Tropical Medicine and International Health doi:10.1111/tmi.12878
volume 22 no 6 pp 708–715 june 2017
Scarification in sub-Saharan Africa: social skin, remedy and
medical import
Roland Garve1, Miriam Garve2, Jens C. Tu€rp1,3, Julius N. Fobil4 and Christian G. Meyer5,6,7
1 Center for Natural and Cultural History of Man, Danube Private University, Krems, Austria
2 Department of Quality Management and Accreditation, Leuphana University, Lu€neburg, Germany
3 University Center for Dental Medicine Basel, University of Basel, Basel, Switzerland
4 Department of Biological, Environmental and Occupational Health Sciences, University of Ghana, Accra, Ghana
5 Duy Tan University, Da Nang, Vietnam
6 Institute for Tropical Medicine, Eberhard Karls University, Tu€bingen, Germany
7 Health Focus GmbH, Potsdam, Germany
Summary Various forms of body modification may be observed in sub-Saharan Africa. Hypotheses and theories
of scarification and tribal marking in sub-Saharan Africa are described, plus the procedure of
scarification, examples from several African countries, assumed effects in prevention and treatment of
diseases, and the medical risks resulting from unsterile manipulation.
keywords scarification, theories of tribal marking, social significance, medical consequences of
scarification, sub-Saharan Africa
community members reluctant to go through and tolerate
Introduction
the painful and traumatic procedure of scarification were
Body modification has been performed for a variety of often excluded from community life and from important
reasons in many societies, and a plethora of historical activities, and they were not considered equally ranking
and current forms of modifications exists. The large spec- members of the collective [4, 5].
trum of artificial body modifications includes, among We recently described the tradition of infant oral muti-
others, cranial and foot binding, branding and ear shap- lation in indigenous groups in Africa and the customs of
ing, female genital mutilation and male circumcision, labret and lip plug wearing in several ethnic groups in
removal or enlargement of body parts, scarification and Amazonia and Africa, including their medical conse-
tattooing, but also modern plastic and aesthetic surgery. quences [6, 7]. Here, we focus on scarification, or cicatri-
Notably, body modification, rather tattooing then scarifi- sation, among indigenous ethnic groups in sub-Saharan
cation, has become increasingly frequent in industrialised Africa.
countries: approximately one-third of US citizens wear
tattoos, with considerable social acceptance [1]. Sadly
Theories on reasons for scarification
punishment, revenge and terror by removing body parts
still occur in some countries. Scarification is an archaic method performed, with a
The skin is a clear and definite boundary between the decreasing tendency, by indigenous dark-skinned ethnici-
self and the environment. Any modification of a sentient ties in Africa, Melanesia and Australia to achieve an irre-
being’s outer physical appearance may well, in a non-ver- versible optical change in the skin surface. A possible
bal way, convey indications, signals and messages to reason for preferring scars rather than tattoos is that pig-
those who understand their meaning. In fact, scarification ments applied in tattoos are barely visible on darker skin;
and tattooing in indigenous groups may be cultural however, combined scarification and tattooing occur, for
imprints and autographs of an individual (‘social skin’) example among the Maori in New Zealand and the
[2]. In anthropology, the transition and transformation of Caraja Indians in Brazil. Burkina Faso, Nigeria and
skin-associated messages into the informed perception of Congo have been claimed to be important centres of
individuals, small groups and larger societies has long ritual scarification [8]. Traditional African masks and
been a key issue [3]. While scarification is a culturally wooden carvings are frequently garnished with tribal-
sanctioned measure to convey messages and signals to specific symbols, which are similar to the scars observed
indicate cultural identity and to treat certain maladies, in the respective group (Figure 1) [9].
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Tropical Medicine and International Health volume 22 no 6 pp 708–715 june 2017
R. Garve et al. Scarification in SSA
Scarification is achieved through cuts of the skin, be it enemies or for ritual grounds, or successful hunting.
removal of skin parts, burns and branding, chemical Scarification may be a sign of dignity and social status.
imprinting, skin laceration and a variety of other tech- The theory of a non-adaptive sexually selected charac-
niques. Although the general acceptance of scarifications ter explains scarification in the context of mating and
appears to be waning [10], in most cases, it is the explicit sexual preferences and is based on the Darwinian theory
desire of an individual and his social community to of sexual selection. Scarifications are aesthetic adorn-
achieve permanent marks and scars, frequently by artifi- ments and intended to stimulate and attract potential sex-
cially deferring the natural course of wound healing and ual partners and to, in principle, allow for polygyny. For
even aggravating dermal restoration and repair. instance, among the Tiv ethnolinguistic group in Nigeria
As most indigenous groups in Africa, Amazonia and and Cameroon, raised keloids have been described to
Asia are currently facing the near evolutionary end of induce strong erotic feelings when touched, both among
their traditions and cultures, information on the meaning, women and men [15].
signification and implications of secondary body embel- The theory of an adaptive pathogen-driven sexually
lishment must be preserved. Current theories addressing selected character is based on the Hamilton–Zuk hypoth-
the reasons for body scarification and tattooing discussed esis, according to which individuals choose sexual part-
among anthropologists and ethnologists are related to (i) ners by variable characteristics which signal and reflect
hardening of the body, frequently experienced during the heritable resistance against infectious pathogens, in par-
transition from childhood to adolescence and, partly ticular against parasites [16]. Scarification is believed to
overlapping, (ii) rite of passage, (iii) a non-adaptive sexu- indicate resistance to pathogens and to demonstrate
ally selected character and (iv) an adaptive pathogen-dri- attractiveness and, thus, a superior value, together with
ven sexually selected character [11]. health, of potential sexual partners. This hypothesis is,
The hardening theory is based on the belief that any among others, one postulation of mating options and
physical and emotional stress exerted on young children behaviour, and it supports the Darwinian ‘good genes’
will allow the individual to withstand strain, both physi- theory. While selection of identical characteristics would
cal and mental, in its later life. Stress experienced in later reduce variation over time, the hypothesis provides one
life may involve a variety of situations, from any kind of explanation of why variation may be maintained through
conflict over sexual matureness, supernatural events to rapid co-adaptional cycles between host and parasites
pathogen infestation. Mutilation in early life is thought over generations. Experimental data of animal models
to enhance strength and accelerate physical, intellectual support the Hamilton–Zuk hypothesis [17, 18].
and cognitive development, a theory supported by experi- Although these theories are well suited to explain many
ments in animals [12]. Physical stress exerted by body aspects of scarification, not all forms and types of scarifi-
modification at the age of approximately two years cation can clearly be assigned to one of these hypotheses.
appears to be positively associated with physical growth Other reasons exist, such as purely aesthetic or medical
[13]. Among indigenous groups, ‘hardening’ is performed explanations, religious justifications and social motives.
on infants and young children until puberty. It may Further body modifications are prayer bumps as found
include ornamental piercing, cauterisation, circumcision among devout Muslims, and cheek gashes developing
and scarification. In this way, young girls may demon- into a typical scar, acquired in duels among homosocial
strate their firm ability of bearing pain at childbirth, or members of collegiate unions. The latter ones could be
to indicate their first menstruation. An important ‘hard- traditionally found among academic circles in several
ening’ process is ‘infant oral mutilation’ (IOM), where parts of Europe, for example in Germany and Austria,
teeth are extracted for ritual or pseudomedical reasons but have become rare and are considered anachronistic.
[6].
Rites of passage accompany the transformation and
Procedure of scarification
progression from one developmental phase to another.
Scarification in or after puberty, as an enduring contrast The procedure of scarification shall be illustrated by the
to younger individuals, emphasises initiation and grants example of the ritual scarification of a Surma woman in
admittance to the adult tribal community. Some authors the territory of the Omo Delta in south-western Ethiopia
include genital mutilation, both male and female, into (RG, own observation): without prior marking or paint-
this group to allow integration into a community and ing of the intended scarification area, a small part of the
gain permanent visible and irrevocable membership [11, skin to be treated is upraised by a wooden hook or an
14]. Other rites of passage may be associated with the edged thorn to subsequently be sliced or removed with a
first childbirth, the first and successive killing of humans, razor blade. This is performed repeatedly for hours,
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R. Garve et al. Scarification in SSA
regardless of continuous bleeding, to achieve a pattern of Tribal scars are frequent and may be observed in many
lesions which later will form the adornment (Figure 2). ethnic groups. In South Sudan, the Dinka and the Nuer
Coagulated blood is occasionally removed with unsterile as well as some other Nilotic groups are marked with tri-
water, and the lesions are impregnated with ash and bal-specific scars on the foreheads. While the Nuer have
mud. Wound healing is purposely retarded by inserting horizontal scars, those of the Dinka are serrated and fan-
unsterile materials, among others crocodile dung, into the shaped (Figure 4). Thus, in the ongoing civil war in South
lesions and by repeated removal of scabs; in fact, inflam- Sudan, members of the conflicting ethnic groups and
matory processes are intended to occur and favour keloid clanships are easily recognisable. Although now forbid-
formation for an extended period of time. While keloids den in parts of South Sudan, tradition still dictates
develop in 10% to 36% of scarified individuals only [10, scarification.
19], formation of keloids is strongly desired, as they are Some East African tribes used hoof-shaped or angled
aesthetic assets, emphasise femininity and increase social motifs, similar to cattle brandings. Impressive adornment
prestige [20]. are the tribal marks of the Schilluk and Toposa groups in
South Sudan. A pearl necklace of punctuated round keloi-
dal scars reaches from one ear to the other, forming a
Examples of scarification
semicircle around the eyebrows. Similarly, Barabaig
Fishbone patterns, avian designs and the imitation of cro- women in Tanzania wear dotted scars surrounding the
codile bites or crocodile skin are motifs that can be entire orbital region to signal female perfection. Compa-
observed in several ethnic groups. These motifs shall fre- rable scars, in addition partly covering the cheeks, are
quently indicate closeness to or even identity with ances- found among Bumi men in Ethiopia [23]. Some presti-
tor initiation animals. The Nigerian Bali and the gious Fulani women show four-three-lane keloid chains
Tanzanian Bondei and Shambaa groups perceive their in their faces to indicate their social rank [24]. In fact,
scars as manifestations of their mythological ancestor the ornaments may serve in these tribes as identity cards,
bird, conferring reincarnation. Crocodile-associated scari- indicating age, puberty, marital status, social status and
fication patters can, for instance, be found in South merits, and they are perceived as signs of attractiveness
Sudan among the Moru, the Tofinu in southern Benin, [25].
the Bobo in Burkina Faso, and the Montol, Merniang Members of the Yoruba in Nigeria have typical face
and Dimmuk in Nigeria [21]. Similar skin ornaments are scars, called kolo. Kolo ornamentation is intended to
also common in New Guinea among some ethnic groups express audacity, perseverance and resolution, but also
of the Sepik area [22]. Scars may be indicative of secret feelings (e.g. mourning, grief, sorrow), religious beliefs,
society membership, which aims at shaping the body to and animal and plant symbols. During scarification, the
perfection through ritual scars [8]. wounds are treated with grime and powdered coal to
In several parts of East Africa, ‘slayer’ scars were achieve a darker appearance of the scar pattern [15]. Tri-
common. Successful hunting or even killing an enemy bal scarification is frequently found in northern Ghana
allowed the fortunate huntsman to decorate himself among members of the Mamprusi, Nanumba, Gonja,
with keloidal scars on the forehead, cheeks, shoulders Frafra, Dagomba and other ethnic groups. The meaning
and upper arms [21]. If dermal space had become of the scars has been described in detail for Ghana [26,
scarce, skin surfaces of his wife(s) or his favourite live- 27] and Burkina Faso [28].
stock were ornamented. Typical for Bantu Tonga tribes
in Zambia, Malawi and Zimbabwe was a long keloid
Medical reasons for and unfavourable consequences
scar reaching from one eyebrow to the other in order
of scarification
to achieve the appearance of a buffalo and to demon-
strate resolute acerbity and decisiveness [21]. The belief Scarification is also performed to find relief from distinct
is that blessed hunters will experience a beneficial spiri- medical conditions and to improve physiological func-
tual transformation and reincarnation, and slayer scars tionality. Punctual branding can be applied for cleansing
symbolise achievements on the way to reach that aim. and disinfection of locally infected lesions or to distract
In some Kenyan and Tanzanian Maasai communities, from a source of severe pain, such as toothache and
circular and semicircular slayer scars on the cheeks cephalgia and other neuropathies. Febrile convulsions
may be observed. Even young boys are decorated with and epilepsy may be treated by branding or cutting the
circular brandings as a tribal identification marker and skin [10]. In Togo, scarification for epilepsy treatment is
as a sign of the desire to become a brave man in the mostly applied on the forehead, clearly identifying indi-
future (Figure 3). viduals scarred in such a way as epileptics [29]. Among
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Tropical Medicine and International Health volume 22 no 6 pp 708–715 june 2017
R. Garve et al. Scarification in SSA
Figure 1 Face masks of the Chokwe ethnic group, Angola, with tribal-specific symbols indicating social ranks (photograph: R. Garve,
own ethnographic collection).
(a) (b)
(c)
Figure 2 (a, b) Scarification of a Surma woman in Ethiopia. Note the upper lip labret and ear adornment shown in Fig. 3A (see Ref.
[7]) (photograph: M. Garve, 2001); (c) Toposa woman in South Sudan (photograph: W. Moritz, 2012).
the Sudanese Nuba, deep temporal cuts are applied to young children and babies in some Congolese groups has
treat headache, while supraorbital scars are administered served explicitly prophylactic and therapeutic purposes
to improve vision [23]. Ritual scarification of adults, [11]. Prevention of diseases through scarification is also
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R. Garve et al. Scarification in SSA
(a) (b)
(c) (d) (e) (f)
Figure 3 (a) Ghanaian woman, tribal marks (photograph: C.G. Meyer, 2016); (b) Toposa woman in South Sudan, shoulder scarring
(photograph: W. Moritz, 2012); (c) Maasai boy in Kenya (photograph: R. Garve, 2016); (d) Toposa woman, South Sudan (photograph:
W. Moritz, 2012); (e) male Maasai in Kenya with scars indicating courageousness (photograph: R. Garve, 1985); (f) Toposa woman in
South Sudan (photograph: W. Moritz, 2012).
(a) (b)
(c) (d)
Figure 4 (a) Male Nuer in South Sudan; typical horizontal forehead scars (photograph: W. Moritz, 2012); (b) female Nuer, South
Sudan; fan-shaped forehead scarification (photograph: W. Moritz, 2012); (c) Surma boy in Ethiopia, parable-shaped forehead scars
(photograph: R. Garve, 2015); (d) Surma girl in Ethiopia, recently applied punctual scarification (photograph: R. Garve, 2015).
712 © 2017 John Wiley & Sons Ltd
Tropical Medicine and International Health volume 22 no 6 pp 708–715 june 2017
R. Garve et al. Scarification in SSA
sought frequently in South Africa [30, 31]. In a study Scarification is a cultural custom in many indigenous
from Congo, frequent indications for curative scarifica- societies in sub-Saharan Africa. We plead for access to
tions were ‘big belly’, ponderal stagnation and recurrent hygienic instruments to apply scars under sterile condi-
bronchitis [32]. Scarification may also be performed to tions in those communities who wish to do so, under the
apply traditional remedies, mostly substances of premise that informed assent is provided by those who
unknown composition [30], and to treat splenic enlarge- are subjected to the procedure. Children must be
ment in childhood malaria as observed in Nigeria [33]. It excluded.
is worth mentioning that there is no proven evidence of
causal relationships between scarification and the thera-
Ethical statement
peutic success of any disorder. However, psychological
and placebo effects are likely. The authors declare no conflict of interest. All individuals
Several non-communicable and infectious conditions shown in the figures provided consent to take their pic-
may result from scarification. Scarification is associated tures and agreed that their photographs might be pub-
with both local dermal hypertrophy and atrophy [10, 19, lished in a scientific journal.
34] and with cutaneous sarcoidosis [35, 36]. In Ghana,
scarification is a risk factor for rapid progression of filar-
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Corresponding Author Christian G. Meyer, Institute for Tropical Medicine, Eberhard Karls University, Tu€bingen, Germany.
E-mail: christian.g.meyer@gmail.com
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