The Honourable Jane Groenewegen
Minister of Health & Social Services

Dear Minister:

I’ve been doing research on infant male circumcision, and am writing to inquire why this operation is an insured service under the NWT Health Care Plan.

Medical societies throughout the world agree that any potential medical benefit from newborn circumcision is so insignificant that it does not clearly outweigh the risks of the surgery itself. The Canadian Paediatric Society advises that newborn circumcision “should not be routinely performed.” All provinces except Manitoba (where the operation is currently under review) have concluded that circumcision of male infants is not a good use of health care resources and have dropped the procedure from the list of insured services. Yukon de-insured the procedure in 1988.

Moreover, leading Canadian ethicists have indicated that circumcision of a child without medical justification presents ethical difficulties and may even violate current provisions of the Criminal Code.

Under these circumstances, I would appreciate it if you would explain why infant male circumcision continues to be an insured service in the Northwest Territories.

Dear Mr. H arrison:

The Minister of Health and Social Services, the Honourable Jane Groenewegen, has asked me to respond directly to your letter of June 1, 2001 dealing with the subject of newborn circumcision as an insured service in the Northwest Territories.

As you indicate, routine newborn circumcision remains an insured service in the NWT. However, we are currently initiating a review of our health benefits programs and your input on this matter is very valuable. For further information or discussion on this, you may contact Dr. André Corriveau, Assistant Deputy Minister for Population Health and Clinical Services directly at [phone no.]

Hon. J. Michael Miltenberger
Minister of Health & Social Services

Dear Minister:

Re: Infant male circumcision as an insured service

I have been doing research on the issue of infant male circumcision. I understand that this procedure continues to be an insured service under the NWT Health Care Plan, and I'm writing to inquire why this is the case.

First I would like to present some background information:

1. The Canadian Paediatric Society (CPS), the governing specialty college in 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 been de-insured in every other jurisdiction in Canada except Manitoba.
3. Top Canadian ethicists have concluded that newborn circumcision presents ethical problems because it is a permanent body modification undertaken without compelling medical need on a person incapable of giving informed consent. 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 & 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 & 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.

In short, routine infant male 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.

I do not understand why the government of the Northwest Territories would continue to fund such a procedure, especially in light of recent statements made by Premier Kakfwi to the effect that the federal government does not appreciate the dire need for health care funding in the North.

I am sure the Department has a reason for insuring routine infant circumcision. I would be very appreciative if you could take the time to explain what that reason is.

Hon. J. Michael Miltenberger
Minister of Health & Social Services

Dear Minister:

I wrote to you on February 8th regarding infant male circumcision as an insured service in the Northwest Territories. Unfortunately, I have received no response to date.

A response would be appreciated, as this issue is of importance to me. I have been researching circumcision for several years, and my letters on the subject have been published in a number of academic journals, including the Lancet, the New England Journal of Medicine, and the Journal of Law and Medicine.

As you are aware, the official position of the Canadian Paediatric Society, the recognized authority on matters related to child health in Canada, is that infant male circumcision "should not be routinely performed." Medical organizations throughout the world agree that infant male circumcision is not medically justified. With the single exception of Manitoba, the procedure has been de-insured in every other province and territory.

The government of the Northwest Territories would not be funding a medical procedure for no reason. For the purposes of my own research, I would be grateful if you could state the reason why routine infant circumcision is an insured service in the Northwest Territories. Is it medical need, or some other factor?

Thank you in advance for clarifying the NWT policy on this issue.

Dear Mr. H arrison:

Thank you for your letter of February 8, 2003, regarding infant male circumcision.

At this time, this procedure is listed as an insured service in the Northwest Territories (NWT) Fee Schedule. The Department of Health and Social Services will consider the appropriateness of circumcision, as an insured service, during our next review of the NWT Fee Schedule.

The Government of the Northwest Territories remains concerned and committed to protection of the public in insuring only those services considered medically necessary.

If you have any questions, please contact Mr. Rick Trimp, Director, Territorial Services Division, at [phone no].

Mr. Rick Trimp
Director - Territorial Services
Health and Social Services

Dear Mr. Trimp:

As you are aware, I have been trying to find out why routine infant male circumcision is an insured service in the Northwest Territories. In a letter dated April 8, 2003, the Minister of Health and Social Services, the Hon. J. Michael Miltenberger, indicated that I should direct my questions to you. I enclose of a copy of the Minister's letter for your ease of reference.

Unfortunately, I have received no response to the phone messages or emails I sent you.

All I want to know is whether the Northwest Territories is paying for routine infant male circumcision on the basis of medical need, or on some other basis. If the criterion is medical need, then could you identify the authorities that consider routine infant circumcision to be medically necessary?

Thanks in advance for your response.

Dear Mr. H arrison:

Thank you for your letter of February 8, 2003, regarding infant male circumcision.

At this time, this procedure is listed as an insured service in the Northwest Territories (NWT) Fee Schedule. The Department of Health and Social Services has identified this fee code as a consideration in preparation for our next review of the NWT Fee Schedule scheduled for winter of 2003-2004.

Thank you for expressing your concerns.

Mr. Rick Trimp
Director - Territorial Services
Health and Social Services

Dear Mr. Trimp:

Re: Insured Services

You indicated in July that this winter Health and Social Services will be reviewing its policy of paying for infant male circumcision. I am writing to provide some background information that may assist Health and Social Services complete its review.

The Canadian Paediatric Society (CPS) is the recognized authority in Canada on matters related to child health. I enclose a copy of the CPS's clinical practice guideline on newborn circumcision. As you can see, the recommendation is that "circumcision of newborns should not be routinely performed." This policy was first issued in 1996 and was reaffirmed in 2002.

An article called Newborn circumcision: an economic perspective was published in the December 1, 1984 issue of the Canadian Medical Association Journal. The authors concluded that any potential monetary benefits of newborn circumcision do not outweigh the costs and consequently the procedure should not be paid for by taxpayer-funded health insurance plans.

Infant male circumcision was de-insured in other Canadian jurisdictions on the following dates:

Alberta	1987
B.C.	1984
N.B.	1994
Nfld./Labrador	1995
N.S.	1997
Ontario	1994
P.E.I.	1993
Quebec	1987
Sask.	1996
Yukon	1988

I trust the above information will be of value to Health and Social Services during the upcoming review.

Hon. J. Michael Miltenberger
Minister of Health & Social Services

Dear Minister:

Re: Infant male circumcision

I am writing to request your assistance in obtaining statistics on newborn circumcision in the Northwest Territories, including Nunavut if possible. I am preparing a paper on the subject of circumcision practices in Canada, and would like to include recent data for each province and territory.

Would it be possible for you to provide me with statistics on the number of circumcisions performed on newborns in the NWT/Nunavut for the fiscal years 1998/99 to 2002/03 inclusive?

I would also appreciate it if you could update me as to whether routine infant circumcision has been de-insured. As you are aware, the procedure lacks one of the essential characteristics of an insured service—namely, medical necessity. Routine circumcision is an elective procedure that is not recommended by the governing specialty college, the Canadian Paediatric Society.

Thank you very much for your assistance in this matter. Do not hesitate to contact me if you would like further information about my request for statistics.

Dear Mr. H arrison:

Thank you for your letter dated May 27, 2004 requesting my assistance in obtaining information on infant male circumcision in the Northwest Territories.

Please find attached, some recent statistics on concerning the number of infant male circumcision procedures that were performed in our Territory over the last 5-year period for which data is currently available. The database does not allow us to separate those that were doe for medical reasons from those done at parents’ request for religious, aesthetic or other reasons. However, a clear downward trend can be noted and, and as indicated with the table, circumcisions done for non-medical reasons have been de-insured since April 1, 2004.

Finally, it is not possible for us to provide you with Nunavut data on this matter and it will therefore be necessary that you communicate directly with their Department of Health and Social Services in Iqaluit.

I trust that this information is satisfactory.

Attachment:

^Top