareness and the international women's health movement [21].

If we examine the religious aspect of female circumcision here, we must say that it is not included in any of the heavenly religions. However, there is also mention of inauthentic hadith on the subject of female circumcision. In one of these fake hadiths, it is reported that the prophet Muhammad (pbuh) summoned a woman that circumcised girls in Mecca and said, "do not cut too deep that is better for the woman and more liked by her husband [22]. Besides this, according to a hadith narrated by Abu Hureyrah, the prophet (pbuh) said: The fitrah (human nature) is five things—circumcision, shaving the pubes, cutting the nails, plucking the armpit hairs, and trimming the mustache [23]." It is clearly stated that this expression does not concern female circumcision and that it was interpreted with bias. Those opposing the people that base this practice on religious requirements cite the Quran as a source for their opposing opinions. In this context they refer to the holy book that is the source of Islam and give examples from verses of the Quran (Surah [passage]:verse of the Quran; Furkan:2, Nur:115, Rum:30, Âli İmrân:6) [22].

One of the best arguments that female circumcision is prohibited in Islam is that the Quran and the sunnah (the verbally transmitted record of the teachings, deeds and sayings, silent permissions (or disapprovals) of the Islamic prophet Muhammad) of the prophet reject practices against human nature. In this context, female circumcision contradicts the systematic thought of the holy Quran [22].

**7**

*The Relationship between Female Circumcision and the Religion*

symbolically, and this is possible with circumcision [19].

that daya are also required the wedding night [24].

requirement in many countries in Africa [26].

The religious assessment should also include the fatwa (Islamic legislation) issued by renowned people and institutions of the Islamic community based on religious foundations that contradict these opinions. These are fatwa that state that female circumcision is legal in Islam and that its prohibition is unwarranted [23]. The continuation of the practice despite knowledge of its harms can be attributed to the culture and the associated emotional behaviors. When the condition is examined in Sudan, the country where female circumcision is most prevalent and where it is practiced in its most severe form, it will be seen that female circumcision is one of the most delicate subjects of that culture. In the Sudanese society where the pride of a family depends on virginity, being circumcised bears the characteristics of a cachet. In the Sudanese society, women must be virgins physically and

Although it is incorrect according to religious references, the opinion that women are a source of mischief and that they should be kept under control that is customary in Muslim societies plays an important role in the continuation of female circumcision in the countries it is practiced in. In a society where non-circumcised women are regarded as prostitutes, the highest authority in the family, the grandmothers continue this practice that is an indispensable aspect of their culture to them. Because it is a matter of honor and pride for the family they themselves

According to Nevâl es-Sa'dâvî, economic reasons play an important role in the origination and persistence of female circumcisions. The historical process shows that the oppression of women began with the evolution into a patriarchal society. The economic interests of society and the moral and religious values of the patriarchal system overlapped and gained support. Historical research shows that chastity belts, circumcision and other forms of violence were methods used to suppress female sexuality. It was aimed to restrain female sexuality and women were not allowed to experience sexuality unless it was for economic reasons. The daya and doctors that earn a living by performing these procedures must also be remembered among economic reasons. The fact that women in Sudan suffer this procedure multiple times due to reasons like marriage, birth, divorce, and re-marriage displays the economic dimensions concerning the practitioners of circumcision. It is known

The subject of circumcision is directly related to female sexuality. Together with the most delicate subjects of society, religion and policy, this relationship is more prominent in less developed countries. Girls that are circumcised are turned into targets vulnerable to physical and mental abuse without the capacity of thinking,

Cultural, social, psychological and economic conditions appear to be the major factors in persisting the practice of female circumcision. Esthetic concerns may also be added to these factors. It is also stated that the concepts of tradition and religion are also strong encouragers [25]. In addition to this opinion, many of the Muslims and academics in the west argue that circumcision is more related to culture than religion. Likewise, the authentic and apodictic references of Islam reject female circumcision. Accordingly, the philosophy of Islamic law (fiqh) only accepts circumcision of boys known by the name "hıtân." Unfortunately, it can be seen that the religion has been manipulated to express that female circumcision is a religious

Raising public awareness has a major importance in combating female circumcision. While the public is enlightened religiously and medically, the rights of women in this area must be protected legally through legal enforcement. The Egyptian Mufti Office has announced that they are against female circumcision and that this practice has no religious basis. Similarly, the Religious Affairs Administration

*DOI: http://dx.doi.org/10.5772/intechopen.86657*

deliver the girls to the dayas.

understanding and judgment.

#### *The Relationship between Female Circumcision and the Religion DOI: http://dx.doi.org/10.5772/intechopen.86657*

*Circumcision and the Community*

before Islam [19].

hierarchic systems [20].

Australia as a result of migration [9, 10, 12].

According to the UNICEF report, around 125 million women have been circumcised to this day, and nearly 30 million girls are in danger of circumcision. Girls between the ages of 3 and 10 are subjected to this torture every year. Egypt (most prominently), Sudan, Ethiopia, Nigeria, Kenya, Indonesia, Malaysia, and Somali are among the countries where the tradition of female circumcision is practiced. It is rarer in Syria, Iraq and Iran and is also seen in Europe, Canada, America and

Our research revealed that female genital mutilation was used in past to treat some female disorders like hysteria, epilepsy, masturbation, lesbianism, sex addiction and mental disorders in the United States of America and west Europe [4, 13]. The social scientists studying this topic have separate views that support each other. Among these, there are opinions that female circumcision dates back to the Neolithic era, that the Egyptians used circumcision to prevent their relatives and slaves from getting pregnant and that it was also prevalent in the Arabian Peninsula

Another aspect of the origin and spread of the tradition of female circumcision is the economic and geographic background. Harsh climate changes between Africa and the inner parts of Asia accelerated the replacement of the democratic and peaceful matriarchal society with a patriarchal society. As Nevâl es-Sa'dâvî has also stated, during the era of the pharaohs Egyptian women held important positions in the field of governing as well as religion. Research conducted supports the opinion that ancient pagan gods were also female. However, the period of goddesses dates further back than the origin of patriarchal societies and feudalism. Women in ancient agricultural societies succeeded to preserve their social and political positions. However, the advancements in agriculture and its evolution into a means of living led to the birth of private ownership. The rise of class discrimination and the developments disrupted the position of women and made them lose their prior prestige and reputation. They were pushed towards the lower levels in all of the

The works of Nevâl es-Sa'dâvî and Esma ed-Darîr on this subject have enabled access to first-hand reliable information and have facilitated raising awareness at a global level. Besides this, apprehension has increased with the development of feminist awareness and the international women's health movement [21].

If we examine the religious aspect of female circumcision here, we must say that it is not included in any of the heavenly religions. However, there is also mention of inauthentic hadith on the subject of female circumcision. In one of these fake hadiths, it is reported that the prophet Muhammad (pbuh) summoned a woman that circumcised girls in Mecca and said, "do not cut too deep that is better for the woman and more liked by her husband [22]. Besides this, according to a hadith narrated by Abu Hureyrah, the prophet (pbuh) said: The fitrah (human nature) is five things—circumcision, shaving the pubes, cutting the nails, plucking the armpit hairs, and trimming the mustache [23]." It is clearly stated that this expression does not concern female circumcision and that it was interpreted with bias. Those opposing the people that base this practice on religious requirements cite the Quran as a source for their opposing opinions. In this context they refer to the holy book that is the source of Islam and give examples from verses of the Quran (Surah [passage]:verse of the Quran; Furkan:2, Nur:115, Rum:30, Âli

One of the best arguments that female circumcision is prohibited in Islam is that the Quran and the sunnah (the verbally transmitted record of the teachings, deeds and sayings, silent permissions (or disapprovals) of the Islamic prophet Muhammad) of the prophet reject practices against human nature. In this context, female circumcision contradicts the systematic thought of the holy Quran [22].

**6**

İmrân:6) [22].

The religious assessment should also include the fatwa (Islamic legislation) issued by renowned people and institutions of the Islamic community based on religious foundations that contradict these opinions. These are fatwa that state that female circumcision is legal in Islam and that its prohibition is unwarranted [23].

The continuation of the practice despite knowledge of its harms can be attributed to the culture and the associated emotional behaviors. When the condition is examined in Sudan, the country where female circumcision is most prevalent and where it is practiced in its most severe form, it will be seen that female circumcision is one of the most delicate subjects of that culture. In the Sudanese society where the pride of a family depends on virginity, being circumcised bears the characteristics of a cachet. In the Sudanese society, women must be virgins physically and symbolically, and this is possible with circumcision [19].

Although it is incorrect according to religious references, the opinion that women are a source of mischief and that they should be kept under control that is customary in Muslim societies plays an important role in the continuation of female circumcision in the countries it is practiced in. In a society where non-circumcised women are regarded as prostitutes, the highest authority in the family, the grandmothers continue this practice that is an indispensable aspect of their culture to them. Because it is a matter of honor and pride for the family they themselves deliver the girls to the dayas.

According to Nevâl es-Sa'dâvî, economic reasons play an important role in the origination and persistence of female circumcisions. The historical process shows that the oppression of women began with the evolution into a patriarchal society. The economic interests of society and the moral and religious values of the patriarchal system overlapped and gained support. Historical research shows that chastity belts, circumcision and other forms of violence were methods used to suppress female sexuality. It was aimed to restrain female sexuality and women were not allowed to experience sexuality unless it was for economic reasons. The daya and doctors that earn a living by performing these procedures must also be remembered among economic reasons. The fact that women in Sudan suffer this procedure multiple times due to reasons like marriage, birth, divorce, and re-marriage displays the economic dimensions concerning the practitioners of circumcision. It is known that daya are also required the wedding night [24].

The subject of circumcision is directly related to female sexuality. Together with the most delicate subjects of society, religion and policy, this relationship is more prominent in less developed countries. Girls that are circumcised are turned into targets vulnerable to physical and mental abuse without the capacity of thinking, understanding and judgment.

Cultural, social, psychological and economic conditions appear to be the major factors in persisting the practice of female circumcision. Esthetic concerns may also be added to these factors. It is also stated that the concepts of tradition and religion are also strong encouragers [25]. In addition to this opinion, many of the Muslims and academics in the west argue that circumcision is more related to culture than religion. Likewise, the authentic and apodictic references of Islam reject female circumcision. Accordingly, the philosophy of Islamic law (fiqh) only accepts circumcision of boys known by the name "hıtân." Unfortunately, it can be seen that the religion has been manipulated to express that female circumcision is a religious requirement in many countries in Africa [26].

Raising public awareness has a major importance in combating female circumcision. While the public is enlightened religiously and medically, the rights of women in this area must be protected legally through legal enforcement. The Egyptian Mufti Office has announced that they are against female circumcision and that this practice has no religious basis. Similarly, the Religious Affairs Administration

of the Republic of Turkey also states that female circumcision is a procedure that the religion Islam prohibits. At this point, the explanations of Nevâl es-Sa'dâvî are important in the religious and medical aspects: Religion comprises the concept of health, love, justice, equality and honesty for all people, man or woman. Thus, a religion that desires to harm and sicken the bodies of girls and women is unthinkable. How could religion order to cut off an organ created by Allah? No organ or anything else is created by Allah randomly [22]. Islam does not allow human nature to be disrupted. On the other hand, male circumcision has been categorized as Sunnah and wajib (that which is proven on the basis of ambiguous evidence) on the basis of Islamic law and certain health benefits.

## **3. Conclusion**

The importance of informing the public and education in ending the practice of female genital circumcision that has no religious basis and endangers the future of children and affects them is evident. Also, the society must acquire a high level of consciousness with the capacity to handle and resolve the problems of children to protect them instead of maiming them by circumcision. Families that want these harmful customs and traditions to come to an end want to enlighten the public and also demand laws and punishments that the whole society will be bound by.

## **Author details**

Özer Birge1 \* and Aliye Nigar Serin<sup>2</sup>

1 Department of Gynaecology and Obstetrics, Akdeniz University Hospital, Antalya, Turkey

2 Department of Gynaecology and Obstetrics, Osmaniye State Hospital, Osmaniye, Turkey

\*Address all correspondence to: ozbirge@gmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**9**

*The Relationship between Female Circumcision and the Religion*

Convention on the Rights of the Child: The Process in Europe and Central Asia; 2006;50. ISBN-10: 88-89129-42-5

[11] UNFPA. 2013. Available from: www. unfpa.org/gender/practices [Accessed: 2

[13] Rodríguez SB. Female Circumcision and Clitoridectomy in the United States: A History of a Medical Treatment. 2014. University of Rochester Press. Available from: www.academia.edu [Accessed: 5

[14] World Health Organization. Division of Family Health. Female Genital Mutilation: Report of a WHO Technical Working Group, Geneva, 17-19 July 1995. 1996. Available from: www.who.int/iris/handle/10665/63602

[Accessed: 3 May 2019]

ISIS. 2001;**92**(2):317-338

2008;**1**(3):135-139

1999;**13**(1):79-106

[15] Knight M. Curing or ritual mutilation? Some remarks on the practice of female and male circumcision in Graeco-Roman Egypt.

A persisting practice. Reviews in Obstetrics and Gynecology.

[17] Obermeyer CM. Female genital surgeries: The known, the unknown, and the unknowable. Medical Anthropology Quarterly.

[19] Hayes RO. Female genital

[16] Nour NM. Female genital cutting:

[18] İlkkaracan P. Women and Sexuality in Muslim Societies (Translator Ebru Salman). İstanbul: İletişim; 2006

mutilation, fertility control, women's

[12] UNICEF. Female Genital Mutilation/Cutting: A Statistical Overview and Exploration of the Dynamics of Change. July 2013;184.

ISBN: 978-92-806-4703-7

May 2019]

May 2019]

*DOI: http://dx.doi.org/10.5772/intechopen.86657*

reproductive health concern. Population

[2] Black JA, Debelle GD. Female genital mutilation in Britain. British Medical

[3] Female Genital Mutilation. ACOG Committee Opinion. Committee on international Affairs. No. 151. 1995. Available from: www.ncbi.nlm.nih.gov

[4] UNFPA is the United Nations Sexual and Reproductive Health Agency. 2013. Available from: www.unfpa.org/gender/ practices [Accessed: 2 May 2019]

[5] Cultural Survival Quarterly Magazine. 1985. Clitoridectomy and Infibulation. Available from: www. culturalsurvival.org [Accessed: 3 May

[6] Macready N. Female genital mutilation outlawed in United States. British Medical Journal.

[7] Chelala C. A critical move against female genital mutilation. Populi.

mutilation, working paper for UNFPA Technical Consultation on Female Genital Mutilation, Ouagadougou, Burkina Faso, 1996; and Toubia N, 1993,

[9] Extract of sample "Female Genital Multilation" WHO. 2012. Available from: https://studentshare.org/ sociology/1457960-female-genitalmultilation [Accessed: 2 May 2019]

[10] UNICEF. Innocenti Research Centre. The General Measures of the

[8] Rushwan H. Female genital

op. cit. (see reference 4)

1996;**313**(7065):1103

1998;**25**(1):13-15

2019]

[1] Kiragu K, mutilation F g. A

Journal. 1995;**310**:1590-1592

[Accessed: 3 May 2019]

Reports. Series Journal. Oct 1995;

**References**

(41 Suppl):1-4

*The Relationship between Female Circumcision and the Religion DOI: http://dx.doi.org/10.5772/intechopen.86657*

## **References**

*Circumcision and the Community*

**3. Conclusion**

**Author details**

Antalya, Turkey

\* and Aliye Nigar Serin<sup>2</sup>

\*Address all correspondence to: ozbirge@gmail.com

provided the original work is properly cited.

1 Department of Gynaecology and Obstetrics, Akdeniz University Hospital,

2 Department of Gynaecology and Obstetrics, Osmaniye State Hospital, Osmaniye,

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

Özer Birge1

Turkey

basis of Islamic law and certain health benefits.

laws and punishments that the whole society will be bound by.

of the Republic of Turkey also states that female circumcision is a procedure that the religion Islam prohibits. At this point, the explanations of Nevâl es-Sa'dâvî are important in the religious and medical aspects: Religion comprises the concept of health, love, justice, equality and honesty for all people, man or woman. Thus, a religion that desires to harm and sicken the bodies of girls and women is unthinkable. How could religion order to cut off an organ created by Allah? No organ or anything else is created by Allah randomly [22]. Islam does not allow human nature to be disrupted. On the other hand, male circumcision has been categorized as Sunnah and wajib (that which is proven on the basis of ambiguous evidence) on the

The importance of informing the public and education in ending the practice of female genital circumcision that has no religious basis and endangers the future of children and affects them is evident. Also, the society must acquire a high level of consciousness with the capacity to handle and resolve the problems of children to protect them instead of maiming them by circumcision. Families that want these harmful customs and traditions to come to an end want to enlighten the public and also demand

**8**

[1] Kiragu K, mutilation F g. A reproductive health concern. Population Reports. Series Journal. Oct 1995; (41 Suppl):1-4

[2] Black JA, Debelle GD. Female genital mutilation in Britain. British Medical Journal. 1995;**310**:1590-1592

[3] Female Genital Mutilation. ACOG Committee Opinion. Committee on international Affairs. No. 151. 1995. Available from: www.ncbi.nlm.nih.gov [Accessed: 3 May 2019]

[4] UNFPA is the United Nations Sexual and Reproductive Health Agency. 2013. Available from: www.unfpa.org/gender/ practices [Accessed: 2 May 2019]

[5] Cultural Survival Quarterly Magazine. 1985. Clitoridectomy and Infibulation. Available from: www. culturalsurvival.org [Accessed: 3 May 2019]

[6] Macready N. Female genital mutilation outlawed in United States. British Medical Journal. 1996;**313**(7065):1103

[7] Chelala C. A critical move against female genital mutilation. Populi. 1998;**25**(1):13-15

[8] Rushwan H. Female genital mutilation, working paper for UNFPA Technical Consultation on Female Genital Mutilation, Ouagadougou, Burkina Faso, 1996; and Toubia N, 1993, op. cit. (see reference 4)

[9] Extract of sample "Female Genital Multilation" WHO. 2012. Available from: https://studentshare.org/ sociology/1457960-female-genitalmultilation [Accessed: 2 May 2019]

[10] UNICEF. Innocenti Research Centre. The General Measures of the Convention on the Rights of the Child: The Process in Europe and Central Asia; 2006;50. ISBN-10: 88-89129-42-5

[11] UNFPA. 2013. Available from: www. unfpa.org/gender/practices [Accessed: 2 May 2019]

[12] UNICEF. Female Genital Mutilation/Cutting: A Statistical Overview and Exploration of the Dynamics of Change. July 2013;184. ISBN: 978-92-806-4703-7

[13] Rodríguez SB. Female Circumcision and Clitoridectomy in the United States: A History of a Medical Treatment. 2014. University of Rochester Press. Available from: www.academia.edu [Accessed: 5 May 2019]

[14] World Health Organization. Division of Family Health. Female Genital Mutilation: Report of a WHO Technical Working Group, Geneva, 17-19 July 1995. 1996. Available from: www.who.int/iris/handle/10665/63602 [Accessed: 3 May 2019]

[15] Knight M. Curing or ritual mutilation? Some remarks on the practice of female and male circumcision in Graeco-Roman Egypt. ISIS. 2001;**92**(2):317-338

[16] Nour NM. Female genital cutting: A persisting practice. Reviews in Obstetrics and Gynecology. 2008;**1**(3):135-139

[17] Obermeyer CM. Female genital surgeries: The known, the unknown, and the unknowable. Medical Anthropology Quarterly. 1999;**13**(1):79-106

[18] İlkkaracan P. Women and Sexuality in Muslim Societies (Translator Ebru Salman). İstanbul: İletişim; 2006

[19] Hayes RO. Female genital mutilation, fertility control, women's

#### *Circumcision and the Community*

roles, and the patrilineage in modern Sudan: A functional analysis. American Ethnologist. 1975;**4**(2):617-633

[20] Es-Sa'dâvî N. The Hidden Face of Eve (Translated by Sibel Özbudun). İstanbul: Anahtar Kitaplar; 1991

[21] Gordon D. Female circumcision and genital operations in Egypt and the Sudan: A dilemma for medical anthropology. Medical Antropology Quarterly, New Series. 1991;**1**(5):3-14

[22] Sâmi 'Avd ez-Zîyb ebu es-Sêhiliyye. Hitên ez-Zekûr ve'l-inâs 'ınde'l-yehûd ve'lmesîhiyyîn ve'l-muslimîn el-cedel ed-dînî ve't-tıbbî ve'l-ictimâ'î ve'lkânûnî. 2012. Available from: http:// www.sami-aldeeb.com/sections/ view.php?id=18&action=publicatio nsm21.01.2014

[23] Muhammed Ali S-BH. Hitên el-înâs eş-şer'î. 4th ed. el-Hartûm: matba'at es-Sidêd; 2009

[24] Saadawi NEl. A creative and dissident life. Infed. 2000. Available from: http://africawrites.org/blog/ the-politics-of-health [Accessed: 3 May 2019]

[25] Essak B, Sailo E, İllahe K. Teşvîh el-ağdâ' et-tenâsuliyye li'l-inâs. (FGM). Helsinki, Tyylipaino: Africarewo ry (African Care Women); 2011

[26] Von der Osten-Sacken T, Uwer T. Is female genital mutilation an Islamic problem? Middle East Quarterly. Winter. 2007:29-36. Available from: http://www.meforum.org/1629/ is-female-genitalmutilation-an-islamicproblem [Accessed: 22 January 2014]

**11**

**Chapter 2**

**Abstract**

care intervention.

**1. Introduction**

Communities

*Shazia Moosa and Lubna Samad*

Scaling Safe Circumcisions in

Male circumcision (MC), although a common and simple procedure, is not available to a majority of the population as a safe, sterile intervention. The convincing evidence of the protective role of circumcision towards the spread of STDs (particularly HIV) led to the establishment of voluntary, adult male circumcision programmes in high-HIV-burden countries. In low- and middle-income Muslim countries, where the need for circumcision is high, there is an evident gap in access to, and delivery of, this procedure. Large-scale programmes aimed at circumcising male babies in settings where circumcision is a religious requirement, as opposed to a medical indication, have not been established. This chapter would draw upon current guidelines and literature, review existing programmes that have attempted to establish community-based safe circumcision initiatives and discuss strategies for sustainable scale-up to meet this huge public health need. We believe it is important to translate existing clinical knowledge into a population-based health-

Amidst the debate on whether the benefits of circumcision outweigh risks, regardless of the reason for circumcision and irrespective of geographical, ethical and socio-economic boundaries, circumcision continues to be one of the commonest surgical procedures performed globally [1]. Since male circumcision (MC) is universal in Muslim and Jewish populations, circumcision prevalence of 99.9% was estimated, and in non-Muslim, non-Jewish states, a minimum prevalence of 0.1% was assumed to calculate the global MC prevalence of 37–39% [2]. This estimate is higher than the one given by the WHO in 2008 which was 30% [3]. The reason for the rise in MC prevalence could be attributed to the rising number of Muslims worldwide [4, 5] and to the initiation of voluntary medical male circumcision (VMMC) programmes encouraged by the WHO and the joint United Nations agency programme on HIV/AIDS—UNAIDS in sub-Saharan African countries as a

**Keywords:** male circumcision, early infant male circumcision, plastibell circumcision, task sharing, health provider, scale-up

preventative strategy to curb the rising incidence of HIV [2].

## **Chapter 2**

*Circumcision and the Community*

Ethnologist. 1975;**4**(2):617-633

roles, and the patrilineage in modern Sudan: A functional analysis. American

[20] Es-Sa'dâvî N. The Hidden Face of Eve (Translated by Sibel Özbudun). İstanbul: Anahtar Kitaplar; 1991

[21] Gordon D. Female circumcision and genital operations in Egypt and the Sudan: A dilemma for medical anthropology. Medical Antropology Quarterly, New Series. 1991;**1**(5):3-14

[22] Sâmi 'Avd ez-Zîyb ebu es-Sêhiliyye. Hitên ez-Zekûr ve'l-inâs 'ınde'l-yehûd ve'lmesîhiyyîn ve'l-muslimîn el-cedel ed-dînî ve't-tıbbî ve'l-ictimâ'î ve'lkânûnî. 2012. Available from: http:// www.sami-aldeeb.com/sections/ view.php?id=18&action=publicatio

[23] Muhammed Ali S-BH. Hitên el-înâs eş-şer'î. 4th ed. el-Hartûm: matba'at

[24] Saadawi NEl. A creative and dissident life. Infed. 2000. Available from: http://africawrites.org/blog/ the-politics-of-health [Accessed: 3 May

[25] Essak B, Sailo E, İllahe K. Teşvîh el-ağdâ' et-tenâsuliyye li'l-inâs. (FGM). Helsinki, Tyylipaino: Africarewo ry (African Care Women); 2011

[26] Von der Osten-Sacken T, Uwer T. Is female genital mutilation an Islamic problem? Middle East Quarterly. Winter. 2007:29-36. Available from: http://www.meforum.org/1629/

is-female-genitalmutilation-an-islamicproblem [Accessed: 22 January 2014]

nsm21.01.2014

es-Sidêd; 2009

2019]

**10**

## Scaling Safe Circumcisions in Communities

*Shazia Moosa and Lubna Samad*

## **Abstract**

Male circumcision (MC), although a common and simple procedure, is not available to a majority of the population as a safe, sterile intervention. The convincing evidence of the protective role of circumcision towards the spread of STDs (particularly HIV) led to the establishment of voluntary, adult male circumcision programmes in high-HIV-burden countries. In low- and middle-income Muslim countries, where the need for circumcision is high, there is an evident gap in access to, and delivery of, this procedure. Large-scale programmes aimed at circumcising male babies in settings where circumcision is a religious requirement, as opposed to a medical indication, have not been established. This chapter would draw upon current guidelines and literature, review existing programmes that have attempted to establish community-based safe circumcision initiatives and discuss strategies for sustainable scale-up to meet this huge public health need. We believe it is important to translate existing clinical knowledge into a population-based healthcare intervention.

**Keywords:** male circumcision, early infant male circumcision, plastibell circumcision, task sharing, health provider, scale-up

### **1. Introduction**

Amidst the debate on whether the benefits of circumcision outweigh risks, regardless of the reason for circumcision and irrespective of geographical, ethical and socio-economic boundaries, circumcision continues to be one of the commonest surgical procedures performed globally [1]. Since male circumcision (MC) is universal in Muslim and Jewish populations, circumcision prevalence of 99.9% was estimated, and in non-Muslim, non-Jewish states, a minimum prevalence of 0.1% was assumed to calculate the global MC prevalence of 37–39% [2]. This estimate is higher than the one given by the WHO in 2008 which was 30% [3]. The reason for the rise in MC prevalence could be attributed to the rising number of Muslims worldwide [4, 5] and to the initiation of voluntary medical male circumcision (VMMC) programmes encouraged by the WHO and the joint United Nations agency programme on HIV/AIDS—UNAIDS in sub-Saharan African countries as a preventative strategy to curb the rising incidence of HIV [2].

## **2. Scale of practice**

## **2.1 Burden of circumcision**

According to the *CIA World Factbook*, the annual global birth rate is estimated to be more than 134.5 million births [6]; assuming half of these to be males and using the above-mentioned global MC prevalence, 25.5 million potential circumcision procedures are required across the globe every year. Religion, culture and medical reasons are the main indications prompting families to opt for circumcision.

## *2.1.1 Religious considerations*

An estimated 23.2% of the world's population comprise Muslims with nearly 69% of them residing in Asia and 27% in Africa [4]; 0.2% are Jews, 80% of whom live either in Israel or the USA; religious traditions in both communities staunchly advocate circumcision.

Taking Pakistan as an example of a developing Muslim country in Asia, an estimated 2.5 million male babies are born in Pakistan every year [6], almost all of whom undergo circumcision in their infancy or childhood [3]. Presently, the vast majority of circumcisions are performed by traditional circumcisers, barbers and untrained paramedical staff using unsterilized instruments and unsafe techniques with no follow-up or record of any complications; only 5–10% of boys present to qualified surgeons and physicians [7]. It would be unreasonable to rely on specialists and general practitioners to fulfill this huge unmet need for safe circumcisions, given that the estimated physician density in Pakistan is 0.978 per 1000 with only about 200 registered pediatric surgeons in the country [8]. In countries where healthcare resources are insufficient, emphasis needs to shift towards developing a public health strategy whereby appropriate non-medical personnel are trained to perform circumcisions safely, using correct technique and modern infection control practices [9].

### *2.1.2 Cultural requirements*

For thousands of years, traditional circumcision has been practiced in African tribes of sub-Saharan region and amongst many ethnic groups around the world, including aboriginal Australasians, the Aztecs and Mayans in the Americas and in the Philippines [3]. The prime reason for circumcision in most of these groups is to emphasize and celebrate the occasion of rite of passage to manhood.

## *2.1.3 Medical indications*

Around 80 percent of American men are circumcised, one of the highest rates in the developed world [10]. The USA is the only country in the world where newborn circumcision in male babies is highly prevalent, allegedly for health benefits [11], and an overwhelming majority gets circumcised in hospitals, soon after birth [12]. According to estimates, 80–95% of male infants were being circumcised in the USA by the 1970s [13]. The US Centers for Disease Control and Prevention (CDC) proclaimed that this trend showed a decline thereafter, possibly influenced by the pronouncements of the American Academy of Pediatrics (AAP) in 1971, deeming there are no valid medical indications for circumcision in the neonatal period [14]. The CDC, however, collects voluntary data only from participating hospitals, some of which withdrew neonatal circumcision services due to financial reasons, thereby

**13**

*Scaling Safe Circumcisions in Communities DOI: http://dx.doi.org/10.5772/intechopen.89437*

from the procedure.

displaying sharp decline in circumcision rates in those particular settings [11, 13]. Many hospitals chose to discontinue coding circumcisions as procedures which may have led to inaccuracy in the collected data; moreover, circumcisions performed during subsequent hospital admissions or as outpatients were not recorded. Therefore, accurate conclusions about the actual number of procedures being performed cannot be drawn. Nelson et al. reported that the incidence of newborn circumcision increased steadily between 1988 and 2000 in the USA from 48.3 to 61.1%, with the overall weighted incidence of circumcision being 54.4% [12]. Revision in the stance of AAP Task Force on Circumcision in 1989 to a more neutral position that stated 'Circumcision has potential medical benefits and advantages as well as disadvantages and risks' and that parental decisions should be based on informed consent, could be a possible factor influencing the circumcision rates. Availability of health insurance is another important factor favorably influencing the numbers of circumcisions [15]. Being the commonest surgical procedure performed in the USA, circumcision exerts a considerable impact on the health system of the country; on one hand, it usurps the medical budget by utilizing the health personnel and consumables that collectively build towards the direct cost of the procedure and its associated complications, and on the other hand, it helps to reduce any potential indirect costs by diseases that are averted as a result of benefits

In recent years, increasing evidence has linked male circumcision to lower rates of asymptomatic urinary tract infection (UTI) [16, 17], especially during infancy and to lower risk of transmission of sexually transmitted diseases, most notably of the HIV [18]. At the end of 2006, an estimated 39.5 million people were living with HIV, and the incidence of new cases was 4.3 million that year [19]. Three randomized controlled trials were conducted to assess the impact of MC on HIV risk [20–22]; all three studies were aborted when interim analysis showed compelling evidence that MC reduces the risk of acquiring HIV through heterosexual sex by 51–60%. This led to global attention on this procedure, thereby encouraging prophylactic circumcision

in many countries with a high prevalence of HIV/AIDS [23], especially in sub-Saharan Africa. The WHO/UNAIDS recommended rapid scale-up of MC in settings where prevalence of heterosexually transmitted HIV infection is high, the levels of

Africa has a unique burden of circumcision with many Muslim-majority countries, a high prevalence of HIV in many countries and cultural preferences in certain tribes. Somalia, a sub-Saharan African Muslim country displaying a very high birth rate and inadequate health services, has an unimpressive physician density of 0.02 per 1000. Uganda has 13.7% Muslims, with a high birth rate, physician density of 0.09 per 1000 coupled with a high burden of HIV cases. Kenya, accommodating 11.2% Muslims, with a high birth rate superimposed with a huge burden of HIV cases and a physician density of 0.2 per 1000 shows 84% of all Kenyan men are

Circumcisions prompted by religious, cultural or general health benefits are not an emergency. However, those required to control the spread of HIV epidemic globally are urgent, and crucial steps need to be taken to ensure their instatement. Therefore, the implementation of 'voluntary medical male circumcision' and 'early infant male circumcision' (EIMC) programmes to tackle HIV spread and high volumes of routine circumcisions, respectively, provide plausible solutions.

male circumcision are low, and populations at risk of HIV are large.

circumcised, predominantly due to cultural obligation [3].

**3. Interventional strategies**

#### *Scaling Safe Circumcisions in Communities DOI: http://dx.doi.org/10.5772/intechopen.89437*

*Circumcision and the Community*

**2.1 Burden of circumcision**

*2.1.1 Religious considerations*

advocate circumcision.

practices [9].

*2.1.2 Cultural requirements*

*2.1.3 Medical indications*

According to the *CIA World Factbook*, the annual global birth rate is estimated to be more than 134.5 million births [6]; assuming half of these to be males and using the above-mentioned global MC prevalence, 25.5 million potential circumcision procedures are required across the globe every year. Religion, culture and medical reasons are the main indications prompting families to opt for circumcision.

An estimated 23.2% of the world's population comprise Muslims with nearly 69% of them residing in Asia and 27% in Africa [4]; 0.2% are Jews, 80% of whom live either in Israel or the USA; religious traditions in both communities staunchly

Taking Pakistan as an example of a developing Muslim country in Asia, an estimated 2.5 million male babies are born in Pakistan every year [6], almost all of whom undergo circumcision in their infancy or childhood [3]. Presently, the vast majority of circumcisions are performed by traditional circumcisers, barbers and untrained paramedical staff using unsterilized instruments and unsafe techniques with no follow-up or record of any complications; only 5–10% of boys present to qualified surgeons and physicians [7]. It would be unreasonable to rely on specialists and general practitioners to fulfill this huge unmet need for safe circumcisions, given that the estimated physician density in Pakistan is 0.978 per 1000 with only about 200 registered pediatric surgeons in the country [8]. In countries where healthcare resources are insufficient, emphasis needs to shift towards developing a public health strategy whereby appropriate non-medical personnel are trained to perform circumcisions safely, using correct technique and modern infection control

For thousands of years, traditional circumcision has been practiced in African tribes of sub-Saharan region and amongst many ethnic groups around the world, including aboriginal Australasians, the Aztecs and Mayans in the Americas and in the Philippines [3]. The prime reason for circumcision in most of these groups is to

Around 80 percent of American men are circumcised, one of the highest rates in the developed world [10]. The USA is the only country in the world where newborn circumcision in male babies is highly prevalent, allegedly for health benefits [11], and an overwhelming majority gets circumcised in hospitals, soon after birth [12]. According to estimates, 80–95% of male infants were being circumcised in the USA by the 1970s [13]. The US Centers for Disease Control and Prevention (CDC) proclaimed that this trend showed a decline thereafter, possibly influenced by the pronouncements of the American Academy of Pediatrics (AAP) in 1971, deeming there are no valid medical indications for circumcision in the neonatal period [14]. The CDC, however, collects voluntary data only from participating hospitals, some of which withdrew neonatal circumcision services due to financial reasons, thereby

emphasize and celebrate the occasion of rite of passage to manhood.

**2. Scale of practice**

**12**

displaying sharp decline in circumcision rates in those particular settings [11, 13]. Many hospitals chose to discontinue coding circumcisions as procedures which may have led to inaccuracy in the collected data; moreover, circumcisions performed during subsequent hospital admissions or as outpatients were not recorded. Therefore, accurate conclusions about the actual number of procedures being performed cannot be drawn. Nelson et al. reported that the incidence of newborn circumcision increased steadily between 1988 and 2000 in the USA from 48.3 to 61.1%, with the overall weighted incidence of circumcision being 54.4% [12]. Revision in the stance of AAP Task Force on Circumcision in 1989 to a more neutral position that stated 'Circumcision has potential medical benefits and advantages as well as disadvantages and risks' and that parental decisions should be based on informed consent, could be a possible factor influencing the circumcision rates. Availability of health insurance is another important factor favorably influencing the numbers of circumcisions [15]. Being the commonest surgical procedure performed in the USA, circumcision exerts a considerable impact on the health system of the country; on one hand, it usurps the medical budget by utilizing the health personnel and consumables that collectively build towards the direct cost of the procedure and its associated complications, and on the other hand, it helps to reduce any potential indirect costs by diseases that are averted as a result of benefits from the procedure.

In recent years, increasing evidence has linked male circumcision to lower rates of asymptomatic urinary tract infection (UTI) [16, 17], especially during infancy and to lower risk of transmission of sexually transmitted diseases, most notably of the HIV [18]. At the end of 2006, an estimated 39.5 million people were living with HIV, and the incidence of new cases was 4.3 million that year [19]. Three randomized controlled trials were conducted to assess the impact of MC on HIV risk [20–22]; all three studies were aborted when interim analysis showed compelling evidence that MC reduces the risk of acquiring HIV through heterosexual sex by 51–60%. This led to global attention on this procedure, thereby encouraging prophylactic circumcision in many countries with a high prevalence of HIV/AIDS [23], especially in sub-Saharan Africa. The WHO/UNAIDS recommended rapid scale-up of MC in settings where prevalence of heterosexually transmitted HIV infection is high, the levels of male circumcision are low, and populations at risk of HIV are large.

Africa has a unique burden of circumcision with many Muslim-majority countries, a high prevalence of HIV in many countries and cultural preferences in certain tribes. Somalia, a sub-Saharan African Muslim country displaying a very high birth rate and inadequate health services, has an unimpressive physician density of 0.02 per 1000. Uganda has 13.7% Muslims, with a high birth rate, physician density of 0.09 per 1000 coupled with a high burden of HIV cases. Kenya, accommodating 11.2% Muslims, with a high birth rate superimposed with a huge burden of HIV cases and a physician density of 0.2 per 1000 shows 84% of all Kenyan men are circumcised, predominantly due to cultural obligation [3].

#### **3. Interventional strategies**

Circumcisions prompted by religious, cultural or general health benefits are not an emergency. However, those required to control the spread of HIV epidemic globally are urgent, and crucial steps need to be taken to ensure their instatement. Therefore, the implementation of 'voluntary medical male circumcision' and 'early infant male circumcision' (EIMC) programmes to tackle HIV spread and high volumes of routine circumcisions, respectively, provide plausible solutions.

### **3.1 Voluntary medical male circumcision**

### *3.1.1 Counseling and dissemination of correct information*

First and foremost, factual information should be clearly provided to high-risk communities in general and to the men opting for circumcision and their partners in particular. MC has shown to reduce, *not eliminate*, the risk of acquiring HIV through heterosexual sex; it is not known whether MC directly reduces sexual transmission of HIV from HIV-positive men to women or if MC has a protective role in men who have sex with men (MSM). MC should be considered only as an adjuvant to therapy along with other HIV prevention measures, and it should not mislead circumcised individuals into considering high-risk sexual behaviors as inconsequential. Additionally, it should be conveyed that abstinence from sexual activity is required after circumcision for at least 6 weeks to ensure that the wound has healed completely; otherwise the circumcised men would be at a higher risk for contracting HIV from an infected partner, or if HIV-positive, then there would be a higher risk of infecting their sexual partners.

#### *3.1.2 VMMC: a preventative strategy*

The vast majority of people living with HIV belong to low- and middle-income countries, particularly in Africa. Immediate intervention proposed by the WHO/ UNAIDS in 2007 for impeding HIV spread was provision and rapid scale-up of VMMC services in at least 14 vulnerable countries in Africa where HIV prevalence was high, spread was predominantly through heterosexual transmission, and MC levels were low [24]. Target was to achieve 20 million circumcisions in HIV-negative men by 2016. By the end of 2013, only 30% of the target was achieved, and a joint strategic action framework was devised by UNAIDS, the WHO and other stakeholders to review the steps in order to expedite the scale-up of VMMC to fulfill the desired goal [25]. Although the time-bound ultimate target seemed ambitious to be achieved by 2016 mainly due to large numbers of trained healthcare workers required along with a continuous flow of funds [24], all involved countries showed an increase in the pace of scale-up of VMMC programmes leading to 12 million circumcisions of adolescent boys and men by the end of 2015 [26]. This proximity to the target encouraged UNAIDS and the WHO to launch a new, more holistic framework for action—VMMC2021. This document gives newer strategic directions on VMMC for HIV prevention and envisions that 90% of males aged 10–29 years will have been circumcised by 2021, in priority settings in sub-Saharan Africa.

It should be kept in mind that VMMC is unlikely to provide public benefit in areas where HIV prevalence is low or is concentrated in specific populations such as intravenous drug users, MSM or sex workers.

#### **3.2 Early infant male circumcision**

Whereas VMMC programmes have been popularly introduced and implemented in high-risk populations, there is a comparative absence of EIMC programmes in relevant countries. To promote the safe circumcision initiative, a manual was developed by joint efforts of the WHO and JHPIEGO in 2010, which also provided the technical guidance for structuring an EIMC [27]. However, large-scale adoption of this recommendation by stakeholders is yet to be seen. For effective implementation, a careful needs assessment should be conducted in advance to investigate the expected scale of requirement.

**15**

*Scaling Safe Circumcisions in Communities DOI: http://dx.doi.org/10.5772/intechopen.89437*

*3.2.2 Developing countries with high-HIV prevalence*

infant health programmes need to be engaged as well.

*3.2.3 Developed countries with a high circumcision burden*

**4. Implementation and scale-up of EIMC programmes**

monitoring and evaluation systems and policy development.

Promotion of early infant male circumcision programmes could be a simple, safe, reasonable and economical strategy in countries where burden of circumcision is high, financial constraints are present, and standard of healthcare services is low. In Muslim-majority countries like Pakistan, male circumcision is considered an essential religious practice; there is unanimous consensus that the male baby should be circumcised. Therefore, the focus needs to be on ensuring that these circumcisions are performed safely, as early as possible in life with the lowest possible risk of complications. Introduction of service delivery programmes, promoting and delivering safe, sterile early infant circumcisions at a subsidized cost or as part of the free public sector healthcare package, could provide a meaningful and long-

The WHO/UNAIDS and UNICEF also recommend EIMC be implemented simultaneously with scale-up of MC services as a long-term strategy for the control of HIV. Modeling studies show promising results for universal MC in sub-Saharan Africa, claiming it could significantly reduce morbidity and mortality associated with HIV over time [19]. For effective execution of EIMC services, maternal and

In countries like the USA with a high prevalence of circumcision or in other developed countries like the UK with pockets of Muslim-majority communities, the need for these procedures is high. Since medical insurance does not cover circumcision, there is risk of this procedure being restricted to affluent or insured patients, as indicated by falling circumcision rates in the USA in patients without insurance coverage [12, 15]. EIMC programmes introduced in these settings could fulfill the patient requirements as well as bring about significant cost reduction associated

The key aspects for successful implementation and scale-up of EIMC include training of health workers, developing programme infrastructure, ensuring supply of equipment and consumables, identifying funding and establishing robust

Health providers need to be provided with theoretical knowledge about basic anatomy of the area and details of the surgical technique [1, 27, 28] and possible complications related to the procedure. This should be followed by practical demonstration of the technique. A US-based training programme employed the Gomco clamp method of circumcision [13] to train certified nurse-midwives (CNMs) in 1981, under supervision of obstetricians. In 1996, volunteer nurses in the UK were trained by consultant urologists to perform Plastibell circumcisions. A similar protocol is being followed by an EIMC programme established in Karachi, Pakistan,

*3.2.1 Muslim-majority countries*

term solution.

with the procedure.

**4.1 Training of health providers**

## *3.2.1 Muslim-majority countries*

*Circumcision and the Community*

**3.1 Voluntary medical male circumcision**

higher risk of infecting their sexual partners.

intravenous drug users, MSM or sex workers.

**3.2 Early infant male circumcision**

expected scale of requirement.

*3.1.2 VMMC: a preventative strategy*

*3.1.1 Counseling and dissemination of correct information*

First and foremost, factual information should be clearly provided to high-risk communities in general and to the men opting for circumcision and their partners in particular. MC has shown to reduce, *not eliminate*, the risk of acquiring HIV through heterosexual sex; it is not known whether MC directly reduces sexual transmission of HIV from HIV-positive men to women or if MC has a protective role in men who have sex with men (MSM). MC should be considered only as an adjuvant to therapy along with other HIV prevention measures, and it should not mislead circumcised individuals into considering high-risk sexual behaviors as inconsequential. Additionally, it should be conveyed that abstinence from sexual activity is required after circumcision for at least 6 weeks to ensure that the wound has healed completely; otherwise the circumcised men would be at a higher risk for contracting HIV from an infected partner, or if HIV-positive, then there would be a

The vast majority of people living with HIV belong to low- and middle-income countries, particularly in Africa. Immediate intervention proposed by the WHO/ UNAIDS in 2007 for impeding HIV spread was provision and rapid scale-up of VMMC services in at least 14 vulnerable countries in Africa where HIV prevalence was high, spread was predominantly through heterosexual transmission, and MC levels were low [24]. Target was to achieve 20 million circumcisions in HIV-negative men by 2016. By the end of 2013, only 30% of the target was achieved, and a joint strategic action framework was devised by UNAIDS, the WHO and other stakeholders to review the steps in order to expedite the scale-up of VMMC to fulfill the desired goal [25]. Although the time-bound ultimate target seemed ambitious to be achieved by 2016 mainly due to large numbers of trained healthcare workers required along with a continuous flow of funds [24], all involved countries showed an increase in the pace of scale-up of VMMC programmes leading to 12 million circumcisions of adolescent boys and men by the end of 2015 [26]. This proximity to the target encouraged UNAIDS and the WHO to launch a new, more holistic framework for action—VMMC2021. This document gives newer strategic directions on VMMC for HIV prevention and envisions that 90% of males aged 10–29 years will have been circumcised by 2021, in priority settings in sub-Saharan Africa. It should be kept in mind that VMMC is unlikely to provide public benefit in areas where HIV prevalence is low or is concentrated in specific populations such as

Whereas VMMC programmes have been popularly introduced and implemented

in high-risk populations, there is a comparative absence of EIMC programmes in relevant countries. To promote the safe circumcision initiative, a manual was developed by joint efforts of the WHO and JHPIEGO in 2010, which also provided the technical guidance for structuring an EIMC [27]. However, large-scale adoption of this recommendation by stakeholders is yet to be seen. For effective implementation, a careful needs assessment should be conducted in advance to investigate the

**14**

Promotion of early infant male circumcision programmes could be a simple, safe, reasonable and economical strategy in countries where burden of circumcision is high, financial constraints are present, and standard of healthcare services is low. In Muslim-majority countries like Pakistan, male circumcision is considered an essential religious practice; there is unanimous consensus that the male baby should be circumcised. Therefore, the focus needs to be on ensuring that these circumcisions are performed safely, as early as possible in life with the lowest possible risk of complications. Introduction of service delivery programmes, promoting and delivering safe, sterile early infant circumcisions at a subsidized cost or as part of the free public sector healthcare package, could provide a meaningful and longterm solution.

## *3.2.2 Developing countries with high-HIV prevalence*

The WHO/UNAIDS and UNICEF also recommend EIMC be implemented simultaneously with scale-up of MC services as a long-term strategy for the control of HIV. Modeling studies show promising results for universal MC in sub-Saharan Africa, claiming it could significantly reduce morbidity and mortality associated with HIV over time [19]. For effective execution of EIMC services, maternal and infant health programmes need to be engaged as well.

## *3.2.3 Developed countries with a high circumcision burden*

In countries like the USA with a high prevalence of circumcision or in other developed countries like the UK with pockets of Muslim-majority communities, the need for these procedures is high. Since medical insurance does not cover circumcision, there is risk of this procedure being restricted to affluent or insured patients, as indicated by falling circumcision rates in the USA in patients without insurance coverage [12, 15]. EIMC programmes introduced in these settings could fulfill the patient requirements as well as bring about significant cost reduction associated with the procedure.

## **4. Implementation and scale-up of EIMC programmes**

The key aspects for successful implementation and scale-up of EIMC include training of health workers, developing programme infrastructure, ensuring supply of equipment and consumables, identifying funding and establishing robust monitoring and evaluation systems and policy development.

## **4.1 Training of health providers**

Health providers need to be provided with theoretical knowledge about basic anatomy of the area and details of the surgical technique [1, 27, 28] and possible complications related to the procedure. This should be followed by practical demonstration of the technique. A US-based training programme employed the Gomco clamp method of circumcision [13] to train certified nurse-midwives (CNMs) in 1981, under supervision of obstetricians. In 1996, volunteer nurses in the UK were trained by consultant urologists to perform Plastibell circumcisions. A similar protocol is being followed by an EIMC programme established in Karachi, Pakistan, since 2016, in which pediatric surgeons are training OR technicians, midwives, health workers and family physicians to perform circumcisions using the Plastibell method.

These training programmes have adopted a similar approach with theoretical training followed by skills teaching, initially performing procedures under close supervision, and subsequently independently with routine monitoring of outcomes. At the end of the training period, a knowledge and skills assessment is carried out before the health providers are certified to practice. This process allows the procedure to be performed safely and efficiently in settings where large numbers of circumcisions are required.

#### *4.1.1 Types of providers*

Task sharing is a well-established approach worldwide, whereby health providers are trained to perform high volume, technically less demanding tasks, under close supervision and monitoring with a referral system in place [29]. The 'manual for early infant male circumcision under local anaesthesia' by the WHO recommends that early infant male circumcision should primarily be the task of nonphysician healthcare workers which include, but are not limited to, nurses, midwives, clinical officers, health officers and assistant medical officers. Non-specialist medical doctors can also be trained for this procedure. The competence of the providers is the single most important factor affecting the outcome of the procedure and, hence, is critical to the success of any large-scale implementation.

Non-medical, religious providers called 'mohels', trained and supervised by the Ministry of Religion and the Ministry of Health, perform circumcisions in Israel [9]. Trained and certified nurses and midwives are another pool of non-medically trained providers that commonly perform this procedure in West Africa. Medically trained providers include obstetricians, pediatricians, general practitioners, general surgeons or pediatric surgeons and urologists, who routinely undertake ritual neonatal circumcisions in hospital settings commonly in countries like the USA and the Gulf states, in addition to performing therapeutic circumcisions in countries around the world.

The selection of the provider is influenced by preference of the family, the cost of the procedure, location, accessibility, culture and socio-economic status of the parents. If adequate numbers of physicians and specialists are available to run an EIMC, this may be the preferred approach in resource-rich settings. The real challenge arises in resource-constrained settings, especially in rural areas, where families approach traditional, untrained providers since they are the only viable option due to convenience, proximity or cost dynamics [9]. In Pakistan, 90–95% of circumcisions are performed by untrained barbers*,* technicians, religious or traditional circumcisers [7], who remain oblivious to the associated risks and are unable to handle complications that occur far too frequently. Similarly, barbers or traditional circumcisers are the popular choice in Egypt, Turkey and Iran for this procedure [9]. Not surprisingly, these untrained and unmonitored providers pose the biggest threat, with short- and long-term sequelae being the norm.

Links between the formal and informal health sectors could help increase the safety and quality of the procedure and enhance the monitoring and evaluation aspect of the program. In Accra (the capital of Ghana), where neonatal circumcision is almost universal, good links have been established between the Public Health Service and traditional circumcisers in order to provide regular training in safe infant circumcision. Similar models should be explored in other settings.

Circumcision is a simple surgical procedure that can be safely performed by a trained person. It does not have to be done by a doctor or a specialist. All types of health providers, whether they are surgeons, nurses, technicians or traditional

**17**

*Scaling Safe Circumcisions in Communities DOI: http://dx.doi.org/10.5772/intechopen.89437*

complications, like retained rings, are unavailable [33].

adequately trained.

*4.1.2 Circumcision techniques*

**4.2 Programme infrastructure**

employed to achieve sustainability.

*4.2.1 Timing of circumcision–a critical factor*

circumcisers [7, 27, 28, 30], have shown comparable results as long as they are

The three common methods of neonatal or early infant circumcision include Plastibell, Mogen clamp and Gomco clamp. Providers can be trained to perform any of these techniques as all of them have comparable safety profiles [27, 31]. Adoption of a single method is recommended to ensure standardization of technique in order to facilitate the training of the providers and their monitoring by making fair comparisons based on occurrence of complications; additionally, employment of a single method enables ease of procurement for the program. Plastibell technique of circumcision is a simple method that is easily taught and can be performed safely by health providers with low complication rates [31–34]. However, the clamping devices may be safer for EIMC in regions where follow-up services to deal with

EIMC programmes best serve their purpose and provide maximum benefit to communities when they are integrated into existing healthcare systems such as the maternal, neonatal and child health (MNCH) programmes. For example, introduction of such programmes at birthing or vaccination centres is advised, where a stream of age-appropriate patients is already expected. Targeting these places would result in early and successful establishment of these programmes. Vertical, solitary programmes may be useful as short-term, pilot programmes or as training centres for health providers in areas where circumcision rates are high and healthcare systems are weak. Once piloted, replication and scale-up strategies should be

Circumcision can be performed at any age. Judaism proposes the eighth day of life in a healthy baby; in Islam, the time could be anywhere between birth and puberty. In some Muslim countries like Pakistan, cultural pressures influence the timing of circumcision. The ritual is ordained to be celebrated as a festive occasion with special arrangements including dinner, requiring the presence of relatives and friends, especially amongst certain ethnic groups. This exerts an unnecessary financial strain on the families who often delay the circumcision of their babies till they have enough money to organize the event, which often makes them cross the beneficial age-limit of 2 months following birth. In order to discourage this practice and to create awareness amongst masses regarding the advantages of early infant circumcision, a video was developed in the national language as a tool for information dissemination by an EIMC programme established in Karachi, Pakistan. The link to this Video 1 (with English subtitles) is available here: https://bit.ly/38be8P5. From the medical point of view, the neonatal period offers the best opportunity for circumcision with avoidance of general anesthesia and its associated challenges; additionally, it provides all possible benefits of circumcision to the baby as early as possible in life, with better and early chances of recovery, lower cost and a lower incidence of post-procedure complications. MC should not be performed until at least 24 hours after birth to ensure the infant is stable and has had time to void, feeding has initiated, and abnormalities, if any, become apparent [27]. Therefore, for large-scale EIMC programmes, early procedures performed from the second day

circumcisers [7, 27, 28, 30], have shown comparable results as long as they are adequately trained.

## *4.1.2 Circumcision techniques*

*Circumcision and the Community*

circumcisions are required.

*4.1.1 Types of providers*

method.

since 2016, in which pediatric surgeons are training OR technicians, midwives, health workers and family physicians to perform circumcisions using the Plastibell

These training programmes have adopted a similar approach with theoretical training followed by skills teaching, initially performing procedures under close supervision, and subsequently independently with routine monitoring of outcomes. At the end of the training period, a knowledge and skills assessment is carried out before the health providers are certified to practice. This process allows the procedure to be performed safely and efficiently in settings where large numbers of

Task sharing is a well-established approach worldwide, whereby health providers are trained to perform high volume, technically less demanding tasks, under close supervision and monitoring with a referral system in place [29]. The 'manual for early infant male circumcision under local anaesthesia' by the WHO recommends that early infant male circumcision should primarily be the task of nonphysician healthcare workers which include, but are not limited to, nurses, midwives, clinical officers, health officers and assistant medical officers. Non-specialist medical doctors can also be trained for this procedure. The competence of the providers is the single most important factor affecting the outcome of the procedure and,

Non-medical, religious providers called 'mohels', trained and supervised by the Ministry of Religion and the Ministry of Health, perform circumcisions in Israel [9]. Trained and certified nurses and midwives are another pool of non-medically trained providers that commonly perform this procedure in West Africa. Medically trained providers include obstetricians, pediatricians, general practitioners, general surgeons or pediatric surgeons and urologists, who routinely undertake ritual neonatal circumcisions in hospital settings commonly in countries like the USA and the Gulf states, in addition to performing therapeutic circumcisions in countries around the world. The selection of the provider is influenced by preference of the family, the cost of the procedure, location, accessibility, culture and socio-economic status of the parents. If adequate numbers of physicians and specialists are available to run an EIMC, this may be the preferred approach in resource-rich settings. The real challenge arises in resource-constrained settings, especially in rural areas, where families approach traditional, untrained providers since they are the only viable option due to convenience, proximity or cost dynamics [9]. In Pakistan, 90–95% of circumcisions are performed by untrained barbers*,* technicians, religious or traditional circumcisers [7], who remain oblivious to the associated risks and are unable to handle complications that occur far too frequently. Similarly, barbers or traditional circumcisers are the popular choice in Egypt, Turkey and Iran for this procedure [9]. Not surprisingly, these untrained and unmonitored providers pose

hence, is critical to the success of any large-scale implementation.

the biggest threat, with short- and long-term sequelae being the norm.

Links between the formal and informal health sectors could help increase the safety and quality of the procedure and enhance the monitoring and evaluation aspect of the program. In Accra (the capital of Ghana), where neonatal circumcision is almost universal, good links have been established between the Public Health Service and traditional circumcisers in order to provide regular training in safe infant circumcision. Similar models should be explored in other settings.

Circumcision is a simple surgical procedure that can be safely performed by a trained person. It does not have to be done by a doctor or a specialist. All types of health providers, whether they are surgeons, nurses, technicians or traditional

**16**

The three common methods of neonatal or early infant circumcision include Plastibell, Mogen clamp and Gomco clamp. Providers can be trained to perform any of these techniques as all of them have comparable safety profiles [27, 31]. Adoption of a single method is recommended to ensure standardization of technique in order to facilitate the training of the providers and their monitoring by making fair comparisons based on occurrence of complications; additionally, employment of a single method enables ease of procurement for the program. Plastibell technique of circumcision is a simple method that is easily taught and can be performed safely by health providers with low complication rates [31–34]. However, the clamping devices may be safer for EIMC in regions where follow-up services to deal with complications, like retained rings, are unavailable [33].

## **4.2 Programme infrastructure**

EIMC programmes best serve their purpose and provide maximum benefit to communities when they are integrated into existing healthcare systems such as the maternal, neonatal and child health (MNCH) programmes. For example, introduction of such programmes at birthing or vaccination centres is advised, where a stream of age-appropriate patients is already expected. Targeting these places would result in early and successful establishment of these programmes. Vertical, solitary programmes may be useful as short-term, pilot programmes or as training centres for health providers in areas where circumcision rates are high and healthcare systems are weak. Once piloted, replication and scale-up strategies should be employed to achieve sustainability.

## *4.2.1 Timing of circumcision–a critical factor*

Circumcision can be performed at any age. Judaism proposes the eighth day of life in a healthy baby; in Islam, the time could be anywhere between birth and puberty. In some Muslim countries like Pakistan, cultural pressures influence the timing of circumcision. The ritual is ordained to be celebrated as a festive occasion with special arrangements including dinner, requiring the presence of relatives and friends, especially amongst certain ethnic groups. This exerts an unnecessary financial strain on the families who often delay the circumcision of their babies till they have enough money to organize the event, which often makes them cross the beneficial age-limit of 2 months following birth. In order to discourage this practice and to create awareness amongst masses regarding the advantages of early infant circumcision, a video was developed in the national language as a tool for information dissemination by an EIMC programme established in Karachi, Pakistan. The link to this Video 1 (with English subtitles) is available here: https://bit.ly/38be8P5.

From the medical point of view, the neonatal period offers the best opportunity for circumcision with avoidance of general anesthesia and its associated challenges; additionally, it provides all possible benefits of circumcision to the baby as early as possible in life, with better and early chances of recovery, lower cost and a lower incidence of post-procedure complications. MC should not be performed until at least 24 hours after birth to ensure the infant is stable and has had time to void, feeding has initiated, and abnormalities, if any, become apparent [27]. Therefore, for large-scale EIMC programmes, early procedures performed from the second day of birth up to 2 months, in otherwise healthy babies, are preferred [27, 35]. Since circumcision is an elective procedure, it should be deferred in case the baby is unwell, underweight, preterm or if any doubts surface during screening. Physiological jaundice is not considered a contraindication; however, if the baby is deeply jaundiced, circumcision should be deferred, and referral for appropriate work up and management should be initiated as soon as possible [35, 36]. Ethical arguments propose that circumcision should be deferred till the patient is old enough to make his own decision; however, delaying or postponing the procedure negates the protective effect of circumcision required as early in life as possible and the concomitant reduced-cost benefit due to avoidance of general anesthesia.

#### *4.2.2 Programme prerequisites*

During the 1970s in the USA when circumcision rates were at their peak, the procedure was considered so beneficial that many hospitals did not require a written consent [13]. However, in 2012, the Task Force on Circumcision (which included members of the American Academy of Pediatrics (AAP), American Academy of Family Physicians (AAFP), American College of Obstetricians and Gynecologists (ACOG) and Centers for Disease Control and Prevention) stated that 'benefits of circumcision outweigh its risks' and strong recommendations were made to obtain 'informed consent' from parents or guardians prior to the procedure [1].

While establishing neonatal male circumcision programmes, the Task Force on Circumcision and the WHO [27] also recommend vitamin K to be routinely administered to the babies before the procedure in order to help prevent post-procedure bleeding. Routine pre-procedure investigations are not advocated nor justified in large-scale EIMC programmes [35]. Circumcision is contraindicated in babies born with genital abnormalities (like epispadias, hypospadias, chordee, ambiguous genitalia, micropenis, buried penis, penoscrotal web or bilateral hydrocele), blood dyscrasias or those with a family history of bleeding disorders.

Additionally, pain relief should be provided to the infant during the procedure. For this purpose, dorsal penile nerve block or ring block could be employed; the former has the advantages of lesser number of pricks and a shorter duration of onset.

#### *4.2.3 Post-procedure care*

If trained providers perform the procedure, post-circumcision complications are generally minor and easily managed. However, they can and do occur, even in the best hands. Health providers should be equipped to handle simple post-procedure complications like minor bleeding requiring application of pressure with or without topical adrenaline or simple cutting and removal of a Plastibell ring that fails to shed spontaneously. If these complications occur in post-clinic hours, then a referral system to handle these or other common complications following circumcision ensures the success of EIMC programmes. The ongoing recruitment and training of health providers in large-scale programmes poses a constant challenge in terms of high chances of occurrence of complications by new trainees; this can be addressed by a reliable referral system to handle these when the need arises.

#### *4.2.4 Patient follow-up and outcome documentation*

Patient follow-up and outcome determination are of utmost importance in any public health intervention. In EIMC programmes, active and passive follow-up after the procedure allows documentation of post-procedure adverse events and

**19**

any circumstances.

*Scaling Safe Circumcisions in Communities DOI: http://dx.doi.org/10.5772/intechopen.89437*

appropriately.

similar services.

minimized.

**4.4 Funding**

**4.3 Programme equipment and consumables**

helps assess parental satisfaction with the process. Diligent and regular review of data allows the programme team to monitor quality and safety outcomes and address any challenges that may be identified. Refresher training and modification of technique or approach may be instituted to address any issues that may arise. A helpline or open access to the clinic allows patients to call or come in with concerns that can either be adequately dealt with by the primary team or referred

Low literacy levels, socio-economic constraints and geographical barriers are all hurdles to early recognition and reporting of complications, which if left unattended, could lead to serious adverse events following a simple procedure like neonatal circumcision [37]. Regular engagement between providers delivering health services and families in the communities, to counsel them before and after the procedure, helps build a rapport which is the basis of successful public health programmes. This bond could be utilized by the providers to probe and carry out a qualitative analysis to judge the acceptability of the programme by the community or to find ways to improve the services by getting direct input from the biggest stakeholders in this arrangement. On the other hand, the health providers could be the source of correct information and guidance for these communities regarding various aspects of health promotion. Participants of the programme usually share their experiences with others in the community; reputation, good or bad, spreads through word of mouth, either encouraging or discouraging others to opt for

Timely procurement of programme equipment like circumcision sets and boards, amongst others, along with adequate stock of consumables, is vital to ensure smooth running of these programmes. The major hurdle towards scale-up of this programme into the community and especially in rural areas is the limitation of availability of central sterile services department (CSSD) for sterilization of instruments used for circumcision. Scale-up of such programmes would be facilitated by the employment of pre-packed circumcision sets, containing single-use, low-cost instruments and consumables. This approach has already been adopted by VMMC programmes [24] in Africa but is currently under consideration and trial for EIMC programmes. Large-scale implementation would allow the cost of these sets to be

Countries which require establishment of EIMC programmes should draft a budget and allocate funds accordingly. Continuity of disbursement of funds is vital for programme operations. In countries where religious circumcision is needed and those with a high requirement of circumcision due to HIV prevalence, EIMC service delivery programmes should be established with no cost or lowest possible cost to the patient. Private donors and governments should consider cost saved from avoidance of occurrence of diseases like UTI and sexually transmitted diseases like HIV. Additionally, circumcisions performed on older children are costlier because of the need of general anesthesia and hospitalization; there is also an increased risk of post-circumcision complications in older children which require medical attention and, hence, account for added expense. Lastly, the societal cost of botched circumcisions in the hands of untrained providers must be avoided under

#### *Scaling Safe Circumcisions in Communities DOI: http://dx.doi.org/10.5772/intechopen.89437*

*Circumcision and the Community*

*4.2.2 Programme prerequisites*

*4.2.3 Post-procedure care*

benefit due to avoidance of general anesthesia.

of birth up to 2 months, in otherwise healthy babies, are preferred [27, 35]. Since circumcision is an elective procedure, it should be deferred in case the baby is unwell, underweight, preterm or if any doubts surface during screening. Physiological jaundice is not considered a contraindication; however, if the baby is deeply jaundiced, circumcision should be deferred, and referral for appropriate work up and management should be initiated as soon as possible [35, 36]. Ethical arguments propose that circumcision should be deferred till the patient is old enough to make his own decision; however, delaying or postponing the procedure negates the protective effect of circumcision required as early in life as possible and the concomitant reduced-cost

During the 1970s in the USA when circumcision rates were at their peak, the procedure was considered so beneficial that many hospitals did not require a written consent [13]. However, in 2012, the Task Force on Circumcision (which included members of the American Academy of Pediatrics (AAP), American Academy of Family Physicians (AAFP), American College of Obstetricians and Gynecologists (ACOG) and Centers for Disease Control and Prevention) stated that 'benefits of circumcision outweigh its risks' and strong recommendations were made to obtain

While establishing neonatal male circumcision programmes, the Task Force on Circumcision and the WHO [27] also recommend vitamin K to be routinely administered to the babies before the procedure in order to help prevent post-procedure bleeding. Routine pre-procedure investigations are not advocated nor justified in large-scale EIMC programmes [35]. Circumcision is contraindicated in babies born with genital abnormalities (like epispadias, hypospadias, chordee, ambiguous genitalia, micropenis, buried penis, penoscrotal web or bilateral hydrocele), blood

Additionally, pain relief should be provided to the infant during the procedure. For this purpose, dorsal penile nerve block or ring block could be employed; the former has the advantages of lesser number of pricks and a shorter duration of onset.

If trained providers perform the procedure, post-circumcision complications are generally minor and easily managed. However, they can and do occur, even in the best hands. Health providers should be equipped to handle simple post-procedure complications like minor bleeding requiring application of pressure with or without topical adrenaline or simple cutting and removal of a Plastibell ring that fails to shed spontaneously. If these complications occur in post-clinic hours, then a referral system to handle these or other common complications following circumcision ensures the success of EIMC programmes. The ongoing recruitment and training of health providers in large-scale programmes poses a constant challenge in terms of high chances of occurrence of complications by new trainees; this can be addressed

Patient follow-up and outcome determination are of utmost importance in any public health intervention. In EIMC programmes, active and passive follow-up after the procedure allows documentation of post-procedure adverse events and

'informed consent' from parents or guardians prior to the procedure [1].

dyscrasias or those with a family history of bleeding disorders.

by a reliable referral system to handle these when the need arises.

*4.2.4 Patient follow-up and outcome documentation*

**18**

helps assess parental satisfaction with the process. Diligent and regular review of data allows the programme team to monitor quality and safety outcomes and address any challenges that may be identified. Refresher training and modification of technique or approach may be instituted to address any issues that may arise. A helpline or open access to the clinic allows patients to call or come in with concerns that can either be adequately dealt with by the primary team or referred appropriately.

Low literacy levels, socio-economic constraints and geographical barriers are all hurdles to early recognition and reporting of complications, which if left unattended, could lead to serious adverse events following a simple procedure like neonatal circumcision [37]. Regular engagement between providers delivering health services and families in the communities, to counsel them before and after the procedure, helps build a rapport which is the basis of successful public health programmes. This bond could be utilized by the providers to probe and carry out a qualitative analysis to judge the acceptability of the programme by the community or to find ways to improve the services by getting direct input from the biggest stakeholders in this arrangement. On the other hand, the health providers could be the source of correct information and guidance for these communities regarding various aspects of health promotion. Participants of the programme usually share their experiences with others in the community; reputation, good or bad, spreads through word of mouth, either encouraging or discouraging others to opt for similar services.

## **4.3 Programme equipment and consumables**

Timely procurement of programme equipment like circumcision sets and boards, amongst others, along with adequate stock of consumables, is vital to ensure smooth running of these programmes. The major hurdle towards scale-up of this programme into the community and especially in rural areas is the limitation of availability of central sterile services department (CSSD) for sterilization of instruments used for circumcision. Scale-up of such programmes would be facilitated by the employment of pre-packed circumcision sets, containing single-use, low-cost instruments and consumables. This approach has already been adopted by VMMC programmes [24] in Africa but is currently under consideration and trial for EIMC programmes. Large-scale implementation would allow the cost of these sets to be minimized.

## **4.4 Funding**

Countries which require establishment of EIMC programmes should draft a budget and allocate funds accordingly. Continuity of disbursement of funds is vital for programme operations. In countries where religious circumcision is needed and those with a high requirement of circumcision due to HIV prevalence, EIMC service delivery programmes should be established with no cost or lowest possible cost to the patient. Private donors and governments should consider cost saved from avoidance of occurrence of diseases like UTI and sexually transmitted diseases like HIV. Additionally, circumcisions performed on older children are costlier because of the need of general anesthesia and hospitalization; there is also an increased risk of post-circumcision complications in older children which require medical attention and, hence, account for added expense. Lastly, the societal cost of botched circumcisions in the hands of untrained providers must be avoided under any circumstances.

#### **4.5 Monitoring and evaluation system**

Strong coordination between the programme team members is important for effective functioning of the program. Adherence to programme guidelines, regular surveillance of data and management of inventory should be ensured by the programme manager. In our experience, the use of a software application for data collection allows real-time monitoring and rapid access to data for analysis which forms a critical part of a large-scale-up implementation. This also serves as an effective monitoring tool. All complications per provider should be recorded and feedback shared with the team on a regular basis to review and revise the technique as required.

Goals and objectives of the programme should be specified when the programme is being conceptualized. Goals are achieved over for a long term (5–10 years); as an example, with effective establishment of EIMC programmes, an increased prevalence of circumcision in infants should be detected. Objectives are shown by results achieved. Additionally, parameters to study the structure, process and outcome indicators should be delineated. These should be monitored routinely to assess the progress of the program. An example of an outcome indicator is the number of post-procedure complications out of the total procedures performed.

#### **4.6 Policy development**

For scale-up of EIMC programmes, it is essential that there is a legal framework supported by policies to ensure that neonatal or early infant circumcisions are performed safely. This includes obtaining informed consent from parents or guardians prior to the procedure and, in the absence of any coercive influence, use of safe technique and sterile instruments along with reliability of trained providers. Most countries display a lacking in it but Israel is an exception [9]. According to Israeli law, circumcision of baby boys up to 6 months of age is considered a religious ritual which can be performed by religious or traditional circumcisers; beyond this age, only qualified surgeons are allowed to do so. Additionally, Israeli government is directly involved in the training of traditional providers or mohels. Formulation of a national policy on similar lines, to promote safe circumcisions in Muslim-majority countries or regions, is urgently required.

Circumcisions are being done by nurses and other health providers in VMMC programmes; however, some countries like Pakistan have not looked at task sharing as a way to address the critical shortage of healthcare professionals. A national health policy framework should be developed to facilitate and encourage task sharing [29]. This has been done successfully in maternal and child health by training nonphysician clinicians (NPCs) and traditional birth attendants (TBAs) in comprehensive emergency obstetric care [38].

While circumcision is being employed as an option to curtail the number of HIV cases, it could well be the source of spread of blood-borne infections like hepatitis or HIV, if aseptic measures are not adopted [35, 39]. Circumcisions performed by untrained traditional providers in non-clinical settings with unsterilized instruments pose the greatest threat. Therefore, awareness and training of health providers to practice a safe, sterile technique in EIMC programmes is imperative for success and scaleup. Policies should be structured to ensure sterility of equipment used for circumcision.

## **5. Existing models of EIMC**

**Table 1** shows a comparison of a few EIMC programmes of somewhat similar characteristics.

**21**

**Country of origin/**

**study reference**

USA/ [13]

UK/ [40] UK/ [28] Pakistan

**Table 1.** *Comparison of EIMC programmes.*

From 2016

3755

Up to

OR technicians, midwives, health

12

Plastibell

3%

method

workers, family med residents

3 months

(ongoing)

1996–2005/9 years

1129

6–14 weeks

Nurses

Not specified

Plastibell

8.2%

method

1996–1998/2 years

168

6–14 weeks

Nurses

3

Plastibell

18%

method

**Year/duration of program** 1981–1991/10 years

1000

Newborns

Certified nurse-midwives

3

Gomco clamp

0.1%

**No. of circumcisions**

**Age of babies**

**Type of provider**

**No. of providers trained**

**Method**

**Complication rate**

*Scaling Safe Circumcisions in Communities DOI: http://dx.doi.org/10.5772/intechopen.89437*

#### *Scaling Safe Circumcisions in Communities DOI: http://dx.doi.org/10.5772/intechopen.89437*

*Circumcision and the Community*

**4.6 Policy development**

countries or regions, is urgently required.

hensive emergency obstetric care [38].

**5. Existing models of EIMC**

**4.5 Monitoring and evaluation system**

Strong coordination between the programme team members is important for effective functioning of the program. Adherence to programme guidelines, regular surveillance of data and management of inventory should be ensured by the programme manager. In our experience, the use of a software application for data collection allows real-time monitoring and rapid access to data for analysis which forms a critical part of a large-scale-up implementation. This also serves as an effective monitoring tool. All complications per provider should be recorded and feedback shared with the team on a regular basis to review and revise the technique as required. Goals and objectives of the programme should be specified when the programme is being conceptualized. Goals are achieved over for a long term (5–10 years); as an example, with effective establishment of EIMC programmes, an increased prevalence of circumcision in infants should be detected. Objectives are shown by results achieved. Additionally, parameters to study the structure, process and outcome indicators should be delineated. These should be monitored routinely to assess the progress of the program. An example of an outcome indicator is the number of post-procedure complications out of the total procedures performed.

For scale-up of EIMC programmes, it is essential that there is a legal framework

Circumcisions are being done by nurses and other health providers in VMMC programmes; however, some countries like Pakistan have not looked at task sharing as a way to address the critical shortage of healthcare professionals. A national health policy framework should be developed to facilitate and encourage task sharing [29]. This has been done successfully in maternal and child health by training nonphysician clinicians (NPCs) and traditional birth attendants (TBAs) in compre-

While circumcision is being employed as an option to curtail the number of HIV cases, it could well be the source of spread of blood-borne infections like hepatitis or HIV, if aseptic measures are not adopted [35, 39]. Circumcisions performed by untrained traditional providers in non-clinical settings with unsterilized instruments pose the greatest threat. Therefore, awareness and training of health providers to practice a safe, sterile technique in EIMC programmes is imperative for success and scaleup. Policies should be structured to ensure sterility of equipment used for circumcision.

**Table 1** shows a comparison of a few EIMC programmes of somewhat similar

supported by policies to ensure that neonatal or early infant circumcisions are performed safely. This includes obtaining informed consent from parents or guardians prior to the procedure and, in the absence of any coercive influence, use of safe technique and sterile instruments along with reliability of trained providers. Most countries display a lacking in it but Israel is an exception [9]. According to Israeli law, circumcision of baby boys up to 6 months of age is considered a religious ritual which can be performed by religious or traditional circumcisers; beyond this age, only qualified surgeons are allowed to do so. Additionally, Israeli government is directly involved in the training of traditional providers or mohels. Formulation of a national policy on similar lines, to promote safe circumcisions in Muslim-majority

**20**

characteristics.


**Table 1.** *Comparison of EIMC programmes.*

## **6. Conclusion**

Impact of EIMC programmes can be realized immediately in countries where religious obligation is the motivation; however, impact on HIV incidence will not be evident until at least 20 years from commencement of the programmes. Implementation followed by scale-up of EIMC programmes should be encouraged as this relieves the stress on the health system of any country requiring high volumes of circumcisions. Technicians, nurses, midwives and health workers could serve as the promising pool of task-sharers to reduce the financial and technical burden without compromising on patient safety and outcomes.

Success of these programmes depends on proper training of health providers, close monitoring of outcomes and a reliable referral system. Additionally, strict adherence to programme protocols and provision of clear instructions to families on the need for early reporting of complications are essential for best results.

## **Conflict of interest**

The authors declare no conflict of interest.

## **Author details**

Shazia Moosa1 and Lubna Samad1,2\*

1 Center for Essential Surgical and Acute Care, Indus Health Network, Pakistan

2 Department of Pediatric Surgery, The Indus Hospital, Karachi, Pakistan

\*Address all correspondence to: lubna.samad@ird.global

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**23**

*Scaling Safe Circumcisions in Communities DOI: http://dx.doi.org/10.5772/intechopen.89437*

[2] Morris BJ, Wamai RG, Henebeng EB, Tobian AA, Klausner JD, Banerjee J, et al. Estimation of country-specific and global prevalence of male circumcision. Population Health Metrics. 2016;**14**(1):4

Urologic Clinics of North America.

[12] Nelson CP, Dunn R, Wan J, Wei JT. The increasing incidence of newborn circumcision: Data from the nationwide inpatient sample. The Journal of Urology. 2005;**173**(3):978-981

[13] Gelbaum I. Circumcision: To educate, not indoctrinate—A mandate for certified nurse-midwives. Journal of Nurse-Midwifery. 1992;**37**(S1):97S-113S

[14] Library TCR. United States

[15] Mansfield CJ, Hueston WJ, Rudy M. Neonatal circumcision: Associated factors and length of

[16] Simforoosh N, Tabibi A, Khalili SAR, Soltani MH, Afjehi A, Aalami F, et al. Neonatal circumcision reduces the incidence of asymptomatic

urinary tract infection: A large

[17] Morris BJ. Why circumcision is a biomedical imperative for the 21st century. BioEssays. 2007;**29**(11):1147-1158

[18] Krieger JN. Male circumcision and HIV infection risk. World Journal of

[20] Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of male circumcision

Urology. 2012;**8**(3):320-323

Urology. 2012;**30**(1):3-13

Geneva: WHO; 2007

[19] WHO. New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications.

statistics/USA/

1995;**41**(4):370-376

Circumcision Incidence. 2010. Available from: http://www.cirp.org/library/

hospital stay. Journal of Family Practice.

prospective study with long-term follow up using Plastibell. Journal of Pediatric

1985;**12**(1):123-132

[3] World Health Organization Report. Male Circumcision: Global Trends and Determinants of Prevalence, Safety and Acceptability. Geneva, Switzerland;

[4] Kettani H, editor. 2010 world muslim population. In: Proceedings of the 8th Hawaii International Conference on

Arts and Humanities. 2010

Development. 2010;**1**(2):154

[5] Kettani H. Muslim population in europe: 1950-2020. International Journal of Environmental Science and

[6] Central Intelligence Agency. The World Factbook. Washington D.C; 2019

[8] '200 paediatric surgeons cater to 45pc population'. Dawn Newspaper. Pakistan. March 04, 2017. [Accessed: 26

[9] Joint United Nations Programme on HIV/AIDS (UNAIDS). Neonatal and Child Male Circumcision: A Global Review. Geneva, Switzerland: World Health Organization Report; 2010

[10] Rabin RC. Steep Drop Seen in circumcisions in U.S. The New York Times. New York City, United States of

[11] Wallerstein E. Circumcision. The uniquely American medical enigma.

[7] Rizvi S, Naqvi S, Hussain M, Hasan A. Religious circumcision: A Muslim view. BJU International.

1999;**83**(S1):13-16

November 2019]

America; 2010

[1] Circumcision AAoPTFo. Male circumcision. Pediatrics.

**References**

2012;**130**(3):e756

2008

## **References**

*Circumcision and the Community*

Impact of EIMC programmes can be realized immediately in countries where religious obligation is the motivation; however, impact on HIV incidence will not be evident until at least 20 years from commencement of the programmes. Implementation followed by scale-up of EIMC programmes should be encouraged as this relieves the stress on the health system of any country requiring high volumes of circumcisions. Technicians, nurses, midwives and health workers could serve as the promising pool of task-sharers to reduce the financial and technical

Success of these programmes depends on proper training of health providers, close monitoring of outcomes and a reliable referral system. Additionally, strict adherence to programme protocols and provision of clear instructions to families on

the need for early reporting of complications are essential for best results.

burden without compromising on patient safety and outcomes.

The authors declare no conflict of interest.

and Lubna Samad1,2\*

\*Address all correspondence to: lubna.samad@ird.global

provided the original work is properly cited.

1 Center for Essential Surgical and Acute Care, Indus Health Network, Pakistan

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

2 Department of Pediatric Surgery, The Indus Hospital, Karachi, Pakistan

**6. Conclusion**

**Conflict of interest**

**Author details**

Shazia Moosa1

**22**

[1] Circumcision AAoPTFo. Male circumcision. Pediatrics. 2012;**130**(3):e756

[2] Morris BJ, Wamai RG, Henebeng EB, Tobian AA, Klausner JD, Banerjee J, et al. Estimation of country-specific and global prevalence of male circumcision. Population Health Metrics. 2016;**14**(1):4

[3] World Health Organization Report. Male Circumcision: Global Trends and Determinants of Prevalence, Safety and Acceptability. Geneva, Switzerland; 2008

[4] Kettani H, editor. 2010 world muslim population. In: Proceedings of the 8th Hawaii International Conference on Arts and Humanities. 2010

[5] Kettani H. Muslim population in europe: 1950-2020. International Journal of Environmental Science and Development. 2010;**1**(2):154

[6] Central Intelligence Agency. The World Factbook. Washington D.C; 2019

[7] Rizvi S, Naqvi S, Hussain M, Hasan A. Religious circumcision: A Muslim view. BJU International. 1999;**83**(S1):13-16

[8] '200 paediatric surgeons cater to 45pc population'. Dawn Newspaper. Pakistan. March 04, 2017. [Accessed: 26 November 2019]

[9] Joint United Nations Programme on HIV/AIDS (UNAIDS). Neonatal and Child Male Circumcision: A Global Review. Geneva, Switzerland: World Health Organization Report; 2010

[10] Rabin RC. Steep Drop Seen in circumcisions in U.S. The New York Times. New York City, United States of America; 2010

[11] Wallerstein E. Circumcision. The uniquely American medical enigma.

Urologic Clinics of North America. 1985;**12**(1):123-132

[12] Nelson CP, Dunn R, Wan J, Wei JT. The increasing incidence of newborn circumcision: Data from the nationwide inpatient sample. The Journal of Urology. 2005;**173**(3):978-981

[13] Gelbaum I. Circumcision: To educate, not indoctrinate—A mandate for certified nurse-midwives. Journal of Nurse-Midwifery. 1992;**37**(S1):97S-113S

[14] Library TCR. United States Circumcision Incidence. 2010. Available from: http://www.cirp.org/library/ statistics/USA/

[15] Mansfield CJ, Hueston WJ, Rudy M. Neonatal circumcision: Associated factors and length of hospital stay. Journal of Family Practice. 1995;**41**(4):370-376

[16] Simforoosh N, Tabibi A, Khalili SAR, Soltani MH, Afjehi A, Aalami F, et al. Neonatal circumcision reduces the incidence of asymptomatic urinary tract infection: A large prospective study with long-term follow up using Plastibell. Journal of Pediatric Urology. 2012;**8**(3):320-323

[17] Morris BJ. Why circumcision is a biomedical imperative for the 21st century. BioEssays. 2007;**29**(11):1147-1158

[18] Krieger JN. Male circumcision and HIV infection risk. World Journal of Urology. 2012;**30**(1):3-13

[19] WHO. New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications. Geneva: WHO; 2007

[20] Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: The ANRS 1265 trial. PLoS Medicine. 2005;**2**(11):e298

[21] Bailey RC, Moses S, Parker CB, Agot K, Maclean I, Krieger JN, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: A randomised controlled trial. The Lancet. 2007;**369**(9562):643-656

[22] Gray RH, Kigozi G, Serwadda D, Makumbi F, Watya S, Nalugoda F, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: A randomised trial. The Lancet. 2007;**369**(9562):657-666

[23] Kim HH, Li PS, Goldstein M. Male circumcision: Africa and beyond? Current Opinion in Urology. 2010;**20**(6):515-519

[24] Ledikwe JH, Nyanga RO, Hagon J, Grignon JS, Mpofu M, Semo B-W. Scaling-up voluntary medical male circumcision-what have we learned. HIV AIDS. 2014;**6**:139-146

[25] WHO. UNAIDS, Joint Strategic Action Framework to Accelerate the Scale-up of Voluntary Medical Male Circumcision for HIV Prevention in Eastern and Southern Africa, 2012-2016. Geneva: WHO; 2011

[26] WHO. A Framework for Voluntary Medical Male Circumcision: Effective HIV Prevention and a Gateway to Improved Adolescent boys'& men's Health in Eastern and Southern Africa by 2021. Geneva: World Health Organization; 2016

[27] WHO. Manual for Early Infant Male Circumcision under Local Anaesthesia. Geneva: World Health Organization; 2010

[28] Palit V, Menebhi DK, Taylor I, Young M, Elmasry Y, Shah T. A unique service in UK delivering Plastibell® circumcision: Review of 9-year results. Pediatric Surgery International. 2007;**23**(1):45-48

[29] WHO. First Global Conference on Task Shifting. Geneva: WHO; 2008

[30] Chaim JB, Livne PM, Binyamini J, Hardak B, Ben-Meir D, Mor Y, et al. Complications of circumcision in Israel: A one year multicenter survey. Israel Medical Association Journal. 2005;**7**(6):368-370

[31] Bowa K, Li MS, Mugisa B, Waters E, Linyama DM, Chi BH, et al. A controlled trial of three methods for neonatal circumcision in Lusaka, Zambia. Journal of Acquired Immune Deficiency Syndromes. 2013;**62**(1):e1

[32] Moosa FA, Khan FW, Rao MH. Comparison of complications of circumcision by'Plastibell device technique'in male neonates and infants. The Journal of the Pakistan Medical Association. 2010;**60**(8):664

[33] Plank RM, Ndubuka NO, Wirth KE, Mwambona JT, Kebaabetswe P, Bassil B, et al. A randomized trial of Mogen clamp versus Plastibell for neonatal male circumcision in Botswana. Journal of Acquired Immune Deficiency Syndromes. 2013;**62**(5):e131

[34] Bode C, Ikhisemojie S, Ademuyiwa A. Penile injuries from proximal migration of the Plastibell circumcision ring. Journal of Pediatric Urology. 2010;**6**(1):23-27

[35] Jan IA. Circumcision in babies and children with Plastibell technique: An easy procedure with minimal complications-experience of 316 cases. Pakistan Journal of Medical Sciences. 2004;**20**:175-180

[36] Eroglu E, Balci S, Ozkan H, Yorukalp O, Goksel A, Sarman G, et al. Does circumcision increase neonatal jaundice? Acta Paediatrica. 2008;**97**(9):1192-1193

**25**

*Scaling Safe Circumcisions in Communities DOI: http://dx.doi.org/10.5772/intechopen.89437*

[37] Samad L, Jawed F, Sajun SZ, Arshad MH, Baig-Ansari N. Barriers to accessing surgical care: A crosssectional survey conducted at a tertiary care hospital in Karachi, Pakistan. World Journal of Surgery.

[38] Gessessew A, Ab Barnabas G, Prata N, Weidert K. Task shifting and sharing in Tigray, Ethiopia, to achieve comprehensive emergency obstetric

[39] Khan N-u-Z. Circumcision–A universal procedure with no uniform technique and practiced badly. Pakistan Journal of Medical Sciences.

[40] Shah T, Raistrick J, Taylor I, Young M, Menebhi D, Stevens R. A circumcision service for religious reasons. BJU International.

2013;**37**(10):2313-2321

care. International Journal of Gynecology & Obstetrics.

2011;**113**(1):28-31

2004;**20**:173-174

1999;**83**(7):807-809

*Scaling Safe Circumcisions in Communities DOI: http://dx.doi.org/10.5772/intechopen.89437*

*Circumcision and the Community*

2005;**2**(11):e298

for reduction of HIV infection risk: The ANRS 1265 trial. PLoS Medicine. Pediatric Surgery International.

[29] WHO. First Global Conference on Task Shifting. Geneva: WHO; 2008

[30] Chaim JB, Livne PM, Binyamini J, Hardak B, Ben-Meir D, Mor Y, et al. Complications of circumcision in Israel: A one year multicenter survey. Israel Medical Association Journal.

[31] Bowa K, Li MS, Mugisa B, Waters E,

Linyama DM, Chi BH, et al. A controlled trial of three methods for neonatal circumcision in Lusaka, Zambia. Journal of Acquired Immune Deficiency Syndromes. 2013;**62**(1):e1

[32] Moosa FA, Khan FW, Rao MH. Comparison of complications of circumcision by'Plastibell device technique'in male neonates and infants. The Journal of the Pakistan Medical

[33] Plank RM, Ndubuka NO, Wirth KE, Mwambona JT, Kebaabetswe P, Bassil B, et al. A randomized trial of Mogen clamp versus Plastibell for neonatal male circumcision in Botswana. Journal of Acquired Immune Deficiency Syndromes. 2013;**62**(5):e131

Association. 2010;**60**(8):664

[34] Bode C, Ikhisemojie S,

Urology. 2010;**6**(1):23-27

2004;**20**:175-180

Ademuyiwa A. Penile injuries from proximal migration of the Plastibell circumcision ring. Journal of Pediatric

[35] Jan IA. Circumcision in babies and children with Plastibell technique: An easy procedure with minimal complications-experience of 316 cases. Pakistan Journal of Medical Sciences.

[36] Eroglu E, Balci S, Ozkan H,

jaundice? Acta Paediatrica. 2008;**97**(9):1192-1193

Yorukalp O, Goksel A, Sarman G, et al. Does circumcision increase neonatal

2007;**23**(1):45-48

2005;**7**(6):368-370

[21] Bailey RC, Moses S, Parker CB, Agot K, Maclean I, Krieger JN, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: A randomised controlled trial. The Lancet.

[22] Gray RH, Kigozi G, Serwadda D, Makumbi F, Watya S, Nalugoda F, et al. Male circumcision for HIV prevention

[23] Kim HH, Li PS, Goldstein M. Male circumcision: Africa and beyond? Current Opinion in Urology.

[24] Ledikwe JH, Nyanga RO, Hagon J, Grignon JS, Mpofu M, Semo B-W. Scaling-up voluntary medical male circumcision-what have we learned.

[25] WHO. UNAIDS, Joint Strategic Action Framework to Accelerate the Scale-up of Voluntary Medical Male Circumcision for HIV Prevention in Eastern and Southern Africa, 2012-2016.

[26] WHO. A Framework for Voluntary Medical Male Circumcision: Effective HIV Prevention and a Gateway to Improved Adolescent boys'& men's Health in Eastern and Southern Africa by 2021. Geneva: World Health

[27] WHO. Manual for Early Infant Male Circumcision under Local Anaesthesia. Geneva: World Health Organization;

[28] Palit V, Menebhi DK, Taylor I, Young M, Elmasry Y, Shah T. A unique service in UK delivering Plastibell® circumcision: Review of 9-year results.

2007;**369**(9562):643-656

in men in Rakai, Uganda: A randomised trial. The Lancet. 2007;**369**(9562):657-666

2010;**20**(6):515-519

HIV AIDS. 2014;**6**:139-146

Geneva: WHO; 2011

Organization; 2016

**24**

2010

[37] Samad L, Jawed F, Sajun SZ, Arshad MH, Baig-Ansari N. Barriers to accessing surgical care: A crosssectional survey conducted at a tertiary care hospital in Karachi, Pakistan. World Journal of Surgery. 2013;**37**(10):2313-2321

[38] Gessessew A, Ab Barnabas G, Prata N, Weidert K. Task shifting and sharing in Tigray, Ethiopia, to achieve comprehensive emergency obstetric care. International Journal of Gynecology & Obstetrics. 2011;**113**(1):28-31

[39] Khan N-u-Z. Circumcision–A universal procedure with no uniform technique and practiced badly. Pakistan Journal of Medical Sciences. 2004;**20**:173-174

[40] Shah T, Raistrick J, Taylor I, Young M, Menebhi D, Stevens R. A circumcision service for religious reasons. BJU International. 1999;**83**(7):807-809

**27**

**1. Background**

**Chapter 3**

Voluntary Medical Safe Male

Circumcision for HIV/AIDS

Background, Patterns, and

The safe male circumcision program has been running for about 10 years now, in Botswana. This chapter uses data derived from the two Botswana AIDS Impact Surveys (BAIS III and IV) conducted in 2008 and 2013, the period before and after the implementation of the SMC program to assess the background, patterns, and correlates of safe male circumcision. Data were analyzed using multivariate logistic regression models. Overall, 785 (12.5%) and 956 (25.2%) men reported to have been circumcised in 2008 and 2013, respectively. Elderly men aged 55–64 years were more likely to have been circumcised than men aged 10–24 years (APR = 3.40, CI = 2.00–5.76 in 2008 and APR = 3.63, CI = 2.36–5.57 in 2013). Men with primary or low and secondary education and those who reside in rural villages (APR = 0.70, CI = 0.54–0.89 in 2008; APR = 0.71, CI = 0.58–0.86 in 2013) were less likely to have been circumcised compared to men who resided in cities and towns. The odds of circumcision were also significantly low among never married (APR = 0.43, CI = 0.24–0.76) and cohabiting (APR = 0.45, CI = 0.26–0.80) men than oncemarried men in 2008. In 2013, the odds of circumcision were significantly low among married men (APR = 0.93, CI = 0.47–1.82). Understanding the background, patterns, and correlates of safe male circumcision is essential for programming and

**Keywords:** voluntary, safe male circumcision, HIV/AIDS, prevention, Botswana

Male circumcision is not a new practice in Africa. It has been practiced for thousands of years as a ritual and a rite of passage to manhood [1, 2]. Similarly, in Botswana, male circumcision has been practiced as far as 1875, marked by an initiation ceremony into manhood called "bogwera" [3]. During the *bogwera* ceremony, young adolescent males were taken through a month-long period of seclusion into the wilderness where they were taught survival skills, tribal laws, and customs [4]. The bogwera was not practiced by all tribes in Botswana; only the Balete and Bakgatla tribes were participating in this ceremony [5]. In 1917, the British High Commissioner

Prevention in Botswana:

Determinants

assessment of the effectiveness of the program.

*Mpho Keetile*

**Abstract**

## **Chapter 3**

## Voluntary Medical Safe Male Circumcision for HIV/AIDS Prevention in Botswana: Background, Patterns, and Determinants

*Mpho Keetile*

## **Abstract**

The safe male circumcision program has been running for about 10 years now, in Botswana. This chapter uses data derived from the two Botswana AIDS Impact Surveys (BAIS III and IV) conducted in 2008 and 2013, the period before and after the implementation of the SMC program to assess the background, patterns, and correlates of safe male circumcision. Data were analyzed using multivariate logistic regression models. Overall, 785 (12.5%) and 956 (25.2%) men reported to have been circumcised in 2008 and 2013, respectively. Elderly men aged 55–64 years were more likely to have been circumcised than men aged 10–24 years (APR = 3.40, CI = 2.00–5.76 in 2008 and APR = 3.63, CI = 2.36–5.57 in 2013). Men with primary or low and secondary education and those who reside in rural villages (APR = 0.70, CI = 0.54–0.89 in 2008; APR = 0.71, CI = 0.58–0.86 in 2013) were less likely to have been circumcised compared to men who resided in cities and towns. The odds of circumcision were also significantly low among never married (APR = 0.43, CI = 0.24–0.76) and cohabiting (APR = 0.45, CI = 0.26–0.80) men than oncemarried men in 2008. In 2013, the odds of circumcision were significantly low among married men (APR = 0.93, CI = 0.47–1.82). Understanding the background, patterns, and correlates of safe male circumcision is essential for programming and assessment of the effectiveness of the program.

**Keywords:** voluntary, safe male circumcision, HIV/AIDS, prevention, Botswana

## **1. Background**

Male circumcision is not a new practice in Africa. It has been practiced for thousands of years as a ritual and a rite of passage to manhood [1, 2]. Similarly, in Botswana, male circumcision has been practiced as far as 1875, marked by an initiation ceremony into manhood called "bogwera" [3]. During the *bogwera* ceremony, young adolescent males were taken through a month-long period of seclusion into the wilderness where they were taught survival skills, tribal laws, and customs [4]. The bogwera was not practiced by all tribes in Botswana; only the Balete and Bakgatla tribes were participating in this ceremony [5]. In 1917, the British High Commissioner

to Botswana passed a law to abolish initiation ceremonies, indicating that they were unhygienic and cruel [6].

In 1985, Botswana had the first HIV/AIDS case. Ever since from that time, a series of response plans and programs have been devised to reduce HIV transmission. In the early 2000s, epidemiological studies observed a significant association between circumcision and low HIV/AIDS prevalence [7–9]. It was found that countries with high circumcision rates recorded the lowest HIV/AIDS prevalence rates, in West, East, and Southern Africa [1]. Most of the studies conducted in these regions found that circumcision reduced vulnerability to HIV [10–12]. In order to provide conclusive empirical evidence, three randomized clinical trials were conducted to assess the effects of safe male circumcision for the prevention of HIV infection through heterosexual contact in South Africa, Uganda, and Kenya [13–15]. These trials congruently showed that HIV transmission was reduced by over 60% among circumcised men.

Owing to the evidence of the protective effects of circumcision against HIV transmission, several studies were undertaken in Botswana. Initial studies assessed the acceptability of safe male circumcision (SMC) among men in Botswana [16]. Subsequently, a mathematical model was used to calculate the public health impact of large safe male circumcision for HIV prevention. It was found that male HIV prevalence reduced from 30 to 10% and female HIV prevalence was reduced from 40 to 20% [17]. In 2009 the government of Botswana through the Ministry of Health and Wellness adopted the voluntary safe male circumcision program [17]. A 5-year strategy was then developed, which aimed at reaching 80% circumcision coverage [17]. According to Dickson et al. [18], less than 20% of males in Botswana had access to male circumcision services in 2010. Although the SMC program has been running for about 10 years in Botswana, recent evidence indicates that the program has failed to achieve its intended coverage [3].

This chapter is therefore intended to provide the background and assess the patterns and correlates of safe male circumcision within the context of a high HIV/AIDS prevalence setting. The chapter starts by providing a brief background on male circumcision and the SMC program in Botswana. It goes on to assess the patterns and determinants of SMC since the introduction of the program in 2009. An understanding of the background, patterns, and correlates of safe male circumcision is essential for programming and assessment of the effectiveness of the program.

## **2. Theoretical framework**

This chapter generally adopts a multifaceted approach that considers HIV/ AIDS risk perception among circumcised men by assessing patterns of circumcision and factors associated with circumcision among men in Botswana. This is done with the assumption that circumcision can only be effective in the context where men consider its health benefits. Most public health studies have often used individual and social behavioral theories to explain why individuals are willing to undertake a certain action and why they behave the way they do [19–22]. Individual behavior models focus on the role of individual characteristics in controlling individual behavior. Thus they focus on how individuals control their behaviors and make reasoned actions that impact those decisions [23]. On the other hand, social models include social pressures, peer influences, cultural expectations, economic factors affecting resource availability, legal and political

**29**

*Voluntary Medical Safe Male Circumcision for HIV/AIDS Prevention in Botswana…*

structures, and political and religious ideologies that restrict individual's options

As circumcision is recommended for medical reasons (especially prevention of HIV acquisition), men who may choose circumcision must also believe that circumcision may reduce chances of HIV acquisition. This model was mainly chosen because, the constructs of this model are key in informing men's decision to accept circumcision. The assumption of TRA is that most behaviors of social bearing are under voluntary control and that a person's intention to perform or not do the behavior is the direct determinant of that action [25]. Consequently, men's intention regarding SMC is determined by personal and social influences. One personal factor is the person's evaluation of the outcome of circumcision, which can be either

Men who perceive that circumcision is necessary for reduction of HIV transmission may choose the procedure. Meanwhile men who believe otherwise may have negative evaluation of circumcision and may choose not to circumcise. Subjective norm is the other determinant of a person's intention which is a person's perception of the social pressures applied to perform the behavior [25]. As illustrated in **Figure 1**, an individual's intentions and behaviors are influenced by certain back-

ground factors which include individual, social, and information factors.

Data used in this chapter was derived from the two Botswana AIDS Impact Surveys (BAIS III and IV). BAIS III was conducted in 2008 before the implementation of SMC program, while BAIS IV was conducted in 2013 after the implementation of the SMC program. The main objectives of the BAIS were to

Among the various individual and social behavioral models, the theory of reasoned action (TRA) has been selected and used in this chapter to explain why men would or would not circumcise. The TRA was developed and revised numerous times by Ajzen and Fishbein [24, 25]. This theory proposes that behavioral intentions are a combined function of the attitude toward performing a particular behavior in a given situation and of the norms perceived to govern that behavior multiplied by the motivation to comply with those norms [26]. The assumption is that human beings are usually quite rational and make systematic use of the information available to them. People consider the implications of their actions before

they decide to engage or not engage in a given behavior [25].

*DOI: http://dx.doi.org/10.5772/intechopen.90916*

and the flow of information [23].

**Figure 1.**

*Theory of reason action [25].*

positive or negative.

**3. Methodology**

**3.1 Data**

*Voluntary Medical Safe Male Circumcision for HIV/AIDS Prevention in Botswana… DOI: http://dx.doi.org/10.5772/intechopen.90916*

#### **Figure 1.**

*Circumcision and the Community*

unhygienic and cruel [6].

circumcised men.

coverage [3].

effectiveness of the program.

**2. Theoretical framework**

to Botswana passed a law to abolish initiation ceremonies, indicating that they were

In 1985, Botswana had the first HIV/AIDS case. Ever since from that time, a series of response plans and programs have been devised to reduce HIV transmission. In the early 2000s, epidemiological studies observed a significant association between circumcision and low HIV/AIDS prevalence [7–9]. It was found that countries with high circumcision rates recorded the lowest HIV/AIDS prevalence rates, in West, East, and Southern Africa [1]. Most of the studies conducted in these regions found that circumcision reduced vulnerability to HIV [10–12]. In order to provide conclusive empirical evidence, three randomized clinical trials were conducted to assess the effects of safe male circumcision for the prevention of HIV infection through heterosexual contact in South Africa, Uganda, and Kenya [13–15]. These trials congruently showed that HIV transmission was reduced by over 60% among

Owing to the evidence of the protective effects of circumcision against HIV transmission, several studies were undertaken in Botswana. Initial studies assessed the acceptability of safe male circumcision (SMC) among men in Botswana [16]. Subsequently, a mathematical model was used to calculate the public health impact of large safe male circumcision for HIV prevention. It was found that male HIV prevalence reduced from 30 to 10% and female HIV prevalence was reduced from 40 to 20% [17]. In 2009 the government of Botswana through the Ministry of Health and Wellness adopted the voluntary safe male circumcision program [17]. A 5-year strategy was then developed, which aimed at reaching 80% circumcision coverage [17]. According to Dickson et al. [18], less than 20% of males in Botswana had access to male circumcision services in 2010. Although the SMC program has been running for about 10 years in Botswana, recent evidence indicates that the program has failed to achieve its intended

This chapter is therefore intended to provide the background and assess the patterns and correlates of safe male circumcision within the context of a high HIV/AIDS prevalence setting. The chapter starts by providing a brief background on male circumcision and the SMC program in Botswana. It goes on to assess the patterns and determinants of SMC since the introduction of the program in 2009. An understanding of the background, patterns, and correlates of safe male circumcision is essential for programming and assessment of the

This chapter generally adopts a multifaceted approach that considers HIV/ AIDS risk perception among circumcised men by assessing patterns of circumcision and factors associated with circumcision among men in Botswana. This is done with the assumption that circumcision can only be effective in the context where men consider its health benefits. Most public health studies have often used individual and social behavioral theories to explain why individuals are willing to undertake a certain action and why they behave the way they do [19–22]. Individual behavior models focus on the role of individual characteristics in controlling individual behavior. Thus they focus on how individuals control their behaviors and make reasoned actions that impact those decisions [23]. On the other hand, social models include social pressures, peer influences, cultural expectations, economic factors affecting resource availability, legal and political

**28**

*Theory of reason action [25].*

structures, and political and religious ideologies that restrict individual's options and the flow of information [23].

Among the various individual and social behavioral models, the theory of reasoned action (TRA) has been selected and used in this chapter to explain why men would or would not circumcise. The TRA was developed and revised numerous times by Ajzen and Fishbein [24, 25]. This theory proposes that behavioral intentions are a combined function of the attitude toward performing a particular behavior in a given situation and of the norms perceived to govern that behavior multiplied by the motivation to comply with those norms [26]. The assumption is that human beings are usually quite rational and make systematic use of the information available to them. People consider the implications of their actions before they decide to engage or not engage in a given behavior [25].

As circumcision is recommended for medical reasons (especially prevention of HIV acquisition), men who may choose circumcision must also believe that circumcision may reduce chances of HIV acquisition. This model was mainly chosen because, the constructs of this model are key in informing men's decision to accept circumcision. The assumption of TRA is that most behaviors of social bearing are under voluntary control and that a person's intention to perform or not do the behavior is the direct determinant of that action [25]. Consequently, men's intention regarding SMC is determined by personal and social influences. One personal factor is the person's evaluation of the outcome of circumcision, which can be either positive or negative.

Men who perceive that circumcision is necessary for reduction of HIV transmission may choose the procedure. Meanwhile men who believe otherwise may have negative evaluation of circumcision and may choose not to circumcise. Subjective norm is the other determinant of a person's intention which is a person's perception of the social pressures applied to perform the behavior [25]. As illustrated in **Figure 1**, an individual's intentions and behaviors are influenced by certain background factors which include individual, social, and information factors.

#### **3. Methodology**

#### **3.1 Data**

Data used in this chapter was derived from the two Botswana AIDS Impact Surveys (BAIS III and IV). BAIS III was conducted in 2008 before the implementation of SMC program, while BAIS IV was conducted in 2013 after the implementation of the SMC program. The main objectives of the BAIS were to provide information to assess whether programs are operating as intended; assess performance of intervention programs; assess whether people are changing their sexual behavior; establish the proportion of people in need of care due to HIV infection; establish the proportion of people who are at risk of HIV infection; assess the impact of the pandemic at household level; and provide information on issues related to the impact of HIV/AIDS on households and communities [27]. BAIS III and IV are the two surveys which have asked the same questions on male circumcision that can be used to assess the patterns and determinants of SMC in Botswana. A sample consisting of 6290 and 3787 men in ages 10–64 years who had successfully completed BAIS III and IV individual questionnaires, respectively, were selected and included for analyses. Respondents who did not complete the individual questionnaire were excluded from the present analysis.

## **3.2 Response variable**

The main variable of interest used in this paper is on "circumcision status." This is based on the percentage of circumcised men between ages 10 and 64 years in the sample population. This variable is derived from self-reported responses to a question that sought to know whether the respondent was circumcised or not.

## **3.3 Explanatory variables**

Sociodemographic variables such as age, sex, residence, education, and religion were used as control variables based on prior empirical research which has shown that conceptually these variables are associated with sexual risk behaviors [28, 29].

## **3.4 Statistical analysis**

Analyses were conducted using SPSS version 25 program (IBM, SPSS, Chicago, IL, USA). In order to assess patterns of circumcision, adjusted prevalence ratios (APR) and their corresponding 95% confidence intervals were obtained using modified Poisson regression models. The associations between male circumcision and sociodemographic and behavioral factors were estimated for each of the surveys. In order to avoid cofounding effects between circumcision and covariates, sociodemographic variables were used as control variables. This ensured that the association between behavioral variables and circumcision becomes credible and discernible. In the adjusted analyses of sexual risk behaviors, sociodemographic characteristics were controlled for. In order to control for cluster effects, complex samples module in SPSS has been used since multistage probability sampling technique was used for both surveys.

## **4. Results**

### **4.1 Patterns of safe male circumcision in Botswana (2008–2013)**

Overall 785 (12.5%) and 956 (25.2%) men in the sample reported to have been circumcised in 2008 and 2013, respectively (**Figure 2**).

**Table 1** shows the sociodemographic characteristics of circumcised men in Botswana (2008 and 2013). The proportion of men who were circumcised decreased with age for both surveys. For instance, in both surveys the highest proportions of circumcised men were found in ages 10–24 (25 and 28.7% for 2008 and 2013, respectively) and lowest in ages 55–64 years (8.3 and 9.8% for 2008 and 2013,

**31**

*Voluntary Medical Safe Male Circumcision for HIV/AIDS Prevention in Botswana…*

*Percentage of circumcised men in Botswana (2008 and 2013). Source: Analyzed from Botswana AIDS Impact* 

10–24 25.0 (184) 2680 28.7 (274) 1490 25–34 31.8 (234) 1600 27.6 (264) 954 35–44 21.8 (160) 934 21.2 (203) 680 45–54 13.1 (96) 586 12.7 (121) 399 55–64 8.3 (61) 318 9.8 (94) 264

Primary/less 13.7 (78) 841 18.8 (161) 930 Secondary 53.1 (302) 2558 49.5 (423) 1688 Tertiary/higher 33.2 (189) 894 31.7 (271) 724

Cities and towns 38.4 (282) 1739 44.1 (422) 1398 Urban villages 31.0 (228) 1901 25.9 (248) 948 Rural villages 30.6 (225) 2478 29.9 (286) 1441

Never married 47.8 (351) 3866 53.7 (513) 2306 Married 24.4 (179) 874 21.9 (209) 635 Cohabiting 23.4 (172) 1251 22.2 (212) 787 Once married 4.5 (33) 127 2.3 (22) 59

Christian 64.4 (426) 3686 81.4 (778) 3089 Other non-Christian 35.6 (236) 2031 18.6 (178) 698

**Circumcised, % (n) N Circumcised, % (n) N**

**Variables 2008 BAIS 2013 BAIS**

respectively). A high proportion of circumcised men in both surveys was found among those with secondary education in 2008 and 2013 (53.1 and 49.5%, respectively), cities and towns (38.4 and 44.1%, respectively), never married individuals

**Total** 12.5 (785) 25.2 (956)

(47.8 and 53.7%), and Christians (64.4 and 81.4%, respectively).

*Characteristics of circumcised men aged 10–64 years in Botswana (2008 and 2013).*

*DOI: http://dx.doi.org/10.5772/intechopen.90916*

**Figure 2.**

**Age**

**Education**

**Residence**

**Marital status**

**Religion**

**Table 1.**

*Surveys III and IV (2008 and 2013).*

*Voluntary Medical Safe Male Circumcision for HIV/AIDS Prevention in Botswana… DOI: http://dx.doi.org/10.5772/intechopen.90916*

#### **Figure 2.**

*Circumcision and the Community*

**3.2 Response variable**

**3.3 Explanatory variables**

**3.4 Statistical analysis**

both surveys.

**4. Results**

provide information to assess whether programs are operating as intended; assess performance of intervention programs; assess whether people are changing their sexual behavior; establish the proportion of people in need of care due to HIV infection; establish the proportion of people who are at risk of HIV infection; assess the impact of the pandemic at household level; and provide information on issues related to the impact of HIV/AIDS on households and communities [27]. BAIS III and IV are the two surveys which have asked the same questions on male circumcision that can be used to assess the patterns and determinants of SMC in Botswana. A sample consisting of 6290 and 3787 men in ages 10–64 years who had successfully completed BAIS III and IV individual questionnaires, respectively, were selected and included for analyses. Respondents who did not complete the individual

The main variable of interest used in this paper is on "circumcision status." This is based on the percentage of circumcised men between ages 10 and 64 years in the sample population. This variable is derived from self-reported responses to a ques-

Sociodemographic variables such as age, sex, residence, education, and religion were used as control variables based on prior empirical research which has shown that conceptually these variables are associated with sexual risk behaviors [28, 29].

Analyses were conducted using SPSS version 25 program (IBM, SPSS, Chicago, IL, USA). In order to assess patterns of circumcision, adjusted prevalence ratios (APR) and their corresponding 95% confidence intervals were obtained using modified Poisson regression models. The associations between male circumcision and sociodemographic and behavioral factors were estimated for each of the surveys. In order to avoid cofounding effects between circumcision and covariates, sociodemographic variables were used as control variables. This ensured that the association between behavioral variables and circumcision becomes credible and discernible. In the adjusted analyses of sexual risk behaviors, sociodemographic characteristics were controlled for. In order to control for cluster effects, complex samples module in SPSS has been used since multistage probability sampling technique was used for

tion that sought to know whether the respondent was circumcised or not.

**4.1 Patterns of safe male circumcision in Botswana (2008–2013)**

circumcised in 2008 and 2013, respectively (**Figure 2**).

Overall 785 (12.5%) and 956 (25.2%) men in the sample reported to have been

**Table 1** shows the sociodemographic characteristics of circumcised men in Botswana (2008 and 2013). The proportion of men who were circumcised decreased with age for both surveys. For instance, in both surveys the highest proportions of circumcised men were found in ages 10–24 (25 and 28.7% for 2008 and 2013, respectively) and lowest in ages 55–64 years (8.3 and 9.8% for 2008 and 2013,

questionnaire were excluded from the present analysis.

**30**

*Percentage of circumcised men in Botswana (2008 and 2013). Source: Analyzed from Botswana AIDS Impact Surveys III and IV (2008 and 2013).*


#### **Table 1.**

*Characteristics of circumcised men aged 10–64 years in Botswana (2008 and 2013).*

respectively). A high proportion of circumcised men in both surveys was found among those with secondary education in 2008 and 2013 (53.1 and 49.5%, respectively), cities and towns (38.4 and 44.1%, respectively), never married individuals (47.8 and 53.7%), and Christians (64.4 and 81.4%, respectively).

Majority of men indicated that they were circumcised later in life for both surveys (56.1% in 2008 and 52.7% in 2013). However, the proportion of men who were circumcised in later life was highest in 2008. As for the place of circumcision, a high proportion of men reported that they were circumcised in a health facility, and this was high in 2013 (78.8%) than in 2008 (69%). Under one-tenth of men (9.3% in 2008 and 7.1% in 2013) reported that they experienced some complications during circumcision. The proportion of men who expressed willingness to be circumcised in was highest in 2008 (58.6%) than in 2013 (49.5%) (**Table 2**).

## **4.2 Determinants of safe male circumcision in Botswana**

Results in **Table 3** present the adjusted odd ratios for the association between safe male circumcision and sociodemographic factors in 2008 and 2013. Age was observed to be a significant correlate of male circumcision in both 2008 and 2013. The odds of safe male circumcision increased with age for both survey periods, with men aged 55–64 years three times (APR = 3.40, CI = 2.00–5.76 in 2008 and APR = 3.63, CI = 2.36–5.57 in 2013) more likely to have been circumcised than men aged 10–24 years. Considering education level, men with primary or less and secondary education were less likely to have been circumcised than men with tertiary or higher education level for both survey periods.

Men in rural villages were less likely to have been circumcised than men who resided in cities and towns in 2008 (APR = 0.70, CI = 0.54–0.89) and 2013 (APR = 0.71, CI = 0.58–0.86). On the other hand, there were no significant variations observed for circumcision and residing in urban villages. The odds of circumcision were significantly low among never married (APR = 0.43, CI = 0.24–0.76) and cohabiting (APR = 0.45, CI = 0.26–0.80) men than once-married men in 2008, while for married men there was no significant variation. In 2013, the odds of


**33**

circumcision.

**5. Discussion**

*Voluntary Medical Safe Male Circumcision for HIV/AIDS Prevention in Botswana…*

10–24 1.00 1.00

Tertiary/higher 1.00 1.00

Cities and towns 1.00 1.00

Once married 1.00 1.00

Other non-Christian 1.00 1.00

**Variable 2008 2013**

25–34 1.76 (1.35–2.30) 1.36 (1.09–1.69) 35–44 2.43 (1.73–3.41) 1.76 (1.35–2.29) 45–54 2.54 (1.65–3.91) 2.41 (1.72–3.38) 55–64 3.40 (2.00–5.76) 3.63 (2.36–5.57)

Primary/less 0.32 (0.22–0.46) 0.36 (0.28–0.47) Secondary 0.72 (0.57–0.91) 0.67 (0.55–0.82)

Urban villages 0.79 (0.63–1.00) 0.90 (0.74–1.10) Rural villages 0.70 (0.54–0.89) 0.71 (0.58–0.86)

Never married 0.43 (0.24–0.76) 1.10 (0.55–2.18) Married 0.68 (0.39–1.18) 0.93 (0.47–1.82) Cohabiting 0.45 (0.26–0.80) 1.05 (0.53–2.08)

Christian 0.81 (0.66–1.00) 0.95 (0.77–1.18)

**Adjusted PR 95% CI Adjusted PR 95% CI**

circumcision were significantly low among married (APR = 0.93, CI = 0.47–1.82) than once-married men, while no significant association was found for cohabiting and never married men. When considering religious affiliation, there was no variation on whether a man was from a Christian or any other religious background and

*Adjusted prevalence ratios for the association between safe male circumcision and sociodemographic factors* 

Due to high HIV prevalence and incidence rates, inadequacy of the response programs such as PMTCT program, BCIC programs, HIV testing and counseling, blood safety program, and STI management and control gave way to safe male circumcision program. The SMC program was seen as essential in adding to the existing strategies in preventing the spread of HIV infection [17]. The combination of research findings in South Africa, Kenya, and Uganda and the WHO/UNAIDS recommendations that male circumcision is efficacious in reducing HIV infection prompted the government of Botswana to scale up this component of HIV prevention and develop national policies, strategies, and implementation plans. Although

*DOI: http://dx.doi.org/10.5772/intechopen.90916*

**Age**

**Education**

**Residence**

**Marital status**

**Religion**

*(2008 and 2013).*

**Table 3.**

#### **Table 2.**

*Selected key safe male circumcision variables.*


*Voluntary Medical Safe Male Circumcision for HIV/AIDS Prevention in Botswana… DOI: http://dx.doi.org/10.5772/intechopen.90916*

#### **Table 3.**

*Circumcision and the Community*

Majority of men indicated that they were circumcised later in life for both surveys (56.1% in 2008 and 52.7% in 2013). However, the proportion of men who were circumcised in later life was highest in 2008. As for the place of circumcision, a high proportion of men reported that they were circumcised in a health facility, and this was high in 2013 (78.8%) than in 2008 (69%). Under one-tenth of men (9.3% in 2008 and 7.1% in 2013) reported that they experienced some complications during circumcision. The proportion of men who expressed willingness to be circumcised

Results in **Table 3** present the adjusted odd ratios for the association between safe male circumcision and sociodemographic factors in 2008 and 2013. Age was observed to be a significant correlate of male circumcision in both 2008 and 2013. The odds of safe male circumcision increased with age for both survey periods, with men aged 55–64 years three times (APR = 3.40, CI = 2.00–5.76 in 2008 and APR = 3.63, CI = 2.36–5.57 in 2013) more likely to have been circumcised than men aged 10–24 years. Considering education level, men with primary or less and secondary education were less likely to have been circumcised than men with tertiary

Men in rural villages were less likely to have been circumcised than men who resided in cities and towns in 2008 (APR = 0.70, CI = 0.54–0.89) and 2013 (APR = 0.71, CI = 0.58–0.86). On the other hand, there were no significant variations observed for circumcision and residing in urban villages. The odds of circumcision were significantly low among never married (APR = 0.43, CI = 0.24–0.76) and cohabiting (APR = 0.45, CI = 0.26–0.80) men than once-married men in 2008, while for married men there was no significant variation. In 2013, the odds of

**Variable 2008 BAIS III 2013 BAIS IV**

At birth 40.3 299 38.1 331 Later in life 56.1 416 52.7 537 Do not know 3.6 27 9.2 88

Health facility 69 511 78.8 753 Traditional 21.9 162 16.2 155 Do not know 9.1 68 5 48

Yes 9.3 69 7.1 68 No 76.1 564 80.9 773 Do not know 14.6 108 12 115

Yes 58.6 3694 49.5 1270 No 41.4 2608 50.5 1295

**% N % N**

in was highest in 2008 (58.6%) than in 2013 (49.5%) (**Table 2**).

**4.2 Determinants of safe male circumcision in Botswana**

or higher education level for both survey periods.

**Time of circumcision?**

**Place of circumcision?**

**Experienced complications?**

*Selected key safe male circumcision variables.*

**Willingness to be circumcised in the next 12 months?**

**32**

**Table 2.**

*Adjusted prevalence ratios for the association between safe male circumcision and sociodemographic factors (2008 and 2013).*

circumcision were significantly low among married (APR = 0.93, CI = 0.47–1.82) than once-married men, while no significant association was found for cohabiting and never married men. When considering religious affiliation, there was no variation on whether a man was from a Christian or any other religious background and circumcision.

### **5. Discussion**

Due to high HIV prevalence and incidence rates, inadequacy of the response programs such as PMTCT program, BCIC programs, HIV testing and counseling, blood safety program, and STI management and control gave way to safe male circumcision program. The SMC program was seen as essential in adding to the existing strategies in preventing the spread of HIV infection [17]. The combination of research findings in South Africa, Kenya, and Uganda and the WHO/UNAIDS recommendations that male circumcision is efficacious in reducing HIV infection prompted the government of Botswana to scale up this component of HIV prevention and develop national policies, strategies, and implementation plans. Although

Botswana is not a traditionally circumcising society, evidence from this study indicates that male circumcision is highly acceptable in Botswana, corroborating the initial evidence [3, 5].

Majority of men who participated in the 2008 and 2013 surveys indicated that they were circumcised later in life and that they were circumcised in a health facility. A relatively low proportion of men reported that they experienced some complications during the procedure. This corroborates findings from other studies which show that when circumcision is done within hygienic clinical settings, there are minor chances of complications [1]. Common complications associated with circumcision in such settings include excessive loss of foreskin, skin bridges, amputation of the glans penis, and buried penis.

Evidence from this chapter indicates that between 2008 and 2013, the period before and after the implementation of the safe male circumcision program, the proportion of men who circumcised doubled. Although the program has not met its target [5], substantial gains have been made in getting high numbers of men to undergo circumcision. The scale-up of safe male circumcision program has benefited immensely from external funding which has supported biomedical marketing in the media including, billboard, radio, and TV advertising. Moreover, a renowned afro-pop artist was contracted as the campaign ambassador during the program in order to attract more men [5]. Additionally, specialized clinics have been set up in selected areas in addition to general public health facilities where SMC is conducted in hygienic, clinical conditions by medical practitioners [5].

On the other hand, the proportion of men who expressed willingness to undergo safe male circumcision had declined by about 10% in 2013. A plausible explanation for this decline is linked to several reasons. First, a review study on the SMC program by Katisi et al. [5] indicates that during the implementation of the program, cultural taboos such as the breaching of secrecy of the circumcision act by inclusion of women in performing circumcision procedure were introduced. Second, there are views that the traditional leadership has been left during the implementation of the program [3]. Lastly, elements of the minimum package for SMC that include counseling and voluntary HIV testing were repeatedly mentioned as other barriers that blocked men from circumcising [5]. HIV testing, in particular, seems to scare men away even if they would opt for circumcision.

Age was a significant predictor of male circumcision. For example, circumcision was found to increase with age, with highest proportions of circumcised men found in ages 55–64 years and lowest in ages 10–24 years. Similar observations were made in Uganda, where it was found that more than half of elderly men indicated that they have been circumcised compared to two-fifths of youth [30]. Although circumcision levels are lowest among young adolescents in Botswana, a study by Lane et al. [31] has shown that at the country level, deliberately prioritizing young adolescents is likely to achieve national coverage targets more quickly and costeffectively than continuing to focus on older, harder-to-reach men. In Botswana, prioritization of younger men is critical to VMMC sustainability. As a result there is the school-going children circumcision initiative, whereby young boys are targeted to undergo circumcision through parental involvement. In this approach young boys consent to undergo circumcision through the involvement of parents. However, the decision to circumcise or not to circumcise lies with the children.

Considering education level, men with primary or less and secondary education were less likely to have been circumcised than men with tertiary or higher education level for both survey periods. This corroborates findings from other studies that men with high education and socioeconomic status have the propensity to undergo safe male circumcision compared to men with low education and poor socioeconomic status [32–34]. Educational attainment predisposes individuals to appreciate

**35**

**Author details**

Mpho Keetile

*Voluntary Medical Safe Male Circumcision for HIV/AIDS Prevention in Botswana…*

health programs better [35]. This is because men who have high education have better perception of the risk of HIV infection than men with low education. Consequently, there is need for more education and information for men with low

Men in rural villages were less likely to have been circumcised than men who resided in cities and towns in 2008. A plausible explanation for this scenario is that in 2008, the safe male program was not yet rolled out in the country. Moreover, men in rural areas are prone to lack of access to information and education. The odds of circumcision were significantly low among never married and cohabiting men than once-married men in 2008. This corroborates findings of a study by Mangombe and Kalule-Sabiti [36] which also found that in Zimbabwe never married and cohabiting men were less likely to circumcise. The main reason being that this cohort of men assumes that they at low risk of HIV infection. Meanwhile, other studies show the contrary that married men are at risk of infection compared to never married

In 2013, the odds of circumcision were significantly low among married than once-married men. Low prevalence of circumcision among married men can also be attributed to low risk of infection, especially where marital fidelity is practiced. There was no variation on whether a man was from a Christian or any other religious background and circumcision. Findings of the association between religion and circumcision are at best mixed. In some contexts, religion is a key predictor of circumcision among men [38], while in other contexts, as is the case in Botswana, it

Safe male circumcision is as an effective additional strategy for HIV prevention. The medical benefits of SMC outweigh the risks. Age, education, residence, and marital status are significant determinants of male circumcision in Botswana. Consequently, more efforts should be geared toward educating men, especially those residing in rural areas and those in cohabiting relationships about the benefits of circumcision. Moreover, women need to be involved in understanding the benefits of male circumcision to ensure effectiveness of the SMC program.

Department of Population Studies, University of Botswana, Gaborone, Botswana

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

\*Address all correspondence to: mphokeet@yahoo.com

provided the original work is properly cited.

*DOI: http://dx.doi.org/10.5772/intechopen.90916*

education to take part in circumcision.

and cohabiting men [37].

is not [39].

**6. Conclusion**

*Voluntary Medical Safe Male Circumcision for HIV/AIDS Prevention in Botswana… DOI: http://dx.doi.org/10.5772/intechopen.90916*

health programs better [35]. This is because men who have high education have better perception of the risk of HIV infection than men with low education. Consequently, there is need for more education and information for men with low education to take part in circumcision.

Men in rural villages were less likely to have been circumcised than men who resided in cities and towns in 2008. A plausible explanation for this scenario is that in 2008, the safe male program was not yet rolled out in the country. Moreover, men in rural areas are prone to lack of access to information and education. The odds of circumcision were significantly low among never married and cohabiting men than once-married men in 2008. This corroborates findings of a study by Mangombe and Kalule-Sabiti [36] which also found that in Zimbabwe never married and cohabiting men were less likely to circumcise. The main reason being that this cohort of men assumes that they at low risk of HIV infection. Meanwhile, other studies show the contrary that married men are at risk of infection compared to never married and cohabiting men [37].

In 2013, the odds of circumcision were significantly low among married than once-married men. Low prevalence of circumcision among married men can also be attributed to low risk of infection, especially where marital fidelity is practiced. There was no variation on whether a man was from a Christian or any other religious background and circumcision. Findings of the association between religion and circumcision are at best mixed. In some contexts, religion is a key predictor of circumcision among men [38], while in other contexts, as is the case in Botswana, it is not [39].

## **6. Conclusion**

*Circumcision and the Community*

the initial evidence [3, 5].

amputation of the glans penis, and buried penis.

in hygienic, clinical conditions by medical practitioners [5].

men away even if they would opt for circumcision.

decision to circumcise or not to circumcise lies with the children.

Botswana is not a traditionally circumcising society, evidence from this study indicates that male circumcision is highly acceptable in Botswana, corroborating

Majority of men who participated in the 2008 and 2013 surveys indicated that they were circumcised later in life and that they were circumcised in a health facility. A relatively low proportion of men reported that they experienced some complications during the procedure. This corroborates findings from other studies which show that when circumcision is done within hygienic clinical settings, there are minor chances of complications [1]. Common complications associated with circumcision in such settings include excessive loss of foreskin, skin bridges,

Evidence from this chapter indicates that between 2008 and 2013, the period before and after the implementation of the safe male circumcision program, the proportion of men who circumcised doubled. Although the program has not met its target [5], substantial gains have been made in getting high numbers of men to undergo circumcision. The scale-up of safe male circumcision program has benefited immensely from external funding which has supported biomedical marketing in the media including, billboard, radio, and TV advertising. Moreover, a renowned afro-pop artist was contracted as the campaign ambassador during the program in order to attract more men [5]. Additionally, specialized clinics have been set up in selected areas in addition to general public health facilities where SMC is conducted

On the other hand, the proportion of men who expressed willingness to undergo safe male circumcision had declined by about 10% in 2013. A plausible explanation for this decline is linked to several reasons. First, a review study on the SMC program by Katisi et al. [5] indicates that during the implementation of the program, cultural taboos such as the breaching of secrecy of the circumcision act by inclusion of women in performing circumcision procedure were introduced. Second, there are views that the traditional leadership has been left during the implementation of the program [3]. Lastly, elements of the minimum package for SMC that include counseling and voluntary HIV testing were repeatedly mentioned as other barriers that blocked men from circumcising [5]. HIV testing, in particular, seems to scare

Age was a significant predictor of male circumcision. For example, circumcision was found to increase with age, with highest proportions of circumcised men found in ages 55–64 years and lowest in ages 10–24 years. Similar observations were made in Uganda, where it was found that more than half of elderly men indicated that they have been circumcised compared to two-fifths of youth [30]. Although circumcision levels are lowest among young adolescents in Botswana, a study by Lane et al. [31] has shown that at the country level, deliberately prioritizing young adolescents is likely to achieve national coverage targets more quickly and costeffectively than continuing to focus on older, harder-to-reach men. In Botswana, prioritization of younger men is critical to VMMC sustainability. As a result there is the school-going children circumcision initiative, whereby young boys are targeted to undergo circumcision through parental involvement. In this approach young boys consent to undergo circumcision through the involvement of parents. However, the

Considering education level, men with primary or less and secondary education were less likely to have been circumcised than men with tertiary or higher education level for both survey periods. This corroborates findings from other studies that men with high education and socioeconomic status have the propensity to undergo safe male circumcision compared to men with low education and poor socioeconomic status [32–34]. Educational attainment predisposes individuals to appreciate

**34**

Safe male circumcision is as an effective additional strategy for HIV prevention. The medical benefits of SMC outweigh the risks. Age, education, residence, and marital status are significant determinants of male circumcision in Botswana. Consequently, more efforts should be geared toward educating men, especially those residing in rural areas and those in cohabiting relationships about the benefits of circumcision. Moreover, women need to be involved in understanding the benefits of male circumcision to ensure effectiveness of the SMC program.

## **Author details**

Mpho Keetile Department of Population Studies, University of Botswana, Gaborone, Botswana

\*Address all correspondence to: mphokeet@yahoo.com

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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[14] Bailey RC, Moses S, Parker CB, Agot K, Maclean I, Krieger JN, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: A randomised controlled trial. Lancet. 2007;**369**(9562):643-656

[15] Gray RH, Li X, Kigozi G, et al. The impact of male circumcision on HIV incidence and cost per infection prevented: A stochastic simulation

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[17] Ministry of Health. Safe Male Circumcision-Additional Strategy for HIV Prevention. Gaborone, Botswana: Government Printers; 2011

[18] Dickson KE, Tran NT, Samuelson JL, Njeuhmeli E, Reed J, et al. Voluntary medical male circumcision: A framework analysis of policy and program implementation in eastern and southern Africa. PLoS Medicine. 2011;**8**(11):e1001133. DOI: 10.1371/ journal.pmed.100113

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[21] Hardcastle SJ, Hancox J, Hattar A, Maxwell-Smith C, Thøgersen-Ntoumani C, Hagger MS. Motivating the unmotivated: How can health behavior be changed in those unwilling to change? Frontiers in Psychology. 2015;**6**:835. DOI: 10.3389/ fpsyg.2015.00835

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sciences: A scoping review. Health Psychology Review. 2015;**9**(3):323-344. DOI: 10.1080/17437199.2014.941722

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[25] Ajzen I, Fishbein M. Understanding Attitudes and Predicting Social Behavior. Englewood Cliffs, NJ: Prentice-Hall; 1980

[26] Ajzen I. From intention to actions: A theory of planned behavior. In: Kuhl J, Bechmann J, editors. Action Control: From Cognitions to Behavior. New York: Springer-Verlag; 1985. pp. 11-39

[27] Statistics Botswana. Botswana AIDS Impact Survey III Report. Gaborone: Government Printers; 2008

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**36**

2008;**22**:567-574

*Circumcision and the Community*

tau.2016.12.02

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10.1155/2013/38750

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and vaginal infections in a randomized trial in Rakai, Uganda. The American Journal of Obstetrics and Gynecology.

[9] Weiss HA, Dickson KE, Agot K, Hankins CA. Male circumcision for HIV prevention: Current research and programmatic issues. AIDS (London, England). 2010;**24** Suppl 4(04):S61-S69. DOI: 10.1097/01. aids.0000390708.66136.f4

[10] Halperin DT, Bailey RC. Male circumcision and HIV infection: 10 years and counting. Lancet. 2000;**354**(9192):1813-1815

[11] Weiss HA, Quigley MA, Hayes RJ. Male circumcision and risk of HIV infection in sub-Saharan Africa: A systematic review and meta-analysis.

[12] Moses S. Male circumcision: A new approach to reducing HIV transmission. CMAJ: Canadian Medical Association Journal. 2009;**181**(8):E134-E135. DOI:

[13] Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, et al. Correction: Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: The ANRS 1265 trial. PLoS Medicine. 2006;**3**(5):e226. DOI: 10.1371/journal.

[14] Bailey RC, Moses S, Parker CB, Agot K, Maclean I, Krieger JN, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: A randomised controlled trial. Lancet.

[15] Gray RH, Li X, Kigozi G, et al. The impact of male circumcision on HIV incidence and cost per infection prevented: A stochastic simulation

2007;**369**(9562):643-656

AIDS. 2000;**14**(15):2361-2370

10.1503/cmaj.090809

pmed.0030226

2009;**200**(42):e41-e47

[2] Sovran S. Understanding culture and HIV/AIDS in sub-Saharan Africa. SAHARA-J: Journal of Social Aspects of HIV/AIDS Research Alliance. 2013;**10**(1):32-41. DOI: 10.1080/17290376.2013.807071

[3] Sabone M, Magowe M, Busang L, Moalosi J, Binagwa B, Mwambona J. Impediments for the uptake of the Botswana Government's male circumcision initiative for HIV prevention. The Scientific World Journal. 2013:1-7. DOI:

[4] Katide G. Female morality as entrenched in Botswana traditional teachings in initiation schools [master of ARTs degree dissertation]. 2017. Available from: https://core.ac.uk/ download/pdf/95521641.pdf

[5] Katisi M, Daniel M. Safe male circumcision in Botswana: Tension between traditional practices and biomedical marketing. Global Public Health. 2015;**10**(5-6):739-756. DOI: 10.1080/17441692.2015.1028424

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**39**

Section 2

Complications of

Circumcision

Section 2
