17 February 2013
To the members of the Canadian Paediatric Society Male Infant Circumcision Policy Committee
The Children’s Health & Human Rights Partnership (CHHRP) is Canada’s first dedicated not-for-profit partnership of medical, legal, and ethics professionals working alongside concerned citizens towards ending forced non-therapeutic genital cutting of children in Canada. We write today to share with you our position and resources as you revise the CPS policy on infant male circumcision.
INTRINSIC VALUE OF THE MALE PREPUCE
The foreskin has been identified to have protective, sensory and sexual functions. Respected Canadian pathologist and medical researcher Dr. John R. Taylor stated:
“The prepuce is a specialized, specific erogenous tissue in both males and females. Therefore, surgical excision should be restricted to lesions that are unresponsive to medical therapy, such as lichen sclerosis of the penis (balanitis xerotica obliterans) or vulva, which is unresponsive to other therapies (e.g. topical clobetasol, intralesional corticosteroids, topical testosterone propionate ointment, etretinate, and carbon dioxide or laser vaporization). Preputial plasty should be considered in place of circumcision whenever possible, so as to preserve the corpuscular sensory receptors, dartos muscle, penile mucosa and complete function of the penis, while avoiding abnormal exposure and keratinization of the glans penis. The complex anatomy and function of the prepuce, along with the fused prepuce/glans penile mucosa in the immature penis, dictates that neonatal circumcision be strictly avoided.”1
We urge the CPS committee to thoroughly consider Dr.Taylor’s contributions in documenting the value and functional purposes of the male foreskin. Numerous recent studies confirm the fact that male circumcision causes sexual dysfunctions for men and negative consequences for their partners. A recent study from Belgium concluded:“The foreskin is more sensitive than the uncircumcised glans mucosa, which means that after circumcision genital sensitivity is lost. In the debate on clitoral surgery the proven loss of sensitivity has been the strongest argument to change medical practice. In the present study there is strong evidence on the erogenous sensitivity of the foreskin. This knowledge hopefully can help doctors and patients in their decision on circumcision for non-medical reason. This study confirms the importance of the foreskin for penile sensitivity, overall sexual satisfaction, and penile functioning. Furthermore, this study shows that a higher percentage of circumcised men experience discomfort or pain and unusual sensations as compared with the uncircumcised population.” 2
IMMEDIATE RISKS AND ADVERSE LONG-TERM CONSEQUENCES
There is documented physiological and psychological damage due to the foreskin unnecessarily being removed. Although not reimbursed under provincial health plans, male infant circumcision by pro-circumcision entrepreneurs remains an all too commonly performed surgery in Canada, with rates varying regionally.3 The typical rationale given for this non-therapeutic surgery is parental preference. 4
There are a number of risks documented in the literature, ranging from hemorrhage to infection to meatal stenosis to death. The psychological consequences of an early circumcision 5 6 7 remain largely undiscussed in the statements of medical societies and have not been incorporated into their recommendations.
In addition, a growing number of adult men believe they were harmed by a circumcision they did not choose, as evidenced by the results of the Global Survey of Circumcision Harm.(see www.CircumcisionHarm.org.)
CANADA’S HUMAN RIGHTS OBLIGATIONS
Children’s human rights are violated when the foreskin is removed unless for truly emergent reasons. No medical organization in the world recommends routine male infant circumcision and a number of national medical organizations strongly condemn the practice 8. While discussion in Canada and the United States appears to still be focused on questionable attempts to justify non-therapeutic genital cutting, countries in Europe, particularly in Scandinavia, have shifted the debate towards the true crux of the issue: human rights and equality. Canada has a long history of acting with leadership and courage to ensure that human rights are safeguarded. John Peters Humphrey OC, a Canadian legal scholar, was the principal drafter of what became the Universal Declaration of Human Rights. In 1991, Canada became a signatory to the United Nations Convention on the Rights of the Child. Male infant circumcision violates this and other human rights legal documents.9 These include:
- The Universal Declaration of Human Rights (UDHR), adopted by Canada in 1948 (http://www.unac.org/rights/actguide/canada.html)
- The United Nations Convention on the Rights of the Child (CRC) ratified by Canada in December 1991. Specifically, Article 24.3 declares that “State Parties shall take all effective and appropriate measures with a view to abolishing traditional practices prejudicial to the health of children.” (http://www2.ohchr.org/english/law/crc.htm)
- The Canadian Charter of Rights and Freedoms, enacted by Canada in 1982 (http://laws-lois.justice.gc.ca/eng/Const/page-15.html)
Under these documents, as well as Canadian criminal law, any form of non-consensual female genital cutting—equal to or less invasive than male infant circumcision, including removal of the female prepuce—has been illegal in Canada since 1997 for any reason, including religion, culture or parental choice. Circumcision of otherwise normal healthy boys is in direct conflict with gender equality rights spelled out in the above documents.
In 2015, boys that were circumcised after this enactment will become adults and could launch Charter-based lawsuits against their circumcisers for violating their human rights. This point requires serious consideration.
It is our sincere hope that, with regard to the social custom of infant male circumcision, the CPS will support the legal and treaty obligations of Canada’s governmental and non- governmental agencies to protect human rights as defined in these documents.
CHHRP invites the CPS to join us and thousands of people around the world in efforts to define, expand, and protect human rights in health relevant settings—such as sexual rights and health—and to uncover substantial inconsistencies in health thinking. One such inconsistency is the unquestioned respect for a female child’s right to genital integrity and autonomy that has heretofore been ignored for the male child. It is our hope to begin a dialogue with the CPS with the mutual goal of promoting the health and human rights of children in Canada.
For future CPS infant circumcision statements, CHHRP encourages the CPS to adopt the following positions:
- the recognition of the protective, sensory and sexual functions of the male prepuce and education on proper care including the associated harm from forcible retraction.
- the recognition that children’s human rights are violated when the foreskin is unnecessarily removed and that there is documented harm caused by it’s loss.
- the discouragement of religious or cultural surgery without medical indication while adopting the World Medical Association’s Declaration of Geneva (2006),which states “I will not use my medical knowledge to violate human rights and civil liberties, even under threat.”
Respectfully submitted by the Co-Founders,
Christopher L. Guest M.D., F.R.C.P.C.
Kira Antinuk, R.C.A., B.S.N.S. (University of Victoria)
1300 King St E PO Box 31011 Kingsway Village PO
Oshawa, ON L1H 8N9
cc. Richard Stanwick, Canadian Paediatric Society President
1 Cold, C. J., & Taylor, J. R. (1999). The prepuce. BJU International, 83 Suppl 1(S1), 34-44. doi: 10.1046/j.1464-410x.1999.0830s1034.x
2 Bronselaer, G.A., Schober, J.M., Meyer-Bahlburg, H.F., T’sjoen, G., Vlietinck, R., Hoebeke, P.B.. (2013). Male circumcision decreases penile sensitivity as measured in a large cohort. BJU Int. doi: 10.1111/j.1464-410X.2012.11761.x.
3 Public Health Agency of Canada. (2009). Mothers’ voices: What women say about pregnancy, childbirth and early motherhood. Ottawa: Public Health Agency of Canada.
4 Elmore, J. M., Baker, L. A., & Snodgrass, W. T. (2002). Topical steroid therapy as an alternative to circumcision for phimosis in boys younger than 3 years. The Journal of Urology, 168 (4 Pt 2), 1746-1747. doi: 10.1016/S0022-5347(05)64404-7
5 Boyle, G.J., Goldman, R., Svoboda, J.S., et al. (2002). Male circumcision: pain, trauma and psychosexual sequelae. J Health Psychol 2002. 7329–343.
6 Taddio, A., Katz, J., Ilersich, A.L., Koren, G., (1997). Effect of neonatal circumcision on pain response during subsequent routine vaccination. Lancet 1997;349(9052):599-603.
7 Yilmaz, E., Batislam, E., Basar, M. M., & Basar, H. (2003). Psychological trauma of circumcision in the phallic period could be avoided by using topical steroids. International Journal of Urology: Official Journal of the Japanese Urological Association, 10(12), 651-656. doi: 10.1046/j.1442-2042.2003.00722.x
8 CIRP, (2012). Circumcision Policy Statements. Retrieved from http://www.cirp.org/library/ statements/ on 4 February 2012
9 Zavales, A., (1995). Introduction to the Urgent Human Rights Proposal (p. 11) in Universal Reproductive & Human Rights: Ordering Corrective Action against North American Circumcisers, Sloatsburg, NY
In 1996 the CPS presented the following conclusions in its Male Infant Circumcision Policy:
“There is evidence that circumcision results in an approximately 12-fold reduction in the incidence of UTI during infancy.”1
A recent Scandinavian study found that girls and boys have about the same incidence of UTI in the first year of life. While non-circumcised female children have a four times higher incidence of UTI in the first six years of life than non-circumcised male children, no special concern is manifested regarding this much higher rate of infection in females and surgery has not been proposed 2
“The incidence rate of the complications of circumcision reported in published articles varies, but it is generally in the order of 0.2% to 2%. Most complications are minor, but occasionally serious complications occur.”3
Williams & Kapila estimated a realistic complication rate of 2% to 10% 4. There is a need for good epidemiological data on the incidence of the surgical complications of circumcision, of the later complications of circumcision and of problems associated with lack of circumcision. We invite you to review the results of the Global Survey of Circumcision Harm for further information about long-term adverse outcomes.
“Evaluation of alternative methods of preventing UTI in infancy is required.”5
As documented in numerous studies, breastfeeding plays a central role in preventing UTIs and does not carry any of the risks of genital surgery. In addition, rooming-in facilitates colonization of the infant’s skin and mucosa with the mother’s own bacteria. The prepuce and other skin and mucosa of the infant should be specifically brought into contact with the mother’s own skin to initiate the child’s natural immunity by passing along her flora.6
“More information on the effect of simple hygienic interventions is needed.” 7
CHHRP members do receive anecdotal reports of physicians, nurses, and other healthcare providers instructing parents to retract the prepuce and clean underneath. This is an outdated practice which involves tearing the synechia, and potentially causing pain, skin tears, inflammation, and infection.
“Information is required on the incidence of circumcision that is truly needed in later childhood.”8
Denniston states: “Since the neonatal circumcision rate in Finland, where virtually every male wishes to preserve his foreskin, is zero, and since the risk of needing a late circumcision in Finland is one in 16,667, it follows that almost all of the circumcisions still being done in North America have no medical necessity, and in fact, are contraindicated.”9
“There is evidence that circumcision results in a reduction in the incidence of penile cancer and of HIV transmission. However, there is inadequate information to recommend circumcision as a public health measure to prevent these diseases.”10
The assumption that circumcision has prophylactic value against heterosexually transmitted HIV infections is mainly based on data collected in Sub-Saharan Africa, which are strongly doubted. The African HIV trials reveal a number of methodological weaknesses 11 and they contradict larger demographic trends in global HIV prevalence. For instance, the United States has a high prevalence of circumcision12, yet has a significantly higher rate of HIV infection compared with countries like Sweden and Japan where the prevalence of circumcision is very low13. HIV from men who had sex with men (MSM) is no different based on circumcision status14. Behavioural factors greatly overshadow any potential protective effect of circumcision and should be the focus of effective and ethical prevention strategies. Even if the African trials were scientifically valid, the evidence can not be applied to justify infant circumcision in countries where the incidence of heterosexual HIV transmission is low15
With regard to penile or cervical cancers, it is known that Human Papilloma Virus (HPV) is largely responsible, transmission of which can be effectively prevented by proper hygiene and the use of condoms. Additionally the recently released HPV vaccine, Gardasil, can play a major role in prevention against genital infections among sexually active men and women. All of these obviate the need for infant male circumcision.
“When parents are making a decision about circumcision, they should be advised of the present state of medical knowledge about its benefits and harms. Their decision may ultimately be based on personal, religious or cultural factors.”16
In 2010, the American Academy of Pediatrics issued a statement to its members suggesting that they honour the practice of performing clitoral nicking on female infants based on personal, religious, cultural or parental wishes. After a significant backlash from the medical community and the public, this statement was rescinded. We hope the CPS will give appropriate consideration to the same fundamental right to bodily integrity for male children that it accords to female children.
1 Canadian Paediatric Society, (1996). Neonatal circumcision revisited. Canadian Medical Association Journal 1996: 154(6):769-780
2 Brandström, P., Jodal, U., Sillén, U., Hansson, S., Institute of Clinical Sciences, Section for the Health of Women and Children, Department of Pediatrics, Göteborgs universitet, Sahlgrenska akademin. (2011). The swedish reflux trial: Review of a randomized, controlled trial in children with dilating vesicoureteral reflux. Journal of Pediatric Urology, 7(6), 594. doi: 10.1016/j.jpurol. 2011.05.006
3 Canadian Paediatric Society, (1996). Neonatal circumcision revisited. Canadian Medical Association Journal 1996: 154(6):769-780
4 Williams, N., and Kapila, L., (1993). Complications of circumcision. British Journal of Surgery; 80:1231-36.
5 Canadian Paediatric Society, (1996). Neonatal circumcision revisited. Canadian Medical Association Journal 1996: 154(6):769-780
6 Winberg, J., Bollgren, I., Gothefors, L., (1989). The prepuce: a mistake of nature? Lancet 1989; 1: 598-599
7 Canadian Paediatric Society, (1996). Neonatal circumcision revisited. Canadian Medical Association Journal 1996: 154(6):769-780
8 Canadian Paediatric Society, (1996). Neonatal circumcision revisited. Canadian Medical Association Journal 1996: 154(6):769-780
9 Denniston, G. (1996). Circumcision and the Code of Ethics. Humane Health Care International, Volume 12, Number 2: Pages 78-80.
10 Canadian Paediatric Society, (1996). Neonatal circumcision revisited. Canadian Medical Association Journal 1996: 154(6):769-780
11 Boyle, G.J., Hill, G., (2011). Sub-Saharan African randomised clinical trials into male circumcision and HIV transmission: Methodological, ethical, and legal concerns. JLM 2011;19: 316-334.
12 Storms, M.R., (1996). AAFP fact sheet on neonatal circumcision: Need for updating. Am Fam Physician 1996;54;1216,1218.
13 UNAIDS, 2002
14 Millett GA, Flores SA, Marks G, Reed JB, Herbst JH. Circumcision status and risk of HIV and sexually transmitted infections among men who have sex with men. JAMA 2008; 300:1674-1684. Errata JAMA 2009; 301: 1126-9.
15 Darby, R., Van Howe, R., (2011). Not a surgical vaccine: there is no case for boosting infant male circumcision to combat heterosexual transmission of HIV in Australia. Austr NZ J Pub Health. 2011;35(5):459-465.
16 Canadian Paediatric Society, (1996). Neonatal circumcision revisited. Canadian Medical Association Journal 1996: 154(6):769-780
September 22, 2012
Dr. Christopher L. Guest, Co-Founder of the Children’s Health and Human Rights Partnership replies to the American Academy of Pediatrics (AAP) revised statement on male infant circumcision calling it “A disservice to Americans”. His reply was published to the AAP’s on-line journal. View journal posting here.
Revised male infant circumcision policy: A disservice to Americans
The American Academy of Pediatrics (AAP) revised statement on male infant circumcision claims “the benefits of circumcision may exceed the risk of complications” but the AAP fails to recognize the sensory and mechanical function of the human foreskin. The foreskin is richly innervated, erogenous tissue which enhances sexual pleasure and it also provides a unique, linear gliding mechanism during sexual intercourse. In 2009, the College of Physicians and Surgeons of British Columbia stated “the foreskin is rich in specialized sensory nerve endings.” In 2010, the Royal Australian College of Physicians stated “the foreskin is a primary sensory part of the penis, containing some of the most sensitive areas of the penis” and in the same year, 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.” The AAP statement fails to consider the obstinate relationship between structure and function as it pertains to the foreskin; circumcision alters the structure of the penis which inevitably alters function. The long term harm and sexual side effects of circumcision have not been adequately studied.
The revised statement also claims “circumcision may decrease the risk of heterosexual HIV transmission” and is supported with selective evidence from randomized control trials from Kenya, Uganda and South Africa. These trials reveal a number of methodological weaknesses and they contradict larger demographic trends in global HIV prevalence. For instance, the United States has a high prevalence of circumcision, yet has a significantly higher rate of HIV infection compared with countries like Sweden and Japan where the prevalence of circumcision is very low. Behavioural factors greatly overshadow any potential protective effect of circumcision and should be the focus of effective and ethical prevention strategies. Even if the African trials were scientifically valid, the evidence can not be applied to justify infant circumcision in North America where the incidence of heterosexual HIV transmission is low.
The revised statement also claims “circumcision may decrease the risk of urinary tract infections” yet the AAP ignores the wealth of international medical evidence to the contrary. Even if circumcision provided complete protection against urinary tract infections, this practice could never be justified based on the ethical principle of proportionality – there are effective and less destructive therapies available for preventing and treating urinary tract infections which do not involve the prophylactic removal of healthy genital tissue.
The AAP’s revised statement ignores the inherent conflict of circumcision with contemporary medical ethics. Infant circumcision violates the fundamental ethical principles of autonomy, beneficence and primum non nocere. Medical associations in the Netherlands, Finland, Sweden, Norway, Denmark, Germany and other countries have stated that there is no justification for performing the procedure without medical urgency. Medical associations in these countries are calling for the practice to stop due to ethical and human rights concerns. The AAP’s new position statement does a disservice to American parents and children.
Respectfully, Christopher L. Guest M.D., F.R.C.P.C.
Conflict of Interest:
August 1, 2012
On 24 July and 01 August of 2012 representatives Tim Hammond and David Saving of the Children’s Health and Human Rights Partnership delivered a letter to the German Consulates General in Vancouver and Toronto addressed to German Chancellor Angela Merkel and the Bundestag. The letter, in both English and German, expressed CHHRP’s concern about any hasty introduction of legislation that would ‘protect circumcision’ from being prohibited. The letter urged Germany’s politicians to consider Germany’s international treaty obligations to children’s rights, as well as the impact that any such legislation would have on the rights of children not only in Germany, but in Canada and around the world.