A S S O C I A T I O N  for  G E N I T A L   I N T E G R I T Y 
Correspondent:
COLLEGE OF PHYSICIANS & SURGEONS
OF MANITOBA
February 25, 1998

Dr. William D.B. Pope
Assistant Registrar
College of Physicians & Surgeons of Manitoba

Dear Dr. Pope:

RE: NEONATAL CIRCUMCISION

I would like to express my concerns in regard to the College’s current guideline on neonatal circumcision.[1] It seems to me that this document contains a number of inaccuracies.

First, I think the guideline may be using the word “indication” in an overly loose fashion when it states in the Preamble that “the commonest indications for [neonatal circumcision] are religious, ethical, and psychosocial.” I consulted three medical dictionaries, namely, Stedman’s, Dorland’s, and Taber’s, and none of them consider the term “indication” to have meaning except in relation to a therapeutic intervention. Stedman’s, for instance, defines indication as “the basis for initiation of a treatment for a disease or a diagnostic test.”

Since routine infant circumcision does not fit the legal definition of “treatment” and is not a diagnostic test, I am unable to see how it can have indications of any kind.

Second, I think the guideline may be stretching the point when it suggests that circumcision may “prevent” various ailments or offer “protection” against HIV. The words “prevent” and “protect” imply 100% effectiveness, when in reality all of the alleged prophylactic benefits mentioned in the guideline are no more than slight. Moreover, all of them have been brought into question by experts.

Though the guideline does not fail to note that circumcision is purported to confer benefits, it omits to mention well-established harms, including loss of a complex, highly innervated anatomical structure performing protective, mechanical, and sensory functions.[2]

Nor does the guideline remind practitioners that invasive, non-therapeutic procedures cannot be undertaken without the voluntary and informed consent of the person undergoing the intervention.[3]

The guideline states that “[o]n occasion a child may have urinary retention secondary to stenosis of the preputial outlet, resulting in a pinhole opening. In the absence of any other abnormalities, this is a specific indication for circumcision.” However, Rickwood states that “the ever-popular ‘pinhole’ meatus occurs in reality only in a few boys with pathological phimosis and deserves consignment to the diagnostic dustbin.”[4] Rickwood goes on to observe that until the foreskin is completely separated from the glans, ballooning during micturition is normal.

Moreover, infants are frequently diagnosed as having phimosis because of incorrect technique in examining the penis, making the opening look smaller than it really is.[5]

Meatal stenosis secondary to circumcision, which the guideline characterizes as rare, has been reported by Van Howe to occur in 8 percent of circumcised boys.[6] Kaplan reports that meatal stenosis is “far more common in circumcised adult men,”[7] while Williams and Kapila state that “[m]eatal stenosis is generally a direct consequence of circumcision that is seldom encountered in uncircumcised men.”[8] Robson and Leung consider that meatal stenosis is the most common complication of circumcision.[9]

Contrary to the guideline’s suggestion that circumcision may be effective in limiting the spread of the human papilloma virus, research has shown that the exact opposite is the case. Genital warts (i.e. human papilloma virus) are significantly more common in circumcised men than in intact men.[10] Further, a detailed study conducted at the University of Chicago found that circumcised men were at greater risk than intact men for contracting a wide range of sexually transmitted diseases. Chlamydia, for instance, was found to occur only in circumcised men.[11]

Researchers at the University of Toronto reported last year that circumcision performed without injected anesthesia was traumatic enough to induce heightened pain responses in infants months later.[12]

I feel the College is using a double standard when it condones circumcision of infant males while simultaneously condemning circumcision of females. The prepuce comprises specialized sensory tissue that forms part of the normal mechanism of reproduction. If a respect for human rights is enough to protect the genitals of a female infant, why are the genitals of normal, healthy male infants considered to be fair game?

Irrational behaviour is easy to spot when it occurs in other cultures, but recognizing it in one’s own backyard takes insight and courage. I feel the Canadian medical profession must start coming to grips with this problem. Judging from the abundant media coverage neonatal circumcision has been receiving lately, I would say that lay persons are ahead of the medical profession in their perception of the ethical issues here.

I enclose a copy of a letter I have written to Dr. Elizabeth Boustcha, Chair of the Health Care Ethics Committee at St. Boniface General Hospital. I also enclose some other material that you may find of interest.

I am providing copies of my letter to two members of the Fetus and Newborn Committee of the Canadian Paediatric Society, Drs. Eugene Outerbridge and Robin Walker. Dr. Outerbridge is the principal author of the CPS position statement on neonatal circumcision.

Yours truly,
 
[signed]
 
D ennis H arrison

Copies to:

Dr. Eugene Outerbridge, Dr. C. Robin Walker

REFERENCES

1. #914, College on the Web, PDRC/02-94.

2. Taylor JR, Lockwood AP, Taylor AJ. The Prepuce: Specialized mucosa of the penis and its loss to circumcision. British Journal of Urology 1996; 77: 291-5.

3. Somerville M. Medical Interventions and the Criminal Law: Lawful or Excusable Wounding? McGill Law Journal 1980;26: 82-96.

4. Rickwood AM. The unkindest cut of all? J. Irish Coll Phys and Surg 1992; 21(3):179-181.

5. Catzel P. The normal foreskin in the young child (letter). South African Med Journal 1982;62:751.

6. Van Howe RS. Variability in penile appearance and penile findings: a prospective study. British Journal of Urology 1997; 80: 776-82.

7. Kaplan GW. Complications of circumcision. Urol Clin North America 1983;10:543-9.

8. Williams N, Kapila L. Complications of circumcision. Brit J. Surg 1993;80:1231-6.

9. Robson WLM, Leung AKC. The circumcision question. Postgrad Med 1992; 91: 237-43.

10. Cook LS, Koutsky LA, Holmes KK. Clinical presentation of genital warts among circumcised and uncircumcised heterosexual men attending an urban STD clinic. Genitourinary Medicine 1993; 69:262-4.

11. Laumann E, Masi C, Zukerman E. Circumcision in the United States: Prevalence, Prophylactic Effects, and Sexual Practice. JAMA 1997; 277: 1052-7.

12. Taddio A, Katz J, Ilersich AL, Koren G. Effect of neonatal circumcision on pain response during subsequent routine vaccination. The Lancet 1997; 349: 599-603.

March 5, 1998

Dear Mr. H arrison:

Re: Neonatal Circumcision

Thank you for forwarding the assembled material relative to this subject. College guidelines continue to be under review, and this material will be of interest to the Standards Committee as its process continues.

Yours sincerely,
 
[signed]
 
KENNETH R. BROWN, M.D.
Registrar

July 30, 1999

Dr. Kenneth R. Brown, Registrar
College of Physicians & Surgeons of Manitoba

Dear Dr. Brown:

Re: Neonatal circumcision

I wish to raise questions in regard to the College’s latest guideline on neonatal circumcision.[1]

The guideline states that circumcision may protect men against HIV infection. However, I have reviewed the medical literature on this subject, and have discovered that about half of the thirty-odd studies which looked at circumcision and HIV infection found no significant correlation between these two variables.[2-17] Moreover, seven studies found that HIV infection was actually more prevalent among circumcised men than inact men.[18-24] I enclose photocopies of these studies for your consideration.

Several authors have warned that any correlation shown so far between circumcision status and HIV infection is likely to be due to confounding factors. Writing in the Journal of the American Medical Association, Dr. Edward O. Laumann of the University of Chicago put it this way: “There are strongly associated social and behavioural covariates with circumcision that include social background characteristics such as age, education, race/ethnicity, and sexual practices and preferences. In short, circumcision is a marker for a complex array of social and behavioural characteristics that are known to be implicated in HIV transmission. Without rigorous, systematic control for cofactors relevant to the particularities of the African context, the prophylactic status of the presence or absence of the foreskin remains an open question.”[25]

It is also worth noting that most of the studies which found a positive correlation between HIV infection and the presence of a foreskin obtained their data from patrons of sexually transmitted disease clinics, while most of the studies which yielded the opposite result were random population surveys. It is my understanding that the latter type of study design is more reliable than the former.

In summary, my review of the scientific literature leads me to believe that any statement to the effect that circumcision may protect against HIV infection is misleading and dangerous. I hope that in keeping with its mission of “service to the public and service to the profession,” the College will re-evaluate its position on the relationship between circumcision and HIV infection.

I would also appreciate answers to the following questions:

  1. The guideline states that 𔄢specific medical indications for the performance of circumcision in the neonate are rare.” Does the College’s Code of Conduct permit physicians to subject neonates to invasive, irreversible surgical interventions that have no specific medical indication? If so, please explain.
  2. Does the College believe Manitoba physicians should follow the Canadian Paediatric Society’s recommendation that circumcision of newborns should not be routinely performed?
  3. Can the College provide assurance that Manitoba physicians have the legal authority to excise healthy tissue from incompetent patients?
  4. Why does the College’s guideline on neonatal circumcision not direct attention to the fact that circumcision ablates specialized sensory tissue?[26-30] The co-author of two recent histological studies of the prepuce, Dr. John Taylor, does not live far away.
  5. The Code of Conduct calls on practitioners to “treat all patients with respect.” In the opinion of the College, does treating all patients with respect mean obtaining the patient’s personal consent for an invasive, irreversible, non-therapeutic surgical intervention? If not, please explain.
  6. The Code of Conduct also enjoins physicians to “provide appropriate care for your patient.” Does the College believe that providing appropriate care for your patient means protecting incompetent persons from nonessential surgery? If not, please explain.
  7. Leading Canadian ethicists have warned that neonatal circumcision presents serious difficulties from the standpoint of ethics. Can the College provide assurance that non-therapeutic infant circumcision is an ethical procedure?

Please make your answers as specific as possible. I look forward to your reply.

Yours truly,
 
[signed]
 
D ennis H arrison

Enclosures

REFERENCES

  1. #914, College on the Web, Pmwc/06-97.
  2. Hira, SK, Kamanga J, Macuacua R, et al. Genital ulcers and male circumcision as risk factors for acquiring HIV-1 in Zambia. J Infect Dis 1990;161:584-5.
  3. Pépin J, Quigley M, Todd J, et al. Association between HIV-2 infection and genital ulcer diseases among male sexually transmitted disease patients in The Gambia. AIDS 1992;6:489-93.
  4. Bollinger RC, Brookmeyer RS, Mehendale SM, et al. Risk factors and clinical presentation of acute primary HIV infection in India. JAMA 1997:278:2085-9.
  5. Chiasson MA, Stoneburner RL, Hildebrandt DS, et al. Heterosexual transmission of HIV-1 associated with the use of smokable freebase cocaine (crack). AIDS 1991;5:1121-6.
  6. Caraël M, Van De Perre PH, Lepage PH, et al. Human immunodeficiency virus transmission among heterosexual couples in central Africa. AIDS 1998;2:201-5.
  7. Moss GB, Clemetson D, D'Costa L, et al. Association of cervical ectopy with heterosexual transmission of human immunodeficiency virus: results of a study of couples in Nairobi, Kenya. J Infect Dis 1991;164:588-91.
  8. Allen S, Lindan C, Serufilira A, et al. Human immunodeficiency virus infection in urban Rwanda: demographic and behavioral correlates in a representative sample of child-bearing women. JAMA 1991;266:1657-63.
  9. Seidlin M, Vogler M, Lee E, et al. Heterosexual transmission of HIV in a cohort of couples in New York City. AIDS 1993;7:1247-54.
  10. Konde-Lule JK, Berkley SF, Downing R. Knowledge, attitudes, and practices concerning AIDS in Ugandans. AIDS 1989:3:513-8.
  11. Van De Perre P, Clumeck N, Steens M, et al. Seroepidemiological study on sexually transmitted diseases and hepatitis B in African promiscuous heterosexuals in relation to HTLV-III infection. Eur J Epidemiol 1987:3:14-8.
  12. Quigley M, Munguti K, Grosskurth H, et al. Sexual behaviour patterns and other risk factors for HIV infection in rural Tanzania: a case-control study. AIDS1997; 11:237-48.
  13. Urassa M, Todd J, Boerma T, et al. Male circumcision and susceptibility to HIV infection among men in Tanzania. AIDS 1997;11:73-80. (study 2)
  14. Urassa M, Todd J, Boerma T, et al. Male circumcision and susceptibility to HIV infection among men in Tanzania. AIDS 1997;11:73-80. (study 3)
  15. Urassa M, Todd J, Boerma T, et al. Male circumcision and susceptibility to HIV infection among men in Tanzania. AIDS 1997;11:73-80. (study 5)
  16. Hudson CP, Hennis AJM, Kataaha P, et al. Risk factors for the spread of AIDS in rural Africa, hepatitis B and syphilis in southwestern Uganda. AIDS 1988;2:255-60.
  17. Laumann E, Masi C, Zukerman E. Circumcision in the United States: Prevalence, Prophylactic Effects, and Sexual Practice. JAMA 1997;277:1052-7.
  18. Barongo LR, Borgdorff MW, Mosha FF, et al. The epidemiology of HIV-1 infection in urban areas, roadside settlements, and rural villages in Mwanza Region, Tanzania. AIDS 1992;6:1521-8.
  19. Grosskurth H, Mosha F, Todd J, et al. A community trial of the impact of improved sexually transmitted disease treatment on the HIV epidemic in rural Tanzania: 2. Baseline survey results. AIDS 1995;9:927-34.
  20. Chao A, Bulterys M, Musanganire F, et al. Risk factors associated with prevalent HIV-1 infection among pregnant women in Rwanda. National University of Rwanda--Johns Hopkins University AIDS Research Team. Int J Epidemiol 1994;23:371-80.
  21. Urassa M, Todd J, Boerma JT, et al. Male circumcision and susceptibility to HIV infection among men in Tanzania. AIDS 1997;11:73-80. (study 1)
  22. Urassa M, Todd J, Boerma JT, et al. Male circumcision and susceptibility to HIV infection among men in Tanzania. AIDS 1997;11:73-80. (study 2)
  23. Urassa M, Todd J, Boerma JT, et al. Male circumcision and susceptibility to HIV infection among men in Tanzania. AIDS 1997;11:73-80. (study 5)
  24. Van Howe RS. Circumcision and HIV infection: review of the literature and meta-analysis. Int J STD & AIDS 1999;10:8-16.
  25. Laumann EO. Advantages and disadvantages of circumcision. (Correspondence) JAMA 1997;278:203.
  26. Cold CJ,Taylor JR. The Prepuce. Br J Urol 1999;83 Suppl 1: 34-44.
  27. Taylor JR et al. The Prepuce: Specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996;77:291-5.
  28. Winkelmann RK. The cutaneous innervation of the human newborn prepuce. J Invest Derm 1956;26:53-67.
  29. Winkelmann RK. The mucocutaneous end-organ. Arch Dermatol 1957:76:225-35.
  30. Winkelmann RK. The erogenous zones: their nerve supply and significance. Proc Mayo Clin 1959;34:39-47.
August 10, 1999

Dear Mr. H arrison:

Dr. Ken Brown has asked me to reply to your letter of 30 July 1999.

Thank you for your comments, criticisms and scientific literature which you have provided to the College. I will be sure to pass these on to the Perinatal and Maternal Welfare Committee of the College which is responsible for the College guideline on neonatal circumcision. College guidelines are reviewed on a regular basis and I am sure that the committee will utilize your material when it next reviews this controversial subject.

You may be interested in knowing that after the committee last reviewed and revised this guideline, the College recommended to Manitoba Health that neonatal circumcision be de-insured. This recommendation was supported by the Manitoba Medical Association but turned down by the Manitoba government.

Again, I thank you for your critical observations.

Yours sincerely,
 
[signed]
 
ROBERT D. WALKER, M.D.
Deputy Registrar

Aug 16, 1999

Dear Dr. Walker:

Neonatal circumcision

Thank you for your letter of August 10th, in response to my comments on neonatal circumcision. You did not answer any of the specific questions I asked, though all were straightforward enough and all came within the purview of the College.

Three simple facts are beyond dispute:

  • neonatal circumcision is not medically required;
  • the procedure removes specialized sensory tissue;
  • it is performed without patient consent.

I believe the College has a moral and legal obligation to take appropriate action based upon these inescapable facts.

Psychologist Ronald Goldman addresses many of the issues surrounding neonatal circumcision in his book, “Circumcision: The Hidden Trauma.” Please accept the enclosed copy with my compliments.

Sincerely,
 
[signed]
 
D ennis H arrison

cc: Dr. Ken Brown

August 28, 1999

Dear Ms. Malofie:

Re: Newborn Circumcision

The College position on this subject, as is the case with all guidelines relative to paediatric care, is under continuing review by our Child Care Committee. The most recent edition of this guideline is attached for your information.

Yours sincerely,
 
[signed]
 
KENNETH R. BROWN, M.D.
Registrar

September 15, 1999

Dear Dr. Brown:

Thank you for your letter of August 28th and for the copy of the College’s guideline on neonatal circumcision.

The guideline says that the alleged benefits of neonatal circumcision are too small to support a recommendation to circumcise neonates. It also says that neonatal circumcision is “not an innocuous procedure.” If neonatal circumcision is not recommended practice, and is not an innocuous procedure, then please explain why Manitoba physicians are being permitted to perform this surgery. Medical ethics forbid subjecting incompetent persons to unnecessary surgical interventions that may cause harm.

In my letter of August 11th, I asked specific questions relating to the ethical, legal, and human rights implications of neonatal circumcision. These questions have been left unanswered, though they concern matters that come well within the College’s purview.

I feel my queries are important because they go to the heart of the ethical practice of medicine. As a citizen and a consumer of medical services, I wish to assure myself that medical services delivered in Manitoba conform to the highest ethical standards. I believe the College has a moral duty and a statutory obligation to respond to my concerns in an appropriate manner.

Accordingly, I would like to put the following questions to you once again:

  1. Can the College provide assurance that it is ethical for physicians to excise normal tissue from non-consenting persons for non-therapeutic purposes?
  2. Can the College provide assurance that a physician who circumcises a child without clear medical indication is respecting that child's right to physical integrity as guaranteed under the Charter of Rights and Freedoms?
  3. Does the College believe that parents have the legal authority to consent to invasive, non-therapeutic surgical interventions being performed on their children? If so, please explain.
  4. Does the College consider male and female circumcision to be comparable practices? If not, please explain.
  5. Is the College concerned that interference with children's genitals for non-medical reasons might constitute child abuse? If not, please explain.
  6. Does the College consider that physicians who circumcise non-consenting persons for non-medical reasons are engaging in professional misconduct?
  7. Is the College prepared to institute a policy prohibiting its members from engaging in non-therapeutic circumcision of children? If not, please explain.

Yours sincerely,
 
[signed]
 
Bettie Malofie

September 28, 1999

Dear Ms. Malofie:

Re: Newborn Circumcision

The clinical practice guideline which I earlier forwarded to you is, I believe, quite clear. These guidelines are reviewed on a regular basis, and I will ensure that the concerns contained in your letter of September 15th are forwarded to the Standards Committee to be included in the review process.

It is quite clear from your letter that you strongly disapprove of newborn circumcision being performed without a clear medical indication. There are, however, still those who support performance of the procedure. Without commenting on the appropriateness of this support, I should make mention of the fact that the College opposed this procedure being continued as an insured service. The recommendation by the College was not supported by Manitoba Health.

Yours sincerely,
 
[signed]
 
KENNETH R. BROWN, M.D.
Registrar

October 12, 1999

Dear Dr. Brown:

My letter of 15 September 1999 was not an expression of disapproval. It was an attempt to find out what basis there is in ethics or law for subjecting an incompetent person to an invasive non-therapeutic surgical intervention. I note that once again my questions have gone unanswered.

You say there are “still those who support the performance of the procedure.” Under Canadian law, the onus falls on those who support the procedure to show they have the moral right and legal authority to carry it out.

It seems to me that to fulfill its obligation to protect the public, the College must either (1) furnish evidence that neonatal circumcision is ethical and legal, or (2) order physicians to stop doing it.

There is no doubt that neonatal circumcision is an invasive non-therapeutic surgical procedure. It removes healthy tissue. I seek an answer the following question: Can an invasive non-therapeutic surgical procedure be performed on a person incapable of giving voluntary and informed consent?

Yours sincerely,
 
[signed]
 
Bettie Malofie

November 23, 1999

Dear Ms. Malofie:

Thank you for your letter of October 12, 1999. Dr. Brown indicated that he would be referring the matters raised to the Standards Committee of the College for review. Once that occurs, Dr. Walker or I will be in further communication with you.

Yours sincerely,
 
[signed]
 
WILLIAM D. B. POPE, M.D.
Registrar

January 6, 2000

Dear Dr. Bhimji:

I am in receipt of your letter of December 16, 1999 on January 4, 2000. The College is in agreement with the statement of the Canadian Paediatric Society recommending that “circumcision of newborns should not be routinely performed.” The College is aware that there are strongly held views both for and against circumcision. There are acknowledged medical reasons to circumcise a male child. At this time, the Manitoba College is not prepared to make a formal endorsation of either position.

As I am sure you can understand, the College would not be prepared to say it would never conduct disciplinary proceedings into a physician’s practice, as each case is reviewed on its merits and the specifics of that case.

At the present time, the College has taken a stand on female circumcision, which its members feel is a different procedure from male circumcision and is performed for different reasons.

Yours sincerely,
 
[signed]
 
WILLIAM D. B. POPE, M.D.
Registrar

March 31, 2000

Dear [name withheld]:

Re: Infant Penis Care and Infant Circumcision

I am in receipt of your letter of March 21, 2000 on March 29, 2000. The College does create and disseminate guidelines and statements on some aspects of care. However, the majority of such information should arise from the appropriate specialist societies and the faculty of medicine. I note two issues in your letter:

  1. Care of the Intact Infant Penis:
     
    This is a matter for education by the Manitoba division of the Canadian Paediatric Society. If they feel an item in the College newsletter is appropriate, it will be included in the future.
  2. Infant Circumcision:
     
    As you are aware, this remains a controversial issue. You may have seen the recent letter to the editor in the Winnipeg Free Press, in which two senior infectious disease researchers from the University of Manitoba, who are world famous for their work, strongly support circumcision as a proven method of decreasing the transmission of HIV. The opinions expressed by Dr. Taylor are not shared by all members of the medical profession. The College will be following the issue as it develops.

You may wish to contact the Canadian Paediatric Society to determine what educative measures are being supported by that organization for its members with regard to the two items you raise.

Yours sincerely,
 
[signed]
 
WILLIAM D. B. POPE, M.D.
Registrar

April 26, 2000

Dear Dr. Pope:

I am awaiting a response to the specific questions I have raised regarding neonatal circumcision. In a letter dated November 23, 1999, you indicated that a reply to my inquiries would be forthcoming. So far no reply has arrived, though five months have passed. Insofar as my questions have to do with standards of professional ethics, I believe they are of the utmost importance.

I wish to know whether or not the alleged prevention of rare diseases is sufficient justification for removing normal body parts from healthy persons who cannot speak for themselves. I respectfully request that the College answer the following questions:

  1. Can the College provide assurance that it is ethical for a member of the College to remove a normal part of an organ from a non-consenting person who is in good health?
  2. Does the College believe that parents have the legal authority to consent to invasive surgical interventions being performed on their children for non-therapeutic purposes? If so, could the College please cite supporting Canadian case law, or provide a reasoned argument.

I believe that as the professional body charged with responsibility for establishing and maintaining professional standards of medical practice in Manitoba,[1] the College should be able to answer the above questions. If I have received no reply by June 30, 2000, then I intend to pursue the matter further with the Honourable David Chomiak, minister responsible for administering the Medical Act.

Yours sincerely,
 
[signed]
 
Bettie Malofie


 
1. Chapter M90, Medical Act, section 36(1)(e)(i).
  May 9, 2000

Dear Mrs. Malofie:

Re: Your letter of April 26, 2000.

Thank you for your letter received May 8, 2000. Following my response of November 23, 1999, the guideline on neonatal circumcision has been withdrawn. The Perinatal & Maternal Welfare Committee recommended deletion of the guideline and the Central Standards Committee of the College concurred.

At the present time, male circumcision remains a procedure that is performed by some physicians with authorization from parents. There appears to be some indication for this procedure.

The College is not preparing to comment further at this time, as there is obviously a difference of opinion on the therapeutic value from different jurisdictions. You are quite at liberty to review this matter further with the Minister.

Yours sincerely,
 
[signed]
 
WILLIAM D. B. POPE, M.D.
Registrar

June 1, 2000

Dear Dr. Pope:

I would like to raise questions in regard to a letter you wrote on May 9th to Ms. Bettie Malofie. In your letter, you state that the College's guideline on neonatal circumcision has been withdrawn.

As you know, I am concerned about the practice of neonatal circumcision and have corresponded with the College in regard to this issue on several occasions over the past three years. I wrote to the College on February 25, 1998, outlining some of the difficulties I saw with the guideline on neonatal circumcision as it stood at that time. The guideline was subsequently revised.

I would appreciate it if you could explain why this revised guideline has now been withdrawn, and what will replace it.

You state that "there is obviously a difference of opinion on the therapeutic value from different jurisdictions." While there may be differences of opinion regarding the therapeutic value of circumcision, I am not aware of any jurisdiction in the world that has weighed the evidence and found neonatal circumcision to be justified on therapeutic grounds.

I am also in receipt of a letter dated March 31, 2000 that you wrote to [name withheld]. In this letter, you refer to research done at the University of Manitoba by Drs. Stephen Moses, Allan R. Ronald, and John R. Taylor. Drs. Moses and Ronald contend that circumcision reduces the risk of contracting AIDS, while Dr. Taylor postulates that circumcision removes specialized sexual tissue.

You describe Drs. Moses and Ronald as “world famous,” while characterizing Dr. Taylor as someone whose views are “not shared by all members of the medical profession.” But it is the views of Drs. Moses and Ronald, rather than those of Dr. Taylor, that have provoked controversy. Their finding that circumcision helps prevent AIDS has been contradicted by carefully controlled studies. For instance, a comprehensive American study involving some 1,500 subjects found that circumcised men are more susceptible to a wide range of sexually transmitted diseases, including HIV infection.[1]

In contrast, Dr. Taylor’s finding that circumcision removes specialized sexual tissue has never been challenged. The anatomical structure of the prepuce is easily verified under a microscope.

Therefore to convey a positive impression of the work of Drs. Moses and Ronald while casting doubt on that of Dr. Taylor is to put the circumcision debate in a false light. For your information, I enclose a copy of three letters published last year by the editor of Sexually Transmitted Infections in response to an article co-authored by Drs. Moses and Ronald.

I would appreciate a response at your earliest convenience. I would be grateful if you could enclose the minutes of the meeting at which the decision was made to withdraw the guideline on neonatal circumcision.

Reference:

  1. Laumann E, Masi C, Zukerman E. Circumcision in the United States: Prevalence, Prophylactic Effects, and Sexual Practice. JAMA 1997;277:1052-7.

Sincerely,
 
[signed]
 
D ennis H arrison

June 7, 2000

Dear Mr. H arrison:

I am in receipt of your letter of June 1, 2000. My previous correspondence to Mrs. Malofie appears self-explanatory. I have nothing further to assist you with at this time.

Yours sincerely,
College of Physicians & Surgeons of Manitoba
Per:
 
[signed]
 
William D.B. Pope, M.D.
Registrar

December 8, 2000

Dr. Eric Stearns
President of the Council
College of Physicians & Surgeons of Manitoba

Dear Dr. Stearns:

Together with several residents of Manitoba, I have been asking the College of Physicians and Surgeons to explain the ethical and legal principles underpinning circumcision of male infants. The College has not given straightforward answers to our questions. For instance, when I inquired whether parents have the legal authority to consent to invasive surgical interventions being performed on their children for non-medical reasons, the College replied simply that “male circumcision is performed by some physicians with authorization from parents.” The question as to whether such authorizations are legally effective was left unanswered.

In its correspondence the College has alluded to potential medical benefits from neonatal circumcision, remarking that “there appears to be some indication for this procedure.” However, the existence of potential medical benefits does not by itself constitute sufficient ethical or legal justification for undertaking a surgical intervention on a person incapable of giving informed consent. Prevention of breast cancer is hardly sufficient justification for removing healthy breast tissue from a young girl. In her new book, The Ethical Canary: Science, Society, and the Human Spirit, Dr. Margaret Somerville, Director of the Centre for Medicine, Ethics and Law at McGill University, addresses the "medical benefits" issue in these terms:

A common error made by those who want to justify infant male circumcision on the basis of medical benefits is that they believe that as long as some such benefits are present, circumcision can be justified as therapeutic, in the sense of preventive healthcare. This is not correct. A medical benefits or “therapeutic” justification requires that overall the medical benefits sought outweigh the risks and harms of the procedure required to obtain them, that this procedure is the only reasonable way to obtain these benefits, and that these benefits are necessary to the well-being of the child. None of these conditions is fulfilled for routine infant male circumcision. If we view a child’s foreskin as having a valid function, we are no more justified in amputating it than any other part of the child’s body unless the operation is medically required treatment and the least harmful way to provide that treatment.

Physicians owe a primary duty of care to their patients. A surgical operation performed without medical justification on a person incapable of giving informed consent is battery, regardless of whether or not the person’s next of kin have given consent. Dr. Somerville observes:

Physicians who undertake infant male circumcision could be legally liable for medical malpractice (civil liability in battery or negligence), which can result in an award of damages simply for carrying out the circumcision even if it was competently performed. They could also, as explained, be charged with criminal liability for assault. In both ethics and law, a physician has a primary obligation of personal care to the patient. This obligation requires the physician both to place the patient first and to “first do no harm.” Physicians who undertake surgery on patients must prove that it is justified.

The risks associated with circumcision are not negligible. Consider the case of David Reimer, a 35-year old Winnipeg resident who was “reassigned” as a girl after his penis was destroyed in a circumcision at St. Boniface Hospital in the 1960s. A medical study on newborn circumcision at the University of Alberta was halted prematurely in 1997 after one of the infants vomited, went into shock, and stopped breathing for more than 25 seconds. Last year a baby in Cleveland, Ohio died from complications of anesthesia being administered to treat complications of circumcision.

All people, including babies and children, have a fundamental human right not to be exposed to unnecessary pain and risk. Parental consent cannot serve as an ethical or legal justification for undertaking an intrusive, irreversible surgical intervention that is not deemed necessary for a child’s health.

Section 36 of the Medical Act, R.S.M. [1987] c. M90, imposes a duty on College Council to “establish and maintain professional standards of medical practice.” I respectfully request that in your capacity as President of College Council you direct the College to give straightforward answers to the following questions:

  1. Is infant male circumcision justified on medical grounds? If not, then on what other grounds can infant male circumcision be ethically and legally justified?
  2. Why has the College withdrawn its guideline on neonatal circumcision?
  3. Does the College believe it is ethical for a physician to circumcise a non-consenting minor for non-medical reasons?
  4. Does the College consider male circumcision to be comparable to excision of the clitoral hood, a procedure prohibited by criminal law? If not, please explain why.
  5. Does the College believe that parents have the legal authority to consent to surgery on a minor child if the operation is not deemed necessary for the child's mental or physical health? If so, please provide a reasoned argument or cite supporting Canadian case law.

Thank you for your assistance in this matter. I look forward to your reply. For your information I enclose a copy of a paper by Dr. Arif Bhimji entitled Infant Male Circumcision: A Violation of the Canadian Charter of Rights and Freedoms. The paper was published recently in an electronic journal called HealthcareLaw. I also enclose a copy of an article entitled "The Ethics of Circumcision" that appeared recently in the Globe and Mail.

Sincerely,
 
[signed]
 
D ennis H arrison

December 19, 2000

Dear Mr. H arrison:

At the present time, the College of Physicians & Surgeons of Manitoba is not prepared to enter into an ongoing debate with you regarding male circumcision. However, with regard to the questions you ask:

  1.  Some male circumcision is justified on medical grounds.
  4.  The College does not consider male circumcision comparable to the excision of the clitoral hood.

Yours sincerely,
College of Physicians & Surgeons of Manitoba
Per:
 
[signed]
 
William D.B. Pope, M.D.
Registrar

December 27, 2000

Dear Dr. Pope:

Thank you for your letter of December 19th. I am not trying to engage the College in a debate. Rather, I am trying to obtain answers to questions concerning important matters that come within the College's purview.

One of the country’s most prominent medical ethicists, Dr. Margaret Somerville, has stated that physicians who perform infant male circumcision are violating current provisions of the Criminal Code. Dr. Eike-Henner Kluge, the Founding Director of the Canadian Medical Association’s Department of Ethics and Legal Affairs, has likened infant male circumcision to “nonconsensual mutilation of a minor.” Any reasonable person would be disturbed by such allegations. I feel that by asking questions of the College I am just doing my duty as a citizen.

As the College has not answered questions 2, 3, or 5 in my letter of December 8th to Dr. Eric Stearns, President of College Council, I am resubmitting them to you for a response:

  2.  Why has the College withdrawn its guideline on neonatal circumcision?
  3.  Does the College believe it is ethical for a physician to circumcise a non-consenting minor for non-medical reasons?
  5.  Does the College believe that parents have the legal authority to consent to surgery on a minor child if the operation is not deemed necessary for the child's mental or physical health? If so, please provide a reasoned argument or cite supporting Canadian case law.

To sum up, allegations have been made that medical practitioners who circumcise healthy boys are engaging in serious wrongdoing. These allegations come not from me, but from distinguished ethicists, legal experts, and even from members of the medical profession itself. In these circumstances, a response from the College of “we are not prepared to enter into an ongoing debate with you" cannot be considered adequate.”

The public is entitled to know the rules governing the performance of surgical operations on people who have nothing wrong with them. I trust the College will fulfil its statutory obligation to protect the public and provide reasonable answers to the questions I have asked in this letter.

For your information, an 18-year-old filed suit in U.S. District Court on December 19th against the physician who circumcised him as an infant. I enclose a news release describing this event.

Sincerely,
 
[signed]
 
D ennis H arrison

cc: Dr. Eric Stearns

July 26, 2001

Dear Dr. Pope:

I’m writing to renew a line of correspondence we had regarding infant male circumcision. I would like to know whether or not this procedure is consistent with medical ethics.

Circumcision is an invasive, irreversible surgical operation. Infants, by definition, are persons. In the opinion of the College, is it ethical for a physician to operate on a person who is legally incapable of giving informed consent and who has no medical need for surgery?

I would appreciate a response to the above question at your earliest convenience.

Yours sincerely,
 
[signed]
 
Bettie Malofie

August 24, 2001

Dear Mrs. Malofie:

Re: Your letter of July 26, 2001

I am in receipt of your letter received July 31, 2001. Nothing has changed at the College of Physicians and Surgeons since your previous correspondence.

Yours sincerely,
College of Physicians & Surgeons of Manitoba
 
[signed]
 
William D.B. Pope, M.D.
Registrar

September 10, 2001

Dear Dr. Pope:

Re: Neonatal circumcision

I have received your letter of August 24th. I would like to clarify what I am asking of the College.

Under section 36 of the Medical Act, R.S.M. [1987] c. M90, it is the College's responsibility to ensure that physicians act competently and ethically. I believe, therefore, that when asked a question about medical ethics, the College should be able to provide a straightforward reply.

I don’t know why the College has repeatedly sidestepped questions related to the ethics of neonatal circumcision. The College of Physicians & Surgeons should be able to justify its stance on circumcision, just as it should be able to justify its stance on any other issue connected with medical practice.

Accordingly, I’m asking the College for a straightforward answer to the following question:

Is it ethical for a physician to remove a healthy part of a normal organ from a person incapable of giving informed consent?

I would appreciate a response at your earliest convenience.

Yours sincerely,
 
[signed]
 
Bettie Malofie

January 18, 2002

Dear Dr. Pope:

I am writing to inquire about the standard of practice in Manitoba with respect to infant male circumcision. I've been researching circumcision for several years. My letters on this subject have been published in a number of academic journals, including the Lancet, the Journal of the American Medical Association, and the Journal of Law and Medicine.

I have obtained data on the incidence of infant male circumcision in several provinces. Recent data for Manitoba and Nova Scotia are presented below for purposes of comparison. The data were supplied by the provincial departments of health.

  MANITOBA NOVA SCOTIA
Male births Newborn circumcisions Rate (percent) Male births Newborn circumcisions Rate (percent)
  1997/98   7,464 2,158 28.9 5,102 127 2.5
1998/99 7,436 1,992 26.8 5,017 103 2.1
1999/00 7,522 1,889 25.1 4,771  77 1.6
2000/01 7,371 1,894 25.7 4,618  68 1.5

Based on the above data, the incidence of infant male circumcision is 12 to 17 times higher in Manitoba than in Nova Scotia. Is this not a surprising degree of variability in a paediatric surgical intervention? Should physicians in different provinces not be following the same rules for operating on infants?

The recognized authority on paediatric health care in Canada, the Canadian Paediatric Society, concluded in 1996 that newborn circumcision is not medically justified, and recommended that the procedure “should not be routinely performed.” This recommendation was reaffirmed by the Society in February, 2001. Does the extremely high usage of newborn circumcision in Manitoba, compared with Nova Scotia, perhaps indicate that Manitoba physicians are not as up-to-date on the latest literature and guidelines on circumcision as their colleagues in other provinces?

The performance of infant male circumcision raises a number of important ethical and legal issues. First and foremost among these is the issue of consent. The Supreme Court ruled in Eve that parents/guardians do not have the legal authority to consent to a non-therapeutic surgical operation being performed on their child. The Court concluded with the following general injunction:

Since, barring emergency situations, a surgical procedure without consent ordinarily constitutes battery, it will be obvious that the onus of proving the need for the procedure is on those who seek to have it performed.

Although the direct and immediate focus of Eve was the non-consensual sterilisation of a young woman with a mental disability, the language of the passage cited makes it clear that the stricture applies to surgical operations in general.

Another important issue is the standard of informed consent. This standard, which was set out by the Supreme Court in Reibl v. Hughes and Hopp v. Lepp, requires physicians to disclose—without being asked—all material risks of treatment, including risks that are special or unusual. In the context of infant male circumcision, the documented risks include hemorrhage, occasionally to the point of requiring a transfusion; life-threatening infections such as meningitis, gangrene, staphylococcal scalded skin syndrome, and scrotal abscess; acute urinary retention leading to renal failure; penile ischemia; necrosis; buried penis; partial or complete penile amputation; iatrogenic hypospadias; total denudation of the penis; pneumothorax; urethral fistula; meatal ulceration; keloid formation; ruptured bladder; gastric rupture; tachycardia and heart failure; myocardial injury; pulmonary embolism; unilateral leg cyanosis; and death.

To assist me in understanding the position of the College on the issue of infant male circumcision, I would appreciate answers to the following questions:

  1. Why does the incidence of newborn circumcision appear to be 12 to 17 times higher in Manitoba than in Nova Scotia? Is this degree of variation considered acceptable in paediatric surgery?
  2. Does the College agree with the Canadian Paediatric Society's recommendation that "circumcision of newborns should not be routinely performed?" If not, then what other body or bodies does the College consider to be authorities on newborn circumcision?
  3. Does the College accept the requirement of therapeutic benefit for a surgical intervention on an incompetent patient, as set out by the Supreme Court in Eve?
  4. Does the College accept the Supreme Court's statement that "the onus of proving the need for the procedure is on those who seek to have it performed," thus requiring the attending physician to receive proof of the need for newborn circumcision from the parents/guardians?
  5. Does the College accept the standards for informed consent set out by the Supreme Court in Reibl v. Hughes and Hopp v. Lepp?

I would appreciate answers to the above questions at your earliest convenience. Thank you for your time.

Yours truly,
 
[signed]
 
D ennis H arrison

cc: Officers of the College

February 5, 2002

Dear Mr. H arrison:

We acknowledge receipt of your letter dated January 18, 2002.

As the College understands the law, parents or legal guardians of children are entitled to provide consent to surgery for their infant children. Of course, the consent must be informed to be valid consent, but it is the parent or legal guardian who must be adequately informed.

Our society has placed the responsibility for overseeing such parental/guardian decisions in the hands of legislators, child protection authorities and the courts. This is not to suggest that physicians have no responsibility in this regard. However, the responsibility of physicians does not extend to substituting their own judgment on a controversial issue for that of the parent or guardian. The physician is ethically obligated to inform the parent/guardian if his/her personal morality would influence the recommendation or practice of any medical procedure that is needed or wanted. As with any procedure, the physician is ethically obligated to discuss the risks of a proposed procedure.

The premise of your correspondence appears to be that neonatal circumcision is never therapeutically necessary. In fact, there are some rare circumstances where the procedure is medically indicated. The College cannot say that neonatal circumcision is never therapeutically necessary and cannot prejudge the issue of whether is medically indicated in any given case. Our obligation is the review the facts of individual cases if concerns arise.

I must say that I fail to see any purpose in speculating with you as to the possible cause of the different incidence of the procedure in Nova Scotia and Manitoba. The foregoing is the position of the College on the issue of infant male circumcision. I have nothing further to add.

Yours sincerely,
College of Physicians & Surgeons of Manitoba
 
[signed]
 
Per: William D. B. Pope, M.D.
Registrar

February 18, 2002

Dear Dr. Pope:

RE: Neonatal circumcision

I am writing to request clarification of some statements in the College’s letter of February 5th. First, however, I feel obliged to clarify my own position. Contrary to the College’s comment that my correspondence “appears to be premised on the belief that neonatal circumcision is never therapeutically necessary,’ I accept the College’s judgment that the procedure is medically indicated in rare cases. My questions and concerns relate solely to the cases where a procedure that is not medically indicated is performed on a patient who is legally incapable of giving informed consent. I believe that description fits most circumcisions performed in Manitoba.

I would be grateful if you would clarify three points in the College’s letter. The first point relates to the limits of proxy decision-making. The College wrote that

as the College understands the law, parents or legal guardians of children are entitled to provide consent to surgery for their infant children...Our society has placed the responsibility for overseeing such parental/guardian decisions in the hands of legislators, child protection authorities and the courts.

In arriving at this understanding of the law, did the College take into account the decision of the Supreme Court in E. (Mrs.) v. Eve, [1986] 2 S.C.R. 388? In Eve, the court ruled that an invasive, irreversible surgical intervention cannot be authorized on an incompetent patient unless the intervention is necessary to protect the patient’s physical or mental health. Are there limitations, therefore, to the College’s statement that parents or guardians can provide consent to surgery for their children? Specifically, does parental consent for surgery require the establishment of a direct therapeutic benefit to the child, as per the Supreme Court’s ruling in the Eve case? I would appreciate clarification of that point.

The second point relates to the responsibilities of physicians. The College stated that

the responsibility of physicians does not extend to substituting their own judgment on a controversial issue for that of the parent or guardian.

Physicians have a responsibility to put patients first. The Canadian Paediatric Society, in its position statement entitled Treatment Decisions for Infants and Children, advises that “no other interests can override those of the child whether they be family stability or well-being, or the well-being of other caretakers.” The College’s own Code of Conduct demands that practitioners “consider first the well-being of the patient.” I would appreciate it if you could explain how the duty to protect patients can be reconciled with the College’s statement that physicians should not substitute their own judgment for that of a patient’s caregivers. What if the caregivers want something for the patient that is medically inappropriate? Perhaps you could also clarify exactly why the College considers newborn circumcision to be a controversial issue. For decades, there has been virtually unanimous agreement among medical organizations throughout the world that the procedure is not medically justified.

The final point relates to the differences between Manitoba and other provinces with respect to the rate of neonatal circumcision. I believe that wide variations in rates of surgery are generally viewed with concern by the medical profession. When the authors of a recent study on ear-tube surgery found an almost ten-fold difference in the rate of this procedure in different parts of Ontario, they made the following comment:

Small-area variations in surgical rates raise concerns about access to care, treatment appropriateness, and the quality and cost of care.[1]

The differences in newborn circumcision rates in Canada appear to be much greater than the variations in ear-tube surgery in Ontario. At about 25 percent, the rate of neonatal circumcision in Manitoba is roughly 17 times the rate in Nova Scotia, and more than 60 times the rate in Newfoundland and Labrador. In light of these dramatic differences, is the College concerned about access to care, treatment appropriateness, and quality and cost of care, in the context of newborn circumcision?

I would appreciate clarification of the above points. Thank you for your time.

Reference:

1.  Coyte CP, Croxford R, Asche CV, et al. Physician and Population Determinants of Rates of Middle-Ear Surgery in Ontario. JAMA 2001;286:2128-2135.

Sincerely,
 
[signed]
 
D ennis H arrison

cc:  Officers of the College

February 26, 2002

Dear Mr. H arrison:

We acknowledge receipt of your letter dated February 18, 2002.

The College’s response to your first and second points is contained in the second sentence you quote: “Our society has placed the responsibility for overseeing such parental/guardian decisions in the hands of legislators, child protection authorities and the courts.”

I reiterate that I fail to see any purpose in speculating with you as to the possible cause of the different incidence of procedures in Nova Scotia and Manitoba.

I have nothing further to add to my previous correspondence to you and therefore do not intend to continue to engage in correspondence with you respecting infant male circumcision.

Yours sincerely,
College of Physicians & Surgeons of Manitoba
 
[signed]
 
Per: William D. B. Pope, M.D.
Registrar

September 5, 2002

Dear Ms. Malofie:

Further to your letter of August 12, 2002, I am writing to inform you that the College will be reviewing the issue of infant male circumcision further.

Yours sincerely,
College of Physicians & Surgeons of Manitoba
 
[signed]
 
William D. B. Pope, M.D.
Registrar

May 5, 2003

Dr. William D.B. Pope
Registrar
College of Physicians and Surgeons of Manitoba

Dear Dr. Pope:

I recently reviewed the article Caution Regarding Routine Circumcision of Newborn Male Infants in the December, 2002 issue of the Manitoba College Newsletter. I would like to commend the College for finally addressing an issue which does not receive due attention, and which the College has previously avoided.

The “Caution” asks Manitoba physicians to consider two documents issued by the College of Physicians and Surgeons of Saskatchewan. Some excerpts from the Saskatchewan documents are presented in the Newsletter verbatim. However, it appears that a significant change has been made to one of the most important passages. Where the original document states, “You can, and should, respectfully decline to perform the procedure,” the version in the Manitoba College Newsletter reads, “You may, and should consider, respectfully declining to perform the procedure.”

If the intention of the article in the Newsletter was to ask Manitoba physicians to reflect on statements made by the Saskatchewan College, then I have great difficulty understanding why anything in the original correspondence would have been altered, especially where the alteration is material, as is clearly the case here. Could you please clarify why the original wording was changed?

If the intention of the article was to put forth a new position by the College, then I would appreciate knowing why the College did not take the same stand that Saskatchewan has taken. Would it not be in the best interests of the public, and of all newborn males, for the College to take a position that protects vulnerable patients from having non-therapeutic, irreversible surgery performed on them without their personal consent? Is it not reasonable to have a uniform standard of practice across the country?

I look forward to a response at your earliest convenience.

Yours truly,

[signed]

Arif Bhimji MD MBA

November 2, 2004

Dr. William D.B. Pope
Registrar
College of Physicians and Surgeons of Manitoba

Dear Dr. Pope:

I am writing to make the College aware of a guideline on infant male circumcision released a few months ago by the College of Physicians and Surgeons of British Columbia. This guideline, which is available on the CPSBC Web site, aims to discourage non-therapeutic male circumcision.

A few excerpts:

  • Routine infant male circumcision is an unnecessary and irreversible procedure.
  • Proxy consent by parents for a non-therapeutic procedure is debatable.
  • The matter of infant male circumcision is particularly difficult in regards to human rights.

As you know, neonatal circumcision was condemned by the College of Physicians and Surgeons of Saskatchewan in 2002. The CPSS advised its members to “respectfully decline to perform the procedure.”

Statistics obtained from the Ministry of Health indicate that Manitoba may have one of the highest rates of infant male circumcision in the country. In 2001/02, the number of infant male circumcisions reimbursed by Manitoba Health was 1,802, representing 25.5 percent of male births. By way of comparison, data obtained from hospital databases in other provinces show that circumcision was performed on only 3.4 percent of male infants born in Quebec, 1.3 percent of those born in Nova Scotia, and 0.2 percent of those born in Newfoundland and Labrador. Manitoba is the only jurisdiction in Canada where routine infant circumcision is still covered by public health insurance.

A ground-breaking anatomical study carried out by Dr. John R. Taylor at the University of Manitoba in the 1990s found that circumcision "ablates junctional mucosa which appears to be an important component of the overall sensory mechanism of the human penis." Removing healthy body parts from an incapable patient presents ethical and legal difficulties. The common law right to bodily integrity is deeply entrenched in our legal system. In a legal case involving the taking of hair samples and tooth impressions from a murder suspect under threat of force, the Supreme Court of Canada ruled that "any invasion of the body is an invasion of the particular person. Indeed, it is the ultimate invasion of personal dignity and privacy." Non-therapeutic surgery on female genitalia is expressly prohibited by the Criminal Code.

In light of the new information about circumcision, and the leadership being shown on this issue by other Colleges, does the CPSM plan to reintroduce a formal guideline on neonatal circumcision? If not, please explain why.

Thank you for taking the time to consider this issue. I look forward to your reply.

Sincerely,

[signed]

D ennis H arrison

November 15, 2004

Dear Mr. H arrison:

Thank you for your letter of November 2, 2004. For your information, I am enclosing a copy of an article entitled Caution Regarding Routine Circumcision of Newborn Male Infants which was published in the College of Physicians and Surgeons of Manitoba (CPSM) newsletter in December, 2002.

At this time, the CPSM has no plans to introduce a formal guideline on neonatal circumcision. The position of the CPSM has been communicated to its members in the enclosed article.

Sincerely,
College of Physicians & Surgeons of Manitoba

[signed]

Per: William D.B. Pope
Registrar

November 25, 2004

Dear Dr. Pope:

Thank you for your letter of November 15th with enclosure. You write that “the position of the CPSM [on neonatal circumcision] has been communicated to its members in the enclosed article.“

However, the enclosed article, which appeared in the December, 2002 issue of the CPSM newsletter, only asks physicians to consider excerpts from documents issued by the College of Physicians & Surgeons of Saskatchewan. Moreover, a sentence in one of the excerpts has been materially changed. Whereas the original Saskatchewan document reads:

You can, and should, respectfully decline to perform the procedure...

the version as reported in the CPSM newsletter says:

You may, and should consider, respectfully declining to perform the procedure...[My italics.]

Thus it is not clear from the article exactly whose position is being communicated. I would appreciate it if you could confirm that the views expressed in the article are in fact those of the College of Physicians & Surgeons of Manitoba.

Sincerely,

[signed]

D ennis H arrison


Top of page

Valid XHTML 1.0!