"Seizing the day": right time, right place, and right message for adolescent male reproductive sexual health: lessons from the Meru of Eastern Province Kenya.
Keywords: male circumcision, Kenya, adolescence, sex education, HIV/AIDS, timely intervention
This paper will examine the context of male circumcision among the Meru of Kenya (see Nyaga, 1997) to explore if the traditional moments of education within the male circumcision rite are still important moments for today's youth in zones where adolescent circumcision is still practised, and outline an intervention project aimed at seizing the day to reach adolescent boys with youth-friendly health messages.
The Meru live on the eastern slopes of Mount Kenya in the central part of Kenya, home to the Meru people (Bell, 1955). The area once boasted a profitable cash-crop economy, but failing harvests and changing rhythms in world coffee production have reduced its stability. Many inhabitants of this region remain subsistence farmers. The provincial capital of the area, Meru, has an HIV prevalence of 35%. its environs are famous for the miraa or Khat, a stimulant leaf chewed in Eastern Africa.
The Meru are traditionally a male-dominated, patriarchal society. Disciplining through violence, particularly within family relationships, provided a means of control. Young Meru people struggle for employment, the division of land through the years having reduced its capacity for substantive returns. Many describe a general apathy and cite idleness as a major problem in their lives and a reason why alcohol, miraa, and cannabis (bhangi), which is grown in the forests of Mount Kenya, are so abused. An estimated 3,929,000 of Kenya's total population of 32 million are between 15 and 24 years old. In this group. 15 percent of the females and 9 percent of the males are HIV-positive. More than 1.1 million adults are HIV-positive in Kenya. Life expectancy dropped in 2001 to 49 years from 57 years in 1990, largely due to AIDS.
On ethnographic maps, all societies in the central Kenyan highlands are shown as practicing male circumcision (Bongaarts. Reining, Way, & Conant, 1989: Caldwell, Orubuloye, & Caldwell, 1997: Dodge & Kaviti, 1965: Moses, Bradley, Nagelkerke, Ronald, Ndinya-Achola, & Plummer, 1990). Meru oral history indicates that they have practiced male circumcision at least since arriving in the area in the late 18th century (Greeley, 1977).
Chogoria Hospital, in the South Meru region, is the largest NGO health provider in the area and serves a population of 528.000. Chogoria Hospital was founded in 1922 by Clive Irvine, a zealous Scottish missionary doctor with farsighted ideals for women's education, industry creation, and public and preventative healthcare. In 1926, Irvine offered hospital-based circumcision as an alternative to traditional circumcision of the field and forest. He retained the particular Meru cut. Several traditional techniques of circumcision (gutanwa) have been identified among the Meru people alongside the period of seclusion and male-only supervision and nursing care (Brown, Micheni, Grant, Mwenda, Muthiri, & Grant, 2001). This hospital service has continued since the 1920s and forms the basis of the intervention programme that this paper will describe.
At the conclusion of their primary education, all Meru boys are expected to be circumcised, regardless of whether they plan to attend secondary school or not. Between mid-November and mid-January, boys are admitted to the hospital for a period of one week, during which time they are circumcised.
An ethnographic methodology was adopted to understand the context and significance of circumcision, past and present. Information was collected from a variety of sources: adult Meru men (55 of the boys' guardians or family-appointed men who accompanied the boys to hospital for circumcision, two traditional circumcisers, 20 traditionally circumcised local men, and 30 male nurses performing circumcision within the health clinic and hospital setting), 140 adolescent boys before and after their circumcision; and old and recent hospital records, local newspaper reports, and literature published on the subject, which were examined to provide corroborating evidence on the traditions and their changes throughout the years.
We used purposive sampling to capture perceptions across a range of age, religious belief, location in Meru, and employment status. All male hospital staff involved in circumcision were interviewed. Alter initial identification of five adult men traditionally circumcised, we used snowballing techniques to identify another 15 men. Their ages range from early 20s to 90 years.
During what we estimated to be the busiest week of circumcision, from previous hospital records, we interviewed each boy until we completed 100 interviews. Fifty-five guardians who came to collect their initiates at the end of this week were also interviewed. A further 40 interviews were completed the following year during the same week.
The authors carried out interviews and focus groups with the older Meru men and hospital staff. Second-year male nursing students carried out the interviews with the initiates and with their guardians. The interviews were conducted in the local language. Interviewers recorded and then translated the interviews into English. We analysed the interviews thematically by coding the interview scripts, focus group material, and supporting documents (i.e., records, local paper clippings). Codes were allocated to emerging themes, which were tested through further discussion among key informants. Support was offered from the principal of the nurse training school and male community health advisors.
The qualitative individual and focus-group interviews with adult Meru men explored their memories of their own circumcision, their age set's circumcision, and their perceptions of present-day circumcision in Meru.
Meru men explained that the whole Meru community still believe that an uncircumcised male. regardless of his age, will always be regarded as a child, unable to own land, marry, or have sexual relations. Traditionally. circumcision took place in a field, near a river, the boy being held in a line by his guardian while a traditional circumciser cut, in quick succession, each of the boys. After the cut the initiates and their guardians were brought from the field to a "seclusion" hut in the forest. As the circumcision cut healed, initiates received teaching about "the ways of men," clan business, secrets of the clan, and male-female relationships. They adopted a new name and learned a new language, enabling them to communicate about sexual or clan business in a secretive way. They emerged from their time in seclusion as new people with a new identity. They returned to their home village, now to live in a separate hut, away from their mother and younger brothers and sisters. As children there was a strong taboo against engaging in sexual relationship. It broke clan law, and it was said to bring uncleanness into the clan. But as men, returning from circumcision, sex was permitted, even encouraged. The expression "cleaning the sword" was used frequently and referred to the act of first sex after circumcision. The constant theme that emerged throughout the data collection was that the "way of childhood was gone forever": those who were circumcised were now men.
Information gathered from guardians indicated that hospital or clinic circumcision has become increasingly popular among the Meru. The fear of HIV/AIDS, exacerbated by the risk of infection through shared unsterile circumcision knives, has encouraged many more families to choose the hospital for the boy's circumcision. Guardians indicated that families expected the boys to learn how to become men and assumed that within a hospital setting information they received would be appropriate and safe.
Interviews conducted with initiates undergoing circumcision focussed on two issues--life before circumcision and their expectations of life after circumcision. Themes emerged that paralleled descriptions given by the older men of their lives before circumcision.
CIRCUMCISION: BEFORE AND AFTER
The boys described how they were treated as children by everyone in their family compound and village. They were not allowed to leave their family compound at night, talk to girls about sexual topics, or engage in any sexual activity. Boys described how their family and community prohibited sexual activity between children. They were also forbidden to drink local beer or go to male meeting houses or bars. "I cannot take beer, or go with my father and uncles when they leave at night to go to the village dukas." They could sit and eat in their mother's kitchen and play with younger children, though. "I still eat with my mother in her place, the kitchen, but soon I will eat with the men." Theirs was the life of a child, but they explained that circumcision was going to change this.
They all saw circumcision as an essential rite. The boys explained that circumcision would allow them to "be ready for secondary school and avoid beatings from older pupils" and "be free from household chores." Every boy said that circumcision was the responsibility of all Meru men, affirmed and demanded by clan law. They explained how their whole family was involved in circumcision, how they had said goodbye to younger children and their grandparents, and how special feasts would be prepared for them on their return to mark the change they had undergone. They talked of how they expected to be recognised as men on leaving the hospital. They spoke of "learning the ways of men," a key part being how to interact with women. They hoped to learn new words and expressions when returning to the community that would allow them to communicate to other men in a way not understood by uncircumcised boys or women. They believed they would have a different relationship with the elders and adult men of their compound; while still being obedient to them, they would now be able sit with them, listening to their stories and learning how to behave and how to deal with political and social problems.
They described how they anticipated having new relationships, new freedoms, and new opportunities on leaving the hospital. They looked forward to being able to speak openly to girls and bring girls to their own rooms. A number said they now could have sex. "I am not hindered from having sex now. I cannot share my mother's kitchen with females, but I can share my room with girls in my separate house. I have full freedom to go out in the evening."
"I can walk at night alone and can sleep with girls. There will be no restriction to sex with girls of my age."
They believed that by being circumcised they would be able to "ejaculate properly." Some boys also talked of the importance of having sex as soon as possible after their circumcision. "If one does not have sex soon after circumcision, the penis will remain soft forever."
The interview findings provided evidence that, although shorter now, the period of segregation and seclusion at circumcision still retains the expectation of change and newness. Boys and their families still desire teaching on sexual matters and life skills. They also expect that circumcision and the teaching will bring about a profound life change.
PUTTING THE FINDINGS TO WORK
Using information about traditional seclusion teaching on the ways of men and framing it within the boys" own expectations, a health education intervention was developed focussing on the themes of:
* becoming a man--physical, psychological, and social changes of puberty and of circumcision;
* interpersonal relationships with girls, peers, parents, and community;
* HIV-AIDS and other sexually transmitted infections (STIs);
* Community expectation--Meru clan systems, chiefs, and sub chiefs;
* substance use and abuse;
* psychology of youth--peer pressure, group identity, risk taking;
* setting goals and achieving them--secondary school life including bullying, self-confidence and self-maturation, and religious commitment.
The themes from the research indicated not only areas of learning expectation but also highlighted areas of potential risk, which the programme sought to deal with.
The programme focussed on choice under the theme "Climbing to Manhood." The intervention was designed to replicate the traditional seclusion teaching on the "'ways of men": provide clear information on current and pertinent youth issues: encourage peer group discussion, active involvement, bonding, and positive peer pressure: and encourage community leaders to reflect on their role of modelling healthy living to young people.
Programme trainers were chosen selectively from the community, reflecting the traditional method of choosing older Meru men to pass on the "ways of men" to the new initiates during their seclusion period. These men, from different professions--teaching, church ministry, government, business, and health--were involved in developing the programme and shared a two-session training plan with hospital staff before the commencement of the programme. An introduction to this training of the trainers session was given by the Community Health Department, highlighting the ethos and the messages that the programme anticipated giving.
Initiates can register for hospital circumcision on any day and usually stay one week after their circumcision. The rolling programme ensured that regardless of the day of entry the initiate received teaching on all the themes.
The programme approach incorporates principles of good practice learned from other youth HIV/AIDS prevention programmes in sub-Saharan African communities. Considerable emphasis is placed on personal capacity and self-confidence building, coping with negative peer pressure, and setting personal development goals to enable the possibility of abstaining from sexual relationships until older.
The programme adheres to the traditional requirements of male-only care throughout the period of operation and seclusion. Special "circumcision" foods are still prepared for the initiates. While limited accommodation and cost made it impossible for each initiate to have his guardian with him throughout the seclusion period, a representative guardian, a head boy of the local boys' school, provided a role model and support. As all circumcisions take place during the December school holiday period, this representative guardian was able to stay with the boys throughout the entire circumcision period.
Programme tools such as videos and educational board games are used. A youth magazine (designed by staff) called Climbing to Adulthood complements the educational sessions. While the programme planners actively espouse gender equality, the format and content of the programme has not placed enough emphasis on developing such issues, particularly the rights and role of women. The faith-based component of the teaching does encourage mutual respect for men and women and provides a lifestyle plan that advocates appropriate female respect and understanding.
An active attempt has been made to challenge stereotypical male roles with their associated acceptance of violence. The programme has invested significant effort in ensuring that the traditional beatings and disciplining, very much a part of the rite of circumcision, are prevented and initiates are given the opportunity to explore the abuse of violence. The boundaries provided by the physical walls of the hospital ward and the psychological walls of the traditional seclusion period offered an intense and secure opportunity for boys to discuss issues of significance.
DID THE PROGRAMME WORK?
While there is significant anecdotal information on the successfulness of the programme, no rigorous full-scale evaluation has been carried out. An evaluation meeting, held three weeks after the end of the first circumcision season, brought together all who had participated in the planning and teaching. The community trainers reported comments from young people in their locality. The mentality of "it could never happen to me" had clearly been challenged during the programme. A trainer described how two boys had told him that they had known men could get AIDS from "sleeping around with many women and loose women," but they had not previously understood that sex with just one girlfriend who was infected could lead to them becoming HIV+. Eight months after the first programme, an evaluation session with the initiates was held. Invitations were sent to 50 young men chosen at random from the circumcision register. Though held during the school holidays, only 24 attended. Those who attended described the pressures from other pupils to try drugs, alcohol, and sexual experiences. They gave examples of how they had resisted unhealthy peer pressure. Some explained that they were laughed at because they did not experiment, but they had learned that they could become addicted, their work could suffer, and they could be thrown out of school. They knew that drugs might seem exciting but had many unpleasant, even dangerous, side effects.
Some said that knowledge and fear of STIs had prevented them from engaging in sex. One young man explained that, after seeing the video on STIs, he had resolved never to engage in risky sexual activity that could lead to such infections; he dreaded having to ask his father for treatment money. In his own words, "I would be so ashamed when my father asked me what the money was for, and I would have to show him the awfulness of that disease." Another boy said that when schoolmates were tempting him to engage in sex, he kept remembering that he could become ill with AIDS. and he felt "no experience is worth dying for."
During traditional circumcision, teaching about the "ways of men" was provided in a time and space rich with the expectation of change and newness. Although shorter now, the period of segregation and seclusion still retains the expectation of change and newness. Boys and their families still desire teaching on sexual matters and life skills. They also expect that circumcision and the teaching will bring about a profound life change.
Enormous resources are being targeted at adolescents in AIDS preventative programmes throughout sub-Saharan Africa. Models of good practice indicate the importance of peer education, gender-appropriate messages, and role modelling. However, information giving during this period, while increasing knowledge, does not necessarily change behaviour. Understanding the significance of both the individual and the community commitment to change and the challenges of reconciling programmes to facilitate personal and societal positive choices remains key in health educational practice.
This paper explores the possibility of identifying cultural moments of ripeness for change, of engaging with the past to provide indicators for change in the future, and of exploring the possibilities of transition rites as formation periods for healthy living. African traditional societies teach us that there is a right time and a right place to give important, life-changing messages. The individual commitment, coupled with the social bonding and community expectation, around the time and place of circumcision creates an environment where behaviour change is possible. With the crises of AIDS and the disillusionment of the young in so many parts of the Western world as well as in rural Africa today, the right message at the right time and place is crucial. Even when traditional rites of passage for young people have faded or appear to be fading, as in Western society, there may still be important opportunities to engage with people in their time of transition. It is time once again to learn from the elders: identifying the moment and then "seizing the day" must be a priority of health educators in all countries and communities.
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Brown, J.E., Micheni, K.D., Grant, E.M.J., Mwenda, J.M., Muthiri, F.M., & Grant A.R. (2001). Varieties of male circumcision: A study from Kenya. Sexually Transmitted Diseases, 28, 608-612.
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Dodge, O., & Kaviti, J. (1965). Male circumcision among the peoples of East Africa and the incidence of genital cancer. East African Medical Journal, 42, 98-105.
Greeley, E.H. (1977). Men and fertility regulation in southern Meru: A case study from the Kenya highlands. Washington: Catholic University of America (dissertation).
Moses, S., Bradley, J., Nagelkerke, N.J.D., Ronald A.R., Ndinya-Achola J.O., & Plummet, F.A. (1990). Geographical patterns of male circumcision practices in Africa: association with HIV seroprevalence. International Journal of Epidemiology, 19(3), 693-697.
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Correspondence concerning this article should be sent to Elizabeth Grant. Department of Community Health Sciences, University of Edinburgh, 20 West Richmond Street, Edinburgh, UK EH8 9DX. Electronic mail: Elizabeth.Grant@lhb.scot.nhs.uk.
Department of Community Health Sciences
University of Edinburgh, Scotland
Community Health Advisor
Nazareth Hospital. Kenya
North East Kenya
Family Practice, Ladywell Surgery
Kenyatta National Hospital
Community Health Education Advisor
Eastern Province, Kenya
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|Publication:||International Journal of Men's Health|
|Date:||Sep 22, 2004|
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