WINNIPEG FREE PRESS Articles and letters on circumcision February 20, 2000 Circumcision prone to disaster David Robert's article on a botched circumcision (Jan 26th) reveals the tip of an iceberg of disasters due to infant male circumcision. The Canadian Paediatric Society warns that the routine circumcision of male infants has no medical justification, yet it goes on, as will desperate attempts to reconstruct, or deconstruct, the penis. A simple if unnecessary operation (circumcision) can become a nightmare involving some of the most sophisticated, prolonged and eventually unsuccessful surgery. The tragedy is all the more complete because, as we have shown, circumcision always removes highly sensitive and irreplaceable sexual tissue (See Taylor JR, AP Lockwood, AJ Taylor. The prepuce: specialized tissue of the penis and its loss to circumcision. British Journal of Urology 1996:77:291-5). Circumcision, whether male or female, is a mutilating procedure and the least we can do for our sons is to accord them the same rights to an intact body as are legally granted our girls. On the bright side, the message about genital integrity seems to be getting through to young parents because there has been a steady decline in the number of circumcisions performed in Manitoba, as in the rest of Canada, over the past few years. Interestingly, this despite the fact that our government is the last in Canada to continue funding the routine circumcision of baby boys. JOHN R TAYLOR
March 3, 2000 Circumcision foe has own agenda Regarding Circumcision prone to disaster (Free Press, Feb. 20). I find it unconscionable that Dr. John R. Taylor would use David Reimer's double tragedy to further his own personal agenda. Dr. Taylor actively opposes circumcision. David Reimer's botched circumcision was a tragedy and a tragedy that was compounded many times over by attempts at gender reassignment. Dr. Taylor warns of dangers resulting from circumcision but fails to mention that failure to circumcise is not without risks. There are risks either way -- and in either case the risks are not great. Dr. Taylor alludes to a number of points and tends to plant seeds of uncertainty. He refers to the tip of an iceberg. What is this iceberg that the medical profession and the media apparently conspire to conceal? The Canadian Pediatric Society does not warn against circumcision, as he states. It does not recommend it as a routine procedure or as a matter of public policy. It says: "The overall evidence of the benefits and harms of circumcision is so evenly balanced that it does not support recommending circumcision as a routine procedure for newborns. There is therefore no indication that the position taken by the CPS in 1982 should be changed." The American Academy of Pediatrics says: "Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision." Dr. Taylor refers to his own 1996 paper published in the British Journal of Urology. His study is a histological study; a study of anatomy that deals with the minute structure of tissues. It was conducted on a small number of corpses. From this he draws far-fetched and unwarranted conclusions as to the effect of circumcision on the adult male sexual experience. A different recent study, one of the few to deal with this subject, in fact reported that circumcised men engage in a more elaborate repertoire of sexual practices, have sex more frequently, experience fewer sexual difficulties and maintain an active sex life as they age (Laumann). He refers to human rights, but aside from Dr. Taylor's own followers, no organization or jurisdiction in the world sees neonatal circumcision in terms of human rights. As the Special Rapporteur of the United Nations puts it: "It would seem inappropriate to consider under one head both female circumcision, which is harmful to health, and male circumcision, which has no undesirable effect and is even considered to be beneficial." He subtly attempts to relate male circumcision to female genital mutilation in the minds of the public; procedures totally different in terms of procedure, intent and magnitude. It is not necessarily the bright side that sees neonatal circumcision dropped by most Canadian provinces (it is more a matter of finance). There is no longer any question that male circumcision reduces the risk of the transmission of HIV. Considering the pioneer work done by our University of Manitoba team with their colleagues in Africa, it may be quite fitting indeed that Manitoba should be the last province to continue funding for neonatal circumcision. I believe that Dr. Taylor's campaign does far more harm than good. It demonizes a procedure that is generally mildly beneficial (but which in the face of an HIV epidemic could be of utmost importance). It encourages some of his more zealous followers to advocate criminalizing neonatal circumcision and thereby infringing unjustifiably upon parental and religious rights. It plants in neonatally circumcised men the seeds of doubt, uncertainty and anxiety where none need nor should exist. Why aren't we born that way? After reading and hearing about the David Reimer situation, maybe parents will have more sense than to put their little boys through the pain and misery of circumcision before they are old enough to make a decision on their own. After all, if we were meant to be circumcised, we would have been born that way. BARRY GATES
March 10, 2000 Long and short of it: sue! I DEMAND an apology and a million dollars. No, make that five million. My parents, soon after my birth, submitted to the quackery of the time and had me circumcised. Recent research has proved this was a terrible thing to do, a mutilation that has caused me a lifetime of physical and spiritual pain. Somebody owes me my foreskin. Don't bother trying to foist someone else's skin on me and don't think you can satisfy me with transplanted or stretched skin. I want the real old foreskin that was taken from me 55 years ago. Failing that, five million dollars, at a rough estimate, might settle that matter. There may be some trouble about who should apologize and who should pay. My parents are in no position to do either and the paediatrician who presided over the act, who I suppose carried it out, has passed on. I might try suing all the paediatricians of Canada on the grounds that they were all doing the same thing and are collectively guilty, but they will soon be bankrupted by paying five million dollars to every Canadian who was ever circumcised. My chances of collecting before the other circumcisees submit their bills are slender at best. I think my best shot lies with suing the government of Canada, which is the guilty party of last resort for all those with old grievances. The government's pockets are relatively deep and it cannot easily dodge away into insolvency to evade judgments. The government was in business when I was pruned and it failed to lift a finger to protect me, tiny helpless newborn that I was, naively trusting that King George VI and the prime minister of the time, Mackenzie King, would uphold truth and justice and shelter me from maltreatment. The specific evidence linking the government of Canada to my misfortune is a trifle thin, but the sob-story elements are dynamite. In an era when new generations right, left and centre are pressing their claims against earlier generations and when these claims are often accepted, I do not see how society can turn me away empty-handed. Once a few trail-blazers like me have established that circumcised Canadians are entitled to compensation, we can go into business. Males who come and display evidence of circumcision in front of an expert committee should be able to collect their share of the award on the spot. Drop your drawers and draw your cash. We who blazed the trail will deduct a small commission from each settlement—because we did the hard work that made the whole thing possible. The committee will have to take precautions against people trying to collect twice for the same mutilation. Perhaps the committee, upon reviewing the mutilated member and ruling that it qualifies, will have to tattoo a serial number on it corresponding to the serial number of the compensation cheque, so that if the owner tries to claim a second time the fraud will be immediately spotted. No tattoo, no cheque. We may be able to scare some claimants away with the tattoo needle and keep the cash for our own noble uses. You can imagine already the objections that will be raised: that the Canadian taxpayers of today took no part in mutilating me, bear no guilt and bear no responsibility for indemnifying me; that the best expert advice at the time, based on close observation and careful thought, favoured circumcision or at least did not forbid it; that my parents, my paediatrician and Mackenzie King himself bore me no ill-will and in fact wanted, from the core of their beings, to do everything they could to ensure my health and happiness. I dismiss these pathetic pleadings with an imperious wave of my hand. Everyone is answerable at the bar of history for the deeds they perform. This will in many cases mean that people now caring for children will be later found to have violated the fads and fashions of a future age, when changing times and changing ways will provide no excuse. If at the bar of history, future generations decide they are not content with spitting on the graves of their ancestors, they may find a way to guilt someone into paying for compensation. You never know how things will come around. Fifty years hence the best opinions may hold that all males should be circumcised. Doctors and parents of today may be condemned for failing to circumcise. Once I get my settlement, I shall spend it fast before someone comes to claim for the next injustice. Terence Moore is a Free Press editorial writer. His column appears on Fridays.
March 11, 2000 Circumcision letter misses point I found J. Pritchard's letter interesting (Circumcision foe has own agenda, Free Press, March 3). How unfortunate that it misses the point. Male circumcision, like female circumcision, is mutilation. How are these two procedures "totally different?" They both entail removal of perfectly healthy, functioning body parts. Those who believe that circumcision is medically indicated need to do their homework. The long-held myth that circumcision is necessary for infection and hygiene control is fiction. Circumcision is not without its complications. Ask David Reimer if circumcision "has no undesirable effect!" Literature also suggests that the effects of the pain newborns must endure during the circumcision may linger. I am just wondering how many of the proponents of circumcision have actually witnessed one for themselves. How many parents have seen a circumcision performed? Perhaps proponents would be interested in knowing that the procedure entails strapping the baby's arms and legs to a table. Also interesting is that some doctors still do not believe that newborns can feel pain. Regardless if the baby receives a local anesthetic or not, the baby still howls and cries. It is heartbreaking. Mutilating children is barbaric. Barry Gates (Why aren't we born that way? March 3) is absolutely right—if we were meant to be circumcised, we would have been born that way! S. GALPIN
March 14, 2000 Research before circumcision CURRENT RESEARCH into foreskin structure appears to puzzle some otherwise keen observers of the circumcision scene (J. Pritchard's letter, Circumcision foe has own agenda, Free Press, March 3). Those who advocate circumcision of male newborns should, at the very least, be prepared to defend their position that the foreskin is no more than a simple flap of skin. Dr. A. J. Lockwood, Alison J. Taylor and I showed how, and possibly why, the foreskin is specialized for sexual function. Our article was published in the peer-reviewed British Journal of Urology of 1996, which is available in all medical school libraries. It describes, for the first time, a special structure we called "ridged band" with a concentration of special nerve endings. It is wrong to imply that the ridged band is a microscopic feature. No one has yet said that our findings are either inconsequential or, worse, dead wrong. Our claim that the foreskin is designed to promote sexual pleasure and basic sexual reflexes has not been challenged. Parents have to be made aware that circumcision may have unfortunate, long-lasting and irreversible consequences. This is the essence of informed consent. Sexual anatomy has long been the target of locker-room titterers, pushing it ever further into academic limbo. Therefore we have to take a fresh look at the scientific basis of, for instance, the burgeoning claims that circumcision is necessary for all newborn males because it is a simple and inconsequential procedure with big paybacks: the prevention of AIDS. If parents do not mind spending an hour or so researching a topic with lifetime consequences I highly recommend three Canadian Web sites: Parents who are not overly impressed by science or their own research should take time to think matters over, always remembering that the foreskin in question belongs to their child. Parents should have a clear and objective knowledge of genital anatomy and function: only then will they develop a healthy respect for their baby's right to an intact penis. Dr. JOHN R. TAYLOR
March 25, 2000 Fund circumcision when parents request it DR. JOHN R. TAYLOR has written an articulate letter arguing that Manitoba Health should not fund circumcision for male infants and that parents should not request their newborn sons to be circumcised. (Research before circumcision, Free Press, March 14.) While this has been the position of many excellent physicians and many parents, approximately half of parents in the United States, Canada and Australia choose to have their infant sons circumcised. Decisions should be made by parents with all the scientific facts currently available. Because we do not feel these were adequately presented in Dr. Taylor's letter, we are stating them, as follows. There are at least three reasons why parents choose not to have their sons circumcised and they include:
The reasons to encourage the ongoing practice of circumcision for society and for individuals include the following:
The pendulum is beginning to swing in favour of male circumcision as a strategy for reducing HIV. Although in Canadian society this decision needs to be made on a case-by-case basis by parents with sound advice from their caregivers, it remains important that the debate be carried out within the context of science and evidence as well as passion and beliefs. We urge Manitoba Health to continue to fund this procedure when parents request it and caregivers concur. ALLAN RONALD
March 28, 2000 Two sides to circumcision issue Regarding Research before circumcision (Free Press, March 14). I am not puzzled by the structure of the foreskin, as Dr. John Taylor suggests. I don't and can't dispute the accuracy of his findings. I am simply skeptical of the conclusions he draws. I am not persuaded that objective physical findings can unerringly be directly translated into subjective experience. Even if they could, it is simply a subjective opinion, and an incorrect one I believe, that they would always be better; that more is always better. I feel that Taylor's presentation of his opinions as virtual dogma obscures the fact that most, if not all, authoritative sources see neonatal circumcision as neutral or mildly beneficial. Further, as I stated earlier, Taylor's campaign is in itself not without some undesirable side-effects. It is not my point to promote neonatal circumcision. It is my point to emphasize that there are two sides to this issue, a fact that Taylor seems unwilling to accept. Taylor mentions three websites, all of which are single-issue strongly anti-circumcision sites. His recommendation of these sites to the exclusion of others makes a mockery of his reference to "informed consent." Truly informed consent requires knowledge of both sides of the issue. The full texts for references I made in my earlier letter can be found at: Canadian Pediatric Society, www.cps.ca/english/statements/FN/fn96-01.htm; and American Academy of Pediatrics, www.aap.org/policy/re9850.html. Two sites openly favourable to neonatal circumcision are: Neonatal circumcision: a current appraisal, www.geocities.com/HotSprings/2754/wiswell.html; and Medical benefits from circumcision, www.personal.usyd.edu.au/~bmorris/circumcision.shtml. As to Research before circumcision, I encourage readers to review Taylor's suggested sites in order to be able to assess their, and his, objectivity: cirp.org; infocirc.org; intact.ca. J. PRITCHARD
March 6, 2002 Stop paying for circumcision Your editorial Manitoba's Health Facts (Jan. 21) tells us that Manitoba chews up health dollars at a faster rate than any other province. I know of one area of wastage that is well-defined, free of medical controversy and easily cured. It also illustrates government's resistance to change in the face of the best available information. For reasons of their own, successive health ministers have steadfastly refused to delist the routine circumcision of male infants. According to major Canadian and American medical associations, including the Canadian Paediatric Society, the routine circumcision of infants less than 30 days of age has no place in modern medicine and should be abandoned for precisely that reason. The fact that a "fee-for-service" is paid for a service that is no service at all seems to have escaped the notice of our listers and delisters. I should add that the routine circumcision of male neonates has long since been delisted in every province except Manitoba, presumably with savings to treasuries as well as to the individuals concerned. So, if our health minister cannot deal with a practice that is wasteful in more ways than one, how can we expect him to deal with less clear-cut issues? DR. JOHN R. TAYLOR
September 16, 2002 Circumcision column lacked even hand In The return of the foreskin (Sept. 5), Catherine Mitchell's opening question sets the tone of the piece: emotional and "gee-whiz" simplistic. The question is presented in such a manner that it is virtually impossible to answer "yes." But the issue is not quite that simple. Some see circumcision, and with good reason, as, on the whole, a beneficial condition. Others see it as religiously significant. One anti-circumcision activist (Robert S. Van Howe, MD, FAAP), after reviewing the literature, was able to find 91 cases (cases, not deaths) of circumcised men developing penile neoplasms during the 93-year period from 1903 to 1996. On the other hand, about 1,000 men each year develop penile cancer, a disease almost entirely preventable by circumcision, but "only" about 200 men die each year in North America from it (American Family Physician, August 1995 v52 n2 p523(4)). These deaths don't make headlines. They are dismissed as statistically insignificant. She states "there are simple arguments supporting each end of the debate" but she fails to elaborate on the other end. There are, in fact, benefits to neonatal circumcision ranging from the well-documented objective to the subjective: a reduction in urinary tract infections (UTIs); a substantial reduction in the rate of penile cancer; prevention against ulcerative sexually transmitted diseases; a reduction in the risk of HIV transmission from infected female to uninfected male; greater ease with cleanliness; the elimination of phimosis, particularly for adolescents; and for many, an improved sexual experience. The question for most is do these benefits justify neonatal circumcision? Individually, they probably don't. Collectively, they can be seen as making neonatal circumcision not only a reasonable choicebut perhaps even the preferred choice. And none of these benefits can be said in defence of female genital mutilation. My point here is not to promote neonatal circumcision. If the reasons Ms Mitchell sets forth are sufficient to persuade her, I have no quarrel with her. But I do believe that when a journalist takes pen in hand to prepare an article which will be published in a major newspaper, she has a professional responsibility to present the issue more evenhandedly. No basis for circumcision Catherine Mitchell's excellent article, The return of the foreskin (Sept. 5) reminds us of the absurdity of routine, newborn circumcision. This surgical procedure (usually performed at about one day of age) has no basis of medical necessity (the hallmark of an insured service), but does have risks, such as bleeding, pain, infection, and worse. Newborn circumcision first began, not as a hygienic measure, but to give thanks for a male child, through the sacrifice of a portion of his maleness, his foreskin. Respected medical groups, such as the Canadian Paediatric Society, have for some years recommended against routine newborn circumcision. Accepting this as a medically unnecessary procedure, no provincial health plan (except Manitoba's) has paid for newborn circumcision for years. In spite of this, and in spite of lobbying our minister of health to stop wasting tens of thousands of dollars a year, Dave Chomiak continues to insist that it is an appropriate insured service. KENNETH J. COLLIER, MD
September 23, 2002 Pro-circumcision letter inaccurate Re: John Pritchard's letter Circumcision column lacked even hand (Sept. 16). Mr. Pritchard complains of bias in Catherine Mitchell's article on newborn circumcision, but his own letter is not exactly a model of fairness and accuracy. For example, Mr. Pritchard's claim that circumcision wards off cancer of the penis is flatly contradicted by no less an authority than the American Cancer Society, which says on its Web site that "circumcision is not of value in preventing cancer of the penis." DENNIS HARRISON
Chomiak alone in foreskin bounty Re: John Pritchard's letter Circumcision column lacked even hand (Sept. 16). Mr. Pritchard seems to know something about the benefits or otherwise of routine infant male circumcision that has evaded the Canadian Paediatric and other medical societies, including the American Medical Association. He did, however, make one statement about which I have first-hand knowledge; he baldly claims that circumcision improves the sexual experience. No backing for this statement was offered but one can only hope he is right, for the sake of those who practise routine neonatal circumcision, as well as for the kids themselves. But I don't think so: As I have pointed out before, circumcision always removes a band of highly specialized and sensitive sexual tissue my colleagues and I, in Winnipeg, called ridged band. With no help from those who prefer to disregard advances in human anatomy and function for their own reasons, ridged band is now implanted in literature on the male foreskin, as witnessed recently by Dr. Gifford-Jones in this paper. Perhaps, one day, this information will receive serious attention from Health Minister Dave Chomiak who, incidentally, has recently confirmed and extended his bounty on the infant foreskin. The fact that he is alone among health ministers in this decision seems not to have influenced his bizarre action. DR. JOHN R. TAYLOR
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