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Dr. Eugene Outerbridge
Principal Author, Neonatal Circumcision Revisited

Dear Dr. Outerbridge:

Thank you for your thoughtful reply of Feb. 18. I appreciate your taking time out from retirement to write to me. I would like to respond to some of the points you made.

In your letter you say physicians must provide parents with accurate information. I agree with you on that point. However, when you go on to suggest that the final decision to circumcise rests with the parents, I must part company with you. The way I see it, a physician should never end up treating a child in a way the physician considers to be medically inappropriate. The Harbourview case may help illustrate this point.

In the fall of 1996, the Harbourview Medical Centre in Seattle, Washington was facing increasing demands from Somali immigrants for circumcision of girls. Harbourview came up with a compromise solution that involved making a nick on the clitoral hood without excising any tissue. When this compromise solution became public, an uproar ensued(1).

We readily perceive that it is inappropriate for a physician to violate the physical integrity of a little girl for non-medical reasons, even when her parents plead that a nick on the genitals is the absolute minimum required to maintain her cultural identity. Yet every year we let tens of thousands of Canadian baby boys undergo a much more drastic operation that, from a medical standpoint, is no more necessary than a nick on the clitoral hood.

You suggest there is a lack of evidence that circumcised men cannot enjoy normal sexual relationships. However, a clear and convincing body of scientific evidence suggests that removal of the foreskin has significant consequences. Rodent studies have found that circumcision has an adverse effect on copulatory behaviour(2). Laumann reported changes in sexual behaviour following circumcision of humans(3). O'Hara and O'Hara found that the mechanics of coitus were different for men who had been circumcised compared with men who had not been circumcised(4). O'Hara and O'Hara also found that women who had had sexual experience with both types of men overwhelmingly preferred non-circumcised partners.

Circumcision removes a specialized structure(5). In fact, Dr. Taylor tells me that the prepuce contains some of the most specialized sensory tissue to be found anywhere on the human body. If removing specialized sensory tissue from the penis leaves that organ with an undiminished capacity for transmitting sensory input, then the laws of physics applicable to the human penis must be different from the laws of physics governing the rest of the universe.

Women who have undergone female circumcision (FGM) tend to deny they have suffered harm. An Egyptian survey found that 79 percent of circumcised women do not agree FGM causes problems for conception or pregnancy, and 82 percent of circumcised women feel FGM should be continued(6). Social scientists attribute this behaviour to the psychological mechanisms of denial and repression(7).

Like women who have undergone FGM, circumcised men seem largely indifferent to their lot. But whereas women's acquiescence in FGM is viewed as evidence of denial and repression, men's silence about circumcision is viewed as evidence that newborn male circumcision is harmless. Is this sex distinction warranted? After all, newborn male circumcision is a traumatic intervention that strips the penis of about half its skin sheath and almost all its fine-touch neuroreceptors. As noted above, it is more invasive than some forms of FGM.

You mention that the information in Dr. Taylor's paper was barely touched on in the position statement because the paper was not available until late in the game. This was no doubt true, though I don't think it can be said that Taylor's findings had not been corroborated by any other study. The unique innervation of the prepuce had been documented at the Mayo Clinic by Winkelmann in the 1950's(8,9,10), and in Germany by Dogiel over a century ago(11,12).

The position statement asserts that circumcision of a newborn boy is a parental prerogative(13), as though it were a well-established fact that parents can authorize surgical interventions on children for non-medical reasons. But the validity of parental permission for infant male circumcision has been brought into question by legal scholars from every corner of the English-speaking world(14,15,16,17). In general, parents can only authorize surgical interventions deemed necessary for a child's health. By the Canadian Pædiatric Society's (CPS) own reckoning, neonatal circumcision does not fall into that category.

It seems to me that the issues which need to be addressed in regard to neonatal circumcision are receiving attention in the inverse ratio to their importance. No right is held more sacred under the common law than the right of every person to physical integrity. If the CPS believes that male children born in Canada can be denied this fundamental right, then the CPS should provide a comprehensive ethical and legal analysis in support of its position, instead of making broad assertions about the paramountcy of parental rights without offering one word of substantiation.

Last fall I visited Dr. Tom Anderson in the Okanagan Valley. He showed me a letter he had received from you, in which you stated that as far as you were aware FGM in Egypt was not generally performed by physicians. It is my understanding, however, that FGM in that country is in fact becoming increasingly "medicalized," with some physicians claiming FGM confers medical benefits strikingly similar to those alleged to accrue from male circumcision. For evidence of this, I invite you to look at a few quotes I have assembled. Click here to view them.

Although I have written this letter in response to personal correspondence I received from you, I have made some points which I would like other people to see. Accordingly, I'm inviting Drs. Francoeur, Jardine, McMillan, Somerville, Walker, Watts, and Williams to view the same Web-based letter you are viewing now. It is not an open letter—the Web address is not available to the general public.

Once again, I wish to express my appreciation for the work you have done on the empirical side. I hope the same will soon be done on the ethical and legal side.

Sincerely,
 
[signed]
 
D ennis H arrison

References:

1. Tom Brune. Refugees' Beliefs Don't Travel Well. Chicago Tribune, October 28, 1996, Page 1.

2. Lumia AR, Sachs BD, Meisel RL. Sexual reflexes in male rats: restoration by ejaculation following suppression by penile sheath removal. Physiol Behav 1979;23:273-7.

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

4. O'Hara K, O'Hara J. The effect of male circumcision on the sexual enjoyment of the female partner. BJU International 1999;83, Suppl. 1:79-84.

5. Taylor JR et al. The Prepuce: Specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996;77:291-5.

6. Egyptian Fertility Care Society, the Population Council, and Macro International. Clinic-based Investigation of the Typology and Self-reporting of FGM in Egypt (Nov. 1996).

7. Goldman R. Circumcision: The Hidden Trauma. Boston, MA: Vanguard Publications, 1997.

8. Winkelmann RK. The cutaneous innervation of the human newborn prepuce. J Invest Derm 1956;26:53-67.

9. Winkelmann RK. The mucocutaneous end-organ. Arch Dermatol 1957:76:225-35.

10. Winkelmann RK. The erogenous zones: their nerve supply and significance. Proc Mayo Clin 1959;34:39-47.

11. Dogiel AS. Die Nervenendigungen in der Schleimhaut der aussen Genitalorgane des Menschen. Arch F Mikr Anat 1893;41:585-612.

12. Dogiel AS. Die Nervenendapparate in der Haut des Menschen. Ztschr F Wiss Zool 1903;75:46-111.

13. "When parents are making a decision about circumcision, they should be advised of the present state of medical knowledge about its benefits and harms. Their decision may ultimately be based on personal, religious or cultural factors." (Fetus and Newborn Committee, Canadian Pædiatric Society. Neonatal Circumcision Revisited. CMAJ 1996;154(6):769-780, at p. 777)

14. Brigman WE. Circumcision as child abuse: the ethical and legal issues. J Fam Law 1985;23:337-57.

15. Queensland Law Reform Commission. Research paper: circumcision of male infants. Brisbane, Australia. QLRC 1993.

16. Circumcising baby boys 'criminal assault'. Ottawa Citizen; 17 October 1997: page A1.

17. Price C. Male Circumcision: An Ethical and Legal Affront. Bull Med Eth 1997;128:13-19.
 

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