Circumcision: If Necessary... But Not Necessarily!

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

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 becomealarmed 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?

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 allgood 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 5inches.

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 canbe 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.

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

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 naturethat 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 againsthis 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.

 Back to the News 1995 page.

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