1. The mission of Manitoba Health is to “protect, preserve and promote the health of all Manitobans.” The Canadian Paediatric Society, which constitutes the leading body of experts on child health in this country, advises that neonatal circumcision is of no net medical benefit to an infant. How does paying for a surgical procedure that offers no net medical benefit protect, preserve, or promote the health of Manitobans?
2. The lawfulness of neonatal circumcision is open to question. As evidence of this, I enclose a copy of an article that appeared in the Ottawa Citizen on October 17, 1997. By insuring a nonessential surgical procedure of dubious legality, is Manitoba Health not exposing the taxpayers of Manitoba unduly to legal risk?
3. Why is Manitoba the only jurisdiction in the country that is continuing to insure neonatal circumcision?

I would appreciate it if you could clarify the above issues.

Yours truly,
 
[signed]
 
D ennis H arrison

Dear Mr. H arrison:

Thank you for your correspondence regarding neonatal circumcision in Manitoba. I am pleased to have this opportunity to respond to your letter.

Infant male circumcision is an insured service in Manitoba if performed within 30 days of the child’s birth. The College of Physicians and Surgeons of Manitoba’s guideline on neonatal circumcision has been made increasingly stringent in recent years, attributing to the continued reduction in the number of neonatal circumcisions performed annually (1,483 in 1996; 1,290 in 1998).

Insured services, which are paid for by Manitoba Health, must be medically appropriate in accordance with the College of Physicians and Surgeons of Manitoba guidelines; therefore, Manitoba taxpayers are not exposed to legal risks. Please be assured that Manitoba Health conducts ongoing reviews of all insured services to ensure optimum use of health care dollars.

Again, thank you for your letter.

Sincerely,
 
[signed]
 
Dave Chomiak

Dear Minister:

Thank you for your letter of December 9th. You have raised issues to which I would like to respond.

Firstly, there is a large discrepancy between the statistics you provided in your letter, and those provided by Manitoba Health to the Circumcision Information Resource Centre in Montreal. You state that the numbers of neonatal circumcisions performed in Manitoba in 1996 and 1998 were as follows:

1996:  1,483
1998:  1,290

But Decision Support Services, Manitoba Health, provided a very different set of numbers to the Circumcision Information Resource Centre:

1996:  2,936
1998:  2,158

I enclose a copy of the above report, dated August 13, 1999, and produced by Ms. Heidi Niedermuehlbichler, Statistical Analyst, Decision Support Services, Manitoba Health.

Secondly, your statement that “insured services...must be medically appropriate in accordance with the College of Physicians and Surgeons of Manitoba guidelines” appears to be in conflict with statements made by Dr. Robert D. Walker, Deputy Registrar of the College. In a letter dated August 10, 1999, Dr. Walker writes:

[T]he College recommended to Manitoba Health that neonatal circumcision in males become a de-insured service. This recommendation was supported by the Manitoba Medical Association but turned down by the Manitoba government.

Furthermore, the College’s guideline on neonatal circumcision advises that “the degree of benefit is small, and does not support a decision to circumcise neonates.”

I enclose a copy of Dr. Walker’s letter and the College's guideline on neonatal circumcision.

Finally, with regard to legal risk, the courts have imposed limits on parental consent for medical treatment. For instance in E. (Mrs.) v. Eve, [1986] 2 S.C.R. 388, the Supreme Court turned down a mother's application for the legal authority to have her mentally retarded daughter sterilized. The court found that the sterilization was (a) unnecessary for the daughter’s mental or physical health, and (b) permanent in its effects. Given these two factors, the court decided that no parent and no court could legally give the consent required for the operation.

If circumcision is not required for an infant’s mental or physical health, then it is arguable, on the basis of Eve, that a parent cannot legally give the consent necessary to perform it. Consequently those who rely on the consent of parents to perform infant male circumcision may be exposing themselves to legal risk. If you do not agree with this analysis, please explain why.

I would like to ask the following questions:

1. Why do the statistics you have provided on the incidence of neonatal circumcision in Manitoba not agree with the statistics provided by Decision Support Services?
2. Why has Manitoba Health ignored the recommendation of the College of Physicians and Surgeons of Manitoba to drop neonatal circumcision from the list of insured services?
3. Does Manitoba Health have a legislative mandate to reimburse physicians for performing services that are not deemed medically necessary?
4. Why is Manitoba the only jurisdiction in the country that still pays for neonatal circumcision?

I would appreciate an answer at the earliest opportunity.

Yours truly,
 
[signed]
 
D ennis H arrison

Dear Minister:

I wrote to you on December 14th, 1999, in regard to insurance coverage for neonatal circumcision. News reports indicate that Manitoba Health is currently reviewing its policy on this matter. Accordingly, I would like to provide you with further information that may assist you in your deliberations.

Radio Sweden informed its listeners recently that a report prepared for the Swedish National Board of Health characterizes circumcision of boys for non-medical reasons as a violation of the United Nations Convention on the Rights of the Child. I enclose a copy of this news item for your consideration.

In its position statement on neonatal circumcision issued in 1996, the Australian College of Paediatrics noted:

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.¹

Neonatal circumcision is the removal of a normal, well-formed body part from a person incapable of giving informed consent. The point at issue is not whether this operation reduces the risk of disease. There are many body parts whose excision in infancy reduces the risk of disease—breast buds, testicles, fingers and toes, to name only a few. The point at issue is whether a potential reduction in the risk of disease constitutes sufficient ethical and legal justification for removing a normal body part from a healthy person who cannot speak for himself.

I trust that when deciding whether to drop neonatal circumcision from the list of insured services, Manitoba Health will not fail to take into account the important ethical, legal and human rights issues raised by the performance of this procedure.

Yours truly,
 
[signed]
 
D ennis H arrison

Dear Mr Chomiak:

Male circumcision for no obvious reason is a troubling but easily resolved aspect of health care in Manitoba. By providing circumcision on demand and as an insured service our Government continues to condone and encourage a practice that is in steep decline in Europe, Canada and elsewhere.

We have shown, for the first time, that circumcision removes highly specialized sexual tissue. Our findings with respect to foreskin (prepuce) anatomy appeared in a peer-reviewed medical journal specializing in urological anatomy and diseases (Taylor et al British Journal of Urology 1996;77:291-5): they are now widely accepted as an original and worthwhile contribution to the medical literature. Ongoing work supports our contention that male circumcision is comparable to female circumcision, also known as female genital mutilation.

The vast majority of circumcisions in Manitoba are purely cosmetic, raising concerns about fundamental human rights as well as about everyday sexual and medical matters. Occasionally, as we are all too well aware, circumcision has debilitating and irreversible consequences. In this respect, premature and extremely sick babies have died, in Manitoba, within a day or so of 'routine' neonatal circumcision, at the insistence of the parents, not the paediatrician. The practice of submitting dying babies to circumcision is reprehensible but goes on, in part, because it is an insured service.

As far as I am aware, babies have little or no protection from cosmetic circumcision under the law, whatever their physical condition. Parents have the absolute right to remove one of the more sensitive and important parts of their baby`s body. Death or injury following circumcision is considered an unfortunate event rather than an offense. Why this should be so is difficult to comprehend when the person who, in a blind rage, injures or kills a baby by shaking may be successfully prosecuted under provisions of the Criminal Code.

As an ex-Pathologist (Health Sciences Centre, Winnipeg) and published investigator of human cardiac and genital anatomy, I should be obliged if you would look into a procedure that is worthless and, all too frequently, interferes with the childhood and adulthood of its unwilling victim.

I shall be glad to provide you with the information you may need in coming to a conclusion on the question of insurance cover for an outdated and harmful practice.

Yours faithfully,
 
[signed]
 
(Dr)John R Taylor MB MRCPE FRCPC

Dear Mr. Chomiak:

Re: Budget Difficulties with Health Care in Manitoba

I am writing in regard to a practice that has become a matter of increasing public concern in recent years: infant male circumcision. I have been researching this subject for over the past month and a half, due to an unfortunate incident in which my pediatrician violated the standard of care of my son’s intact penis.

While I did not know much about the ethics concerning circumcision at the time my son was born in December 1998, I have learned a lot about it since. Because of this new knowledge, I have written to my pediatrician expressing my concern over her inappropriate actions (copy enclosed). I am even more concerned about the general lack of information available both to health professionals and parents alike. Whether infants are mistreated by ignorance or intent on the part of doctors and/or parents, the damage is the same.

It has become clear to me (and many other people) that infant male circumcision is no different than infant female circumcision. In both cases, a health body part is removed with no medical justification, without the child's consent, and causing irreparable damage and loss of adult sexual functions. That parents are allowed to request this procedure for their children based on cultural reasons, religious beliefs, aesthetics and tradition is a human rights tragedy. In Canada steps have been taken to prohibit female circumcision—acknowledging it is a serious form of child abuse—yet males receive no such protection. This is discriminatory and unjustified.

In 1996 the Canadian Paediatric Society (CPS) issued a policy statement recommending that “circumcision of newborns should not be routinely performed.” The American Academy of Pediatrics made a similar statement in 1999. No national or international medical organization in the world currently advocates neonatal circumcision as a routine measure. Clearly there is now a high level of consensus in the medical community that neonatal circumcision is not medically justified (copies of their statements are also enclosed, for your review).

In summary, since both male and female circumcision are medically unnecessary, I am deeply troubled that only females are currently being protected from this damaging, irreversible, excruciatingly painful form of sexual abuse. Furthermore, I am even more troubled that Manitoba is the only province left in Canada that covers infant male circumcision in its health plan. In this day of tight budgets, why on earth would non-recommended, unindicated foreskin amputations of healthy infants be funded by the taxpayers? As a parent, I am deeply concerned. As a taxpayer and Canadian citizen I am outraged. While removing male infant circumcision from the Manitoba Health Care plan will not cure the budget difficulties, it would be a very logical place to start. If you take the time to discuss this matter with the appropriate parties, I am confident that common sense will prevail, and it will be a step in the right direction for the budget.

Finally, I would like to do what I can to educate others about the harm of infant circumcision and the proper care of intact genitals so no other babies will suffer what my son has been through. I would appreciate any assistance you could give me in this objective.

Please contact me at [phone no.] if you require further information or would like to speak to me about this request. I hope to hear from you soon.

Yours truly,
 
[signed]
 
Name withheld

Dear Mr. H arrison:

Thank you for your letter requesting additional information regarding infant male circumcision in Manitoba. I apologize for any confusion created by the discrepancy in numbers that you received regarding the number of infant male circumcisions performed in Manitoba.

The statistics that I provided to you in my last letter were in direct answer to your July 9, 1999 letter, which specifically referred to the number of infant male circumcisions performed in Manitoba by paediatric physicians. The numbers I provided were for circumcisions performed by paediatric physicians and general practitioners only. The statistics you received from Decision Support Services referred to the number of circumcisions performed by all medical specialists, including the above two groups.

Physicians determine the cases where medical necessity exists within the guidelines provided by the College of Physicians and Surgeons. Physicians submit claims for the procedures that meet these guidelines, and Manitoba Health is legally bound to pay for the services.

As you can appreciate, we are a government maintaining the policies of the previous government. Over the next year, we will be reviewing all policies, including insured circumcisions, in order to ensure optimum use of our health care dollars.

I trust that this letter clarifies any confusion resulting from the figures provided to you in our previous correspondence.

Sincerely,
 
[signed]
 
Dave Chomiak

Dear Dr. Taylor:

Thank you for your correspondence outlining your concerns regarding insurance coverage for the circumcision of male infants.

I agree with you that this is a very sensitive yet important issue. At this time, our government is still operating under some of the policies and practices introduced by the previous government. We recognize that we will need to re-examine many of those policies to ensure the best possible health care for Manitobans and the most efficient use of our health care dollars. Improvements to our health care system will be an ongoing process throughout our administration and while I cannot commit to changing the policy surrounding male circumcision, your suggestions and input will be a valuable contribution to our revision process.

Thank you again for your letter. I appreciate you have taken the time to write to me with your concerns.

Sincerely,
 
[signed]
 
Dave Chomiak
Minister of Health

Dear [name withheld]:

Thank you for your correspondence outlining your concerns regarding insurance coverage for the circumcision of male infants. I agree with you that this is a very sensitive, yet important issue.

At this time, our government is still operating under some of the policies and practices introduced by the previous government. We recognize that we will need to re-examine many of those policies to ensure the best possible health care for Manitobans and the most efficient use of our health care dollars. Improvements to our health care system will be an ongoing process throughout our administration and while I cannot commit to changing the policy surrounding male circumcision, your suggestions and input will be a valuable contribution to our revision process.

Thank you again for your letter. I appreciate you have taken the time to write to me with your concerns.

Sincerely,
 
[signed]
 
Dave Chomiak
Minister of Health

Dear Minister:

I have corresponded with you in the past on the subject of insurance coverage for routine infant circumcision. I am writing to provide further information.

Male circumcision has been touted as a possible weapon in the fight against AIDS, since most studies from Africa have found an association between absence of male circumcision and increased susceptibility to HIV infection. The problem is that not all studies have found this relationship. Some of the most thoroughgoing have found either no relationship or an association in the opposite direction. A cross-sectional population survey in Tanzania found no evidence that circumcised men were at lower risk for HIV infection,¹ while a cross-sectional study from Rwanda found that pregnant women were significantly more likely to be infected with HIV if the father had been circumcised.²

Thus it is not possible to say conclusively that circumcision helps prevent AIDS. In any case, using AIDS prevention as a justification for circumcising non-consenting children presents ethical and legal difficulties. These difficulties have been summarized in an article entitled Respecting children’s human rights published in the Montreal Gazette on October 24, 1998. The author of the article was Dr. Margaret Somerville, a professor in the faculties of law and medicine at McGill University and one of Canada's top medical ethicists. I enclose a copy for your information.

I hope this additional material is of value to you. I would appreciate it if you would explain on what basis Manitoba Health might consider retaining neonatal circumcision as an insured service. The operation is not recommended by any medical organization, and it has been de-insured in every other province.

Sincerely,
 
[signed]
 
D ennis H arrison

Dear Minister:

I am writing to provide further information pertaining to insurance coverage for routine circumcision of male infants. I enclose a copy of an article entitled Newborn circumcision: an economic perspective which appeared in the December 1, 1984 issue of the Canadian Medical Association Journal. The authors found that newborn circumcision is “not economically beneficial” and concluded that “public health care dollars should be spent on preventive and therapeutic measures of more certain health and economic benefit.” As you are aware, newborn circumcision has now been de-insured in every province except Manitoba.

I also enclose a copy of a letter I received recently from Dr. Michel Caraël, an official of UNAIDS, the United Nations AIDS agency. Dr. Caraël says that although there is evidence of a “strong association” between circumcision status and HIV in sub-Saharan Africa, many “operational and research questions” remain to be answered before UNAIDS can draft a policy on the issue.

Association does not mean causation. African tribes that practise circumcision may be at lower risk for HIV transmission because of other factors, such as more frequent washing, abstinence from alcohol, or a stricter code of sexual behaviour. In Canada, more new AIDS cases result from injected drug use than from heterosexual intercourse.

Sincerely,
 
[signed]
 
D ennis H arrison

Dear Minister:

I am writing to provide further information that may be helpful in coming to a decision regarding insurance coverage for infant male circumcision. 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.

You may be hearing from people who seek to justify infant male circumcision on the basis of medical benefits. But to be ethically and legally justified on the basis of medical benefits, a procedure must confer medical benefits that outweigh the risks and harms taken as a whole. Moreover, the procedure in question must be the only reasonable way of obtaining those benefits, and the benefits must be necessary for the well-being of the child. Infant male circumcision does not meet any of these conditions.

I hope this information is of value.

Sincerely,
 
[signed]
 
D ennis H arrison

Dear Minister:

I have come across an article that may be of further assistance to Manitoba Health in coming to a decision regarding insurance coverage for infant male circumcision. The article, which was published in the September, 1997 issue of the journal Archives of Disease in Childhood, is entitled Routine male neonatal circumcision and risk of infection with HIV-1 and other sexually transmitted diseases.

Note the following statements:

...a protective effect [against HIV infection] was not found across all studies.

...being heavily circumcised has not prevented the USA from becoming the industrialised country most burdened with HIV, while the opposite is true for the UK.

I hope this information is of value.

Sincerely,
 
[signed]
 
D ennis H arrison

Dear Mr. H arrison:

Thank you for your correspondence regarding neonatal circumcision as an insured benefit in Manitoba. I read with interest the document you provided on infant male circumcision by Dr. Arif Bhimji, and have provided it to my department for review.

I appreciate your interest in our province's health care services. Please be assured that Manitoba Health will be including neonatal circumcision as part of the larger review of insured/deinsured benefits for our 2001/2002 budget year. The issues you have raised in your letters have been noted and I have asked my department to consider them when we review this specific health care policy.

Again, thank you for your correspondence.

Sincerely,
 
[signed]
 
Dave Chomiak

The Hon. Dave Chomiak
Minister of Health

Dear Minister:

I have written to you several times over the past year on the subject of infant male circumcision. As you are aware, the Canadian Paediatric Society advises that this operation “should not be routinely performed.” The College of Physicians and Surgeons of Manitoba has recommended to Manitoba Health that infant male circumcision be de-insured, and I understand this recommendation was supported by the Manitoba Medical Association. Every province in the country except Manitoba has dropped neonatal circumcision from the list of insured services because the procedure is not medically required and resources are urgently required elsewhere in the health care system.

Under these circumstances, why does Manitoba Health retain infant male circumcision as an insured service?

I would appreciate an answer at your earliest convenience.

Sincerely,
 
[signed]
 
D ennis H arrison

Dear Mr. Chomiak:

I’m writing to ask why newborn circumcision is an insured service in Manitoba. Medical organizations around the world agree that circumcision is not required to protect an infant’s health, and the operation has been dropped from the list of insured services in every other province.

Manitoba Health would not be spending taxpayers’ money for no reason. Can you tell me specifically what the reason is for funding circumcision of healthy male infants?

I would appreciate a reply at your earliest convenience.

Yours sincerely,
 
[signed]
 
Bettie Malofie

Dear Mr. H arrison:

Thank you for your most recent letter regarding infant male circumcision as an insured service.

I understand that this issue is of great importance to you and I wish that I could provide you with more definitive information, or a fresh response. At the present time, our government has not yet had the opportunity to fully review this issue. I am cognizant of the latest recommendations made by various stakeholders and have noted your concerns and will give them thorough consideration as we continue our review.

I appreciate your ongoing interest in this matter.

Sincerely,
 
[signed]
 
Dave Chomiak

Dear Ms. Malofie:

Thank you for your correspondence regarding newborn circumcision. I appreciate that you have written to me.

Manitoba Health is reviewing this policy and your input is a valuable contribution to this process. I regret that I cannot provide you with a more definitive response at this time; however, I would like to assure you that your concerns will be given consideration during our review.

Thank you for your interest in this matter.

Sincerely,
 
[signed]
 
Dave Chomiak

Dear Minister:

Thank you for your letter of September 13, 2001. You write that you cannot give me a definitive answer as to why newborn circumcision is an insured service, because Manitoba Health has not finished reviewing its policy on this issue.

Regardless of whether or not the policy is under review, there must be a reason why it has remained in effect until now. I don’t understand what this reason could be. Newborn circumcision is not medically necessary. The Canadian Paediatric Society has been advising against the procedure since 1975, and it has been dropped from the list of insured services in every other province.

I would appreciate it if you could state the reason why newborn circumcision continues to be an insured service in Manitoba at the present time.

Sincerely,
 
[signed]
 
Bettie Malofie

Dear Minister,

Re: Routine infant circumcision as an insured service

I’ve received confirmation from the Manitoba College of Physicians and Surgeons that they do not support the continuation of routine infant circumcision as an insured service in Manitoba. Medical organizations throughout the world seem to agree that routine circumcision of male infants is not medically indicated or required.

Given this circumstance, I’m becoming increasingly puzzled as to why Manitoba, alone among the provinces, continues to fund routine infant circumcision. Does the Manitoba government agree that

1. routine circumcision is not medically necessary, and
2. funding for procedures that are not medically necessary lies outside the mandate of Manitoba Health?

I would appreciate it if you could clarify the above points.

Sincerely,
 
[signed]
 
D ennis H arrison

Dear Ms Malofie:

Thank you for your letter regarding the coverage of newborn circumcision as an insured service. I am pleased to specifically explain why the procedure is an insured service in Manitoba.

Newborn circumcision appears in the Manitoba Physician’s Fee Manual, as regulated under the Manitoba Health Insurance Act. In Manitoba, this procedure is an insured service if done: within 30 days of a child’s birth; or for any age if a medical condition necessitates it.

All services insured by Manitoba Health are reviewed on an ongoing basis to ensure the best use of health care dollars.

Thank you for your letter. I trust that I have answered your enquiry.

Sincerely,
 
[signed]
 
Dave Chomiak

Dear Minister,

I’m writing to request clarification of your letter dated December 12, 2001, regarding newborn circumcision as an insured service. You write that in Manitoba, newborn circumcision “is an insured service if done: within 30 days of a child’s birth; or for any age if a medical condition necessitates it.”

Does this mean that Manitoba Health considers circumcision to be medically necessary for 30 days after birth? If not, then what is the basis for funding this procedure? If Manitoba Health is insuring a procedure that is not medically necessary or medically recommended, then I would appreciate knowing why other procedures, such as ear piercing or routine eye exams, are not covered.

Given that the Canadian Paediatric Society does not recommend circumcision as a routine procedure, whom does Manitoba Health consider to be the authority on the medical need for newborn circumcision?

I would appreciate clarification of the above points.

Sincerely,
 
[signed]
 
Bettie Malofie

Dear Mr. H arrison:

Thank you for your letter, directed to me by Premier Gary Doer, regarding infant male circumcision in Manitoba.

I appreciate your interest in this issue. This procedure is currently an insured service under the Manitoba Health Services Insurance Act, if done within 30 days of a child’s birth; or for any age if a medical condition necessitates it. As you are aware, all services insured by Manitoba Health are reviewed on an ongoing basis to ensure the best use of health care dollars. Manitoba Health has not yet concluded its review of the policy to pay for newborn circumcisions at this time.

Thank you again for taking the time to express your concerns.

Sincerely,
 
[signed]
 
Dave Chomiak

Dear Ms. Malofie:

Thank you for your ongoing correspondence regarding infant male circumcision in Manitoba.

Circumcision appears in the Manitoba Physicians’ Fee Manual, which is a Regulation under the Manitoba Health Services Insurance Act. As you already know from previous communication, this procedure is an insured service if done: within 30 days of a child’s birth; or for any age if a medical condition necessitates it. A fee for this service is listed in the Regulation, and until circumcision is de-insured, Manitoba Health must make a payment for this service to the physician. However, the fee provision in no way implies, as you write, that “Manitoba Health considers circumcision to be medically necessary for 30 days after birth.” It simply means that a circumcision is covered if done within 30 days of a child’s birth, as well as for any age if a medical condition warrants it.

As you are aware, services insured by Manitoba Health are reviewed on an ongoing basis to ensure the best use of health care dollars, hence accounting for why other procedures, “such as ear piercing or routine eye exams, are not covered.” I can advise you that Manitoba Health has still not yet completed its review of the policy to pay for newborn circumcisions at this time, but that a conclusion is forthcoming.

I do appreciate the feedback from Manitobans who take the time to write to me, and I hope that you find this information useful.

Sincerely,
 
[signed]
 
Dave Chomiak

Dear Minister:

I’ve written to you several times in an effort to find out why infant male circumcision remains an insured service in Manitoba, long after it has been de-insured in every other province. The only answer I have received is that the matter is under review. I have asked the following questions about the review process:

1. Is medical need the standard that must be met?
2. If so, whom does Manitoba Health consider to be the authority on the medical need for infant male circumcision?

Unfortunately, I have received no answers to these questions, despite the government’s commitment to transparency and accountability.

According to Hansard, you rose in the Legislative Assembly shortly after 3 p.m. on May 29th, 1997, to ask the then Minister of Health, the Honourable Darren Praznik, what proposals were on the table to reduce the cost of health care. Minister Praznik replied that the College of Physicians and Surgeons had recommended de-insuring non-therapeutic male circumcision.

Five years have passed since that exchange took place in the legislature. I am once again requesting a reasonable explanation as to why Manitoba Health has not implemented the recommendation made by the College of Physicians and Surgeons five years ago.

Yours sincerely,
 
[signed]
 
Bettie Malofie

Dear Ms. Malofie:

Thank you for your continued correspondence regarding infant male circumcision.

The last time we corresponded, I informed you that Manitoba Health had not yet completed its review of the policy to insure infant male circumcision. In the course of our review, we considered numerous expert opinions, as well as the opinions of Manitobans, like you, who took the time to express their concerns on this issue. Since then, I can advise you that Manitoba Health completed its review of the policy, and reached a decision to continue insuring infant male circumcision.

As you are already aware, Manitoba Health regularly reviews which services are insured in order to ensure the best use of health care dollars. For instance, we have recently made some difficult decisions about insured benefits in the area of chiropractic care, in order to help contain costs.

In response to your first question, I must reiterate the information in my last letter to you. A fee for this service is listed in the Regulation, and Manitoba Health must make a payment for this service to the physician. However, the fee does not imply that “Manitoba Health considers circumcision to be medically necessary”; rather, it simply means that a circumcision procedure is covered if done within 30 days of a child’s birth, as well as for any age if a medical condition necessitates it.

In response to your other questions, I can assure you that Manitoba Health takes the expert opinions of our medical professionals very seriously. We entrust the decisions regarding medical care to those same professionals, who also help our government make informed decisions about health care policy.

I hope that you find this information useful and that it provides you with some closure on this issue.

Sincerely,
 
[signed]
 
Dave Chomiak

Dear Minister:

I would like to ask some questions about the government’s recent decision to continue paying for newborn circumcision. For some years now, Manitoba has been the only province providing this procedure at public expense.

The College of Physicians and Surgeons of Saskatchewan recently issued a memo to its members warning them that routine circumcision of male infants is not good medical practice. The memo advises physicians not to perform the procedure. A copy of this memo is enclosed for your information.

By encouraging newborn circumcision through a public subsidy, Manitoba seems to be pursuing a policy that is at cross-purposes with that of Saskatchewan. In addition, Manitoba’s policy appears to be out of alignment with medical opinion in Manitoba itself. Both the College of Physicians and Surgeons of Manitoba and the Manitoba Medical Association are on record as being opposed to continued public funding for routine infant male circumcision. Moreover, the recognized authority on child health in Canada, the Canadian Paediatric Society, recently reaffirmed its position that newborn circumcision “should not be routinely performed.”

In short, Manitoba’s policy of paying for newborn circumcision seems to be out of step with the policies of all other provincial health ministries and out of sync with current medical opinion. In such circumstances it seems reasonable to ask Manitoba Health to justify its policy. Accordingly, I’m re-submitting the following two questions for a response. I have asked these questions in previous correspondence, but unfortunately they haven't been answered.

1. When deciding whether to provide public funding for a medical procedure, is medical need the standard that must be met?
2. If so, whom does Manitoba Health consider to be the authorit(ies) on the medical need for infant male circumcision?

Perhaps you could also comment on the lack of alignment between the policies in Manitoba and Saskatchewan. One province is subsidizing a surgical operation that is being actively discouraged in a neighbouring province. Does Manitoba Health believe this is acceptable?

I would appreciate responses to the above questions at your earliest convenience.

Yours sincerely,
 
[signed]
 
Bettie Malofie

Dear Ms Malofie:

Thank you for your ongoing correspondence regarding infant male circumcision. I appreciate the documentation you attached from the College of Physicians and Surgeons of Saskatchewan.

As I have previously and frequently communicated to you, Manitoba Health reviewed its policy for the insurance of newborn circumcision, and received numerous expert opinions relating to this issue. After careful consideration, Manitoba Health decided to continue to insure newborn circumcision.

In regard to your first two questions, I do believe that I have sincerely answered them in previous correspondence. One, determining coverage for a medical procedure is done carefully and thoughtfully, as based on the expert opinions of many health care professionals, who are current in their field, and take their responsibility very seriously. I’m not sure what you mean by “medical need,” as I am not a doctor, but I can tell you, again, that we entrust decisions regarding medical care to those same professionals. We rely upon their authority to help us make informed decisions about health care policy, including coverage of a given procedure.

I don’t know what more to add about this matter, except to reiterate again that Manitoba Health does not consider any one person or professional body to be the final authority. In other words, Manitoba Health routinely and regularly conducts reviews of its services, in order to ensure the best use of our health care dollars, and relies upon, as stated above, the expert opinions of many health care professionals.

In response to your question about the alignment of policies between the provinces, I can advise you that each province is responsible for determining how best to distribute its own health care dollars.

Thank you, again, for your correspondence. I do take your opinions seriously, and I can assure you that they will be considered during our next review of this matter. However, I have nothing new to add to this matter at this time, and I regret that the information could not be more favourable to you.

Sincerely,
 
[signed]
 
Dave Chomiak

Dear Minister:

I’m writing to request clarification of your letter of October 24th regarding Manitoba Health’s decision to continue public funding for infant male circumcision.

The gist of your letter is that Manitoba Health’s decision was based on expert medical opinion. However, the consensus of opinion in the medical community today, as reflected in the position statements of medical organizations throughout the world, is that newborn circumcision is not medically justified. For that reason, the procedure has been de-insured in every other province.

In response to my question as to whether medical need is the standard that must be met for public funding of a medical procedure, you wrote, “I’m not sure what you mean by ‘medical need’, as I am not a doctor.”

The concept of medical need is used on Manitoba Health’s own Web site. Under Health Care Coverage, it says:

Manitoba Health directly pays physicians' services that are medically required for you or your dependants.

The Web site also says that Manitoba Health does not pay for services which are not medically required. Moreover, you yourself have publicly stated that access to health care should be based on medical need, not on ability to pay. I’m surprised, therefore, that you’re uncertain as to what “medical need” actually means.

Manitoba’s policy on newborn circumcision is at variance with established medical opinion and out of alignment with the policies of all other provincial ministries of health. In such circumstances, I think Manitoba Health has an obligation to justify its policy in an open and transparent way. Accordingly, I would appreciate answers to the following questions:

1. Does newborn circumcision fit Manitoba Health’s definition of a medically required procedure? If not, then on what basis is it being insured?
2. Why did Manitoba Health reject the expert opinions of the College of Physicians and Surgeons of Manitoba, the Manitoba Medical Association, and the Canadian Paediatric Society? On whose expert opinion did Manitoba Health base its decision to continue funding newborn circumcision?
3. Why is routine circumcision an insured service only if done within 30 days of a child’s birth? Why is circumcision excluded from insurance coverage after 30 days except when necessitated by a medical condition?

I believe my questions are reasonable and deserving of straightforward answers. I would appreciate a reply at your earliest convenience.

Yours sincerely,
 
[signed]
 
Bettie Malofie

Dear Ms Malofie:

Thank you for your continued correspondence regarding infant male circumcision, a matter about which you are obviously very well informed.

I appreciate the interesting and ongoing dialogue that our correspondence has generated around this topic, and I commend your commitment and dedication to procuring answers for your many questions. However, I must resist engaging in the semantic wordplay that your newly modified versions of previous questions might otherwise engender, and continue to be as straightforward as possible.

It may be that the decision to insure infant male circumcision is “at variance” with other opinions in other Canadian jurisdictions; however, that does not mean that Manitoba Health is not open and transparent about its decision to insure infant male circumcision. In fact, I have openly addressed your questions in repeated correspondence.

May I point out again that determining coverage for a medical procedure is done carefully, as based on the expert opinions of many health care professionals, who are current in their field, and take their responsibility seriously. We rely upon their authority to help us make informed decisions about health care policy, including service coverage.

I understand that your questions arise from another perspective, and I sense your frustration with me in what you may think is my attempt to dodge your questions, or to remain uninformed about this topic, or how it is in other jurisdictions.

Right now, in Manitoba, we are insuring circumcision for infant males, and that fact will not change until we conduct another review. It is not necessary for you to write to us again at that time. I appreciate the thoughtful articulation of your opinion, and I promise you that we will bring your concerns forward during a future review.

I do sincerely hope that you will accept the present circumstances, although you may not be in agreement with them.

Sincerely,
 
[signed]
 
Dave Chomiak

Dear Minister Chomiak:

I understand that Manitoba Health recently made a decision to continue insuring circumcision of male infants. Since I consider circumcision to be an important issue, and have been researching it for several years, I would like to obtain some information on how Manitoba Health reached its decision.

First I would like to present some background information:

1. The Canadian Paediatric Society (CPS), the recognized authority in Canada on matters related to child health, concluded in 1996 after a comprehensive review of the medical literature that infant male circumcision ”should not be routinely performed.” The CPS reaffirmed its position in March, 2002. Policy statements similar to that of the CPS were issued by the American Academy of Pediatrics in 1999 and by the Royal Australasian College of Physicians in 2002. Currently no national medical organization in the world considers routine circumcision of male infants to be medically justified, let alone medically necessary.
2. Due to the lack of medical necessity, routine infant circumcision has long since been de-insured in every other province.
3. Canada’s top ethicists have concluded that newborn circumcision is unethical because it is a permanent body modification undertaken without compelling medical need and without the personal informed consent of the patient. As such, it infringes on the basic human right to physical integrity as well as the Charter right to security of the person.
4. There is a growing consensus in the Canadian medical profession that routine infant circumcision should be abandoned. Over the past year, two medical licensing authorities in Canada have taken steps to discourage the performance of this procedure. In its Fall, 2002, newsletter, the College of Physicians and Surgeons of British Columbia informed its members that newborn circumcision is a “cosmetic surgical procedure which should only be undertaken after detailed discussion with the parents.“ The College of Physicians and Surgeons of Saskatchewan went further, warning physicians that the expected benefits of newborn circumcision do not outweigh the potential risks, and that “it would generally be considered imprudent if not improper for a surgeon to perform such a surgical procedure.” The Saskatchewan college also cautioned physicians that if they perform routine infant circumcision, they could be vulnerable to lawsuits brought by the parents or the infant himself when he reaches the age of majority.
5. The vice-president of the Saskatchewan Medical Association, Dr. Joel Yelland, stated in the September 3, 2002 issue of the Canadian Medical Association Journal that he could not understand why physicians would perform newborn circumcision today, given the medical and legal risks involved.
6. Last August a five-week old infant in B.C. died from circumcision complications, highlighting the fact that circumcision is not a trivial operation.
7. In the Nordic countries, where only Jewish and Muslim boys are routinely circumcised, governments are taking measures to regulate male circumcision because of mounting concerns about safety, and because of an increasing awareness of the human rights issues raised by performing medically unnecessary body modifications on minors. In June, 2001, the Swedish parliament passed a law placing certain restrictions on the performance of male circumcision, and a debate on whether male circumcision should be allowed is currently underway in Denmark. The newly-appointed head of the Danish Council of Ethics, Dr. Ole Hartling, favours prohibiting all circumcisions of minors unless required for therapeutic reasons. Meanwhile, the Norwegian Council for Medical Ethics has informed the board of the Norwegian Medical Association that non-therapeutic circumcision of children is inconsistent with fundamental principles of medical ethics. The council has invited relevant religious leaders in the community to work on replacing circumcision with symbolic rituals that do not involve a surgical procedure.

In short, routine infant circumcision does not seem to have any of the characteristics of an insured service. Not only is it universally regarded as medically unnecessary, but it is also the subject of ethical, legal and human rights controversies. Therefore it is not readily apparent to me why a social democratic administration such as that of Manitoba—or for that matter why any prudent administration—would decide that routine infant circumcision should be publicly funded at this time, especially in light of the urgent need for funding in other, highly critical areas of health care.

I am sure Manitoba Health had good reasons for its decision to continue insuring circumcision of male infants. I would appreciate some detailed information about how the decision was reached. Specifically, I would be interested in knowing what specialists were engaged in the discussion.

Thank you for taking the time to consider this issue.

Sincerely,
 
[signed]
 
D ennis H arrison

Dear Mr. H arrison:

Thank you for your continued correspondence regarding infant male circumcision, a matter about which you are obviously very well informed.

I appreciate your thoughtful summary of an alternate position, and I am pleased to answer your query about the decision making process. When you last wrote, we were still assessing this matter, and had not yet concluded our review of the policy to insure infant male circumcision. We have since reached the decision to continue insuring infant male circumcision at this time.

We determine coverage for medical procedures with due diligence, as based upon the expert opinions of many health care professionals, who are current in their field. We rely upon their authority to help us make informed decisions about health care policy, including service coverage and, in this case, the decision to continue insuring this procedure.

I understand that your questions arise from another perspective, and I sense your frustration with our administration in appearing uninformed about this topic, and how it is addressed in other jurisdictions. Right now, in Manitoba, we are insuring infant male circumcisions, and that will remain the case until we conduct another review.

I appreciate the comprehensive summary of your opinion, and I assure you that we will bring your concerns forward during a future review.

I do hope that you will accept the present circumstances, although you may not be in agreement with them.

Sincerely,

[signed]

Dave Chomiak

Dear Minister Chomiak:

Thank you for your letter of February 17th regarding the issue of public funding for infant male circumcision.

I’m sure that Manitoba Health’s decision to continue insurance coverage for infant male circumcision was made with due diligence. Nevertheless, I would like to know some of the particulars of the decision, in view of the fact that the other provinces reviewed the same body of evidence as Manitoba, and concluded without exception, that newborn circumcision should be de-insured.

Accordingly, I am respectfully requesting the following:

• minutes of the various committee meetings that were held;
• names of the specialists who were consulted;
• clarification as to whether or not Manitoba Health considers the Canadian Paediatric Society and the College of Physicians and Surgeons of Manitoba to be the final authorities on the medical need for surgical operations on children.

If you would be kind enough to provide me with the basic information I am requesting, then I can apply for the rest through the Freedom of Information and Protection of Privacy Act.

I would appreciate a response at your earliest convenience.

Sincerely,

[signed]

D ennis H arrison

Hon. Gary Doer
Premier of Manitoba

Dear Premier:

I have been trying to find out for over two years why infant male circumcision remains an insured service in Manitoba, long after it has been de-insured in all other provinces. Essentially, I would like to know if this procedure is being funded on the basis of medical need, or on some other basis. I feel this question is reasonable and deserves a straightforward response from the government of Manitoba.

Unfortunately, I have been unable to obtain a satisfactory response from Health Minister Dave Chomiak, though I have written to him a number of times. The only reply I have received from Minister Chomiak is that the government’s decision to continue funding neonatal circumcision is based on “numerous expert opinions.” The minister’s response is hard to understand because there has been a consensus in the medical community for decades that infant male circumcision is not medically justified. The recognized authority on medical practice in Manitoba, the College of Physicians and Surgeons, is on record as being opposed to continued public funding for newborn circumcision. The governing medical specialty college, the Canadian Paediatric Society, recommends that newborn circumcision “should not be routinely performed.”

I don’t know why Manitoba Health has repeatedly refused to give clear reasons for funding this procedure. The government should be open and transparent about decisions to fund or not to fund a medical service, especially if the decision goes against the consensus of medical opinion and runs counter to the policies of all other provinces.

In his latest correspondence, dated December 23, 2002, Minister Chomiak once again refused to state whether Manitoba Health considers infant male circumcision to be medically required. Minister Chomiak added that it was “not necessary” for me to write to him again.

I am appealing to you for some answers because I have no other recourse, except possibly for a writ of mandamus. Could you tell me if infant male circumcision is being funded because it is deemed medically necessary? Or if it is not deemed medically necessary, then why is it being funded?

Thank you in advance for your response. For your reference, I enclose copies of my latest correspondence with Minister Chomiak.

Sincerely,

[signed]

Bettie Malofie

Hon. Dave Chomiak
Minister of Health

Dear Minister,

Re: infant male circumcision

I am writing to request further clarification of Manitoba Health's policy of paying for the above procedure. My continuing concerns arise from the fact that newborn circumcision has been condemned by two of Canada's top medical ethicists: Dr. Margaret Somerville, Director of McGill University’s Centre for Medicine, Ethics and Law, and Dr. Eike-Henner Kluge, founding Director of the Canadian Medical Association’s Department of Ethics and Legal Affairs.

In previous correspondence, you indicated that circumcision is an insured service in Manitoba if done within 30 days of an infant’s birth. However, it has come to my attention that the Manitoba Medical Association (MMA) seems to dispute your assertion. In the November, 2001 issue of their newsletter, the MMA notes that under the Health Services Insurance Act, only medical services which are “medically required” are insured services. Since newborn circumcision is hardly ever medically required, the MMA advises physicians to “direct bill” for the procedure. A copy of the MMA statement is enclosed.

To help me understand the Government’s policy on this issue, I would appreciate it if you could clarify whether or not routine infant circumcision (i.e. circumcision that is not medically required) is an insured health service within the meaning of the Canada Health Act. If it is, then why are Manitoba doctors direct-billing for it? If it isn’t, then why is Manitoba Health paying for it?

Thank you for your attention in this matter.

Yours sincerely,

[signed]

Bettie Malofie

Dear Ms Malofie:

Thank you for your recent letter and documentation regarding infant male circumcision. I appreciate the opportunity to respond to your correspondence.

As outlined in my letter to you dated July 30, 2002 the fee for circumcision listed in the Regulation does not imply that Manitoba Health considers this to be medically necessary. It simply means that the procedure is covered if done within 30 days of a child’s birth. The procedure is also covered at any age where it becomes medically necessary.

Physicians solely determine the requirements for circumcision on an individual basis. Manitoba Health relies on the decisions made by the providers of service. Manitoba Health will continue to insure circumcision of infant males until such time as another review is conducted.

I appreciate that you have taken the time to share your views with me, and I wish you all the best.

Sincerely,

[signed]

Dave Chomiak

Hon. Tim Sale
Minister of Health

Dear Minister:

Re: Infant male circumcision

I am writing to inquire about Manitoba Health’s policy of paying for the above procedure under Medicare. I have been researching the issue of circumcision for several years. My opinions on the subject have been published in a number of academic journals, including the Lancet and the Journal of Law and Medicine.

Earlier this year, the College of Physicians and Surgeons of British Columbia released a formal policy discouraging routine infant circumcision. The policy describes the operation as “medically unnecessary” and notes that it may constitute a human rights violation. A similar guideline was issued two years ago by the College of Physicians and Surgeons of Saskatchewan. In Manitoba, the medical association not only opposes continued public funding for routine circumcision, but has even gone so far as to advise its members to ignore Manitoba Health’s official policy on the issue.

It is evident that the medical profession is becoming increasingly concerned about the ethical implications of infant male circumcision. In such circumstances, Manitoba’s policy of encouraging the operation through a public subsidy is extraordinary, especially in light of funding shortfalls in critical areas of health care. Routine infant circumcision has long since been de-listed in all other provinces.

The Manitoba government must be subsidizing infant male circumcision for a reason. I would really appreciate it if you could tell me what that reason is.

Thank you in advance for your reply.

Sincerely,

[signed]

D ennis H arrison

Hon. Tim Sale
Minister of Health

Dear Minister:

Re: Infant male circumcision

I wrote to you regarding the above issue a month ago, but so far have received no reply. A copy of my letter of November 12th is enclosed for your reference.

I would like to add to my earlier correspondence by drawing attention to an article entitled Caution Regarding Routine Circumcision of Newborn Male Infants, published in the December, 2002 issue of the newsletter of the College of Physicians and Surgeons of Manitoba. The article states clearly and unequivocally that infant male circumcision is not a recommended procedure. A copy of the article is enclosed.

The Canadian Paediatric Society (CPS), the recognized authority on child health in Canada, has just launched a Web page called Circumcision: Information for parents (posted November, 2004).

On this Web page, the CPS says that “circumcision is a ‘non-therapeutic’ procedure, which means it is not medically necessary.” The CPS goes on to say that “the CPS does not recommend routine circumcision for newborn boys. Many paediatricians no longer perform circumcisions.”

The Health Services Insurance Act empowers the Minister of Health to provide insurance for residents of the province in respect of services that are “medically required.” Infant male circumcision clearly does not fall within that category. I look forward to your explanation as to why Manitoba is still insuring this procedure.

Sincerely,

[signed]

D ennis H arrison

Dear Mr. H arrison:

I am writing in response to your correspondence about infant male circumcision.

The fee for circumcision listed in the regulations under the Health Services Insurance Act does not imply that Manitoba Health considers this procedure to be medically necessary. Rather, it means that the procedure is covered if done within 30 days of a male’s birth, as well as at any age where a medical condition necessitates it.

The requirements for circumcision are determined solely by the patient's physician on an individual basis. Manitoba Health does not interfere with or influence the decisions made by the providers of these services. Until such time that a review is conducted, Manitoba Health will continue to insure circumcision for infant males.

Thank you for taking the time to share your views with me.

Sincerely,

[signed]

Tim Sale

Dear Minister:

Thank you for your letter of January 27th. I would appreciate clarification of two points.

The first point is in relation to your statement that infant male circumcision is “covered if done within 30 days of a male’s birth, as well as at any age where a medical condition necessitates it.”

Could you explain why circumcision of males older than 30 days is not covered unless necessitated by a medical condition?

The second point concerns your statement that “the fee for circumcision listed in the regulations under the Health Services Insurance Act does not imply that Manitoba Health considers this procedure to be medically necessary.”

The fees listed in the Payments for Insured Medical Services Regulation, under the Health Services Insurance Act, are for insured medical services. These are defined in the Act as “all services rendered by a medical practitioner that are medically required.”

Could you clarify the reason why a fee for newborn circumcision appears in the Payments for Insured Medical Services Regulation?

Thank you in advance for your reply.

Sincerely,

[signed]

D ennis H arrison

Dear Mr. H arrison:

Thank you for your follow-up letter regarding infant male circumcision. I appreciate the opportunity to clarify my previous response to you.

When tariffs are negotiated into the Physician’s Manual, Manitoba Health along with the Manitoba Medical Association determines the rules that govern the payment of procedures. In the case of two tariffs for circumcision, the following was determined:

• one tariff would be for newborns under 30 days old and would not require further information reported on the claim for service
• one tariff would be for males over 30 days old with medical conditions reported on the claim for service

Our Government recognizes that there are different points of view with respect to infant male circumcision. Therefore, we rely on the advice of the medical professionals who render these services.

I hope that this information has addressed your concerns.

Sincerely,

[signed]

Tim Sale

Dear Minister:

Thank you for your letter of April 25th. Unfortunately, it does not address either of the two questions I raised. It merely restates Manitoba Health’s policy on payment for male circumcision.

What I would like to know is why funding is restricted to cases of medical need after a male is 30 days old, but not before. No other province or territory has one tariff for circumcision of males up to 30 days of age, and another tariff, with different terms and conditions, for circumcision of males older than 30 days. Under the Canada Health Act, insured residents are entitled to insured health services on uniform terms and conditions. Arbitrary age distinctions are inconsistent with the principle of universality, not to mention the Charter of Rights and Freedoms.

I would also appreciate it if you could clarify what you mean when you say that the rules governing payment for circumcision were determined by Manitoba Health “along with the Manitoba Medical Association.” The MMA does not even consider routine infant circumcision to be an insured service.

Sincerely,

[signed]

D ennis H arrison

Dear Mr. H arrison:

Thank you for your letter dated May 6, 2005, to the Minister of Health. I have been asked to respond on his behalf.

Manitoba Health acknowledges that there will always be different points of view with respect to infant male circumcision. The government’s position on this issue remains as stated in previous correspondence.

Thank you for taking the time to write.

Sincerely,

[signed]

Bev Ann Murray
Assistant Deputy Minister

Dear Ms. Murray:

RE: Infant male circumcision as an insured service

Thank you for your letter of August 22, 2005 regarding the above subject.

According to the Manitoba Medical Association (MMA), neonatal circumcision is not an insured service in Manitoba except in the rare cases where it is medically required. (See enclosure: MMA Newsletter, November 2001, p. 6.) I’m having trouble reconciling the MMA’s statements with those of Manitoba Health. When neonatal circumcision is not medically required, is it an insured service in Manitoba or not? A simple “yes” or “no” response would be appreciated.

Sincerely,

[signed]

D ennis H arrison

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