Stigmatisation & Male Circumcision

Further discussions with the residents within the community North of Kampala brought more valuable insights to the fore (6). There is a critical interplay between cultural beliefs and stigmatisation of diseases, in particular HIV and illness ‘associated with sexuality’, and the barriers to accessing healthcare. This includes commuting distance, lack of required services, and cost contributing to their health-seeking behaviour. This has resulted in low uptake of test and treat regimes, perpetuating the spread and severity of some deadly diseases, as well documented in literature (8).

Casting the net wider, stigmatisation and societal pressures/beliefs are also influential in many traditional rituals, an example of which is the public circumcision of males. In some tribes referred to as ‘Imbalu’, this signifies the transition of boyhood to manhood and is a rite of passage in several communities (9). In some cases, it is a requirement for men to be able to marry, as proof that a man can protect his wife (9). From a cultural perspective, the ceremony is a celebration involving music, dance and sharing of indigenous history, culture and knowledge (10).

However, from a health perspective, this has been a source of contention for multiple reasons. Firstly, it is not always conducted in a sterile environment by a trained surgeon, introducing the risk of complications and infection, including HIV (in some cases, the same blade would be used to circumcise multiple boys) (11). This ceremony can also be associated with forms of ritualised violence. In some communities, men refuse or abscond, they are forcefully circumcised; furthermore, in some cultures, after the procedure itself is complete, a girl from the community is then selected to have intercourse with the newly circumcised man, and in theory, she ‘cannot refuse’(9). Importantly, the central tenet of this ceremony is that the recipient cannot show signs of pain or fear, as this is a sign of ‘cowardice’ and a ‘lack of manliness’ (12-14). As such, there are a myriad of ways that health-seeking behaviours are impacted by the cultural norms surrounding Imbalu. Further qualitative research on this might improve understanding of the practice and its impact on the perception of men in wider society and their interaction with healthcare.

Given the benefits of male circumcision, there has been a large push by the Ministry of Health to provide and encourage more circumcision in medical facilities by trained professionals (15). Coupled with religious practice and increasing education, fewer men are opting for the full ceremony, but in some areas, it is still practiced traditionally (10). There is an interesting balance to strike here on preserving cultural identity and heritage, whilst improving health outcomes and safety (10).