Traditional Male Circumcision in Uganda: A Qualitative

Focus Group Discussion Analysis

Amir Sabet Sarvestani1, Leonard Bufumbo2, James D. Geiger3, Kathleen H. Sienko4,5*
1 Design Science Program, University of Michigan, Ann Arbor, Michigan, United States of America, 2 Family Health International, Kampala, Uganda, 3 Department of
Pediatric Surgery, University of Michigan, Ann Arbor, Michigan, United States of America, 4 Department of Mechanical Engineering, University of Michigan, Ann Arbor,
Michigan, United States of America, 5 Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan, United States of America

Abstract
Background: The growing body of evidence attesting to the effectiveness of clinical male circumcision in the prevention of
HIV/AIDS transmission is prompting the majority of sub-Saharan African governments to move towards the adoption of
voluntary medical male circumcision (VMMC). Even though it is recommended to consider collaboration with traditional
male circumcision (TMC) providers when planning for VMMC, there is limited knowledge available about the TMC landscape
and traditional beliefs.

Methodology and Main Findings: During 2010–11 over 25 focus group discussions (FGDs) were held with clan leaders,
traditional cutters, and their assistants to understand the practice of TMC in four ethnic groups in Uganda. Cultural
significance and cost were among the primary reasons cited for preferring TMC over VMMC. Ethnic groups in western
Uganda circumcised boys at younger ages and encountered lower rates of TMC related adverse events compared to ethnic
groups in eastern Uganda. Cutting styles and post-cut care also differed among the four groups. The use of a single razor
blade per candidate instead of the traditional knife was identified as an important and recent change. Participants in the
focus groups expressed interest in learning about methods to reduce adverse events.

Conclusion: This work reaffirmed the strong cultural significance of TMC within Ugandan ethnic groups. Outcomes suggest
that there is an opportunity to evaluate the involvement of local communities that still perform TMC in the national VMMC
roll-out plan by devising safer, more effective procedures through innovative approaches.

Citation: Sabet Sarvestani A, Bufumbo L, Geiger JD, Sienko KH (2012) Traditional Male Circumcision in Uganda: A Qualitative Focus Group Discussion
Analysis. PLoS ONE 7(10): e45316. doi:10.1371/journal.pone.0045316
Editor: Linda M. Niccolai, Yale School of Public Health, United States of America
Received April 17, 2012; Accepted August 20, 2012; Published October 17, 2012
Copyright: ß 2012 Sabet Sarvestani et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: Sources of funding for this work included the Gates Grand Challenges Exploration Phase I Grant (http://www.grandchallenges.org/explorations/) and
the University of Michigan Center for Global Health Junior Faculty Engagement Award (http://www.globalhealth.umich.edu/). The funders had no role in study
design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: sienko@umich.edu

Introduction up plans for clinical male circumcision are being considered as a

strategy against HIV/AIDS by sub-Saharan African Ministries of
HIV/AIDS remains a major health challenge throughout the Health, traditional providers will continue to function as an
world, especially in sub-Saharan Africa, where it accounts for 68% important source of service [10]. In fact, many international public
(or 22.5 million) of global HIV cases [1]. The use of male health organizations believe that clinical male circumcision will
circumcision as an efficacious biomedical intervention against HIV never completely replace traditional practices due to both the
transmission has been demonstrated in three randomized cultural implications and the human resource constraints pending
controlled clinical trials [2–4], which show a consistent protective in the near future [9,11]. Typically, providers with limited or no
effect of approximately 60% risk reduction among heterosexual formal clinical training perform TMC in non-clinical settings.
men. More than 35 epidemiological studies [5–6] reinforce the While some evidence supports TMC’s effectiveness against HIV
results of the controlled trials. Faced with such evidence, the transmission [12–13], the life-threatening risks and health
governments of most sub-Saharan countries are adopting policies complications of its practice are alarming. Studies evaluating the
and programs to ‘‘roll-out’’ voluntary medical male circumcision complications due to TMC have found rates varying from 35%
(VMMC) with the support of international public health (Kenya) to 48% (South Africa) [5,14]. Infection, delayed wound
organizations such as the World Health Organization and USAID healing, glans amputation and injury, bleeding, loss of penile
[7]. In 2009, the Ugandan Ministry of Health (MoH) began to sensitivity, excessive removal of foreskin, and death are the major
discuss a national plan for voluntary mass circumcision of adult complications reported [5,14–17].
males [8]. Uganda’s HIV prevalence rate is 6.5%, and almost 70% of
In many of these countries, traditional male circumcision Ugandan males remain uncircumcised [18]. Approximately 10%
(TMC) has been practiced for centuries, particularly as an (3.5 million) of the population belongs to ethnic groups which still
initiation ritual and rite of passage into manhood [9]. As scale- practice TMC [18]. The Ugandan National Safe Male Circum-

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 Traditional Male Circumcision in Uganda

Figure 1. Map of Uganda. Stars indicate locations of FGDs. Source: Central Intelligence Agency World Factbook.
doi:10.1371/journal.pone.0045316.g001

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 Traditional Male Circumcision in Uganda

cision policy, a roadmap for implementation of an effective male Ugandan Shillings (UGX), or about USD 3.75, to reimburse their
circumcision program, acknowledges the importance of under- transportation expenses and time of participation.
standing TMC and its associated cultural aspects when devising
methods to make TMC safer. Two suggested approaches, based Participants
on experiences in other countries, include the integration of TMC Three primary groups participated in the FGDs. Group one
into official health care systems and the intensive training of included traditional senior cutters responsible for cutting proce-
traditional providers [5,19–20]. Considering both the limitations dures. Group two included assistant cutters or guardians who help
of implementing VMMC in areas traditionally practicing circum- prepare boys (candidates) for circumcision, assist during the
cision and the promise of TMC for reducing infection transmis- procedure, and advise candidates on post-operative care. Group
sion, the objective of this paper is to characterize TMC practices in three included clan leaders, who serve as community gatekeepers
Uganda and the cultural implications by using a comprehensive responsible for preserving the cultural aspects, such as TMC, of
focus group discussion (FGD)–based qualitative analysis. Ulti- their respective ethnic groups. Each primary group attended a
mately, such information can inform the strategies to make TMC separate FGD designated by specific ethnicity. Table 1 shows the
safer and to fully utilize the resources available to support location, number of participants, and the groups’ degree of
Uganda’s gradual transition towards VMMC. involvement in the FGDs.

Methods Focus group discussion topics

Focus groups were structured around the following topics:
To our best knowledge, this study is the first countrywide FGD-
based qualitative analysis to understand the culture, traditions, and 1. Cultural and traditional significance of TMC.
customs of TMC in Uganda.
2. General information on TMC.
Ethics statement 3. Roles, responsibilities, and training processes for cutters and
assistant cutters/guardians before, during, and after TMC.
The study was reviewed by the Institutional Review Board
(IRB) of the University of Michigan in Ann Arbor, Michigan, 4. Cutting techniques and handling of TMC adverse events.
USA, which determined that it met US federal criteria for 5. Recent changes in TMC, and views and suggestion on how to
exemption, including not more than minimal risk to subjects make TMC safer.
(exemption #2 (45 CFR 46.101(b)(2)). The University of
Michigan’s IRB informed the Uganda National Council of
Science and Technology about this study and its exempt status. Qualitative data collection and management
All study team members received training in the ethical conduct of Predetermined themes, such as TMC’s cultural importance,
human subjects’ research. There were two data collection periods logistics of the practice, cutters’ training procedure, and tools used
(2010 and 2011) utilizing focus groups. Although the study was during TMC were selected prior to holding the FGDs. Several
considered exempt, participants were fully informed about the experts reviewed the planned themes and associated questions.
nature of the study prior to each FGD and were asked for their The FGDs were audio and video recorded. All files were
verbal consent. Also, they were able to leave at any time during the transcribed verbatim by two of the study team members. Study
discussions; however, none of the participants opted to leave prior team members also cross checked the transcription results to
to the completion of the focus groups. Participants during the 2010 ensure rigor and accuracy. Transcripts were reviewed, and
data collection sessions also provided written consent. For the reoccurring themes based on the five topics above were identified
focus groups conducted in 2011, the consent process was also to develop a codebook. After an in-depth review of the
audio recorded. No form of identifier (name, age, living location, transcriptions and cross-analyses of the four ethnic groups (Sebei,
clan) was collected from the participants. During FGDs, partic- Bagisu, Baamba, Bakonzo) and different participant groups (clan
ipants were assigned numbers or responded anonymously. leaders, traditional cutters, assistant cutters) additional codes were
derived for further characterization. Hence, the codebook, which
Focus group discussion settings was initially based on predetermined codes, evolved through an
In Uganda, Sebei, Bagisu, Baamba, and Bakonzo ethnic groups iterative process with the emergence of new information, which
practice TMC. The Sebei and Bagisu ethnic groups reside in was either unique to a given ethnic group or common across all
eastern Uganda, while the Baamba and Bakonzo people reside in groups.
the western region. The HIV rate for Bagisu and Sebei men is
3.5%, while that of Baamba and Bakonzo men is 5.7% [18]. It is Results
estimated that 80% of Sebei and Bagisu men are circumcised. The
Cultural and traditional significance of TMC
circumcision percentage of Baamba and Bakonzo men is unknown
In order to understand the cultural and traditional importance
[18]. The study team held 26 FGDs (total of 208 participants) from
of TMC in each ethnic group, open-ended questions such as the
August 2010 to June 2011. Each focus group consisted of 6–12
following were asked:
participants and was run by trained US and Uganda study team
members, who remained the same across FGDs. Focus groups 1. What are the traditions, customs, and rituals associated with
were held in local health clinics in Kapchorwa and Mbale districts male circumcision in your ethnic group?
(eastern Uganda) and Bundibugyo and Kasese districts (western
2. What are the reasons parents decide to circumcise their sons
Uganda), as indicated with red stars in Figure 1, and lasted for
traditionally?
approximately 1 hour. They were conducted in the local language
and translated simultaneously into English by an interpreter from All participants agreed and even emphasized that traditional
the same ethnic group, who was trained in social science research male circumcision is a major milestone in the process of becoming
and familiar with TMC. The participants were paid 10,000 a man.

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 Traditional Male Circumcision in Uganda

Table 1. Participant background and demographics.

Ethnic Group FGD Location Cutters Assistant Cutters/Mentors Clan Leaders Total (%)

Sebei Kapchorwa 20 21 22 63 (30.3%)

Bagisu Mbale 14 16 16 46 (22.1%)
Baamba Bundibugyo 11 10 17 38 (18.3%)
Bakonzo Kasese 22 21 18 61 (29.3%)
Total (%) 67 (32%) 68 (33%) 73 (35%)

doi:10.1371/journal.pone.0045316.t001

‘‘It [circumcision] is the time when a boy is initiated to become a man, When asked if there were reasons for TMC beyond cultural
to become his own person, when he has to take responsibilities. beliefs, some participants from different ethnic groups cited health
Traditionally, if a boy not cut traditionally will not be allowed to benefits.
inherit and always will be called coward. Once he is born, family
knows he must be cut traditionally. He is raised with that mentality and Candidate’s age, TMC’s season, cost, cutting time, and
prepared for that important day [sic].’’ (clan leader – Bagisu) number of traditional cutters
‘‘Once the boy is born, they know that he must be circumcised Sample questions to stimulate discussion on the logistics and
traditionally. So boys are brought up knowing they have to be operations of TMC included the following:
circumcised in a traditional way [sic].’’ (clan leader – Bagisu)
1. What is the age range of the boys when they are circumcised?
‘‘The process begins with dancing. The initiate goes around inviting his
relatives and friends to attend the ceremony. Until the last day that is 2. What time of year is TMC performed?
called the eve of the circumcision. That’s when some rituals are done 3. How many circumcisions, on average, does each cutter
and in the morning the cutting is done [sic].’’ (clan leader – Sebei) perform during this time frame? How many traditional cutters
are associated with your ethnic group?
The Bugisu region (eastern Uganda, Bagisu ethnic group) is
Table 2 shows the candidates’ age range, ethnic group, season,
considered the birthplace of TMC in Uganda. Common belief
and the associated cost. The highest number of TMCs occurs in
holds that the first male circumcision was performed in the region
August and December due to school holidays. In eastern Uganda
centuries ago. Even today at the start of each circumcision season,
TMC is performed only in even years, while in western Uganda
the first cohort of candidates is circumcised in the Bugisu region.
TMCs can be performed at any time depending on demand.
This tradition is part of the cultural belief system to such an extent
There is no fixed age limit in any of the ethnic groups, but the
that those who are not circumcised traditionally are strongly
age range for eastern Ugandan candidates is relatively older (14–
stigmatized within their communities.
18 years) than that of western Uganda (2–15 years). The cost of
TMC varies from UGX 5,000 to 40,000, or approximately USD
‘‘There is a big difference between a person circumcised at the hospital 2.00 to 16.00 (Uganda GDP per capita is USD 1,300.00). The
and one circumcised at home. Reason being that if you were circumcised candidate’s parents are responsible for the payment, although the
in the hospital then you will never be an heir. And also if a child is going price is negotiable and depends on the family’s financial ability.
to be circumcised, you cannot advise because you did not go through a Cutters performing procedures in the Sebei ethnic group are given
normal circumcision. When you are circumcised in the hospital, people a chicken and 20–40 liters of locally brewed beer in addition to the
look down upon you and know you are not as strong as others [sic].’’ cash payment. Almost half of what a cutter receives must be given
(clan leader – Bagisu) to his assistant.
When asked about the number of cutters in active practice, the
In the Sebei and Bagisu ethnic groups, candidates announce Sebei, Baamba, and Bakonzo indicated about 20 cutters and the
their decision to be circumcised by dancing publicly in their Bagisu indicated about 1000 cutters. This very high number is due
villages a few days prior to the day of circumcision. They visit the to the Bagisu’s growing population, the historical importance of
homes of their relatives and invite them to the circumcision TMC, and the social emphasis on training more cutters to meet
ceremony. During this time, they receive gifts from their relatives demand. The average number of cuts performed by each cutter in
and help their parents prepare food and brew beer for the each season is 170 (Sebei), 90 (Bagisu), and 200 (Baamba and
ceremony. Bakonzo). Cutting time is significantly shorter in the Bugisu and
In the Baamba ethnic group, to ensure the safety of the Sebei regions (Table 2).
procedure, sometimes a male relative of the candidate, typically a
maternal uncle, stands behind the cutter, armed with a spear and Role, responsibilities, and training process for cutters and
ready to strike the cutter if the cut injures the boy in an unexpected assistant cutters/guardians, before, during, and after TMC
way. The following open-ended questions were asked to learn about
the role of senior and assistant cutters and to understand whether
‘‘Family head stands behind the senior cutter holding the spear. The they underwent any systematic training:
reason for it is that, if in any case, the procedure was done badly leading 1. Can you describe your role (as a cutter/assistant cutter) during
to death, then he would hit the cutter [sic].’’ (clan leader – Baamba) the traditional circumcision in detail?

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 Traditional Male Circumcision in Uganda

Table 2. General information on TMC for the four ethnic groups studied.

Ethnic Group Age Range (yrs) Circumcision Season Cost Range Cutting Time (sec) Active Cutters

Sebei 14–18 Every even year, months of August and UGX 20,000–40,000 (USD 8–16)10–50 20
December
Bagisu 14–18 Every even year, months of August– UGX 5,000–15,000 (USD 2.0– 5–10 1000
September and December–January 6.0)
Baamba 5–15 Every year, months of August and UGX 5,000 (USD 2.0) 120–180 20
December
Bakonzo 2–15 Every year, months of August and UGX 5,000–15,000 (USD 2.0– 120–180 20
December 6.0)

doi:10.1371/journal.pone.0045316.t002

2. What do you do to prepare the candidate before and after average, Sebei guardians who participated in the FGDs had 14
TMC? years of experience.
3. What makes one cutter better than another? Notably, only the Bagisu group has formed a union of cutters
4. What type of training, if any, is required to become a cutter or and assistant cutters and registered the organization with the local
assistant cutter/mentor? government. Not everyone within the Bagisu group can become a
cutter, since the journey is a spiritual one that is not afforded to
The Sebei did not have a traditional cutter of their own until the many. The process typically starts with the onset of a mysterious
mid-1980s; instead they asked Bagisu cutters to perform the sickness, during which the individual dreams of ancestral spirits
procedure. However, in the last 20 years, the Sebei trained their which encourage him to become involved in TMC. When the
cutters by shadowing those of the Bagisu group. individual falls ill and does not respond to traditional or modern
medicine, he is taken to the elders of the community. Depending
on the situation and the individual’s background and circum-
‘‘We thought of the money they [Bagisu cutters] were making. We
stances, the elders decide if he is ready to become involved in
thought why are we losing this money? That is why we started
TMC. If accepted by the elders, the individual begins to shadow a
performing circumcision [sic].’’ (clan leader – Sebei) senior cutter as an assistant.
A few days before each circumcision season, the local district
A Sebei cutter’s role is simply to perform the actual cut of the health office in the Mbale District holds training sessions for TMC
foreskin. cutters and their assistants that provide instruction on safe and
hygienic practices and adverse events management. Cutters must
‘‘A good cutter is the one who cuts fast, but does not hurt the head of the obtain a certificate from the district health office upon finishing the
penis.’’ ‘‘[a good cutter is determined] based on the size of the wound. training session before they can perform that season. Cutters in the
The quicker it heals means the person who circumcised is better in Bagisu group are solely responsible for the circumcision cut and
cutting.’’ ‘‘A good cutter is one who cuts and no [foreskin] part is left. the assistant cutters are responsible for preparing the candidate. A
So, during the healing process the mentors have been able to identify these good Bagisu cutter should hold strong ties to the community and
cutters and let the community know [sic].’’ (cutter – Sebei) know how to make a fast cut without complications. Senior cutters
attending the FGDs had been working as senior cutters on average
Most Sebei cutters lack formal training, other than occasional for 13 years.
meetings with others involved in TMC to talk about their Assistant cutters take instructions from senior cutters. The
experiences, and shadowing elders. assistants manage and control the crowds, which typically gather
at the circumcision ceremony, ensuring that the cutter and
candidates are not disturbed. They also care for the wound
‘‘In some cases they [cutters] have seminars among themselves that’s following the procedure. The Bagisu group requires its assistants to
coordinated by their seniors, those who have been cutting for a long time shadow senior cutters extensively before the seniors and clan
and have been training them [sic].’’ (cutter – Sebei) leaders determine whether they are ready to graduate to senior
cutter. Bagisu assistant cutters who participated in the FGDs had
Sebei cutters who attended the FGDs had been practicing on been working as assistant cutters on average for 11 years.
average for 10.5 years. Assistant cutters in Sebei are referred to as Among the Baamba and Bakonzo, TMC is considered a family
‘‘guardians or mentors’’ and are responsible for coaching the business. Cutters and assistant cutters from both ethnic groups
candidate, preparing him for the cut, and advising him on post- who participated in the FGDs said they were involved in TMC
operative care for the wound. Guardians also ensure that a clean because of their fathers and grandfathers. No formal training exists
knife is used for each candidate and that cutters wash their hands in either ethnic group. Rather, a good cutter typically performs a
before the procedure. consistent cut, leaves a minimal amount of foreskin, and uses a
new razor blade for each candidate.
‘‘Mentors assist cutters to make sure that candidates have been
circumcised very well [sic].’’ (clan leader – Sebei) ‘‘In order for somebody to become a senior cutter, it is about consistency
and speed in the [cutting] procedure [sic].’’ (cutter – Baamba)
A good mentor is one whose candidates do not fear the
procedure and whose recovery periods are one week or less. On

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 Traditional Male Circumcision in Uganda

A senior cutter must learn to effectively manage complications. ‘‘In compare to Bagisu, Sebei cut less amount of foreskin because cutting
To prevent possible complications, Bakonzo cutters frequently visit too much makes healing process complicated [sic].’’ (cutter – Sebei)
candidates post-procedure to clean the wounds and advise parents
on proper care. In the Baamba and Bakonzo groups, cutters who Figure 2 and Table 3 summarize the cutting techniques used by
participated in the FGDs had been working on average for 40 and the four ethnic groups. As shown for the Sebei and Bagisu, the first
24 years, respectively. two cutting steps are identical. But for the second cut, Sebei cutters
Assistant cutters in both ethnic groups hold young candidates on leave some foreskin intact. The final row of images shows the
their laps while the cutter performs the circumcision. In the outcome of the traditional cut. The pink area shown is a layer of
Baamba ethnic group, assistant cutters remain with the candidate inner foreskin. The red area depicts the open wound caused by the
for a few hours post-procedure to care for the wound and manage cut.
potential complications. A Baamba assistant cutter explained: In the Baamba ethnic group, a candidate arrives at the
designated cutting area and the cutter strips him down. If too
‘‘We wash the wound after cut with water. We also stay around for few young to stand alone, the boy is held by a male family relative or
hours to take care of the boy to make sure he is fine. Then, we hand him by the assistant cutter. After exposing the penile shaft, the cutter
to his parents [sic].’’ (assistant cutter – Baamba) pulls the foreskin to measure the amount to be cut. Similar to the
process followed by the Bagisu and Sebei, the cutter uses his
thumbnail to indicate where the cut should be made. A razor
Assistant cutters in the Bakonzo remain with the candidate for a
blade provided by the parents of the candidate is used to make a
half hour post-procedure. Assistant cutters in the Baamba and
small incision to allow the cutter and his assistant to tear apart the
Bakonzo who participated in the FGDs had been working on
skin. Once the incision is made, the assistant cutter tears the skin
average for 10 and 22 years, respectively.
by pulling it apart up to the penis corona. Finally, the cutter uses
the razor blade to cut away any remaining skin (Fig. 2). After the
Cutting techniques and handling of TMC adverse events cut, the assistant cutter washes the penis with clean water, but does
To obtain information about cutting techniques unique to each not use medical supplies to dress the wound. Cutters in Bakonzo
ethnic group, their associated adverse events, and the view of local explained their method as a simple pull on the foreskin followed by
communities on potential changes to make TMC safer, the a cut through it with a razor blade (Fig. 2). If they feel the inner
following questions were asked: layer is too long, they cut it radially around the penile shaft,
1. What are the techniques used for traditional circumcision cuts otherwise the first cut suffices. In this technique, the cutting style
in your ethnic group? Is there any variation among cutters’ depends on candidate’s age. If the boy is younger than five years
methods? How much foreskin is cut? old, the cutters usually perform an initial cut and a radial cut. If
the candidate is older, one vertical cut is enough to consider the
2. Have you ever heard of a circumcision that has resulted in an boy circumcised.
adverse event? If yes, what was the reason? Who is to blame if Participants in all of the FGDs identified excessive bleeding,
an adverse event happens? prolonged wound healing, infection, glans injury and amputation,
While it should be acknowledged that there is no set TMC and unfinished cuts requiring additional cuts as the most common
‘‘style’’, the majority of cutters in the Sebei and Bagisu groups adverse events. Sebei and Bagisu participants also mentioned the
share the same method. That is, a candidate ready to be risk of deafness due to excessive festivities with loud music and
circumcised is called to the center of the area designated for the crowds.
circumcision ceremony. The boy stands and holds his hands up as
the cutter removes his clothing to expose the penile shaft. The ‘‘Complications happen due to rushing and the speed of the process.
cutter pushes the glans inside and pulls the foreskin forward. The There will be inaccuracy and imperfect cutting by the cutter [sic].’’
pushing and pulling sequence is performed three to four times (clan leader – Sebei)
While pulling the foreskin, he places his thumbnail where he can
feel the glans. He uses his nail to mark where the glans ends and to One Bagisu cutter complained about the uncontrollable and
protect it against the cut. While the foreskin is pulled, the cutter crowded public who surround the candidate and cutter to watch
uses a traditional knife to cut through it. After the first cut, the the ceremony:
assistant cutter holds the glans as the cutter removes the remaining
foreskin (inner layer) through a radial cut using the same knife.
Cutters do not dress the wound with any medical supplies. Clan ‘‘Sometimes the complications they [candidates] are getting is because of
leaders attending the ceremony are responsible for supervising the the rowdy crowd. Sometimes they become so crowded and they push you
process. [sic].’’ (cutter – Bagisu)

No focus group participant would identify the party responsible

‘‘Cutting method depends on the length of the foreskin. During the for an adverse event, although a few cutters blamed their assistant
cutting ceremony clan leaders stand by the candidate and advise if there or the candidate, citing the failure to adequately care for the
is too much or less skin cut. They also make sure the cutter acts wound. Assistant cutters and clan leaders mostly blamed the
responsibly if a complication happens [sic].’’ (cutter – Sebei) cutters, claiming that it was their responsibility to ensure the
candidate’s safety.
The major difference between Sebei and Bagisu cutting styles is
that the Sebei do not cut some of the skin from the inner layer
whereas the Bagisu cut the entire foreskin.

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 Traditional Male Circumcision in Uganda

Figure 2. Illustration of traditional circumcision cutting techniques by ethnic group. Columns depict TMC cutting techniques per ethnic
group. Rows show cutting process steps (row 1: pull foreskin and push glans; row 2: initial cut; row 3: secondary cut; row 4: circumcised penis).
doi:10.1371/journal.pone.0045316.g002

Recent changes in TMC, views, and suggestions for blade per candidate during circumcision is one of the most
making it safer significant changes mandated by the Uganda MoH. The change
To capture recent changes to the traditional circumcision was implemented in early 2000 across all ethnic groups. Eastern
ceremony and to explore the potential for additional future groups still use a traditional knife whereas the Baamba and
changes to make TMC safer, the following questions were asked: Bakonzo groups use razor blades.

1. Have the traditions, customs, and rituals associated with ‘‘Due to country’s development of change of time, now we have changed
circumcision in this region changed over time? If yes, how?
some customs and rituals. Now, we use one-time use razor blades and
Why?
have made the cutting procedure and ceremonies more decent [sic].’’
2. Would you support changes in TMC practice to make it safer? (cutter – Baamba)
What type of changes would you considering? ‘‘Cutters nowadays must have different [separate] knives per candidate
As mentioned, custom, ritual and cutting methods vary by [sic].’’ (clan leader – Bagisu)
ethnic group. However, the use of one traditional knife or razor

Table 3. Circumcision cut style and performer per ethnic group.

Ethnic Group Cut Performed by Cutting Style

Sebei Cutter Push the glans in. 2. Pull the foreskin forward. 3. Cut through
foreskin with a traditional knife. 4. Hold the glans and perform
a radial cut. Leave some amount of foreskin uncut.
Bagisu Cutter Push the glans in. 2. Pull the foreskin forward. 3. Cut through
foreskin with a traditional knife. 4. Hold the glans and perform
a radial cut. Remove the foreskin fully.
Baamba Cutter with assistant cutter Push the glans in. 2. Pull the foreskin forward. 3. Make an
incision through foreskin with a razor blade. 4. Tear apart the
foreskin by hand. 5. Cut any remaining foreskin through a
radial cut with a razor blade.
Bakonzo Cutter Push the glans in. 2. Pull the foreskin forward. 3. Cut through
the foreskin with a razor blade. 4. If the cutter feels the inner
layer is long, perform a radial cut.

doi:10.1371/journal.pone.0045316.t003

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 Traditional Male Circumcision in Uganda

Another change is connected to the spread of organized Bagisu counterparts, they leave some of the foreskin intact unlike
religions in Uganda. For instance, Muslims prefer to circumcise the Bagisu, who cut the entire foreskin. The side effects of such
their sons at an early age (typically 7 days old). Catholics and cutting style variations include longer healing times and potentially
Anglicans oppose the excessive festivities surrounding TMC, the different protection levels against HIV/AIDS transmission; a
over-consumption of alcohol, and promiscuity. Hence, an ethnic report from the Forum for Collaborative HIV Research recom-
group’s religious preference can motivate a change in TMC mends leaving less than 3 mm of foreskin (although this is an on-
practice. going area of research) in a clinical circumcision for the most
effective protection [21]. Complications cited by several focus
group participants are consistent with the adverse events identified
‘‘For some people, due to their modern religious beliefs, they don’t
in previous studies [9]. They revealed that rapid cutting methods
participate in dancing ceremonies. They just cut traditionally and leave are effective in reducing instant pain but can increase the risk of
it at that [sic].’’ (clan leader – Bagisu) glans injury and amputation and cause larger wounds and
‘‘Initially we were using traditional knives, just very sharp and small. scarring. Participants from the Baamba and Bakonzo ethnic
There is now a razor blade per candidate. Each candidate is also groups recalled fewer adverse events, which we attribute to the
provided with his own water. After circumcising him, we wash the fresh younger age of their candidates, the fact that Baamba assistant
cut with clean water [sic]’’ (cutter – Baamba) cutters remain with the patient for a few hours post-cut, and that
Bakonzo cutters perform a follow-up visit a few days later.
Although there have been changes in custom and rituals, a For the Bagisu group, TMC represents a sense of pride. Unlike
Bagisu cutter expressed: the three other groups, the Bagisu had formed a union comprised
of cutters and assistant cutters to determine how to best preserve
‘‘No matter what has changed around circumcision, the bottom line and TMC’s cultural significance in an era when festivities, elaborate
dances, and other forms of celebration centered around TMC
the most important factor is that the boy must be cut traditionally [sic].’’
have been greatly reduced. In western Uganda, celebrations are
(cutter – Bagisu)
rare and in the east they are shorter and less well attended. Focus
group participants from various backgrounds emphasized that
Participants were also asked about potential reforms in TMC they would not completely abandon TMC, even if the side-events
that can help reduce its adverse events. that typically accompany the ritual disappear. From a policy
perspective, local communities’ willingness to detach from some
‘‘We accept promoting other tools for circumcision. When we are looking traditions signals a potential opportunity to discuss how to make
at how the world has been in the past and now, there have been many TMC safer, but only if the local leaders are included in the
complications [with TMC], so we are positive to adopt scissors and planning and implementation.
razor blades for the procedures, as long as it reduces the risks to the Focus group participants offered several reasons for preferring
circumcision [sic].’’ (clan leader – Sebei) TMC over clinical circumcision, such as cultural significance, low
‘‘In villages lack the equipments, so if there is a way, a tool, that cost, and individual’s resistance to the modern health care system.
specifically can reduce the pain and maybe fast healing, we can welcome Although some participants were aware of the positive impact of
circumcision in reducing HIV transmission, it is unclear whether
it very well [sic].’’ (clan leader – Bakonzo)
traditionally circumcised males will experience the same level of
protection from HIV transmission [12–13].
The majority of the FGDs emphasized that information on the
We suggest that a reliable clinical infrastructure providing
importance and health benefits of circumcision should be provided
voluntary mass medical male circumcisions by trained individuals
and that families should be informed about what to look for when
using appropriate equipment is the best long-term solution to
selecting a cutter.
reduce circumcision-based HIV transmission rates in sub-Saharan
Africa. However, a number of significant barriers identified by the
‘‘Better is that to make people educated to know how to have African Ministries of Health and emphasized in our paper make it
circumcision safe. Unless we educate them about that complications will unlikely that the VMMC vision for Uganda will be realized in the
continue [sic].’’ (cutter – Bagisu) near future [22]. Among the critical issues cited for the slow scale-
up of clinical male circumcision are a shortage of human resources
Most participants also stressed the need to inform people about for programming and service delivery; a lack of buy-in from social
adverse events. When asked about venues to disseminate such gatekeepers such as traditional clan leaders and key decision
information and by whom, the participants cited: churches and leaders; and a poor understanding of how policy-makers might
mosques (religious leaders); radio talk shows (clan leaders); and engage Ugandans in order to influence behavioral change [22].
schools (teachers). Other suggestions included stocking health The strong cultural significance of TMC reaffirmed through the
clinics with wound-dressing supplies, clean gloves, and sterile razor FGDs demonstrates the reluctance of local communities to partake
blades for cutters to purchase for a minimal fee. in the government’s mass VMMC roll-out plan. However, timely
changes in TMC practices, such as minimizing the TMC related
Discussion festivities, using one knife/razor blade per candidate, and
acceptance of local health staff supervision in some cases in
In Uganda, as in most other sub-Saharan African countries Bagisu (e.g., mandatory training certificates by local health office
where TMC is practiced, traditional circumcision marks the entry for all cutters) demonstrate the possibility of acceptance in the
to manhood. However, there are variations in the logistics and future. Indeed, changing attitudes at the community level may
performance of TMC among Uganda’s four ethnic groups. For open the door for health care providers, key decision-leaders, and
instance, eastern groups tend to circumcise at an older age than policy-makers to explore a hybrid model that standardizes cutting
those in western Uganda. There are also variations in cutting style and ensures effective protection against HIV/AIDS trans-
styles. For example, even though Sebei cutters are trained by their mission. Sharing responsibility between the trained health care

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 Traditional Male Circumcision in Uganda

provider who is responsible for the cut and caring of the wound different ethnic groups and the quality of the data collected,
and the local cutter who is responsible for cultural rituals might saturation was achieved and no new information emerged during
also mitigate the risks of excessive bleeding and glans damage, and the final FGDs. Opinions presented in the FGDs represent the
reduce overall healing time. knowledge, assumptions, and understanding of the participants.
The limited information about the effectiveness of TMC against While the participants are considered experts in this field, their
HIV/AIDS suggests the need for both a systematic evaluation of opinions may not reflect the most accurate facts about TMC.
TMC’s role in HIV prevention and the creation of innovative Furthermore, there may be minor grammatical (real-time trans-
approaches to reduce adverse events. While the initial attempt lations reported herein without modification) and contextual
should focus on making TMC safer, communities that still practice related issues associated with translating the FGD participants’
TMC need to be made aware of VMMC’s health benefits. For responses from their local languages to English. Finally, this work
men who are already circumcised traditionally, the educational on four ethnic groups that practice TMC in Uganda may not be
campaigns should provide information about the limited protec- relevant for other communities in sub-Saharan Africa that also
tive effects of TMC against HIV/AIDS to adjust for risk practice TMC. We conclude, however, that, communities’
compensation behavior. The results of the FGDs support these attitudes and reactions to change, common adverse events, and
and earlier suggestions to engage local communities that perform the challenges associated with making TMC safer are expandable
TMC in the planning and execution of an effective, safe mass male concepts.
circumcision roll-out plan [22]. A meeting of NGO representatives We suggest that our research is an important factor in
and sub-Saharan African Ministries of Health officials who met in developing both a safe TMC program and the educational and
2009 to discuss their progress with the mass scale-up of VMMC informing methods required for an effective national mass male
and to evaluate the common challenges, states that ‘‘it is important circumcision roll-out. Further studies should be undertaken to
to maintain engagement with traditional circumcisers and to avoid evaluate the adverse events of TMC in Uganda and its potential
alienating them and to use this opportunity for promoting safer
effectiveness for public health purposes, and to identify the
traditional practices.’’ [22]. This is especially true in communities
potential methods and approaches needed to convince local
where TMC provides status and a source of revenue. Traditional
communities to adopt safe practices and potentially transition to
cutters can be involved by educating them about sterile, hygienic
VMMC.
practices and methods to manage complications and risks. The
FGD results also demonstrate an opportunity for gradual
transition of TMC practicing communities to accept VMMC. Acknowledgments
To implement such transitions and innovative approaches, The authors thank The Bill & Melinda Gates Foundation. We also thank
collaboration can be undertaken with local religious and David Sokal, Rebecca Thornton, Meeraj Thaker, Moses Lee, Richard
community leaders, and information about the importance of Gonzalez, and Cheryl Moyer who gave constructive comments, feedback,
VMMC and the methods to reduce adverse events of TMC can be and advice, communities, district health offices, and the Family Health
disseminated to Uganda’s media, schools, and public venues. International 360 Country Office in Uganda who helped with organizing
This paper represents the first attempt to demonstrate the FGDs, and Media Academica, LLC, for illustrations of cutting techniques.
landscape of TMC in Uganda. However, the findings reported
here should be considered with specific limitations. While the Author Contributions
study team made great efforts to include a wide range of informed Conceived and designed the experiments: AS JDG KHS. Performed the
stakeholders, it is possible that the final study does not reflect the experiments: AS LB JDG KHS. Analyzed the data: AS. Contributed
full spectrum of beliefs and opinions about TMC in Uganda. reagents/materials/analysis tools: KHS. Wrote the paper: AS LB JDG
Nevertheless, considering the number of participants from KHS.

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