Sex initiation camps, child marriages and polygamy, the lesser-known side of cervical cancer in Africa

Malawi has the highest rate of cervical cancer in the world, affecting about 3,684 women, with only about 500 of them surviving.

SINCE 2007 Africa’s First Ladies have put their weight behind the “Forum of African First Ladies against Breast, Cervical and Prostate Cancer” - and with good reason. 

Cervical cancer is a major issue in Africa: it is the most common cancer in women in eastern and central Africa and there are 80,419 incidents every year with approximately 53,334 deaths. This makes it the region with the highest rate in the world. In fact in 2014, of the countries with the top 20 highest incidences of cervical cancer, 16 were African. 

Malawi has the highest rate of cervical cancer in the world, affecting about 3,684 women, with only about 500 of them surviving. Next in line were Mozambique and Comoros.

Whilst there are plenty of challenges in preventing and curing cervical cancer - most notably late detection due to a lack of screening and treatment policy, strategies and programmes - there are also particularly worrying social circumstances which could be perpetuating the high rates of cervical cancer in Africa’s women and which also need to be addressed. 

Sex initiation camp

In Malawi for example, despite the high rates of cancer incidents and low survival rates, in some parts of the country there exists a disturbing coming of age tradition that could be contributing to these high figures. 

Young girls, some as young as eight, are taken to a type of “initiation camp” during their holidays by an older woman known as a an “anamkungwi” or “key leader”. Here they are taught about how to engage in sexual acts so that “when they return to their villages they should cook and clean—and have sex.”

Whilst all women are potentially at risk of developing cervical cancer at some point in their lifetime, according to the World Health Organisation, one of the most common risk factors for it include an early age of first intercourse. 

This is because early age at first sexual intercourse has been associated with an increased risk of high-risk human papillomavirus (HPV) infection, a sexually transmitted infection, that in susceptible women is responsible for virtually all cases of invasive cervical cancer. According to the WHO, the prevalence of the cancer-causing HPV (strains 16/18) in women with cervical cancer in Africa is 69.7%. 

Young girls are largely unaware of the risks and are being told to have unprotected sex making their chances of contracting HPV even higher. To make matters worse, many countries that have high rates of cervical cancer mortality and morbidity are also burdened with high rates of HIV. 

Recent findings are showing that HPV infection doubles the risk of acquiring HIV in women and also, that HIV significantly increases risk of persistent HPV infections, which can lead to cervical cancer. This is particularly worrying in countries like Malawi where 10% of the population, aged between 15 - 49 (therefore more likely to be sexually active), is HIV-positive. 

Child brides

This is also particularly concerning on a continent where estimates show that child brides could rise to 15 million by 2030. 

In Tanzania for example the youngest legal age for marriage for girls is 15 and the country is ranked 6th in Africa in terms of cervical cancer incidents. The age these child brides first have sex though could be far younger because even though the law dictates that a girl of 15 years and above is considered an adult, the Penal Code provides that persons of “African or Asiatic descent” may marry or permit marriage of a girl under 12 in accordance with their custom or religion if marriage is not intended to be consummated before she is 12. 

Another country with high rates of child marriages is Mozambique, and once again this country has one of the highest incidences of cervical cancer in the world - coming in second behind Malawi.  Here, 21% of girls are married by the age of 15 and 56% by the age of 18 - the 7th highest rate of child marriage in the world - and about 65 cases of cervical cancer per 100,000. 

Multiple partners and polygamy

In an interview with Evan Sequeira, a specialist on obstetrics & gynaecology based in Kenya, he said that “even more than just the young age, it’s the multiplicity of partners that increases the risk of cervical cancer”. This because that increases the chances of contracting HPV and which is why doctors “suggest that girls between the ages of 9 - 26 have the vaccination against HPV, before their sexual debut”. 

This is a particular problem for Africa since multiple partners, even in marriage, is more the norm than the exception. Polygamy is explicitly abolished in law in just a handful of countries: Ethiopia, Guinea, Cote d’Ivoire, Ghana, Benin, Angola, Rwanda, Burundi and Tunisia. Polygamy is reported to increase the risk of cervical cancer two-fold, and the risk increases with an increasing number of wives. 

So whilst the challenges related to high cost of immunisation, treatment, early detection and access remain, without addressing some of these root social situations, there will be little progress in effectively and sustainably combatting this silent killer.

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