The graph above shows the number of initiation deaths in the Eastern Cape. A total of 1133 deaths have been recorded since 1995. Accurate statistics are not available for the number of amputations, but their number is roughly twice the number of deaths. The moral demise that accompanies the ritual is another major point of concern and is further outlined below.


Secrecy and sacredness

Details of the ritual are to be kept secret from females or non-initiated males. This complicates supervision, especially in Pondoland where the majority of the elders have not undergone the ritual themselves. It also impedes discussion of problems in a public space.

Accessibility of initiation schools

Traditionally initiation schools are built in secluded locations, away from the communities. Some of these locations are virtually inaccessible and hard to find, making adequate monitoring difficult and complicating matters in the event of an emergency.

Construction of initiation schools

Large plastic sheets are commonly used for the construction of the hut. Plastic retains heat and does not allow for air circulation. The inside temperature is further increased by cramped and crowded structures, and a fire that is continuously kept burning or smouldering. Initiates loose fluids via sweating which, in combination with the undesirable practice of fluid restriction, can rapidly lead to dehydration.

All contemporary initiation schools have a very small entrance that makes it difficult to exit the structure in the event of fire. This has led to several fatalities over the years.


Poor aseptic practices lead to transmission of diseases such as HIV and hepatitis B. One single traditional spear is commonly used to circumcise all initiates without intermediate sterilization. Washing the foreskin (and applying an antiseptic) prior to the procedure reduces the wound infection risk, however this is rarely practiced.

Usually the traditional surgeon will either pull the foreskin or stretch it over his thumb after which he severs it. Often the foreskin is ‘chopped’ rather then excised, resulting in a higher number of surgical complications. This is further aggravated by alcohol and substance abuse by the traditional surgeon during the procedure.

Surgical complications are excessive bleeding, ragged and/or asymmetrical circumcision wounds, excessive removal of skin (leaving large wounds that are prone to infection), and failure to remove the foreskin entirely. Severe genital mutilations such as injury to the glans or urethra are uncommon.

Wound care

Traditionally herbs with a weak antiseptic effect are placed directly onto the wound, after which a cloth bandage is applied. Experienced traditional attendants will reduce the wound size by pulling the skin of the penile shaft towards the glans, which is secured in place using a certain bandaging technique. This is an important technique to reduce the risk of infection: small wounds are less likely to become infected.

Poor hygienic practices are abundant. Most attendants do not use gloves, nor do they wash their hands before each dressing change. Bandages are reused on different initiates. Leaves are rubbed against the sole of the foot before application onto the wound. All these practices introduce bacteria into the wound and spread them from one initiate to the other.

Tightly applied bandages compromise the blood supply of the skin which leads to delayed wound healing. Deep blood vessels may be occluded leading to gangrene (dead tissue). Additionally, tissue that is starved of oxygen is vulnerable to infection.

Fluid and dietary restrictions

Almost all initiation schools restrict fluid intake during the first eight days following circumcision, as an endurance test and to prevent ‘umlambo’ (see under complications). This highly undesirable practice leads to dehydration, which in turn can lead to acute renal failure and shock. Other complications, such as wound and chest infections, are much more likely to occur in dehydrated initiates.

The degree of fluid restriction differs from school to school; some even mix the drinking water with soil. Food usually consists of staple food only leading to nutritional deficiencies.

Sleep deprivation

Initiates are believed to be endangered by witches during the so-called twilight phase between boyhood and manhood. The white clay offers protection, and they are made to sing throughout night to keep witches away, which leads to sleep deprivation.

Pre-existing medical conditions

Certain pre-existing medical conditions are not necessarily picked up on medical examinations if they are well controlled: such as asthma, diabetes mellitus, epilepsy and mental health issues. However, these conditions can easily exacerbate because of the strenuous circumstances in initiation schools.

'Western' medication is usually not allowed in initiation schools, and initiates that bring their medication along may be perceived as 'weak'. Therefore medication is often not taken, which leads to exacerbations of the pre-existing medical condition.


Complications are often attributed to witchcraft for which traditional medication is given. Medical attention is usually sought when the situation becomes untenable. The delay between the onset of complications and seeking medical attention is an important factor in the severity of the condition at presentation. Of great concern is the fact that almost all deaths occur at the initiation schools without any opportunity for intervention by medical personnel, and usually within the first eight days after circumcision.

Moral demise

The ritual was traditionally regarded as an educational institution where initiates were taught about social responsibilities and conduct. These traditional values have diminished and emphasis is now placed on circumcision and on physical ordeal. Teachings are often omitted, and the integrity of the ritual is further undermined by harmful attitudes.

The hierarchy in initiation schools leads to dangerous situations. Initiates are only allowed to speak with their traditional attendant. They are not supposed to complain about pain, even though this can be a sign of a medical complication (such as increasing pain when the penile blood supply is impaired). Marijuana and alcohol abuse amongst attendants and so-called helpers is the norm that often leads to physical abuse of the initiates.

A close relationship has emerged between unmanaged initiation schools, youth criminality and interpersonal violence. Worrying issues are the high number of school dropouts following initiation, and alcohol and substance abuse amongst initiates.

Physical abuse and torture

The physical ordeal is designed to effect discipline and to prepare the initiates for the hardships of manhood. Endurance testing has reached far-reaching forms that could be classified as torture (extreme fluid restrictions, chronic sleep deprivation, assaults). 

All initiates suffer from some form of abuse. They are commonly beaten on their heads, and the practice of ‘nose pulling’ sometimes leads to nasal lacerations. Even penile bandages are often tightened as a form of punishment. Severe beatings occur frequently. Some initiates are being burnt with objects, and I have seen one initiate whose penile bandage had been yanked off repeatedly.

Development of complications is sometimes seen as a result of weakness or cowardice on the part of initiates and leads to firmer measures. This is especially the case when the relationship is poorly balanced between initiate and traditional attendant (in which old grievances may play a role).

Cultural prejudice

There is much resistance to ‘western’ methods despite the considerable variations in the way the ritual is practiced throughout the Province. Cultural prejudice may be so great that uncircumcised or ‘improperly’ circumcised men are attacked and beaten for their lack of conformity.

Intrinsically linked to this is the social dynamic that discourages an initiate leaving the bush to seek medical attention, and stigmatizes the initiate who has done so as if he has contaminated the ritual and failed the test of manhood. Fairly frequently initiates are being abducted from hospitals by their traditional attendants for similar reasons.

Financial burden

The financial burden for families is rather large. Besides paying the traditional surgeon, they are also expected to pay for the pre-circumcision medical examination, buy several blankets and a goat, bring food and traditional beer to the initiation school, and buy new clothes and alcohol for the homecoming ceremony.

The traditional surgeon charges on average R250 per initiate. They are often accused of having commercialized the ritual and blamed for the high number of complications. However, as said before, complications arise mostly from inadequate wound care for which traditional attendants are responsible.

Health care

Roughly 10% of the initiates visit an health care institution for treatment, usually with moderate to severe complications. This places a significant burden on health care resources. Psychosocial services for initiates with botched circumcisions are usually not available.

Initiates suffering from mild complications often remain under the care of their attendants, also after the initiation season has ended. Their complications usually heal with time.

Common misconceptions

Public misconceptions about the problems accompanying the ritual are very common. Traditional leaders and government officials often use them as an excuse for the lack of improvement, in the same way that they single out minor problems outside their sphere of influence and present them as major issues.

The most common misconception is about illegal initiation schools. It is often claimed that they are responsible for most complications. This is fuelled by inaccurate statistics of the Department of Health in which deaths are wrongly ascribed to illegal schools on a regular basis.  However, illegal schools are more frequent in areas where the ritual is poorly regulated, such as Nyandeni local municipality, which in itself is also a risk factor for complications. Overall, the complication rate is roughly equal between illegal and legal schools.

Another widespread belief is that HIV causes the increase in initiation deaths. However, most initiates are HIV negative. Infected initiates are usually above 25 years old and almost all have near normal CD4 counts (meaning their immune system is functioning well).

Underlying problems

The underlying problems are lack of competence, lack of supervision, and lack of regulation. This is especially true for Pondoland where large numbers of young boys undergo initiation, which leads to the disproportionally high incidence of complications in the area. However, it should be kept in mind that all areas in the Eastern Cape are affected by complications to a greater or lesser extent.

Lack of competence on the part of traditional attendants is the main cause of mortality and morbidity. Adequate wound care is of utmost importance to prevent infection and penile injury. Many of the attendants have not been trained formally and lack the necessary knowledge and skills. I have come across first-time attendants of only 20 years of age, who had the responsibility for initiation schools accommodating over 25 initiates.

Relatives, community members, and traditional leaders are often not actively supervising initiation schools. Adequate supervision is important because it acts as a safety net: harmful practices can be corrected at an early stage before complications arise. If complications do occur, they can be identified early and managed accordingly.

Lastly, the overwhelming number of stakeholders is poorly cooperating on provincial, district, subdistrict and local level. Efforts to improve the current situation are badly coordinated, seem rather haphazard, and are mainly reactive in nature. Traditional leadership fails to take responsibility and is often not actively involved in the preservation and responsible execution of the ritual. Effective community regulation is not in place.


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