[CIRP Note: This file contains English translations of three articles by Raymond Bernatchez regarding circumcision that were published in French in Montreal on 26 November 1996.]

Unofficial translation
[Translator's notes appear in square brackets or as footnotes]

CIRCUMCISION: If Necessary...But Not Necessarily!

By Raymond Bernatchez

Do you know what Newfoundlanders and Quebeckers have in common? You'll never
guess. Of all the citizens of Canada, it is the males of Quebec and
Newfoundland that are the least circumcised; it is they who succeeded, better
than the others, to keep their original foreskins intact at birth.

Dr. Pierre Williot, Clinical Associate Professor at l'Universite de Montreal
and Head of the Division of Paediatric Urology at Sainte-Justine Hospital
[Montreal's principal French children's hospital], explains that circumcision
is essentially a phenomenon related to anglophone culture, and that if it is
practiced far less in Quebec than in the other provinces of Canada, it is
practiced relatively less today in Canada than in the United States.

Setting aside the religious rituals practiced by Jews and Muslims, we
understand better the phenomenon of "medical" circumcision. Originally
advocated by British doctors, under the reign of the puritan Queen Victoria
(to prevent, medically, the harmful effects of...childhood masturbation!),
this practice proceeded to spread to all of the Anglo-Saxon world, including
the United States. The majority of European countries, however, refused to
follow in the footsteps of the British, as, for that matter, 80% of the
world's countries, which don't practice circumcision except in cases of
absolute necessity.

"In the majority of European countries," the doctor said, "it is less than
10% of the population that will require a circumcision. In Finland, for
example, circumcision has been practiced on less than 1% of the population."

>From 1% of the male population in Finland to over 85% of the male population
in the United States in 1985, there is a big difference! Where do we find
ourselves in Quebec? According to a spokesperson 4)Info-Circoncision (yes, it
indeed exists!), the circumcision rate in Quebec in 1987 was 3%, compared to
38% in Ontario.

In 1949, the British themselves put an end to this practice which, in the
United States meanwhile, established itself to the point where in 1980, close
to 85% of newborn males were systematically being circumcised.

Quebec and Newfoundland are the two most antagonistic provinces one toward
the other in regards to constitutional wrangling, and all Canadians know
this; hence the humorous significance of this surprise question.
What are the reasons that still justify the medical practice of circumcision
in Quebec hospitals? What are the reasons that could cause Dr. Williot, for
example, to perform this surgical intervention consisting in the incision of
the foreskin and its complete removal?

"Only those circumcisions which are medically necessary are covered by
l'Assurance-maladie du Quebec [Quebec Medicare], while those performed for
other reasons, of an aesthetic or religious nature, have to be paid for by
the requesting parents (at Sainte-Justine Hospital, this fee is of the order
of $550). This, already, gives you an idea," the specialist said.

What could be these "medical necessities"? Dr. Williot mentions paraphimosis
(when the foreskin gets caught behind the glans and can't be brought forward
otherwise) or in cases of repeated infections of the glans, namely in certain
adult diabetics. The doctor also mentions the rare possibility, in a child of
less than two years old, of a phimotic preputial ring having been forcibly
dilated through forced retraction, thus provoking tears and subsequent
scarring, resulting in problems. He also mentions rare diseases of the skin
that may prevent any degree of retraction, as well as repeated infections of
the glans. For the rest, that's to say in the majority of cases, Dr. Williot
advocates less invasive solutions. His recommendation to parents is, above
all, not to become alarmed unnecessarily.

Manual retraction "At birth, there are two reasons why the foreskin cannot be
retracted. The first is that it is too narrow at its extremity, like the
collar of a turtle-neck. The other reason is that the foreskin and the glans
adhere completely to one another; there is no cleavage, therefore, between
the foreskin and the glans. In the majority of cases, infants don't have any
cleavage at birth."

Need a doctor, therefore, intervene, by performing a circumcision?

"Not necessarily," the doctor replied. "Usually, Mother Nature herself takes
care of the problem with time. At the base of the glans, there is a portion
that we call the coronal sulcus. At this point on the glans, there are
usually no adhesions. Cells from the mucous membrane of the foreskin and the
skin of the glans will desquamate, or form flakes if you prefer. These
desquamated cells will accumulate at the base of the glans, in the sulcus,
and will form a sort of paste called smegma. Smegma will accumulate over the
years and the pressure it contributes in creating will result, eventually, in
a space between the glans and the foreskin. This, then, is a physiological
mechanism of the freeing of the adhesions. Most of the time, this works.
Irritated by the smegma, some children will manipulate the glans to find
relief, thereby contributing to the disengaging of the foreskin from the
glans. Erections, of a mechanical rather than a sexual origin in young
children, also play a role. The glans exerts pressure on the foreskin,
thereby contributing to dilate the phimotic ring and to free the adhesions."

Dr. Williot points out that when one explains this phenomenon to parents> as
well as indicates to them that the foreskin serves a purpose -- that of
protecting the glans -- and that the sensitivity of a protected glans is
undoubtedly greater than that of a glans which is no longer protected, they
generally abandon the idea of exposing the child's glans by circumcision.
This intervention requires general anaesthesia and causes pain to the baby.
Knowing this, parents usually opt for a much gentler method, that's to say
manual retraction done with patience during the child's bath. If at five
years of age the desired result is not yet achieved, parents can at that
point help the dilation process with a cortisone or steroid cream. One must
allow Nature the chance to do her work.



Why This Veritable "Phobia" Of An Important Part Of The Body?

By Raymond Bernatchez

United in an international non-governmental organization called National
Organization of Circumcision (sic) (NOCIRC) [correction: NOCIRC stands rather
for National Organization of Circumcision Information Resource Centers],
people have undertaken, since the last few years, to fight against infant
circumcision. NOCIRC considers this practice to be medically unjustified in
the great majority of cases, and considers that parents and doctors should no
longer be permitted to affect, without valid reason, the body of a newborn
obviously incapable of giving his consent.

"The organization is concerned about the bioethics of this question," said
John Antonopoulos, the Montreal spokesperson and coordinator of the Centre
d'information et de documentation sur la circoncision [Circumcision
Information Resource Centre] (Info-Circoncision).

Although NOCIRC is opposed to all forms of circumcision, be they performed
for religious or other reasons, during our meeting, John Antonopoulos
preferred to exclude religious reasons from our discussion and to concentrate
on the other aspects of the issue.

Antonopoulos qualifies as a "phobia" the fact that, to this day, some parents
insist that their doctor remove the foreskin of their male child at birth.

"Their modern-day phobia is that the foreskin is a dangerous, unhealthy
structure that puts the individual at risk. If people start off with the
principle that the foreskin is bad, it is obviously good, therefore, to
remove it. Thinking this structure useless, they have it removed from their
infant in all good conscience."

The reasoning is faulty at its source, according to John Antonopoulos. The
foreskin is not only a structure that does not put an individual at risk who
practices good hygiene (as is the case, for that matter, for all other parts
of the body), but it has existential value, as well as an undeniable
physiological value.

A normal part of the organism "It is a normal, integral past of the penis.
Its most obvious function is that of protecting the glans. The surface of the
glans is normally of a certain thinness or thickness, of a certain moisture,
a certain suppleness, a certain texture and a certain colour; therefore, of a
certain sensitivity, because of all of these."

"The foreskin maintains the glans in these optimal conditions, and the
secretions provided by the foreskin, smegma (as long as one doesn't leave it
to accumulate), lubricate the surface of the glans. By removing a person's
foreskin, the glans of his penis finds itself perpetually in an environment
it was not conceived to be in. In contact with air, clothing, etc..., the
surface of the glans thickens. This phenomenon is called the process of
keratinization. The surface of the glans dries out, its colour changes, and
all these factors together have a reductive impact on the sensitivity of the
glans itself. The foreskin serves another function: a mechanical-lubricating
one. This skin being a moveable structure, this mobility provides
the mechanical lubrication "In having their child circumcised, that is, in
having his foreskin removed at bird, some, no doubt, imagine that they are
depriving their child of but a small piece of skin. In point of fact,
however, in adulthood, this "small piece of skin", as our illustration
demonstrates, is equivalent to a total surface area of 3 inches by 5 inches:
it is comprised of a 1.5 inch by 5 inch band of external skin, its internal
surface is comprised of a band of mucous membrane whose surface area is also
1.5 inches by 5 inches.

"This mucous membrane is highly innervated and its nerve endings provide a
very particular sensation," John Antonopoulos underlined.

Condoms against AIDS Proponents of circumcision even suggest that the
foreskin puts an individual unnecessarily at risk, in adulthood, notably for
sexually transmitted diseases. What of that?

John Antonopoulos refutes this argument. As concerns urinary tract infections
in infancy, he says that the risk is of the order of 1% in uncircumcised
infants, while being 0,1% in circumcised infants. He recognizes that it is
ten times less, but is quick to add that one is not justified in removing the
foreskins of 99% of male infants in order to protect 1% of the population,
which in any case can be protected by other means.

Increased risk of HIV transmission having been evoked in medical circles,
Antonopoulos responds that only a condom can effectively protect a person
against the risk of transmission, be he circumcised or not. If, in the
absence of a condom, trauma to the foreskin's mucous membrane during sex can
serve as a portal of entry into the organism for the virus, the same holds
true for a circumcised man, as in the instance of a lesion occurring during
sex, as a result of too taut a skin surface.

"There is a growing number of men, in the United States particularly, who
are awakening to the fact that a part of them was removed without their
consent, and who are consternated by this fact," adds the spokesperson of the
Centre d'information et de documentation sur la circoncision. Some of these
men are interested in the idea of being able to "restore" their foreskin. It
is, in fact, possible for a circumcise man to lengthen the skin which is
behind his glans, non-medically, by means of light to moderate stretching of
the skin, practiced regularly over a long period of time (18 to 36 months
depending on the person's objectives)2.

2 The most commonly employed means of keeping the shaft skin moderately
stretched forward over the glans for several hours at a time is medical
adhesive tape, which has been cut, folded and shaped in a particular fashion,
depending upon the method chosen, and which is applied by the individual to
his own skin.

The most thorough resource on the subjects of both nonsurgical and surgical
"foreskin restorations methods, as well as infant circumcision, is The Joy of
Uncircumcising! Exploring Circumcision: History, Myths, Psychology,
Restoration, Sexual Pleasure and Human Rights, by psychologist Jim Bigelow,
PhD., one of the pioneers of modern nonsurgical foreskin restoration, who
presented his work at the Third International Symposium on Circumcision, at
the University of Maryland, May 1994. Since its publication in 1992
(Hourglass Publishing), this book has been reviewed by The Journal of The
American Medical Association, The British Journal of Urology, The British
Medical Journal, The Journal of Plastic and Reconstructive Surgery, The
Journal of Nurse-Midwifery and The Journal of Orgonomy. (The second edition
was published in 1995. ISBN 0-934061-22-X, 250 pages, 269 references, 387
notes, 213 personal letters.)
The penis thus "restored" regains some of the characteristics of the
original penis, (not all, however, the mucous membrane itself not being able
to be reconstituted), namely a certain sensitivity on the surface of the
glans. There also exist surgical "restoration" procedures.

What NOCIRC hopes for, above all, is that parents become aware of all these
facts, and that they stop demanding systematically, for reasons of social
conformity (especially as concerns the U.S.), the circumcision of their
child.

For more information on the subject, you can reach a spokesperson of the
Centre by calling if o-Circoncision at (5 14) 844-CIRC or by writing to:
Info-Circoncision, C.P. Les Atriums, P.O. Box 32065, Montreal, QC H2L 4Y5.



Subject: Montreal La Presse 11/26/95 #4

No Doctor Is Obliged To Perform A Medically "Unjustified" Circumcision

By Raymond Bernatchez

No doctor is obliged to perform a medically unjustified circumcision on a
child, even if the parents request it. This position was communicated to us a
few days ago by a spokesperson of the College des medecins du Quebec [College
of Physicians of Quebec], who specified, however, that the College refuses to
take a position on this issue, still considered very controversial in medical
circles.

What is one to understand from this? It would seem that the College refuses
to interfere as an arbiter in the vast circumcision debate which encompasses
diverse aspects, religious ones notably, but that it recognizes that certain
parents demand a circumcision for their child, invoking reasons of a medical
nature that don't always have a raison d'etre.

On the basis of his Code of Ethics, a doctor can refuse to perform a
medically unjustified circumcision, and the parents can't oblige him to act
against his will.

In fact, the Code specifies that "a physician must only provide care or give
a prescription for medication or treatment when medically necessary" [article
2.03.21 of the Code de deontologie des medecins (Physicians' Code of
Ethics)]. The Code also states that "a physician must ignore any intervention
by a third party which could influence the performance of his professional
duties to the detriment of his patient" [article 2.03.50]. And, further
still, it states that he "must ignore any interference which does not respect
his professional independence" [article 2.03.54]. [These three articles
quoted from the Code are the actual text of the English version of the
Physicians' Code of Ethics.]

Although one can't oblige a Quebec physician to perform a circumcision, said
Brigitte Junius, director of communications of the College des medecins du
Quebec, nothing prevents a parent from seeking out other physicians who may
consent (for reasons that are proper to them and which are not of a medical
nature) to performing such a procedure. It should be clear, however, that
l'Assurance-maladie du Quebec [Quebec Medicare] does not assume the cost of
an intervention practiced under these circumstances, and that the costs must be
entirely assumed by the parents, as if it were an intervention of esthetic
surgery.

Lawsuits in the U.S. According to the Centre d'information et de
documentation sur la circoncision [Circumcision Information Resource Centre],
Quebec physicians ought to refuse to perform circumcisions on infants with a
view simply to satisfying the demands of parents. If they do perform the
intervention, they are acting in contradiction with bioethics and with their
Code of Ethics.

John Antonopoulos, spokesperson for the Centre, specified, however, that his
organization, affiliated with the National Organization of Circumcision (sic)
(NOCIRC) [correction: NOCIRC stands for National Organization of Circumcision
Information Resource Centers], doesn't intend, at this time in any case, to
wage a legal battle against doctors who consent to performing a circumcision,
not required for medical reasons, on a child.

"I prefer, for the time being, to provide information to the public,"
Antonopoulos stated. "Even if circumcision is inconsistent with the strictest
interpretation of the law, I prefer to change attitudes rather than pointing
fingers and going to court. There are already lawsuits being fought in the
United States however. It's coming."

Antonopoulos maintains that no one has the right to remove a normal, healthy,
functioning structure from another person without their consent (as is indeed
the case with a newborn). "If, in our day and age, we attempted to remove
even the smallest piece of skin from a baby girl, that wouldn't fly," he
stated further. "Obviously, if a circumcision is necessary, one can't object.
But it should be stressed that circumcision is a measure of last resort, and
should not be performed unless all other means have been attempted."

Correction re: "NOCIRC"; Sunday, Dec. 3, 1995, Health Section, page 5:

A Follow-Up Of Our Files ...After having read our report on circumcision last
week, several of our readers contacted the Centre d'information et de
documentation sur la circoncision, affiliated with NOCIRC (National
Organization of Circumcision Infommation Resource Centers). Many of these
people having expressed a particular interest regarding foreskin restoration,
we will be coming back to this subject in the future.