In a statement released on 9 September the Canadian Pediatric Society confirmed its long-standing opposition to routine circumcision of male infants and boys. The new policy states clearly that the recommendation of the CPS is against circumcision because the benefits are small and outweighed by the risks. This outcome has surprised some observers, who were expecting the CPS to follow the American Academy of Pediatrics to conclude, while not recommending circumcision, that the benefits exceeded the risks, and that circumcision was a matter of “parental preference”. In rejecting this assessment as scientifically unsound, the new CPS policy aligns itself with those of the Royal Australasian College of Physicians and child health experts in Britain and all European countries. Their position leaves the Americans more isolated than ever as the only medical organisation in the world to think that there is anything worthwhile in routine circumcision. Scholars have criticised the risk/benefit calculus as inadequate for the “circumcision decision”, as it fails to consider the value of the foreskin and the likely future wishes of the boy, or to give adequate weight to bioethical and human rights principles. It is nonetheless significant that the CPS could recommend against circumcision after a narrow calculation of the strictly medical issues considered pretty much on their own. Once you add the functions of the foreskin and bioethical issues to the equation, the case against circumcision becomes overwhelming.
Media release by Canadian Pediatric Society
Media release by Attorneys for the Rights of the Child
Brian Earp, University of Oxford
The following critique by Brian Earp, research fellow at the University of Oxford is forthcoming in the Canadian Journal of Pediatrics and is available at his Academia.edu page.
The latest statement from the Canadian Pediatric Society (CPS) on newborn male circumcision exhibits both strengths and weaknesses.
Strengths include
(1) acknowledgement that the foreskin is not redundant skin; that it “serves to cover the glans penis and has an abundance of sensory nerves” (p. 4); that it is adherent at birth and may take several years to become fully retractile; that this is normal and should not be pathologized as phimosis; that true phimosis can be treated non-surgically;
(2) acknowledgement that the absolute risk for UTIs in boys is low; that it would take 100+ circumcisions to prevent 1 case; that UTIs may be over-diagnosed in genitally intact boys; that UTIs can be treated non-surgically; that “UTIs in children with normal kidneys do not result in long-term sequelae” (p. 2);
(3) acknowledgement that the absolute risk of female-to-male heterosexual transmission of HIV in countries such as Canada and the USA is low; that findings from African trials concerning adult men may not translate to newborn boys in developed countries; that circumcision does not reduce male-to-female transmission of HIV; that safe sex practices must continue to be emphasized;
(4) acknowledgement that penile cancer is rare in developed countries; that its association with intact male genitalia is primarily explained by the presence of phimosis; that HPV vaccines are expected to “dramatically decrease the incidence rate of cervical cancer” (p. 3), thereby obviating a role for circumcision;
(5) acknowledgement that circumcision is painful; that this pain may have long-term adverse sequelae; that circumcision is a procedure with “lifelong consequences … performed on a [healthy] child who cannot give [his] consent” (p. 4); that the “authority of substitute decision makers is … usually limited [to] interventions deemed to be medically necessary” (p. 4); that newborn male circumcision does not satisfy this condition.
Weaknesses include
(1) failure to engage seriously with the literature on negative sexual effects of circumcision.[1][2][3] This includes a recent analytic review by Bossio et al.[4] as well as several published critiques of the studies by Kigozi et al. and Krieger et al.,[5][6] the latter of which did not use validated instruments. The CPS authors also conflate adult circumcision and infant circumcision in this section.[5]
(2) failure to state that the cited cost-effectiveness estimate concerning lifetime risk of HIV acquisition did not demonstrate cost savings for circumcision in the majority population of white males;
(3) failure to explain the inclusion of a brochure by an Australian pro-circumcision lobbying group with no official status[7] as one of three “Selected resources” (p. 5), rather than the official brochure of the Royal Australasian College of Physicians (RACP),[8] which advocates against neonatal circumcision;
(4) failure to consider analogous interventions in girls.[9] The non-therapeutic removal of any amount tissue from the female genitalia prior to an age of consent, including procedures that are less invasive than male circumcision, is a crime in Canada, notwithstanding any health benefits that might or might not ensue.[10]
References
[1] Frisch M, Lindholm M, Grønbæk M. Male circumcision and sexual function in men and women: a survey-based, cross-sectional study in Denmark. Int J Epidemiol 2011;40(5):1367-1381.
[2] Bronselaer GA, Schober JM, Meyer‐Bahlburg H F, et al. Male circumcision decreases penile sensitivity as measured in a large cohort. BJU Int 2013;111(5):820-827.
[3] Dias J, Freitas R, Amorim R, et al. Adult circumcision and male sexual health: a retrospective analysis. Andrologia 2014;46(5):459-464.
[4] Bossio JA, Pukall CF, Steele S. A review of the current state of the male circumcision literature. J Sex Med 2014;11(12):2847-2864.
[5] Earp BD. Sex and circumcision. Am J Bioeth 2015; 15(2):43-45.
[6] Frisch M. Author's response to: Does sexual function survey in Denmark offer any support for male circumcision having an adverse effect? Int J Epidemiol 2012;41(1):312-314.
[7] Earp BD, Darby RJ. Does science support infant circumcision? A skeptical reply to Brian Morris. Skeptic 2015;25(3)23-30.
[8] Royal Australasian College of Physicians. Policy statement and brochure for parents.
[9] Earp BD. Female genital mutilation and male circumcision: Toward an autonomy-based ethical framework.
[10] Earp BD. Do the benefits of male circumcision outweigh the risks? A critique of the proposed CDC guidelines. Front Pediatr 2015;3(18):1-6.
“On right track, but could do better”
VICTORIA, BRITISH COLUMBIA – (Sept. 9, 2015) – A just released policy on infant male circumcision by the Canadian Paediatric Society (CPS) was judged today by the Children’s Health & Human Rights Partnership (CHHRP) to be a step in the right direction, but was “nevertheless ‘predictably inadequate’ with respect to several specific issues." CHHRP Medical Director Dr. Christopher Guest, MD, FRCPC, said the new policy is consistent with international paediatric associations that affirm infant boys should not have their healthy foreskins routinely removed. Citing the position of the CPS that recognizes the unique sensory functions of the male foreskin, Dr. Guest asserted that, “A growing number of medical associations now recognize that an intact penis with a foreskin contributes to sexual pleasure for the male and his partner.” According to Guest, in 2010 the Royal Dutch Medical Association concluded, “the foreskin is a complex erotogenic structure that plays an important role in the mechanical function of the penis during sexual acts.”
“Circumcision alters the structure of the penis, which inevitably alters function. Long term harm to men from infant circumcision has never been studied” Guest said. Despite this, Guest says men are reporting long-term adverse consequences at the Canadian-based online Global Survey of Circumcision Harm. Although the CPS failed to include it, Guest says scientific evidence has emerged that supports these men’s claims. In 2011, Dr. Morten Frisch published findings in the International Journal of Epidemiology showing that in Denmark, where circumcision is rare, ‘circumcision was associated with frequent orgasm difficulties in Danish men and with a range of frequent sexual difficulties in their female partners, notably orgasm difficulties, dyspareunia [difficult or painful sexual intercourse] and a sense of incomplete needs fulfilment.’
Guest faulted the CPS for inclusion of “convenient untruths,” most notably a discussion of HIV being lower in circumcised men. He says such claims are based on methodologically weak African trials, which contradict global HIV trends, for example the United States, which has a high circumcision rate, yet a significantly higher rate of HIV infection than Sweden and Japan where circumcision is rare. “Even if the African trials were scientifically valid, they cannot be used to justify infant circumcision because infants are not sexually active persons,” he said. “Soap and water and safer sex practices, including condoms, can prevent disease.”
According to Guest, the CPS failed to include crucial information from a 2012 report by the International NGO Council on Violence Against Children, which CHHRP sent to the CPS in 2014. The report stated that “non-consensual, non-therapeutic circumcision of boys, whatever the circumstances, constitutes a gross violation of their rights, including the right to physical integrity, to freedom of thought and religion and to protection from physical and mental violence.”
“Medical associations in the Netherlands, Finland, Sweden, Norway, Denmark, Germany, and others confirm that there is no justification for circumcising infants in the absence of medical urgency,” Guest stated. “The CPS is out of step with those medical associations, who also urge an end to the practice due to ethical and human rights concerns.”
Although the CPS concluded that routine infant circumcision is not recommended, and that the benefits of the surgery do not outweigh the risks (contrary to a 2012 claim by the American Academy of Pediatrics), Guest contends that the position statement is still insufficient due to its ambiguity in leaving the decision up to parents. “Parents are not physicians. They do not have the medical knowledge to decide if surgery is medically indicated for their child,” Guest asserted. He went on to say that, “Leaving a decision about medically unnecessary surgery up to parents is an ethical failure on the CPS’ part. Where else in medicine do physicians place this burden on parents, in order to obviate their own professional responsibility?”
“Preservation of bodily integrity is a basic and universal human right that the CPS must articulate clearly in future statements,” Guest said. “We Canadians, as well as our institutions and government, have an obligation to protect that right for all citizens, regardless of gender or age.”
The Children’s Health & Human Rights Partnership was established in 2012 as a partnership of professionals in the fields of medicine, ethics, and law to further public education regarding non-therapeutic genital surgery on Canadian children. The CHHRP statement is available here.
Like Australia, Canada has a past history of widespread circumcision, but a dramatically falling incidence over the past couple of decades. Also as in Australia, it has been the medical profession itself, led by paediatric health authorities, that has taken the initiative to discourage the practice. In recent times Canadian medical authorities have been among the most outspoken opponents of routine (prophylactic) circumcision, and they have issued several cautions against the practice. Parallel with this attitude, State health authorities in the Canadian provinces (Manitoba partially excepted) do not pay for medically unnecessary circumcision operations, nor reimburse parents through the Canadian equivalent of Medicare unless the procedure is essential to correct a problem.
Among the Canadian health authorities that have issued policies that recommend against circumcision is the College of Physicians and Surgeons of British Columbia, which released a revised policy in September 2009. The following points are highlights of the statement.
“Infant male circumcision was once considered a preventive health measure and was therefore adopted extensively in Western counties. Current understanding of the benefits, risks and potential harm of this procedure, however, no longer supports this practice for prophylactic health benefit. Routine infant male circumcision performed on a healthy infant is now considered a non-therapeutic and medically unnecessary intervention.”
The new policy states clearly that “routine removal of normal tissue in a healthy infant is not recommended.” It also points out that:
The policy recommends that doctors should:
The full text of the policy appears below.
Until recently, only public health and religious views were taken into consideration in the debate over infant male circumcision. However, our understanding of medical practice must change as research findings become available. The College is issuing this guide for physicians regarding routine infant male circumcision in light of evidence-based medicine and contemporary principles in ethics, law and human rights.
Infant male circumcision was once considered a preventive health measure and was therefore adopted extensively in Western countries. Current understanding of the benefits, risks and potential harm of this procedure, however, no longer supports this practice for prophylactic health benefit. Routine infant male circumcision performed on a healthy infant is now considered a non-therapeutic and medically unnecessary intervention. From a religious standpoint, infant male circumcision is acknowledged to be an important ritual and an integral part of Jewish and Islamic religions. Male circumcision is also practiced in other parts of the world as a rite of puberty.
A wider societal discussion on infant male circumcision is warranted based on a current understanding of bioethics that takes into account the non-therapeutic nature of the procedure as well as the high importance it plays in religious and traditional customs. This paper provides a discussion on current medical perspectives as well as relevant legal, human rights, and ethical considerations.
Medical Perspectives
Circumcision removes the prepuce that covers and protects the head or the glans of the penis. The prepuce is composed of an outer skin and an inner mucosa that is rich in specialized sensory nerve endings and erogenous tissue. Circumcision is painful, and puts the patient at risk for complications ranging from minor, as in mild local infections, to more serious such as injury to the penis, meatal stenosis, urinary retention, urinary tract infection and, rarely, even haemorrhage leading to death. The benefits of infant male circumcision that have been promoted over time include the prevention of urinary tract infections and sexually transmitted diseases, and the reduction in risk of penile and cervical cancer. Current consensus of medical opinion, including that of the Canadian and American Paediatric Societies and the American Urological Society, is that there is insufficient evidence that these benefits outweigh the potential risks. That is, routine infant male circumcision, i.e. routine removal of normal tissue in a healthy infant, is not recommended.
Legal Considerations
To date, the legality of infant male circumcision has not been tested in the Courts. It is thus assumed to be legal if it is performed competently, in the child’s best interest, and after valid consent has been obtained.
At all times the physician must perform the procedure with competence and at all times, the parent and physician must act in the best interests of the child. Signed parental consent for any treatment is assumed to be valid if the parent understands the nature of the procedure and its associated risks and benefits. However, proxy consent by parents is now being questioned. Many believe it should be limited to consent for diagnosis and treatment of medical conditions, and that it is not relevant for non-therapeutic procedures.
Human Rights Considerations
The matter of infant male circumcision is particularly difficult in regards to human rights, as it involves consideration of the rights of the infant as well as the rights of the parents. Under the Canadian Charter of Rights and Freedoms and the United Nations Universal Declaration of Human Rights, an infant has rights that include security of person, life, freedom and bodily integrity. Routine infant male circumcision is an unnecessary and irreversible procedure. Therefore, many consider it to be “unwarranted mutilating surgery”.
Many adult men are increasingly concerned about whether their parents had the right to give consent for infant male circumcision. They claim that an infant’s rights should take priority over any parental rights to make such a decision. This procedure should be delayed to a later date when the child can make his own informed decision. Parental preference alone does not justify a non-therapeutic procedure.
Others argue that this stance violates the parents’ right to religious or cultural expression, and that adherence to their religious and cultural practices would be in the best interests of the infant. Ethical Considerations
Ethical considerations regarding infant male circumcision centre on the welfare (or “best interests”) of the infant and the potential benefit and harm associated with the procedure. Ethics points us to corrective vision, i.e. to question practices that have become routine, or which we take for granted.
Therefore, each request for the procedure should be carefully evaluated, and an agreement to perform the procedure should take into consideration the ethical principles of beneficence (duty to benefit); non-maleficence (do no harm); veracity (accurate information); autonomy (consent); and justice (fairness).
These principles are articulated in specific responsibility statements in the CMA Code of Ethics. Also included below are items relating to physicians rights and care of the patient.
Beneficence (duty to benefit)
1. Consider first the well-being of the patient.
14. Recommend only those diagnostic and therapeutic procedures that you consider to be beneficial to your patient and not others.
For consideration
Medical evidence is that the benefits of routine infant male circumcision do not outweigh the risks of complications from the procedure. Best interests also take into account the infant’s social circumstances.
Non-maleficence (do no harm)
33. Refuse to participate in or support practices that violate basic human rights.
For consideration
Routine infant male circumcision does cause pain and permanent loss of healthy tissue.
Veracity (adequate information)
13. Make every reasonable effort to communicate with your patients in such way that information exchanged is understood.
For consideration
Discussion should include the new understanding that there is a lack of evidence of a real medical benefit in routine infant male circumcision, that it is non-therapeutic, and that only in rare situations is there any clinical indication for the procedure. Specifics of potential risks and complications should also be explained. It is important to ensure a meaningful discussion between physician and parents, and that the information provided is understood.
Autonomy (informed consent)
12. Provide your patients with the information they need to make informed decisions about their medical care, and answer their questions to the best of your ability.
For consideration
Parents must be given accurate and impartial information to assist them in making an informed decision. The infant, the actual patient, is unable to give consent. Proxy consent by parents for a non-therapeutic procedure is debatable.
Justice (fairness)
29. Recognize that community, society and the environment are important factors in the health of individual patients.
For consideration
Physicians should understand the basis for the request and consider the infant’s social and cultural circumstances and what might be in the infant’s best interest.
Physicians’ Rights
8. Inform your patient when your personal morality would influence the recommendation or practice of any medical procedure that the patient needs or wants.
For Consideration
If your personal beliefs dictate against infant male circumcision, this should be made known to your patients, with an offer of referral to another physician competent in performing the procedure.
Care of the Patient
3. Provide for appropriate care for your patient, including physical comfort and spiritual and psychosocial support.
4. Practice the art and science of medicine competently and without impairment.
6. Recognize your limitations and the competence of others, and, when indicated, recommend that additional opinions and services be sought.
For consideration
As with any medical procedure, if for religious or cultural reasons you decide to perform an infant male circumcision, ensure that your skills are current. Expertise can be maintained only if a sufficient number of such circumcisions are performed.
Recommendation
Best medical practice includes the following standards of practice for doctors who are asked to circumcise male infants:
[Conclusion]
This paper is intended to help physicians use their professional judgement when a request is made for routine infant male circumcision. While parental preference is important, factors like the best available evidence regarding potential benefits and complications, alternatives to this intervention, the infant’s best interest, and current understanding of bioethics should be taken into consideration.
You are not obliged to act upon a request to circumcise an infant, but you must discuss the medical evidence and the current thoughts in bioethics that dissuade you from performing this procedure. You must also inform the parents that they have the right to see another doctor.
If you decide to perform the procedure for religious, cultural or other reasons:
American Academy of Pediatrics. Task force on Circumcision. Circumcision Policy Statement. Pediatrics 1999; 103: 686-693
British Medical Association Committee on Medical Ethics: The Law and Ethics of Male Circumcision: guidance for doctors, March 2003
Canadian Medical Association. Code of Ethics. Can Med Assoc J 1996; 155: 1176A-B
Canadian Paediatric Society. Neonatal circumcision revisited. Can Med Assoc J 1996: 154(6): 769-780
College of Physicians and Surgeons of BC. Code of Ethics. Policy Manual.
College of Physicians and Surgeons of Manitoba. Neonatal Circumcision. Winnipeg: College of Physicians and Surgeons of Manitoba 1997
College of Physicians and Surgeons of Saskatchewan. Caution against Circumcision of Newborn Male Infants. Feb 2002
Christakis DA, Harvey E, Zerr DM et al. A Trade-off Analysis of Routine Newborn Circumcision. Pediatrics 2000. 105: 246-249
Goodman J. Jewish Circumcision: an alternative perspective. BJU International 1999. 83: Suppl. 1, 22-27
Paton M. The Ethics of Circumcising Male Babies. The Bioethics Bulletin (June 1992). Edmonton, University of Alberta.
Richards D. Male Circumcision: Medical or Ritual? Journal of Law and Medicine 1996. 3:371-376
Somerville M. Altering Baby Boys’ Bodies: the ethics of male circumcision. The Ethical Canary: Science, Society and Human Spirit. Toronto: Viking, 2000:202-219
Szasz T. Routine Neonatal Circumcision: Symbol of the Birth of the Therapeutic State. Journal of Medicine and Philosophy 1996:21:137-14, 8 September 2009
Read policy at website of College of Physicians and Surgeons of British Columbia