|
Home > Correspondence > Medical Societies
Correspondent: CANADIAN PAEDIATRIC SOCIETY September 18, 1998 Dr. Emmett Francoeur
Dear Dr. Francoeur: I would like to raise questions in regard to a medical study undertaken by the University of Alberta for the purpose of measuring pain responses in infants undergoing circumcision. The study was halted prematurely after two infants were traumatized so severely that they became ill. I enclose a copy of the abstract. As I have outlined in a letter to Dr. Donald Morrish, chair of the ethics committee that reviewed and approved the study, I am concerned about the fact that researchers subjected infants to surgery which the researchers themselves considered to be medically unnecessary. Can it ever be appropriate to undertake invasive surgery if the patient is an infant and the physician considers that the surgery is medically unnecessary? For your information, I enclose a copy of the correspondence I have had with Dr. Morrish. I also wonder if you would be kind enough to explain exactly what the Canadian Paediatric Society means when it says in its practice guideline on circumcision that "circumcision of newborns should not be routinely performed." (Fetus and Newborn Committee, Canadian Paediatric Society. Neonatal Circumcision Revisited. CMAJ 1996; 154(6): 769-80). This sentence seems to mean that circumcision of newborns may be performed under certain conditions; but I can't conceive what these conditions might be. If neonatal circumcision is non-therapeutic--and that seems to be the conclusion reached in the guideline--then what would be the justification for ever performing it? I would appreciate your clarifying this matter. Sincerely
encl.
January 30, 1999 Emmett Francoeur, MD
Dear Dr. Francoeur, I am writing with regard to the issue of infant circumcision in Canada. I was born 45 years ago in Winnipeg at the Maternity Pavilion of the General Hospital. I was circumcised several days after birth by my mother's obstetrician, Dr. Harry Medovey. I have never been happy with the results of that procedure, and the scar I must bear for the rest of my life. If the law would allow I would sue that hospital and doctor for doing this to me. Several years ago I began studying the subject of infant circumcision in an effort to understand how and why this happened to me, and why it continues to happen to so many others. In the past few years the information available on this subject has been abundant. Dr. John Taylor's study of the specialized nerves of the prepuce and their loss due to circumcision, (as published in the British Journal of Urology), is particularly relevant. Dr. Margaret Somerville's statement that infant circumcision is comparable to criminal assault was long overdue. In the past year the story of "John-Joan" the Canadian boy whose penis was burned off in a circumcision accident in 1964 was reported widely in North America. Particularly interesting was that in these many reports on "John's" accident, only a very few mentioned that the accident was from circumcision. The most in depth coverage of this story was in Rolling Stone magazine, and while the writer, (who won an award for his story), revealed that "John" was diagnosed with phimosis at seven months of age, he did not realize that such a diagnosis is totally premature in such a young child. Most people I spoke with were confused by this story, wondering, "What kind of accident puts a baby's penis at such risk?" Perhaps the most shocking fact is that circumcision persists because it follows a pattern of abuse. Circumcised children grow up to enforce their experience on others. This is becoming a known and well understood fact, supported by some of the most renowned researchers of child development, and human sexuality. I am aware of the statement of the Canadian Paediatric Society, saying that they do not recommend infant circumcision, but I think this is a weak and ineffective position. I'm sure they do not recommend amputating any other healthy parts of human babies, or depriving infants of any other parts of their natural senses, but there are too many Canadian doctors who continue doing this under the guise of being "culturally sensitive" to the parent's wishes, or simply "to make the baby look just like daddy". Some of these so called doctors even proudly advertise their speciality. I have had enough, and so have a growing number of thoughtful and intelligent Canadians. It is time for this form of sexual wounding to stop. If an informed adult wants to have their genitals reduced and permanently altered, fine, but allowing this to continue on unconsenting minors is, (as Dr. Somerville has put it), criminal. Given the information currently available, along with the public's enlightenment and interest in human rights, it seems to me this issue is going to grow. I'm hopeful that a younger group of men will realize what was done to them, and begin to hold the doctors that cut them responsible. This has already begun to happen with lawsuits in the United States. Has the Canadian Paediatric Society taken any steps recently to understand this issue in more depth, or made arrangements to word their position on infant circumcision more strongly, reflecting the current wisdom to protect children from this form of wounding? Sincerely,
February 8, 1999 Dear Mr. Loewen, This note is in response to your letter of January 30, 1999. Your comments have been taken very seriously by me and the Society in this very difficult area of discussion. In fact, it is very helpful for us to receive your thoughts because it confirms what our reading is of some of the changes in societal beliefs about this surgical intervention of circumcision. I would like you to know that all our statements regularly undergo review so that we may add or change sections in accordance with newly acquired scientific information. These statements are always available to our members, for their use and for their comments. At the moment we have taken no new steps to examine this statement, nor to embark on new in-depth studies of the issue. Nevertheless I will consult with my colleagues in the committees you noted for their advice and to see if they have any activities planned. I do thank you for your interest in this topic and assure you that we will do our best to apply all recent knowledge to any re-formulation of our statement. Sincerely, [signed] Emmett Francoeur M.D.,C.M.,FRCPC
February 8, 1999 Dr. Emmett Francur, President
Dear Dr. Francur: Although the postmark on this letter is from outside of Canada, I am a dissatisfied product of Canadian medicine. I'd like to explain to you why; and why such dissatisfaction ought to matter to you. Your understanding of this matter may prompt you to take action to safeguard Canadian children in a way that was denied me. The reason for my dissatisfaction is my very unwanted circumcision which was executed by a Dr. MacWilliam in Chatham, Ontario on December 8, 1949, with the full and accurate knowledge that I was perfectly healthy and normal at the time. I came into the world whole, but I was not allowed to leave the hospital in one piece. My central genital organ was damaged without the consent of my parents, but that is irrelevant since I would repudiate any such "consent" anyway. I realize that you may have difficulty with my use of the word "damaged" when such damage has yet to be acknowledged by medical associations. Yet, part of my body was destroyed. It is simply that the destruction of the male foreskin mysteriously escapes recognition as damage by those whose eyes seem open, but who do not wish to see. Today we know that the male foreskin contains specialized erogenous nerves [1]. We know that its loss leads to keratinization that further reduces sexual pleasure [2]. We know that chlamydia prefers circumcised men [3]. We know that circumcision causes severe pain [4], and long-lasting enhanced pain susceptibility [5]. These are ample reasons for being unhappy about one's circumcision, but they are not my prime concern. My personal and intense dissatisfaction with my non-voluntary and unnecessary circumcision stems from two other issues. 1) I fully resent the intentional disfigurement inflicted upon my body, to the extent that I have regrown a "faux foreskin" through tissue expansion techniques [6]. My wife and I both enjoy it although it obviously lacks the valuable innervation of the original. 2) My body integrity has been willfully violated, quite possibly only for profit. Without any diagnosis, no one could know otherwise. It is important to note that males have ample reason for such dissatisfaction, both medical and personal. As such, their displeasure demands consideration with respect to the primary rule of ethics: the golden rule, which guides us to avoid actions that may not only be detrimental, but also unwanted by others. To the best of my knowledge, this rule has not been repealed by "medical" ethics. Indeed, it is the reason for "primum non nocere"; because such harms do engender dissatisfaction, especially when they are real and permanent while the supposed "benefits" of neonatal circumcision are statistical and rare. Thus the purpose of informed consent -- the acceptance of risks, including dissatisfaction, by an informed patient -- cannot be obtained when the patient isn't yet capable of speech! For this reason, the guidelines of the American Academy of Pediatrics Committee on Bioethics suggest that non-urgent invasive procedures be delayed until a child is old enough to consent or refuse [7]. Partial amputation of a healthy penis falls directly into such a category, and indeed doing it to healthy children produces the same result as the sickest form of assault and battery, ie: a sexually wounded child. This a major failure of medical ethics. That a tiny fraction of children might need it as surgery one day [8] in no way justifies doing it en masse, to mutilate children known to be healthy. The arrogant supposition that "doctors know best" has temporarily clouded the grim reality that healthy children are being painfully wounded and deprived of their sexual birthright, at the hands of the medical profession. Please find the enclosed tape of my appearance on W5 wherein my anger was broadcast to all of Canada twice. My justified displeasure has produced a very public response that questions the correctness and ethics of Canadian medicine. Some of my comments will appear in Maclean's Magazine within the next few months. No longer will it be possible to say that males "don't mind" being unnecessarily circumcised. I do this to help spare other Canadian boys the emotional pain that intentional genital mutilation has caused me and many others. What I do is vindicate the anger of boys and men about their mutilation. As others join me in such public criticism, it shall surely get worse to be on the wrong side of this issue. But it shall be our duty to continue until we see steps taken to protect baby boys from unnecessary genital diminishment, as girls are already protected by explicit law. I call upon you to issue strict guidelines protecting male children to the same extent as females: no diagnosis means no cutting. Delay would only serve to further erode the trust placed in Canadian medical authorities particularly with respect to their self-governance. I urge you to act quickly both for the children and to help preserve the beneficent image of the medical profession. Yours truly,
cc:
References:
February 17, 1999 Dear Dr. Francur: I wrote to you on September 18, 1998 requesting clarification of the Canadian Pædiatric Society’s clinical practice guideline on neonatal circumcision. I wasn’t sure of the meaning of the phrase, “should not be routinely performed.” Under what conditions is it appropriate for a physician to circumcise a newborn male? I also raised questions about an Alberta study in which newborn males undergoing circumcision were traumatized to the point of danger. I am sure you will be replying in due course, though as yet I have received no response. Meanwhile, I have been studying the practice guideline carefully and would like to make further comments. I find it odd that although the guideline does not hesitate to point out the need for more research in such areas as determining the best type of anæsthesia,[1] evaluating alternative strategies for preventing urinary tract infections,[2] and investigating the effect of simple hygienic interventions,[3] there is only silence on the need for more research into the functions of the foreskin. Astonishingly, the guideline views the discovery of numerous specialized nerve endings in the mucosal surface of the prepuce not as a sign of the need for further study of the prepuce, but as a sign of the need for pain control when the prepuce is summarily cut off![4] Why this singular lack of interest in preserving the functional integrity of the penis? A study just published in the BJU International found that the prepuce accounts for most of the dartos muscle of the penis, thus providing further evidence of specialized function and furnishing additional grounds for believing that the foreskin is an essential component of human anatomy.[5] I note that the impetus for putting an end to this abuse is coming not so much from the ranks of the medical profession, as from ethicists, journalists, and concerned citizens. The lawfulness of neonatal circumcision has been brought into question by legal scholars around the world, most recently by Dr. Margaret Somerville of McGill University. I hope the Canadian Pædiatric Society will review its position statement on neonatal circumcision to ensure that this document not only reflects the current state of scientific knowledge, but also rests on a firm ethical and legal foundation. Sincerely,
References:
Copies to:
March 7, 1999 Dear Mr. H arrison, This note is in response to your letter of February 17, 1999. Your comments have been taken very seriously by me and the Society in this very difficult area of discussion. In fact, it is very helpful for us to receive your thoughts because it confirms what our reading is of some of the changes in society’s beliefs about this surgical intervention of circumcision. I would like you to know that all our statements regularly undergo review so that we may add or change sections depending on newly acquired scientific information. These statements are always available to our members, for their use and for their comments. At the moment we have taken no new steps to examine this statement, nor to embark on new in-depth studies of the issue. It is our responsibility to look at the whole clinical picture. As one of the many voices raised in this debate, we are pleased to add your information to the list. The American Academy of Pediatrics has recently published its statement and has come to much the same conclusions as our Society. Thank you for your interest. Sincerely,
^Top |