By the time winter has ended, thousands of young South African boys will have gone through a month-long traditional rite of passage and become men.

But becoming a man can be a life-threatening business. The ancient ritual has come under fire in recent years as health authorities report serious complications from botched circumcisions by traditional surgeons.

In the Eastern Cape, where circumcision is a source of pride for the Xhosa ethnic group, 12 initiates have died and more than 20 illegal traditional surgeons have been arrested in the last month. According to the provincial health department, nearly 100 youths were hospitalised, while 350 were rescued from "fly-by-night [initiation] schools".

For the past two months, health officials have been driving through the rough, hilly terrain of the province, swooping down on dodgy initiation schools to rescue young boys from the risk of infections, penile amputations, and death.

Impact of HIV research findings

Male circumcision is in the spotlight, now more than ever: in March 2007, the World Health Organisation and UNAIDS issued recommendations, giving a green light for the use of male circumcision for HIV prevention, after study findings showed that it could reduce the risk of infection.

"Everyone is excited about this ... will it mean more initiates coming [to be circumcised]? I don't know, it's still early days," Henderson Dweba, head of traditional health services in the Eastern Cape health department, told IRIN/PlusNews.

South Africa's government has yet to decide whether to offer circumcision services as part of its HIV prevention and treatment plan. There are also fears that a growing demand for circumcision could see the mushrooming of quacks and unscrupulous surgeons.

"If the supply [of safe practitioners] does not meet the demand ... men could opt for unsafe services, and look to alternative traditional settings," warned Catherine Hankins, Associate Director, Department of Policy, Evidence and Partnerships at UNAIDS.

The initiation schools in the largely rural Eastern Cape, where most of the country's traditional circumcisions take place, are perhaps not quite what the UN officials, who drafted the recommendations in Montreux, Switzerland, had in mind when calling for the service to be "provided safely in sanitary settings, with adequate equipment and with appropriate counselling and other services".

The Xhosa rite of passage is described either as going "to the bush" or "to the mountains", and includes seclusion in a hut for up to a month, with very little contact, if any, with women. The cutting, by a traditional surgeon, is performed without anaesthesia - the pain is an important feature of becoming a man.

"It is not what you would consider clinical circumcision, but traditional. It has been done since time immemorial ... people are used to doing things that way; there has never been clinical input," Dweba commented.

Hankins, scientific advisor to UNAIDS, described this as a "red flag" issue, and noted that the biggest barriers to rolling out male circumcision as a prevention method were not only cost, but concerns about safety - hence the emphasis on circumcision being performed in a clinical setting.

The Eastern Cape government, mindful of the significance attached to traditional circumcision, has chosen a more "realistic" approach, advocating the "application of health standards in a traditional setting." According to Dweba, "a clinical [approach] is scorned by many of our people; it's not something we can consider".

A system that works?

Six years ago, the Eastern Cape government introduced legislation requiring traditional practitioners who perform the operation to seek permission from a medical officer, who must also license each circumcision school. The Act, which provides for fines of up to R10,000 (US$), or 10 years in jail, also provides for schools to be inspected by health department officials.

"This is not the 'wild, wild West'," said Dweba. "These quacks don't stand a chance: we have legislated [the practice], we introduced a system which works, there is a budget for it ... iingcibi (traditional surgeons) are being trained, and we have designated medical officers, registered nurses, health promotion officers, environmental health practitioners."

"No circumcision is to be done without [our] permission. Everybody must follow the procedures, no one is above the law," he insisted.

Getting permission, however, is a long, drawn-out process: traditional surgeons have to apply for a licence not only to carry out the operation, but also to run an initiation school and care for the initiates. Young men are also required to obtain written consent from their parents, as well as medical clearance from a public health facility.

When it was time for Richard (last name withheld), 21, to "become a man" three years ago, his elder brother dropped him off outside the gates of Thafalofefe hospital, a small district facility near the dry and dusty Gcina village, in the rural Centani district.

"It was packed and I had to wait for hours because there was only one person helping us, and then, when the nurse finally saw me, he started lecturing me about sex and then gave me an injection, and I still had to get all the paperwork," said the engineering student.

The young, anxious-looking male nurse at Thafalofefe hospital, who began working with initiates during the summer circumcision season in December 2006, is the first port of call for the area's initiates and traditional surgeons. He pages through a thick ledger containing handwritten entries of initiates, schools, traditional nurses and surgeons, going back to 2004.

"When they come for their papers, they also receive antibiotics and health education, I tell them: 'just because you are going to be a man, doesn't mean you are immune from all these diseases, and you can engage in risky behaviour. You must look after yourself and restrain yourself before you go to the bush'."

According to his superior, Matron Ndandane, last year's winter circumcision season led to 32 admissions: 29 young men developed septicaemia after "going to the bush", while the other three were epileptic and mentally challenged and came to be circumcised in the hospital.

The health officials at the hospital said the tedious paperwork was not the main problem. "You can get complications even if you are registered, and these are as a result of the poor management of the wound afterwards," said a nurse who asked not to be named.

At the health department offices in Bhisho, the provincial capital, Dweba agreed: "The cutting itself is not a problem; it's poorly dressed wounds, dehydration ... which can cause you to die or lose your penis."

He said traditional surgeons and nurses were not always knowledgeable about microbiology. "Those guys don't know about germs ... they hear that there are these things called germs but what they can't see, they can't relate to."

Most traditional surgeons also did not use bandages, heightening the risk of developing infections, because they preferred to use the customary method of applying wild leaves to the wound. "They [wild leaves] are pretty proficient, they do what they are supposed to do," Dweba maintained.

According to Dodoma Mthandekisi, a member of the tribal authority in Gcina village, the traditional nurses - young men who tend the initiates after circumcision - were largely to blame.

"Now ... they are feeding the young boys [initiates] alcohol, dagga [marijuana] and cigarettes ... the young men, at this stage, have not healed properly and can get injured easily; they suffer from dehydration, they are being starved ... it is carelessness, this is what is killing these boys," he told IRIN/PlusNews.

Mthandekisi said the traditional surgeons in the area were a bit more careful, as they were monitored by members of the tribal authority. "We don't have as many deaths here. There's a law now that says things must be done in a certain way," the wizened grandfather commented. "We welcome it, as long as we are involved."

The laws are there, the financial resources are trickling in, and so are the staff members required to oversee traditional circumcision; but every year the authorities in the Eastern Cape report deaths and serious complications from botched traditional circumcisions.

"I don't understand why there's no stronger outcry, especially from mothers. Kids are coming back as dead bodies," remarked Dr Denis Mahoney, who practices in the coastal town of Port St Johns, near Lusikisiki, and other rural areas with some of the highest recorded rate of complications after traditional circumcisions.

Mahoney and the other doctors in Port St Johns seldom perform circumcisions. "I've only done six this past year. People prefer to do it traditionally; they don't come to doctors," he told IRIN/PlusNews.

So how does it go wrong? The problem, according to Sizwe Kupelo, is that unskilled surgeons and quacks are now catering to people trying to avoid the lengthy legal route. Young boys are running away from home to be circumcised by illegal surgeons who do not demand consent forms signed by officials and parents; some underage boys and their parents lie, telling surgeons the youngsters are 18.

Dweba warns that his department will continue to clamp down on illegal initiation schools and "these butchers". "We will jail them - you don't play games with the life of a child."