Elizabeth Moreau
Director of Communications
Canadian Paediatric Society

Attn: Elizabeth Moreau—

Thanks very much for sending me the statement on neonatal circumcision. The medical pros and cons appear to have been dealt with in a thorough and objective manner, which I find quite refreshing, but there was nothing at all pertaining to the function of the male foreskin and the consequences of its removal. I should think this would be important enough to include in such a document, especially since it would add considerable weight to the “con” side of the issue.

The Globe and Mail’s medical reporter recently wrote a news story in which he described circumcision as the “trimming of a flap of skin that covers the head of the penis.” If the public believes that the male foreskin is nothing more than a “flap of skin,” one which is apparently dispensable, and physicians believe pretty much the same thing, the parents faced with deciding whether or not to have their baby boys circumcised will not have the full and accurate information to which they’re entitled. They will remain uninformed, or worse, they will be misinformed—more likely the latter.

Stephen Lewis spoke in Halifax about the U.N. Convention on the Rights of the Child. It’s my understanding that Canada has signed and ratified this agreement and thus it is legally bound to comply with its provisions—one of which condemns all forms of ritual sexual mutilation. Ritual mutilation is that which is performed for non-therapeutic reasons, whether on a male or a female, only because it’s “required” by the family’s church, because it’s a “tradition” in the particular community, or it’s expected by certain members of the family.

Why then are at least 25 per cent of males born in Canada being circumcised? If you know of anyone who may be able to answer this question, or just might like to discuss it, please let me know how I can get in touch with that person.

Thanks,
 
[signed]
 
Thomas Anderson, PhD

Dear Dr. Anderson:

Your letter to Elizabeth Moreau of the Canadian Paediatric Society has been passed on to me for comment as I was the principal author of the CPS clinical practice guidelines on circumcision and am therefore familiar with the discussions and perspectives that went into their preparation.

If we had found references that were other than mere statements of opinion regarding the function of the prepuce and the consequences of its removal we would have included them. However we found only one in our extensive literature search. That was Dr. Taylor’s paper describing the specialized nerve endings in the inner mucosal surface of the prepuce. It had not been published in a peer reviewed journal by the time the CPS clinical practice guidelines were published in March 1996. However we knew about this work, thought it was important to include and used an earlier reference from the proceedings of a conference at which Dr Taylor had presented his data, in order to develop the discussion in the paragraph “What is the prepuce?” If the Globe and Mail’s medical reporter had read that paragraph I do not believe he would have written what he wrote. Actually the CPS practice guidelines are on the internet and that paragraph title stands out clearly when you read the list of contents. So he would not even have had to phone or write the CPS for a copy, or wait for it to come. However the description of the prepuce as a simple fold of skin is what is written in the medical and anatomy textbooks, when it is commented upon at all. In reality it will take some time before this newer information becomes incorporated in medical textbooks, as there is at least a two to three year period for the preparation and publication of any new edition of a medical text. The real problem here may be that no one had actually looked at the histologic structure of the tissue previously.

There is no one, or simple answer to your question. I am sure you know some of the answers (e.g. parental choice for religious reasons, or because other family members are circumcised) even though you may feel they are not acceptable. I personally do not believe legal processes are the answer in and of themselves. My understanding of the UN Convention on the Rights of the Child is what you state. But in Egypt in 1997, the female circumcision rate is 70% although Egypt (also a signatory I believe) has laws against the practice, (which incidentally were not upheld in a recent Egyptian court decision). Also on a point of accuracy, female circumcision is not generally performed by physicians in Egypt, but by others from my understanding.

Abolition of child poverty is also a component of the Convention on the Rights of the Child, yet more than 20% of the children in Canada now live below the poverty line and the percentage is increasing. We have a lot yet to do in Society to correct inappropriate practices, and inequities. While the circumcision rate in Canada is now about 25%, that is about half what it was in the early 1970s. I think it will likely continue to fall. Indeed several provinces no longer pay for routine neonatal circumcision, which will also encourage the downward trend. A goodly number of parents however feel sufficiently strongly that they want their sons circumcised, that they will, and do, pay for the procedure themselves.

In the long term I agree with you that education is the key to a reduction of the practice, education of health professionals, and of the public. However I have concern that it is very difficult to alter practices that are a part of religious or cultural beliefs. Until we better understand the origins of such practices, and how to alter people’s belief structures I do not see a total end to the practice. I hope however, that we will see a continued reduction in its incidence without medical misinformation further contributing to the controversy.

Yours sincerely,
 
[signed]
 
E.W.Outerbridge MD FRCP(C)

cc: Elizabeth Moreau, Dr D McMillan

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