Correspondent:

CANADIAN ETHICISTS
Correspondence with Lawrence Barichello

I have been researching the issue of neonatal circumcision for some time now, both as a journalist and as a concerned citizen. I am writing to ask your professional opinion on a number of related ethical issues. First, I would like to outline the general state of knowledge on this matter as it stands today.

RELEVANT MEDICAL ISSUES

A. Lack of Necessity

No national medical organization in the world today supports the opinion that infant male circumcision is medically indicated. The Canadian Paediatric Society has made three statements, in 1975, 1982 and 1996. In each statement, it upholds and indeed strengthens its position that circumcision is not necessary, and may be harmful to the infant. For example, the CPS concluded that "Circumcision of newborns should not be routinely performed,"[1] and as early as 1975, that "there is no medical indication for circumcision during the neonatal period,"[2] and refers to circumcision as a "mutilative operation of questionable benefit."[3]

1. According to the CPS, any reasons to choose circumcision must be ascribed to "social status,"[4] "conformity,"[5] or "ritual."[6]
    
2. British Medical Association (1996): "It is rarely necessary to circumcise an infant for medical reasons."[7]
    
3. Australasian Association of Paediatric Surgeons (1996): "The Australasian Association of Paediatric Surgeons does not support the routine circumcision of male neonates, infants or children in Australia."[8]
    
4. The American Academy of Pediatrics also concluded last year that the "data are not sufficient to recommend routine neonatal circumcision."[9]
    
5. Even if the statements from these authorities were completely disregarded, and one argued a case for the prophylactic benefits of routine infant circumcision, the surgery is at very best non-therapeutic.[10]

B. Harm Suffered

1. It seems obvious that the removal of tissue from an organ as sensitive as the penis must be presupposed to detract from its sensitivity, unless it has been shown otherwise. In reference to this issue, research by Dr. John Taylor, a pathologist at the University of Manitoba, concludes that: "Circumcision ... ablates junctional mucosa that appears to be an important component of the overall sensory mechanism of the human penis."[11] The Taylor article also states that "Meissner's corpuscles of the prepuce may be compared with similar nerve-endings in the fingertips and lips," and that "the prepuce provides a large and important platform for several nerves and nerve endings....the innervation is impressive".[12] The article refers to parts of the foreskin as "primarily sensory tissue."[13]
    
2. These new studies show the sexual importance of the foreskin. However, the sensory importance of the prepuce was recognized as early as 1959, when Dr. Winkelman of the Mayo Clinic wrote:
   
   

   [T]he specific type of erogenous zone is found in the mucocutaneous regions of the body. Such specific sites of acute sensation in the body are the genital regions, including the prepuce, penis, clitoris, and external genitalia of the female, and the peri-anal skin, lip, nipple and conjunctiva. It is the special anatomy of these regions that require the use of the term "specific" when one speaks of erotic sensations originating in the skin. This anatomy favors acute perception.[14]

   Thus, rather than being a surgery with no consequences to the patient save that of therapy/lack of therapy, circumcision clearly diminishes the organ's sexual sensitivity.

C: Lack of Consent

1. Under Canadian law, the onus is on physicians and parents to show that a child will derive a clear benefit from a proposed surgical intervention. In a landmark court case, Re "Eve,"[15] it was ruled unlawful for a parent to consent to surgery on their child because of questionable advantages and lack of benefit to the patient. The surgery was considered to be "a serious intrusion" and "irreversible" could not be authorized for non-therapeutic purposes under the parens patriae jurisdiction. Valid third-party authorization to surgery on a child depends upon the surgical intervention being therapeutic. In the vast majority of neonatal infant circumcisions, this is not the case. Even if prophylactic benefits were presupposed (in contradiction to the CPS's and AAP's extensive research), this does not constitute therapy.
    
2. The Australian College of Paediatrics notes: "The possibility that routine circumcision may contravene human rights has been raised because circumcision is performed on a minor and is without proven medical benefit."[16]

RELEVANT LEGAL ISSUES

1. Canada became a party to the UN Convention on the Rights of the Child on 13 December 1991. The Government of Canada is now obliged to honour the terms of the Convention. Article 19(1) says:
   
   

   States Parties shall take all appropriate legislative, administrative, social and educational measures to protect the child from all forms of physical or mental violence, injury or abuse, neglect or negligent treatment, maltreatment or exploitation, including sexual abuse, while in the care of parent(s), legal guardian(s) or any other person who has the care of the child.[17]

2. In March 1992, the colleges of physicians and surgeons in Ontario and BC banned the performance of Female Genital Mutilation (FGM) by their members, ruling it an act of professional misconduct.
    
3. In 1997, the Canadian Parliament amended Section 268 of the Criminal Code, which deals with aggravated assault, to specifically prohibit all forms of female genital mutilation. They used gender-specific terms, and did not include male genital mutilation.[18]
    
4. Under Sections 15 and 28 of the Canadian Charter of Rights and Freedoms, constitutional rights are guaranteed equally to both sexes:
    
   15(1) Every individual is equal before and under the law and has the right to the equal protection and equal benefit of the law without discrimination and in particular, without discrimination based on race, national or ethnic origin, colour, religion, sex, age or physical or mental ability.[19]

My request is for your professional opinion on the following:

1. Is there any ethical justification for performing non-therapeutic infant male circumcision?
    
2. Is it ethical and legal for physicians to perform non-therapeutic circumcision without the personal consent of the patient? Is this something that parents can legitimately consent to?
    
3. Is the protection of females under the criminal code not discrimination on the basis of sex, and therefore contrary to the Canadian Charter of Rights and Freedoms?
    
4. Do you believe that when performed today, circumcision of newborn boys is a human rights violation?

Could you provide me with any references, papers, etc, that you feel may help me to understand your responses to these questions or this situation in general? I am aware that circumcision is a controversial subject and that many people are reluctant to speak about it openly. At your request I am willing to regard our communication as private if this would make you feel more comfortable. If you need any further references or supporting documentation, or if you have any questions whatsoever, please feel free to contact me—I would be more than happy to provide you with any assistance that you need.

I thank you for your time in helping me to clarify this matter.

Sincerely,
 
[signed]
 
Lawrence Barichello