Three Canadian position statements on circumcision

Canada: one small step for Saskatchewan,
a smaller one for British Columbia
one step back and two forward for Manitoba

Saskatchewan: College Urges Doctors Not To Circumcise

The College of Physicians and Surgeons of Saskatchewan has advised its members to "accurately and effectively convey the message" that infant male circumcision is "not a recommended procedure."

Here is the full text of the memo:

February 20, 2002.

TO: Members of the College

FROM: Registrar

RE: Caution Against Routine Circumcision of Newborn Male Infants

The practice of medicine is increasingly becoming evidence based. There is a strong and growing consensus that medical intervention should be based upon sound evidence of expected benefit that outweighs the potential risk of any such intervention.

Where there is little evidence of expected benefit from a surgical procedure, but well recognized risk of surgical complications that may cause harm, it would generally be considered imprudent if not improper for a surgeon to perform such a surgical procedure.

Notwithstanding these fundamental principles, 27.6% of newborn males were circumcised in this province in 2000-2001, in spite of the fact that the Canadian Paediatric Society (CPS) has for two and a half decades explicitly cautioned against routine circumcision of newborn male infants.

Since August 1996, infant circumcision has not been a publicly insured service in Saskatchewan. The decision to de-insure the service was based partly on the lack of valid medical indications for the procedure.

Even though citizens must now personally pay for this service, the incidence of routine male circumcision has dropped only moderately over the past five years.

The relatively high rate of newborn male circumcision in Saskatchewan stands in very sharp contrast to that in some other regions of the country. For example, in Nova Scotia the rate has dropped to 1.5%, while in Newfoundland/Labrador it has dropped to 0.6%.

Such high infant circumcision rates in Saskatchewan in the face of an explicit caution from the CPS is of great concern to the College of Physicians and Surgeons, and ought to be a concern to all physicians who perform the procedure.

Is it possible that so many Saskatchewan physicians are totally unaware of the position of the CPS, and the research evidence that supports that position?

If physicians are unaware [sic] of the evidence against routine newborn circumcision, why do they continue to practice in a manner that ignores this evidence?

In my dialogue with Saskatchewan physicians about this issue, I’ve encountered many who claim to be “neutral” in their opinion about routine circumcision, but perform the procedure strictly on the basis of parental preference.

On the surface, that approach might seem commendable as it seems sensitive and responsive to parental values. However, it begs the question as to whether the parents are appropriately informed about the benefits and risk of this procedure. Even more importantly, it begs the question as to whether physicians are providing accurate and adequate information to parents that is likely to yield a truly informed decision on their part.

Informed consent to any surgical procedure relies on an assumption that the decision maker possesses full and accurate information about both the benefits and risks of the procedure. The onus is cast upon the surgeon, who might perform the procedure, to ensure that such information is not only conveyed to the decision maker, but is understood by the decision maker.

It is difficult to identify any other domain of medicine in which physicians would feel comfortable playing such a passive role in a decision pathway culminating in surgery. It is also difficult to identify any other domain of medicine in which practice patterns stand in such stark contrast to research evidence.

When the Council of the College of Physicians and Surgeons reviewed this issue at its last meeting, it directed the Registrar to initiate an effective educational strategy to raise professional and public awareness of this issue. The first step in that strategy is this memo, which is directed to all members of the College who perform circumcisions, or are likely in a position to influence parental decision making on this issue.

These are my recommendations to you:

(1) First, be sure that you are fully and accurately informed about the research literature on this subject, which serves as the basis for the CPS position against routine circumcision of newborn male infants.

You can obtain a copy of the CPS Position Paper, and a succinct summary of the relevant research evidence by logging on to the CPS website at www.cps.ca.

If you are not able to access this information from the CPS website, please give Ms. Jo-Anne Wolan a call at the College. We will be pleased to send you a written copy of the CPS position paper.

(2) In any dialogue you have with patients about potential circumcision of their newborn male infants, be sure that you accurately and effectively convey the message that this is not a recommended procedure.

(3) If parents remain adamant in their preference that circumcision be performed, notwithstanding their awareness of the research on the subject, remember that you are under no obligation to perform any surgical procedure for which there are not valid medical indications. You can, and should, respectfully decline to perform the procedure just as you respectfully decline to carry out other requested medical acts that you regard to be inappropriate.

(4) If the parental request for infant male circumcision is based exclusively upon religious beliefs and values, and you are inclined to act in deference to those religious beliefs and values, you would be prudent to require parental signature of a consent document which clearly stipulates that the circumcision in question is not medically indicated and is being performed in accordance with parental religious practices.

In such cases, physician would be prudent to consult with and seek advice from the Canadian Medical Protective Association before proceeding.

A graphic of the actual memo (off site).

This memo is excellent as far as it goes, and Intactivists must applaud it - loudly.

It could well have gone further, however, and said:

The ethics of infant circumcision, lacking clear medical need, are in doubt. However
- The first responsibility of the doctor is toward the infant patient, not his parents.
- Parents may not consent to unnecessary surgery on behalf of their child.
- When the patient has no medical condition or clear cosmetic need, the doctor has a responsibility not to operate.
- Nor should the doctor pass the buck by referring the parents to another doctor who will.
It is not for doctors, as doctors, to perform religious rituals.
Medical circumcision does not by itself comply with any religious requirements.

British Columbia: College cops out on ethics, leaves it to parents

The Council of the College of Physicians & Surgeons of British Columbia leaves "routine infant male [but not female] circumcision" to "parental choice" suggesting only mild discouragements and relying on time to end the practice.

COLLEGE OF PHYSICIANS AND SURGEONS OF BRITISH COLUMBIA · FALL 2002 · ISSUE 38

INFANT MALE CIRCUMCISION

The matter of routine infant male circumcision was a subject of discussion at a recent meeting of the College Council. The College has received repeated requests from special interest groups and individuals to "ban" this procedure.[Why the scare quotes? The College has the power to order its members not to perform surgery unless criteria are met, such as clear medical need or informed consent of the actual patient, effectively banning routine infant circumcision.] Their objections to routine infant male circumcision are based on a variety of factors including the lack of medical indications, the right of the newborn to make its own long term decisions, immediate risks, long term effects, ethical issues, and so on. [Note the dismissive "...and so on." The factors cited should be enough to make them take the issue much more seriously.]

The College's position on routine infant male circumcision is that it is a matter of patients' (or parental) [Note how they blur this important distinction] choice, which may be based on traditional, religious, cultural or personal preference. The issue of perceived medical necessity is, in the opinion of most experts, no longer pertinent. Though some studies suggest slightly lower frequencies of urinary tract infection and decreases in HIV transmission in circumcised males, most physicians agree that the procedure should be regarded as a "cosmetic" procedure and in North America should be approached as such. Younger physicians (coming out of training programs) often do not have skill or experience in performing circumcisions and also may have little interest in acquiring such skills or being involved in the procedure.

College Council did not identify any necessity to place restrictions on the availability of routine infant male circumcision, except to remind physicians that when performed routinely, this is a cosmetic surgical procedure which should only be considered after detailed discussion with the parents. This allows parental request and consent to be based on accurate and comprehensive information.

[Thus the College has completely abrogated any responsibility for upholding medical ethics.]

Such discussions should include the fact that infant circumcision is not a medical necessity, that many experts including national pediatric associations do not recommend it, that there are risks such as bleeding and infection which can be significant in rare instances, and that currently the majority of male infants are not circumcised.

Also, physicians should be aware that they are not required to accept the parents' request for routine circumcision if they are personally unable or unwilling to perform the procedure. Such requests should be referred to others in those situations.

[They are not required to do that either. Is that what they would do if the child were a girl?]

It is Council's opinion that the requests for this procedure will decrease through the natural evolution of public and medical opinion [...to which this memo has failed to make any contribution]. As a uniquely North American cultural trend in the absence of medical indications, (except for requests based upon religious beliefs [What business do doctors have performing surgery for religious reasons?]) routine infant circumcision will likely become an uncommon procedure.

The College of Physicians and Surgeons of Manitoba

In its December 2002 newsletter, the College waters down Saskatchewan's recommendation to opt out, but (hooray!) acknowledges the foreskin's erogenous function, the Intactivism movement, the penis-owners' retroactive opposition and the risk of litigation.

Newsletter

Caution Regarding Routine Circumcision of Newborn Male Infants

Over the past six months, the Saskatchewan College has provided all its members with two documents discussing the issue of routine male circumcision. With permission of that College, the following excerpts are presented for your consideration:

A. Recommendations by the Saskatchewan College:

(i) Be sure that you as a physician are fully and accurately informed about the research literature on this subject, which serves as the basis for the Canadian Paediatric Society position against routine circumcision of newborn male infants. A copy of this position paper and a summary of the relevant research may be obtained from the CPSS website.

(ii) In any dialogue with patients about potential circumcision of newborn male infants, be sure that you accurately and effectively convey the message that this is not a recommended procedure.

(iii) If parents remain adamant in their preference that circumcision be performed, notwithstanding their awareness of the research on the subject, remember that you are under no obligation to perform any surgical procedure for which there are not valid medical indications. You may, and should consider respectfully declining [this has been changed without comment from "should respectfully decline" in the Saskatchewan letter] to perform the procedure just as you respectfully decline to carry out other requested medical acts that you regard to be inappropriate.

(iv) If the parental request for infant male circumcision is based exclusively upon religious beliefs and values, and you are inclined to act in deference to those religious beliefs and values, you would be prudent to require parental signature on the consent document which clearly stipulates that the circumcision in question is not medically indicated and is being performed with parental religious practices.

B. It is the expectation of the College that all physicians exercise sound professional judgement in all the professional decisions they make. In the exercise of professional judgement, physicians ought to consider many factors, including the preference of patients (guardians), the best available evidence with respect to potential benefits and risks of a contemplated intervention, and alternatives to that intervention. Maintenance of professionalism demands that physicians decline to become little more than robots who perform an array of medical interventions on demand. No physician should be coerced to perform a medical procedure that is contrary to his/her professional judgement.

When physicians receive requests for infant male circumcision, it is important that physicians take ample time to gain an understanding of the basis for the request, to provide accurate detailed information to parents about the potential benefits, risks and alternatives, and to gauge their understanding of that information.

If parents persistently request circumcision of a newborn male infant after a thorough dialogue about benefits, risks and alternatives, a physician is not obligated to perform the procedure if he/she does not regard the procedure to be medically indicated and appropriate. Physicians may respectfully decline to perform this medical procedure, just as they respectfully decline to prescribe medications that are not medically indicated, and as they decline to offer medical opinions contrary to their best professional judgement.

Where infant male circumcision is requested for religious rather than medical reasons, there is a high probability that the procedure will be performed by someone other than a physician if the option is not made available through a physician. Where a physician is confronted with a request for infant male circumcision based upon religious rather than medical reasons, and where physicians may be inclined to comply with such a request as the 'lesser of two evils', even though contrary to his/her medical judgement, the College recommends that physicians obtain advice from the CMPA about appropriate documentation of the consent process, so that it explicitly defines the conditions under which the procedure is performed. [This is not what the College would recommend if the baby were a girl.] Obtaining informed consent for any procedure requires disclosure of all relative benefit and risks of the anticipated procedure, as well as alternatives to that procedure. A prudent physician will make a reasonable effort to achieve understanding of the information that is shared with parents/guardians.

To formulate and certify a professional opinion that a patient has understood the nature, effect, risks and alternatives of a contemplated medical intervention requires more than one way disclosure of risks to the patient. It requires two way dialogue through which the physician has reasonable potential to gauge the understanding held by the patient or guardian.

The Canadian Paediatric Society has concluded that the overall evidence of the benefits and harms of circumcision is so evenly balanced that it does not support recommended [sic, presumably "recommending"] circumcision as a routine [apparently meaning "without medical need" rather than "without consent"] procedure for newborns. Infant male circumcision is often treated as a minor procedure with virtually no risk or significant complications. That is not true. Infant male circumcision may lead to complications that range from minor to severe. A study reported in the British Journal of Surgery (1993) suggested that complication rates range between 2%-10%. [Other studies suggest higher rates.]

In many countries, including Canada, citizen groups are gaining a higher profile and more credibility among the general public. They are brin[g]ing to light new evidence that the male prepuce may play an important physiological and psychological role in adult male function, which has to date been largely ignored in any consideration of harm associated with infant male circumcision. As a consequence of the public awareness raised by these groups, a growing number of adult males and/or their parents are now expressing strong resentment against physicians who performed infant male circumcision many years ago at their request. The retroactive anger towards these patients [sic, presumably "physicians"] is generally based upon arguments that parents were given woefully inadequate information about the potential adverse impact on adult male function, and inadequate information about normal infant penile development and hygiene. While the College's primary mandate is public protection, we encourage physicians to give careful thought to the long term risks [i.e. of litigation] that may occur by taking an inappropriately casual approach to infant male circumcision driven exclusively by parental preference without valid medical indications for the procedure.

The College of Physicians and Surgeons of Manitoba

Back to the Intactivism index page.