Editorials

Thursday, September 5, 2002, p. A14.

The return of the foreskin

Catherine Mitchell

What would you say to a doctor who stood at your hospital bedside, a day after you gave birth and said: "Congratulations. Now give me your newborn son. We want to do a quick surgical procedure; just a few quick cuts. It's not medically necessary -- heck, it's not even medically advised -- but it will give him a look some people prefer."

Most would report that doctor. Yet, that description (of the procedure, not the process) pretty accurately applies to elective circumcision for newborns and thousands of parents still request that their days-old sons get circumcised. Odd, to say the least, given that circumcision is not supported by numerous medical societies in Canada, indeed the world.

Manitoba is the only province that pays for routine circumcision of newborns. It pays a petty $19.50 to the physician. It takes all of few minutes.

Manitoba and Saskatchewan are said to have the highest rates of circumcision in Canada, at 26 per cent and 27 per cent respectively. (Newfoundland is said to be lowest, at 0.6 per cent.) But Saskatchewan delisted circumcision as an insured procedure long ago and the College of Physicians and Surgeons there has aggressively pursued the issue with physicians, challenging them to do the medically appropriate thing and tell parents that the risks outweigh the benefits.

And so the question is, why?

Why subject a newborn baby boy to the pain and suffering -- the operation itself is done with pain control but drugs wear off -- and the risk of an unnecessary medical procedure?

This is not about the British Columbia baby who, at five weeks, died last month following circumcision. The cause of the death is unknown, but in any case, medical literature indicates that death is a very rare outcome. Yet there are risks in any medical procedure and in circumcision they run from minor bleeding to severe, indeed.

This is about the seemingly cavalier attitude some doctors and parents have about subjecting a days-old infant to a surgery the very thought of which can turn grown men's legs to jelly. Some physicians refuse to do elective circumcisions, but clearly not all feel this strongly.

In Manitoba, 1,802 newborns were circumcised last year. That's 26 per cent of the boys born that year, compared to 35 per cent circumcised in 1992.

That it has not dropped further may be due to a passive attitude about a surgical procedure that 30 years ago was recommended and believed to be beneficial.

But there is also ample argument supporting each end of the debate and people who come to the issue with bias can choose accordingly. As far as medical evidence is concerned, however, it is almost overwhelmingly against lopping off the foreskin without compelling medical reason.

I say almost because from Manitoba research springs evidence that circumcision has protective value against HIV.

For years, internal medicine specialists and microbiologists undertaking AIDS research in Africa have been documenting a powerful association that shows uncircumcised men at much higher risk for contracting HIV through heterosexual sex. The risk is as much as three times greater for uncircumcised men as it is for circumcised men. It was first noted as a "tentative observation" by scientists from the University of Manitoba in 1987 and has gathered steam with a cascade of similar observational studies by many others.

To underscore those studies, Dr. Stephen Moses and colleagues from the United States and Kenya are conducting clinical trials with a particular group of Kenyan men. Imagine that; grown men signing up for an experiment involving circumcision. Must be mighty powerful motivation.

And there is -- in Kenya, where rates of HIV infection run from an astounding 14 per cent to 30 per cent. In Canada, 4,000 people test positive for HIV each year and there are 50,000 -- less than one per cent of the Canadian population -- living with HIV today. Circumcision appears good medicine in Africa, but is it relevant to Canada? I suspect that if you ask your doctor, he or she would say no.

Yet it's the closest you'll get to a rational reason for routinely circumcising babies in Canada. Most parents request it out of what's referred to as "social" factors -- because dad's been circumcised or to follow religious dogma.

We rage at the thought that female circumcision (more accurately described as genital mutilation) takes place in Canada. We've even outlawed it. But few parents could medically defend circumcising their children.

It seems to me that if you can look at your newborn and decide then that he is likely to be among a high-risk population, like those in Africa, then you have your answer as to whether it is appropriate to circumcise.

Otherwise, let him decide for himself when he hits the age of reason.