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Letter to the Canadian Paediatric Society Male Infant Circumcision Policy Committee May 19, 2014

19 May 2014

To the members of the Canadian Paediatric Society Male Infant Circumcision Policy Committee

cc. Dr. Andrew Lynk, MD, Canadian Paediatric Society President

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. Our work is in accordance with the Canadian Charter of Rights and Freedoms and international human rights law.

We write today to inform you of important developments surrounding the practice of infant male circumcision which should be seriously considered when formulating any future policy statements on the practice in Canada. We offer this with the hope that the Canadian Paediatric Society will take a strong stand in favour of allowing males—when there is otherwise no immediate medical need—to decide upon and consent to circumcision at an age when they can fully understand the consequences.

Such a stand would be consistent with the international movement of child protection advocates, especially paediatric and medical societies and children’s ombudspersons in Europe, who recognize this issue as an important human rights concern.

We enclose for your benefit a copy of the 2012 report from the International NGO Council on Violence against Children. This groundbreaking report identifies numerous harmful practices based on tradition, culture, religion or superstition that violate the rights of children.

While we encourage you to read the entire report for contextual reasons, we wish to draw your attention to those sections we believe are relevant to the present discussion of neonatal circumcision.

Page 7 lists general categories of rights violations based on tradition, culture, religion and superstition. It is difficult to argue that circumcision of otherwise healthy newborns is not a medical, cultural or religious tradition and that many parental motivations for requesting newborn circumcision can be considered superstitious or based on fear of the unknown, e.g., “My uncle had to be circumcised as an adult so we might as well do it to our son now” or “My son will be psychologically harmed if he doesn’t look like his circumcised father or the other boys”.

The report goes on to state (bolding is ours): “The list includes a number of practices perpetrated through false beliefs about child development and the cause and treatment of ill-health. These may stem from religious edict or belief, or from tradition or superstition or in some cases be promoted by health practitioners.”

This is the case especially in North America, where paediatric societies take ambiguous stands and fail to firmly reject any medical justification for newborn circumcision and who issue statements that ignore the functions, benefits, and natural development of the foreskin, while failing to identify the newborn’s inherent right to bodily integrity. You will take note that the practice of male circumcision is specifically identified on pages 21 and 22 as a traditional practice that violates the rights of male children (to bodily integrity). The report states 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.”

The report also recognizes that “There are now substantial established campaigns against non-therapeutic, non-consensual circumcision of boys and growing support to end it, particularly within the medical community.” The rest of the paragraph from which this excerpt was taken, we believe, is mandatory reading for any paediatric association that claims to have its child patients’ best interests at heart.

Page 47 of the report asserts that health practitioners should be encouraged to work actively to eliminate these harmful practices as parts of their codes of ethical conduct. We at CHHRP assert that this duty to child patients extends to the issuance of a neonatal circumcision policy that explicitly identifies the right of the child to physical integrity and eventual self-determination.

It has become increasingly clear that Europeans are taking seriously their pledge to protect children as well as their international treaty commitments regarding this group of vulnerable citizens. Their medical associations, child welfare agencies, and some legislative bodies reject the promotion of circumcision of otherwise healthy children, especially when such promotion is done by medical professionals and associations.

The American Academy of Pediatrics (AAP) has been publicly condemned by international paediatric authorities for its shoddy 2012 statement that failed to recognize the functions of the foreskin, the medical ethics involved in non-therapeutic circumcision, and the important human rights that are violated by those who circumcise otherwise healthy children. We direct you to one such rebuke signed by 38 physicians from 16 European nations, and Canada’s own Dr. Noni MacDonald.
Source: http://intaction.org/circumcision-policy-denounced/
Full Document: http://pediatrics.aappublications.org/content/early/2013/03/12/peds.2012-2896.full.pdf+html

As further evidence of the cultural bias and personal and professional ignorance of AAP Task Force members on this matter, in October 2013 at the 20th Pitts Lectureship in Medical Ethics at the Medical University of South Carolina in Charleston, South Carolina two members of the AAP Task Force on Circumcision were asked by a member of the audience to identify the functions of the foreskin. Task Force member Dr. Michael Brady stated “I don’t think anyone knows the functions of the foreskin” and later reiterated “Nobody knows the functions of the foreskin.”

Source: http://arclaw.org/our-work/presentations/charleston-debate-marks-turning-point-movement-recognize-circumcision-human-r

It deeply concerns us to report that the bias does not end there. Dr. Andrew Freedman, one of the AAP circumcision policy task force members, when asked if he had a son and whether he had him circumcised, was quoted as saying: “Yes, I do. I circumcised him myself on my parents’ kitchen table.” We at CHHRP certainly hope the CPS has taken the necessary steps to guard against such blatant conflicts of interest amongst the members of its Male Infant Circumcision Policy Committee.
Source: http://www.thejewishweek.com/features/new-york-minute/fleshing-out-change-circumcision

We also note that much media attention has been paid recently to a recent review that attempts to equate neonatal circumcision with vaccination. Any clear-thinking individual can see the many ways in which this is a false equivalency; however, if left unchecked, this logically unsupportable notion may gain traction among the public. We hope that any future CPS statement on circumcision will refute such attempts to conflate these two practices.
Source: http://www.ctvnews.ca/health/circumcision-should-be-seen-in-the-same-light-as-childhood-vaccination- study-1.1757650#ixzz2xkx6ATBP

 

SUMMARY

Canada has always been a leader in the international arena when it comes to recognizing human rights — in many cases long before our immediate neighbours to the South. We look forward to a forthcoming update from the CPS on this topic and sincerely hope that the update will not embarrass Canadians by merely parroting the AAP statement, but will be a document that all Canadians can be proud of by progressively incorporating the important issues described in the enclosed report.

 

In unity for the children,

 

Dr. Christopher L. Guest, MD, FRCPC Medical Director

Kira Antinuk, RN, BScN Nursing Director

Tim Hammond Outreach Director

David Saving Technical Director

Dr. Arif Bhimji, MD Advisory Board Member

Dr. Cameron Bowman, MD, FRCSC Advisory Board Member

Dr. Kaleb Montgomery, HBSc, DTCM Advisory Board Member

Jessica Forbes, RM Advisory Board Member

Kerstin Helén, RN, RM, BScN Advisory Board Member

Tony Chacon, RN, BSN, MN(c) Advisory Board Member

Geoffrey T. Falk, BSc, MA Advisory Board Member

Tracy Cassels, BA, MA, PhD(c) Advisory Board Member

 

 

Circumcision – Medical and Ethical Opposition

MEO Lecture poster May

Speaking to expectant parents about circumcision is challenging. How can health care providers ensure they are providing current, evidence-based information which takes into account their professional ethical responsibilities?

Join Dr. Christopher Guest, MD, FRCPC, for an in-depth exploration of:

  • the historical origins of circumcision
  • worldwide trends in circumcision
  • the sexual and physiologic function of the foreskin
  • evolutionary perspectives on the foreskin
  • medicalization of circumcision during the Victorian era
  • examination of the medical claims in support of circumcision
  • circumcision and HIV transmission
  • circumcision and medical ethics
  • circumcision and human rights

MAY 22, 2014

Refreshments from 6:30 pm

Program 7:00 – 9:00 pm

Hosted by Born Midwives

205-766 (Old) Hespeler Rd, Cambridge, ON Tel: (519) 267-7266

Bring your business card for a door-prize draw!

Registration fee: $25.00 Secure your registration online here.

 

Call For Abstracts

The National Organization of Circumcision Information Resource Centers (USA),
Intact America, Genital Autonomy (UK and Australia), and the Sexpo Foundation (Finland) present

GENITAL AUTONOMY 2014

“Whole Bodies, Whole Selves: Activating Social Change”
The 13th International Symposium on Genital Autonomy and Children’s Rights
University of Colorado
Boulder, Colorado, USA
July 24-26, 2014

The International Symposia on Genital Autonomy and Children’s Rights promote interdisciplinary dialogue about genital cutting practices of male, female, and intersex children, and on strategies for protecting children from medically unnecessary genital alteration. The Symposia offer an informational and practical platform for effecting social change and are designed to be of interest to legal, medical, and mental health professionals; scholars, educators, and students; policy makers and the media; activists and the general public.

Abstracts are currently being accepted for 20-minute plenary presentations in the areas of:

• genital alteration of male, female, and intersex infants and children
• medicine, anatomy, sexuality
• psychology, sociology, anthropology
• religion, history
• law, ethics, human rights
• activism and social change

The deadline for abstract submission is December 15, 2013. Please email your abstract to nocirc@cris.com. Submitters will be notified of the status of their submission by February 15, 2014.

Each submission must include:

• Author’s name and contact information (email, telephone, mailing address).
• Author’s biography of 100 words or less, including degrees/credentials and current affiliations, for use in the Program and Syllabus of Abstracts.
• Title of presentation.
• Abstract of 150 words or less.

 

Birth & Beyond – London, Ontario

The Children’s Health & Human Rights Partnership was invited once again to the incredible Birth and Beyond Conference, in London, Ontario November 7, 8 & 9th, 2013. CHHRP’s Medical Director, Dr. Christopher Guest, presented a compelling lecture on medical and ethical opposition to male infant circumcision and our fantastic volunteers assisted Conference guests with print and video resources.

http://www.birthandbeyondconference.ca

 

 

 

 

 

 

 

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CHHRP Director Wins Ethics Award

CHHRP Nursing Director Kira Antinuk, RN, BScN, MN discusses events that prompted her to research circumcision and pursue a nursing career. Antinuk’s article, “Forced genital cutting in North America: Feminist theory and nursing considerations” was published in the September issue (20: 723-728) of Nursing Ethics and Antinuk was awarded the 2013 Paul Wainwright Nursing Ethics prize.

CORRESPONDENCE TO THE CANADIAN AIDS SOCIETY

CORRESPONDENCE TO THE CANADIAN AIDS SOCIETY:

30 September 2013

 

Dear Monique Doolittle-Romas,

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 our concerns 
regarding your policy on male circumcision and HIV.

In particular, we ask the Canadian AIDS Society (CAS) to incorporate two issues into your male circumcision policy:

1) The methodologically flawed nature of studies that allegedly support male circumcision in the campaign against HIV

2) CAS male circumcision policy implications

 

Methodology

While many well-intentioned health organizations have cited the African 
circumcision trials as reliable evidence that male circumcision is an effective tool in the fight against HIV/AIDS, these studies are misleading. For example, 
assuming the quoted 50-60% risk reduction was scientifically valid, this is a “relative risk” reduction, as opposed to an “absolute risk” reduction. The 
absolute risk reduction in these studies was 1.31% – a significantly smaller number than the figure touted publicly.123 (Please see Appendix A for an 
explanation of relative and absolute risk reduction). This misleading and 
unscientific data manipulation falsely implies that male circumcision is 
effective at preventing HIV/AIDS. Many men may believe that they no longer need to use condoms after undergoing circumcision. Furthermore, these 

African trials contradict larger demographic trends with respect to circumcision and HIV/AIDS prevalence.  For instance, the United States has a high circumcision rate but also has a significantly higher rate of heterosexual HIV transmission than other countries where circumcision is very rare. Collectable data from African countries shows circumcising countries also have a higher prevalence for HIV/AIDS, (see Appendix B). Correct and consistent use of condoms reduces HIV transmission by an absolute risk reduction of 80% 4 – far higher than the alleged 1.31% absolute risk reduction for male circumcision. Effective and ethical prevention strategies should emphasize correct condom usage, which is still required even after circumcision.

As Boyle, G. J., & Hill, G. stated, “While the ’gold standard’ for medical trials is the randomised, double-blind, placebo-controlled trial, the African trials suffered design and sampling problems including; problematic randomisation and selection bias, inadequate blinding, lack of placebo-control (male circumcision could not be concealed), inadequate equipoise, experimenter bias, attrition (673 drop-outs in female-to-male trials [7% drop out rate]), not investigating male circumcision as a vector for HIV transmission, not investigating non-sexual HIV transmission, as well as lead-time bias, supportive bias (circumcised men received additional [safe sex] counselling sessions), participant expectation bias, and time-out discrepancy (restraint from sexual activity only by circumcised men).”5 Many other scientific papers have also been highly critical of the HIV trials as a method for HIV/AIDS reduction.6789

 

CAS Male Circumcision Policy Implications

The CAS states in its circumcision policy statement, “Ultimately, it is another prevention option that should be available to those who choose it as such”. This begs a serious ethical and human rights question of whether the parent has the right to choose or whether consent must come from the individual to whom the genitals belong, once he reaches an appropriate age.  It is the individual who must live with the permanent physical, sexual, and psychological effects of the surgery, as well as any additional surgical complications. For further information, please see the results of the Global Survey of Circumcision Harm at www.circumcisionharm.org

We receive frequent reports that many of these African circumcision programs, intended for consenting adult men, are in fact influencing North American parents to impose forced circumcision on their newborn male infants. Since these children will not become sexually active for many years, subjecting them to a permanent surgical alteration, in a misguided attempt to prevent future disease, violates their personal autonomy and robs them of their right to physical integrity as guaranteed in the Canadian Charter of Rights and Freedoms.

Canadian human rights law and treatises maintain that all children have equal protection under the law. These include:

The Universal Declaration of Human Rights (UDHR), adopted by Canada in 1948 (http://www.un.org/en/documents/udhr/)

The United Nations Convention on the Rights of the Child (CRC) ratified by Canada in December 1991. Specifically, Article 24.3 declares, “State Parties shall take all effective and appropriate measures with a view to abolishing traditional practices prejudicial to the health of children.” (http://www.un.org/documents/ga/res/44/a44r025.htm)

The Canadian Charter of Rights and Freedoms, enshrined in the Canadian constitution in 1982 (http://laws-lois.justice.gc.ca/eng/Const/page-15.html)

Any form of non-consensual female genital cutting—equal to or less invasive than male infant circumcision, including removal of the female prepuce—for any reason, including the potential to reduce vulvar cancer or sexually transmitted diseases, has been illegal in Canada since 1997.1011 Circumcision of otherwise normal healthy boys is in direct conflict with gender equality rights spelled out in the above documents.

 

The Valid Function of the Foreskin

“The prepuce [foreskin] is an integral, normal part of the external genitalia that forms the anatomical covering of the glans penis and clitoris… The prepuce is richly innervated, erogenous tissue.”12  It also serves an important mechanical function, providing a linear bearing mechanism during sexual intercourse.1314 For further information on the form and function of the penis and the mechanics of intercourse please visit the cited references.

Respect for a child’s developing sexuality, regardless of gender, is recognized in the 1997 Valencia Declaration of Sexual Rights adopted by the XIII World Congress of Sexology, which states:

“We urge that societies create the conditions to satisfy the needs for the full development of the individual and respect the following sexual rights: …The right to autonomy, integrity and safety of the body. This right encompasses control and enjoyment of our own bodies, free from torture, mutilation and violence of any sort.”15

 

Summary

CHHRP invites the CAS to join 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 thus far been ignored for the male child.

It is our hope that the CAS will recognize that male circumcision is not an effective tool in the fight against HIV/AIDS. We also hope that the CAS recognizes the human rights and possible Canadian legal implications of suggesting male circumcision as part of a HIV/AIDS prevention strategy. We look forward to a continuing dialogue with the CAS.

 

Respectfully submitted by,

Christopher L. Guest M.D., F.R.C.P.C.

Medical Director, Children’s Health & Human Rights Partnership

 

1300 King St E PO Box 31011
Kingsway Village PO
Oshawa, ON L1H 8N9

 

 

References

 

1 Bailey, R.C., Moses, S., Parker, C.B., Agot, K., Maclean, I., Krieger, J.N., et al. Male circumcisi1on for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet 2007; 369: 643-56 doi: 10.1016/S0140-6736(07)60312-2 pmid: 17321310.

2 Auvert, B., Taljaard, D, Lagarde, E., Sobngwi‐Tambekou, J., Sitta, R., & Puren, A. (2005). Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS medicine, 2 (11), e298.

3 Gray, R. H., Kigozi, G., Serwadda, D., Makumbi, F., Watya, S., Nalugoda, F., et al. (2007). Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. The Lancet, 369 (9562), 657‐666.

4 Wilton, J. (2013). Condoms: Tried, tested and true? From CATIE: Canada’s source for HIV and hepatitis C information:http://www.catie.ca/pif/spring‐2013/condoms‐tried‐tested‐and‐true

5 Boyle, G. J., & Hill, G. (2011). Sub‐Saharan African randomised clinical trials into male circumcision and HIV transmission: methodological, ethical and legal concerns. Journal of law and medicine, 19 (2), 316.

6 Green, et al., (2010). Male Circumcision and HIV Prevention: Insufficient Evidence and Neglected External Validity. Am J Prev Med 2010;39(5):479–482

7 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. Australian and New Zealand Journal of Public Health, 35: 459–465. doi: 10.1111/j.1753‐ 6405.2011.00761.x

8Frisch, M., Aigrain, Y., Barauskas, V., Bjarnason, R., Boddy, S. A., Czauderna, P., et al. (2013). Cultural bias in the AAP’s 2012 technical report and policy statement on male circumcision. Pediatrics , 131 (4), 796‐800.

9Van Howe, R. S. & Storms, M. R. (2011). How the circumcision solution in Africa will increase HIV infections. Journal of Public Health in Africa 2011; 2:e4 doi: 10.4081/jphia.2011.e4

10 Government of Canada. (2013, July 15). Justice Laws Website. From Criminal Code s 266 Assault: http://laws‐lois.justice.gc.ca/eng/acts/C‐46/page‐131.html#docCont

11Parliament of Canada. (n.d.). BILL C‐27. From Parliament of Canada:http://www.parl.gc.ca/HousePublications/Publication.aspx?DocId=2329459&File=16

12 Cold, C. J., & Taylor, J. R. (1999). The prepuce. BJU international , 83 (S1), 34‐44.

13 Anatomy of the Penis, Mechanics of Intercourse (http://www.cirp.org/pages/anat/)

14 Animation on the foreskin linear bearing mechanism during sexual intercourse (http://www.circumstitions.com/Works.html)

15 World Association for Sexology. (2007, November). Valencia Declaration on Sexual Rights.

 

Appendix A
WHAT DOES RELATIVE RISK REDUCTION AND ABSOLUTE RISK REDUCTION MEAN?

The misleading Relative Risk Ratio

Newspapers like big numbers and eye-catching headlines. They need miracle cures and hidden scares, and small percentage shifts in risk will never be enough for them to sell readers to advertisers (because that is the business model). To this end they pick the single most melodramatic and misleading way of describing any statistical increase in risk, [Or “Reduction” in the case of circumcision and HIV] which is called the ‘relative risk increase’.

Let’s say the risk of having a heart attack in your fifties is 50 per cent higher if you have high cholesterol. That sounds pretty bad. Let’s say the extra risk of having a heart attack if you have high cholesterol is only 2 per cent. That sounds OK to me. But they’re the same (hypothetical) figures. Let’s try this. Out of a hundred men in their fifties with normal cholesterol, four will be expected to have a heart attack; whereas out of a hundred men with high cholesterol, six will be expected to have a heart attack. That’s two extra heart attacks per hundred. Those are called ‘natural frequencies’.

Natural frequencies are readily understandable, because instead of using probabilities, or percentages, or anything even slightly technical or difficult, they use concrete numbers, just like the ones you use every day to check if you’ve lost a kid on a coach trip, or got the right change in a shop. Lots of people have argued that we evolved to reason and do maths with concrete numbers like these, and not with probabilities, so we find them more intuitive. Simple numbers are simple.

The other methods of describing the increase have names too. From our example above, with high cholesterol, you could have a 50 per cent increase in risk (the ‘relative risk increase’); or a 2 per cent increase in risk (the ‘absolute risk increase’); or, let me ram it home, the easy one, the informative one, an extra two heart attacks for every hundred men, the natural frequency.

As well as being the most comprehensible option, natural frequencies also
contain more information than the journalists’ “relative risk increase”.

Excerpt from “Bad Science” by Ben Goldacre, Fourth Estate, London (2008), p 256-9

 

 

Appendix B
Male circumcision and HIV prevalence in Africa

“There appears to be no clear pattern of association between male circumcision and HIV prevalence. In 8 of 18 countries with data, as expected, HIV prevalence is lower among circumcised men, while in the remaining 10 countries HIV prevalence is higher among circumcised men…

Findings from the 18 countries with data present a mixed picture of the association between male circumcision and HIV prevalence. In eight of the countries (Burkina Faso, Cambodia, Côte d’Ivoire, Ethiopia, Ghana, India, Kenya, and Uganda), HIV prevalence is higher among men who are not circumcised, although the difference between circumcised and non-circumcised men is slight, except in Kenya, where the difference is substantial (HIV prevalence of 11.5 percent for non-circumcised men compared with 3.1 percent for circumcised men). In 10 of the countries (Cameroon, Guinea, Haiti, Lesotho, Malawi, Niger, Rwanda, Senegal, Tanzania, and Zimbabwe) HIV prevalence is higher among circumcised men.”

United States Agency for International Development (USAID) February 2009

 

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